• The wreckage of VH-PDC at Orange. (ATSB)
    The wreckage of VH-PDC at Orange. (ATSB)

The Australian Transport Safety Bureau (ATSB) has found that spatial disorientation contributed to the crash of a Cirrus SR22 at Orange last year.

A pilot and instructor were on board VH-PDC conducting night training at Orange in May 2018 when the aircraft crashed during a go-around attempt. The aircraft was destroyed and both the occupants were seriously injured.

The ATSB investigation report released today found that during the go-around the pilot became spatially disoriented, which resulted in a loss of control. According to the report, the instructor was not aware the pilot had become disoriented and so continued to direct the pilot rather than intervene.

During the go-around, the aircraft pitched up in response to power and began to roll to the left. Because the pilot–who had a private instrument rating–lost sight of the runway lights and the night was pitch black, he became disoriented.

"When full power was applied, the aircraft pitched up," the report states. "As the pilot was attempting to transition his scan onto the instruments, the instructor, whose attention was on the attitude indicator, directed him repeatedly to level the wings – 'wings level'.

"The pilot observed the runway lights disappear off to the right and felt the aircraft was in a roll as he was trying to focus his attention on the attitude indicator."

Although the pilot reported trying to correct the aircraft, it struck a fence and came to rest upside down. The time from the decision to go-around to impact was only seven seconds.

The instructor reported that she did not take control in this situation because the side-stick in the SR22 made it difficult to do so, and also because the during the previous night circuit the pilot had responded well to direction. She also said that by the time she understood the pilot was disoriented there was no time left to avoid the crash.

The incident also prompted the ATSB to issue a warning to would-be rescuers about the risk involved with ballistic recovery systems (airframe parachutes). In this instance, the Cirrus Airframe Parachute System (CAPS) rocket fired uncommanded nine minutes after the crash.

"The post-impact deployment of the aircraft’s parachute recovery system highlights an important safety message for emergency personnel and others who attend aviation accidents, to be aware of the potential dangers of an unactivated rocket-deployed parachute systems," the ATSB warned.

"The mishandling or misidentification of these systems could be fatal."

The full investigation report and ballistic recovery system warning can be found on the ATSB website.


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