Alert system may have averted fatal air crash: coroner


A coroner has called for terrain collision warning systems to be installed in small aircraft carrying multiple passengers following an inquest into the death of five men in a crash.

QBuild workers Wayne Ganter, 63, Henry Roebig, 62, Wayne Brischke, 57, contractor Mark Rawlings, 49, and pilot Stuart Weavell, 36, died when a Cessna 404 plunged into a dune at Lockhart River in far north Queensland on March 11, 2020.

The men had flown from Cairns that morning, and the crash happened while attempting a second landing in poor visibility.

Coroner Nerida Wilson held five days of hearings in Cairns in July and released her findings on Wednesday, which agreed with the results of an Australian Transport Safety Bureau investigation.

Two passengers posted pictures on social media from the aircraft that showed heavy rain and low visibility.

Another passenger sent a text four minutes before the 9.19am crash stating "the first attempt at landing was unsuccessful, the runway was not visible, and there was heavy rain".

"The pilot believed he was 1000 feet higher than he actually was during most of the descent (before the final approach) and did not effectively monitor the aircraft's altitude and descent rate for an extended period due to experiencing a very high workload," Ms Wilson wrote.

The coroner's first recommendation was for the Civil Aviation Safety Authority to require the fitting of a terrain awareness and warning system (TAWS) to small aircraft capable of carrying six more more passengers and intending to land during poor visibility and at night.

TAWS uses a digital map of terrain heights and the aircraft's direction to predict potential collisions with the ground if the pilot does not change course or gain altitude.

The ATSB found the Cessna that crashed at Lockhart did not have a TAWS system on board and was not required to have one installed.

"If a terrain warning system providing aural and visual alerts had been installed and operational it is probable the accident would not have occurred," Ms Wilson said in her findings.

She also called for evaluation of the effectiveness of satellite-guided Baro-VNAV systems in assisting pilots to land at runways such as those at the Lockhart River aerodrome by tracking and predicting their angle of descent to the ground.

Among Ms Wilson's other recommendations were for a pilot education program about the hazards of relying on a less precise method of landing guidance, called GNSS RNAV, and the need to maintain navigational awareness during poor weather.

She urged the federal government, Lockhart River Aboriginal Shire Council and the aerodrome company to fund upgrades including a Precision Approach Path Indicator (PAPI) lighting system that would give pilots visual feedback on whether their landing approach was too high or low.

"I extend my deepest and most sincere condolences to the senior next of kin and their wider families for the deaths of these much-loved men in such tragic circumstances," Ms Wilson said.