Friday, September 30, 2011

Air controller partly to blame for fatal crash. Piper PA-31 Cheyenne, VH-TNP. Australia

An air traffic controller failed to notify a pilot his plane was veering off course when it crashed and killed all six people on board, a Victorian coroner has found.

The Piper Cheyenne aircraft was flying from Bankstown Airport in Sydney to Benalla, 200 kilometres north-east of Melbourne, when it crash-landed into a tree-covered ridge on July 28, 2004.

It had veered more than 7.5 nautical miles off its path before crashing.

Killed were particle board company director Robert Henderson, his daughter Jackie Stark, her husband Alan, their Queensland friends Belinda Andrews and Geoff Brockie and pilot Kerry Endicott.

Victorian coroner Paresa Spanos on Friday found an air traffic controller showed poor judgment when he did not advise the pilot he had veered off track.

At the time, Mr Endicott was flying in cloud with no visual clues that he was flying off course and he must have thought everything was fine, Ms Spanos said.

However, air traffic controller Kevin Carey had received two alerts showing the plane had moved 7.5 nautical miles off its route.

Ms Spanos said Mr Carey failed to comply with his obligations as an air traffic controller because he dealt with the alerts by changing the flight data based on his assumptions rather than by communicating with Mr Endicott.

Mr Carey relied on Mr Endicott's competence as a pilot to support his decision not to contact him about the alerts, the coroner said.

"In so doing, he contributed to the accident as there was a lost opportunity for avoidance of the accident," she said.

Ms Spanos apologised to the families of the victims for the delay in her finding.

Outside court, Alan Stark's father Barry Stark said the families had expected that finding.

"Our main concern was the amount of time it took to get around to today," he said.

"It's now been seven years since the accident, three years since the inquest.

"Hopefully now it's a full stop and that's behind us and we can get on from there.

"I was waiting for an explanation, but all we got was the apology so I assume that's all we're going to get, but that's life."

Mr Stark said he was "trying hard" not to bear ill-feeling towards the air traffic controller.

"My point has always been if he'd just done that little bit more this whole thing might have been avoided," he said.

Ms Spanos commended Airservices Australia for making recommendations including enhancing the air traffic system with a graphic tool displaying an aircraft's cleared route on the controller's screen.

The air traffic services manual was also changed to make it mandatory to communicate alerts with a pilot.

Ms Spanos said if the aircraft was fitted with a terrain awareness and warning system - which at the time was not a legal requirement for smaller planes - the accident might have been prevented.

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