Air safety investigators have confirmed that a pilot involved in a fiery 2017 fatal crash at a Melbourne shopping center was earlier involved in a near collision that took him within a few hundred feet of another plane near Victoria’s Mt Hotham.
A long-awaited final report by the Australian Transport Safety Bureau also found pilot Max Quartermain failed to follow procedures and gave inconsistent reports about his position while attempting to land at Mt Hotham in September, 2015.
Quartermain and four American tourists died just under 18 months later when the B200 Beechcraft Super King Air he was flying crashed into a shopping complex and exploded at Melbourne’s Essendon Airport in February, 2017.
The four US nationals —Greg DeHaven, Russell Munsch, Glenn Garland and John Washburn — were on a golfing trip to King Island.
READ Fireball as plane slams into Melbourne shopping center.
Investigators looking at the Mt Hotham incident said Defence Department radar showed that Quartermain’s plane, VH-OWN, passed about 300ft below another aircraft, VH-LQR, that was also on approach to Mt Hotham.
Neither aircraft could see each other and investigators said that the pilot of VH-LQR probably avoided a collision by reacting to Quartermain’s irregular position reports.
“After detecting inconsistencies in the position reports from the pilot of VH-OWN, the pilot of VH-LQR stopped his descent at 8,000 ft,’’ they said. “As a result, the separation between the aircraft was around 300 ft, ± 150 ft, and a collision was likely avoided.”
The report shows Quartermain ran into trouble as he approached the airport in low visibility shortly ahead of other aircraft.
While experiencing problems with his GPS and autopilot, Quartermain descended 400ft below the permitted safe altitude of 7700 ft and failed to turn to intercept the inbound approach track to the runway.
Instead, he continued to track to the north and descended to 6300ft before aborting the approach.
The ATSB said he “twice climbed the aircraft without following the prescribed missed approach procedure and maneuvered in the Mount Hotham area”.
”Significant maneuvering was also observed as VH-OWN was on final approach to the Mount Hotham runway,” it said.
The report found difficulties Quartermain experienced in operating the GPS and autopilot resulted in “an unexpected reduction in the level of flight automation” and an increase in workload.
This affected Quartermain’s ability to follow the established tracks such as the published approach and missed approach. He also did not communicate his position accurately to the other aircraft or air traffic control.
Investigators noted there were missed opportunities for air traffic control to help Quartermain even though he was in airspace where aircraft were not separated by a controller.
“Although radar coverage in the area was limited, there were opportunities for the air traffic controller to identify when VH-OWN was having tracking difficulties during all three approaches, and when VH-OWN tracked towards the expected position of VH-LQR,’’ it said.
“However, this position information was not effectively communicated, resulting in a missed opportunity to prevent a potential controlled flight into terrain and/or collision with VH-LQR.”
The pilot underwent flight testing by a Civil Aviation Safety Authority delegate and then by a flying operations inspector, who recommended remedial training before undergoing a further flight test.
He was deemed proficient and competent to resume operations after the subsequent flight test.
But the ATSB noted in its safety message: “Maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced.
“Additionally, as the responsibility for separation from other airspace users and terrain in Class G airspace lies with aircrew, it is imperative that pilots maintain the skills to navigate accurately, and interpret and utilize traffic information to maintain safe separation.”
The ATSB has been criticised for the time taken to release the final report.
