Pilots knew of pressurisation fault months before triple fatal jet crash near Cloncurry: report

A Queensland plane that crashed in 2023, killing all three on board, had a pressurisation fault so bad company pilots flew for months at low altitudes to avoid blacking out, a damning report has found.

Will Jennings was one of three people on board this Gulfstream plane to perish in a crash near Cloncurry in 2023. Images: Facebook/Yiwen Song, JetPhotos

A plane that crashed in 2023 near Cloncurry in the state’s northwest, killing all three on board, had a pressurisation fault so bad company pilots flew at low altitudes to avoid blacking out, a damning report has found.

The Australian Transport Safety Bureau found cabin pressure was so faulty for “many months’’ before the twin turboprop Gulfstream crashed that pilots employed by the operator would descend to lower altitudes or use emergency oxygen.

And investigators claim in their report that even after panicked air traffic controllers called the operator with their fears that the crash pilot had hypoxia — dangerously low blood oxygen — it failed to alert them to the known fault. He and his passengers died soon after.

“Had it been (reported) at that time the aircraft could have been directed to a lower, safer altitude,” the Australian Transport Safety Bureau report said.

The scathing June 19 report said air traffic controllers lost contact with the pilot several times, forcing them to issue multiple emergency radio broadcasts including to a nearby military plane.

Will Jennings was one of three people who died in a plane crash while imaging bushfires in northwest Queensland. Picture: Facebook

The report said the pilot was slurring his speech and showed signs of confusion.

Soon after, he went into an “unrecoverable’’ spin 3km above the ground before radio contact was lost for the final time, about two hours after the plane took off from Toowoomba.

“Over a period of many months, the accident aircraft’s pressurisation system was not reliably maintaining the required cabin altitude,” ATSB Chief Commissioner Angus Mitchell said.

“This led some company pilots to employ a variety of actions in the aircraft to manage the potential and deadly effects of hypoxia, including at times briefly descending to lower altitudes and improperly using emergency oxygen systems.’’

The crash pilot descended for about six minutes early in the doomed flight, the ATSB confirmed.

Air traffic control recordings of his speech revealed significant, progressive impairment, including slow, stuttering and flat speech, operational mistakes and signs of confusion.

The damning report said Victorian-based aerial firefighting firm AGAIR, which operated the Gulfstream, knew about the pressurisation problem but never reported it.

Will Jennings had only recently graduated before being killed in the crash.

“The intermittent defect was known about by AGAIR senior management, who attempted to have it rectified,” Mr Mitchell said.

“However they did not formally record the defect, communicate it to the safety manager, undertake a formal risk assessment of it, or provide explicit procedures to pilots for managing it.

“Instead, AGAIR management personnel participated in and encouraged the practice of continuing operations in the aircraft at a cabin altitude of 19,000ft (5500m) and as such required the use of oxygen, without access to a suitable oxygen supply.”

Flight data showed the pilot had managed the intermittent pressurisation issue by short descents and by using the aircraft’s emergency oxygen system.

“This represented a practice of using a critical safety system designed for emergency use only, in order to continue a commercial activity,” Mr Mitchell said.

“This was a tragic and entirely unnecessary accident that underscores the dangers of operational practices which circumvent critical safety defences.’’

Since the accident, Airservices Australia had launched a review of “checklists’’ to detect pilot hypoxia.

The ATSB has also issued a formal safety recommendation to AGAIR to conduct an independent review of its operations.

No other action has been taken and the company is not charged with any criminal wrongdoing.

A Gulfstream 695A Jetprop Commander 1000. Picture: Yiwen Song/JetPhotos

“I acknowledge the final report released today from the ATSB regarding the tragic loss of our workmates some 18 months ago,’’ Agair CEO Rob Bpschen said in a statement.

“Every day my thoughts remain with the loss that has come about, to their families, friends, community and our business. Today my thoughts are even more present.

“AGAIR has accepted, as a responsible operator, all the safety recommendations made by the ATSB within their final report.

“Over the last 12 months, we have implemented many of the recommendations and we are continuing to work through those which remain.

“AGAIR is committed to maintaining a generative aviation safety culture within its business and is continuing to improve safe and effective flying operations.

“However, despite the findings in the ATSB final report, I understand the causes of this tragic accident are still being reviewed.’’

Will Jennings.

Those on board included 22-year-old William ‘Will’ Jennings, whose devastated parents spoke out at the time about their grief at losing their only son.

The mechanical engineer was imaging bushfires in the Tara when the plane crashed near the Eloise Copper Mine after taking off from Toowoomba.

His father Joe Jennings said that his son had recently graduated from university.

“We were just getting ready to pay all his student loans,’’ he said.

“He always tried to help people and unfortunately that’s what he died doing.’’

His mother Denise Jennings said Will had reassured them that the role was safe.

Originally published as Pilots knew of pressurisation fault months before triple fatal jet crash near Cloncurry: report