FINAL REPORT: ATSB reveals findings into fatal plane crash
A REPORT into a plane crash at Agnes Water that killed a UK tourist found better restraints could have prevented such serious injuries.
After a "complex" investigation, Australian Transport Safety Bureau could not determine what caused the power loss and engine failure of 1770 Castaway's Cessna 172M when it crashed into the dunes at Middle Island on January 10, 2017.
There were four people on board, including pilot Les Woodall, the UK woman, a 13-year-old boy and an Irish woman.
In its report, ATSB recommended upper torso restraints (UTRs, shoulder belts or harnesses) be worn by all passengers on small aeroplanes and for tourism operators to brief passengers about when and how to adopt a brace position.
The investigation also uncovered "regulatory oversight" by CASA during its audits of the business.
The business was owned and operated by chief pilot Bruce Rhoades, who relocated to Victoria after the accident.
Mr Rhoades died last month after a year-long battle with brain cancer and leukaemia.
Late last year Mr Rhoades spoke publicly about how he believed he had been unfairly targeted by CASA and disputed many of its findings.
The report said despite substantial research showing seatbelts that include UTRs reduce risk of injury compared to lap belts only, they are not compulsory.
In the Cessna 172M, the two front seats had a lap belt and UTR and the rear seats had lap belts only.
The woman who was killed was sitting in the rear-left seat.
The 13-year-old boy in the rear-right seat suffered a fractured vertebrae in the neck, a significant internal head injury, fractured pelvis and fractured left ankle.
While the pilot and the other passenger in the front seat were injured, they did not suffer neck injuries.
"Had such restraints been fitted, the rear-seat passengers' injuries would very likely have been less severe," it said.
In 2001 CASA released a discussion paper on the proposal to mandate the installation of shoulder harnesses for all passengers in small aircraft.
The following year CASA told ATSB the installation of the equipment for all passengers would be "strongly recommended".
But in May 2019, 18 years since the discussion paper was released, CASA could not identify any further information to operators on UTRs.
In a statement, the ATSB told The Observer the second safety message was for pilots to conduct landings straight ahead or with only small changes in direction in the event of engine failure or power loss.
The engine failure occurred while Mr Woodall was conducting an aeroplane landing area inspection at about 60 feet.
The report said Mr Woodall was faced with a "very difficult decision" and he had "limited options".
Mr Woodall completed a left turn for a beach landing.
" … The aircraft did not have sufficient performance to avoid collision with terrain," it said.
The ATSB also found the operator's procedures and practices did not manage risks of engine failure or power loss when at low height.
Although it said it did not contribute to the accident, ATSB said there were other "problems" identified with the business's activities.
It said the documented flight hours underestimated the actual flight hours, and the aircraft exceeded the maximum takeoff weight.
It estimated the aircraft was 17kg above its maximum takeoff weight.
CASA corporate communications manager Peter Gibson said it would formally respond to the recommendations.
Mr Gibson said CASA had made improvements to the way it conducted audits.
"We will actively look at what lessons we can learn from this ATSB report," he said.
"The work the ATSB does in analysing the factors behind accidents is extremely valuable."
ATSB recommended operators and pilots review flight procedures to ensure emergency landings are possible at a low height.
It also recommended risk of engine failure or power loss is considered by operators and pilots when conducting inspections at below 500 ft.