ATSB finds triple fatality fire surveillance crash was ‘preventable’ in damning report

A Victorian aviation company knew its fire mapping Gulfstream wasn’t supplying reliable air to the pilot but kept it flying until it crashed, killing all on-board, the ATSB has found.

The remains of a twin turboprop that crashed near Cloncurry in northwest Queensland, killing all three people on board. Picture: ATSB.

A Victorian aviation operator knew a fire surveillance aircraft was defective but allowed it to continue flying until it crashed in northwest Queensland, killing three people on board.

The Australian Transport Safety Bureau has delivered its final report on the November 4, 2023 crash near Cloncurry, finding the pilot lost consciousness due to a known pressurisation defect in the twin turboprop Gulfstream 695A.

The flight from Toowoomba was being undertaken to map fire zones near Mount Isa with a pilot and two camera operators on board.

Operator AGAIR based in Stawell and headed by Rob Boschen, had known for many months the aircraft’s pressurisation system was not reliably maintaining the required cabin altitude, which meant the air supply to occupants could be compromised.

In an effort to manage the issue, pilots were at times descending to lower altitudes and improperly using emergency oxygen systems, with the encouragement of those in charge.

On the final tragic flight of VH-HPY, air traffic control called AGAIR’s head of flight operations after receiving communication from the pilot which indicated he may be suffering a lack of oxygen.

The controller expressed concern there “might be an oxygen issue in the aircraft” but the AGAIR manager did not reveal the known defect.

ATSB chief commissioner Angus Mitchell said had that information been passed on, air traffic control could have ordered the aircraft to descend to a lower, safer altitude and eventually landed safely.

“This was a tragic and entirely unnecessary accident that underscores the dangers of operational practices which circumvent critical safety defences, and the insidious and deadly potential of altitude hypoxia,” he said.

As a “no fault” investigator, the ATSB cannot take action against AGAIR.

It’s understood shortly after the crash, the Civil Aviation Safety Authority did briefly ground the operator while inspections were carried out on the aircraft.

But since then AGAIR has returned to the skies, carrying out aerial firefighting, aerial agriculture work, aerial imaging and mapping and aircraft maintenance.

Mr Mitchell noted that AGAIR senior management had previously attempted to rectify the pressurisation defect but kept no formal record of the issue or provided explicit procedures for pilots for managing it.

An email sent by the pilot of the crash flight on October 22, 2023 made it clear the problem continued and revealed he and the first camera operator had “some symptoms” (of hypoxia).

Despite the admission, the head of flight operations simply thanked him for the updates and for “keeping it going over the last few weeks”.

“We are getting great feedback and preparing for sustained operations over the summer,” wrote the manager.

Will Jennings who was killed in plane crash near Cloncurry.

As well as the pilot, one of the two camera operators on board VH-HPY was aware of the defect, and had told their family there were “workarounds to deal with the issue”.

The second camera operator, 22-year-old Will Jennings from the US, was in Australia to help with the bushfire-fighting effort and was unaware of the risk of hypoxia on the Gulfstream.

Neither the pilot nor the first camera operator have been named.

In a statement shared with The Australian, Mr Boschen acknowledged the ATSB’s final report and said AGAIR had accepted all the safety recommendations made.

“Every day my thoughts remain with the loss that has come about, to their families, friends, community and our business,” Mr Boschen wrote.

“Today, my thoughts are even more present. 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.”

The State Coroner is yet to announce a formal inquiry into the crash, but has been briefed by the ATSB.