The Mt Disappointment event.
AO- 2022 - 16 is an active investigation; the ATSB report may be found - HERE -.
The last 25 short seconds of this flight clearly define the end result of a series of events which should be made into a mandatory training module at every flight school and flying group. Most IFR pilots would immediately spot the 'traps' as would experienced 'mountain' pilots - the forecast clearly defined the risks.
ATSB/ BoM - "The forecast for cloud in area C was for a broken layer from 2,000-3,000 ft and a broken layer from 3,000-8,000 ft. Area A was forecast to have few cloud from 3,000-5,000 ft.
ATSB/ BoM - "At 0758, at Kilmore Gap, the relative humidity was 95% and the wind was 17 kt from 171°. The cloud cover was few at 394 ft and broken at 3,510 ft above ground level. At 0811 the cloud had become broken at 394 ft above ground level.
All the clues are there - broken layers - unstable, humid conditions, 17 knots of Southerly breeze, operation below LSALT - between mixing layers? One aircraft got lucky, the other didn't. The passenger reports describe accurately just how fast Murphy can operate with a potential victim at low level, over high ground, between layers of cloud. 25 seconds was all it took, the slim margin between escape and sudden death.
ATSB -"The passenger in the front right seat had flown in helicopters for about 30 years. The passenger recalled that, as they crossed Mount Disappointment, heavy cloud rolled in resulting in ‘a white-out with ground visibility no longer evident’
ATSB -"The passenger looked outside and saw cloud in front and to the left, and then heard the pilot announce they were going ‘hard left’. When the passenger next looked outside, they ‘could not see anything, it was like a white‑out’.
A classic scenario - one which, IMO defines one of the only possible 'inadvertent' entries into IMC - at night on instrument approach - layers of cloud merge and all the ground lights vanish - hit the TOGO and get out of Dodge. But in daylight, operating VFR - there is little excuse and the importance of a back door and a defined limit point when pushing your luck are essential - 25 seconds and 800 feet the difference between one escape and one tragedy. Worth a moments thought ain't it.
ATSB - "Therefore, they elected to take a more direct track to their destination, which took them over Mount Disappointment, to the east of Kilmore Gap (Figure 2). While tracking north towards Mount Disappointment, the helicopters were above a layer of scattered cloud with an estimated top of 2,500-3,000 ft and below a layer of broken cloud with an estimated base of about 4,500 ft.
Perfect setting for CFIT, the crash site and final event horrific -
ATSB - "The ATSB’s site survey established that XWD had impacted a large old growth tree (Figure 4), which broke the upper tree trunk and severely disrupted the cabin. The helicopter then descended on a southerly trajectory at an angle of about 45° to ground impact. The vegetation surrounding the accident site was comprised of 2 distinct levels of growth. A new growth canopy that had an average height of 24 m, and old growth trees that had an average height of about 70 m. The old growth tree break was about 41 m above ground level (elevation of 759 m). The elevation of the base of this tree was 718 m, which indicated that the elevation of the top of the tree was likely about 2,585 ft (788 m). Therefore, the tree impact very likely occurred between 2,490–2,585 ft (759–788 m).
![[Image: ao-2022-016-pic-5.png]](https://www.atsb.gov.au/media/5781223/ao-2022-016-pic-5.png)
No amount of regulation can prevent a repeat event; the regular fatal and serious events resulting from VFR operators being trapped in IMC demands serious consideration, from grass roots to executive level. There are options; easy access to Night VMC with basic instrument flight skills; navigation exercises with emphasis on weather navigation and escape plans (back door exits), mandatory competence on rate 1 turns under the hood. There is much that could be done, officially and unofficially. It remains a given that some folks will 'push their luck' and, sometimes you have to - can't be avoided - but how to put an old head on young shoulders is a puzzle which has baffled mankind since the cave.
Ramble over - apologies - but repetitive, mostly avoidable accidents just keep happening; perhaps a road show could help reduce the rate - education not intimidation - even a mandated standard for basic instrument flight - I don't pretend to know the answer - but, we need to find one - before the inevitable next ATSB report is released on the same subject.
Right -O back to my knitting it is.
AO- 2022 - 16 is an active investigation; the ATSB report may be found - HERE -.
The last 25 short seconds of this flight clearly define the end result of a series of events which should be made into a mandatory training module at every flight school and flying group. Most IFR pilots would immediately spot the 'traps' as would experienced 'mountain' pilots - the forecast clearly defined the risks.
ATSB/ BoM - "The forecast for cloud in area C was for a broken layer from 2,000-3,000 ft and a broken layer from 3,000-8,000 ft. Area A was forecast to have few cloud from 3,000-5,000 ft.
ATSB/ BoM - "At 0758, at Kilmore Gap, the relative humidity was 95% and the wind was 17 kt from 171°. The cloud cover was few at 394 ft and broken at 3,510 ft above ground level. At 0811 the cloud had become broken at 394 ft above ground level.
All the clues are there - broken layers - unstable, humid conditions, 17 knots of Southerly breeze, operation below LSALT - between mixing layers? One aircraft got lucky, the other didn't. The passenger reports describe accurately just how fast Murphy can operate with a potential victim at low level, over high ground, between layers of cloud. 25 seconds was all it took, the slim margin between escape and sudden death.
ATSB -"The passenger in the front right seat had flown in helicopters for about 30 years. The passenger recalled that, as they crossed Mount Disappointment, heavy cloud rolled in resulting in ‘a white-out with ground visibility no longer evident’
ATSB -"The passenger looked outside and saw cloud in front and to the left, and then heard the pilot announce they were going ‘hard left’. When the passenger next looked outside, they ‘could not see anything, it was like a white‑out’.
A classic scenario - one which, IMO defines one of the only possible 'inadvertent' entries into IMC - at night on instrument approach - layers of cloud merge and all the ground lights vanish - hit the TOGO and get out of Dodge. But in daylight, operating VFR - there is little excuse and the importance of a back door and a defined limit point when pushing your luck are essential - 25 seconds and 800 feet the difference between one escape and one tragedy. Worth a moments thought ain't it.
ATSB - "Therefore, they elected to take a more direct track to their destination, which took them over Mount Disappointment, to the east of Kilmore Gap (Figure 2). While tracking north towards Mount Disappointment, the helicopters were above a layer of scattered cloud with an estimated top of 2,500-3,000 ft and below a layer of broken cloud with an estimated base of about 4,500 ft.
Perfect setting for CFIT, the crash site and final event horrific -
ATSB - "The ATSB’s site survey established that XWD had impacted a large old growth tree (Figure 4), which broke the upper tree trunk and severely disrupted the cabin. The helicopter then descended on a southerly trajectory at an angle of about 45° to ground impact. The vegetation surrounding the accident site was comprised of 2 distinct levels of growth. A new growth canopy that had an average height of 24 m, and old growth trees that had an average height of about 70 m. The old growth tree break was about 41 m above ground level (elevation of 759 m). The elevation of the base of this tree was 718 m, which indicated that the elevation of the top of the tree was likely about 2,585 ft (788 m). Therefore, the tree impact very likely occurred between 2,490–2,585 ft (759–788 m).
No amount of regulation can prevent a repeat event; the regular fatal and serious events resulting from VFR operators being trapped in IMC demands serious consideration, from grass roots to executive level. There are options; easy access to Night VMC with basic instrument flight skills; navigation exercises with emphasis on weather navigation and escape plans (back door exits), mandatory competence on rate 1 turns under the hood. There is much that could be done, officially and unofficially. It remains a given that some folks will 'push their luck' and, sometimes you have to - can't be avoided - but how to put an old head on young shoulders is a puzzle which has baffled mankind since the cave.
Ramble over - apologies - but repetitive, mostly avoidable accidents just keep happening; perhaps a road show could help reduce the rate - education not intimidation - even a mandated standard for basic instrument flight - I don't pretend to know the answer - but, we need to find one - before the inevitable next ATSB report is released on the same subject.
Right -O back to my knitting it is.