‘Risky’ Gippsland crash pilot slipped through the cracks, says ATSB

According to eyewitness accounts, CCTV footage, flight data, and examination of the site and wreckage by the ATSB, the aircraft went into an accelerated stall during a steep turn during the local area flight.

“The stall occurred during the third orbit over the area, the lowest and slowest of the three,” ATSB chief commissioner Angus Mitchell said.

“As the aircraft turned steeply to the left it entered a stall, at a height too low to recover.”

Smith, who had received his CASA-approved pilot’s licence three months before the accident based on his Recreational Aviation Australia (RAAus) recreational pilot certificate from Adventure Flight Training, had a “reported history of conducting low flying and slow steep turns”, the ATSB said.

“The investigation revealed a trend of risky flying behaviour by the accident pilot, which was likely compounded by inadequate knowledge from a flight training school that had developed irregular practices in the delivery of training and had inadequate supervision,” Mitchell said.

“While many people knew of the pilot’s risky flying behaviour and had attempted to counsel them, there was no evidence that any of the incidents were reported to authorities, and the counselling efforts were ultimately unsuccessful.

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“In addition, the aircraft was newly acquired by the pilot, and they had not received transition training, so were likely unaware that, while the accelerated stall characteristics of the accident aircraft were unknown, there were indications that it would be abrupt.”

As part of its investigation, the ATSB interviewed “several parties” involved with the Adventure Flight Training flying school, which had closed in August 2024, three months before the accident, following a safety-related suspension notice against its chief flying instructor.

In particular, a look at Smith’s exam history revealed “several errors about aerodynamic stalling in exams conducted during 2024, and it was concluded the pilot likely had inadequate knowledge of the relationship between angle of bank, load factor and stall speed,” the ATSB said.

“These accounts, as well as an examination of available records, identified a series of irregularities with the way the school trained and examined its pilots for certification,” Mitchell said.

“The ATSB found RAAus had inadequate controls to mitigate the irregular examination practices identified at the flying training school.”

While RAAus had also issued safety-related suspensions against all Adventure Flight Training graduates for “potential knowledge deficiencies”, CASA failed to check if any of those graduates had used their RAAus certificates to gain CASA licences.

“It was subsequently found that two more pilots held a CASA-issued licence, granted based on the RAAus certificates they had earned at the Adventure Flight Training school,” Mitchell said.

Additionally, the ATSB found that the aircraft itself had “design deficiencies” which made the crash more severe, but CASA’s guidance material for amateur-built experimental aircraft “does not recommend consideration of the crashworthiness of seating and fuel tank installation”.

“These issues included a lack of energy attenuation in the landing gear and seating, and the installation of a fuel tank between the engine and instrument panel that ruptured and caused the post-crash fire,” Mitchell added.

“Given the importance of energy attenuation for crashworthiness, and the susceptibility of aircraft fuel tanks to rupturing, the ATSB concluded that the amateur-built industry could benefit from additional guidance in these areas.

“These characteristics within the design of the aircraft, in this case, increased the risk of occupant injuries, and I would urge amateur builders and designers to consider these factors for their own aircraft.”

Both CASA and RAAus have since updated, or are in the process of updating, their systems and procedures, including an online exam system at RAAus, and more robust processes around reports of suspensions, variations or cancellations of authorisations at CASA.