Investigators determine a lack of autopilot knowledge contributed to the death of a student pilot on her first solo cross-country flight near Millbrook

A student pilot on her first solo cross-country flight died when her aircraft crashed near the top of Black Mount, near Millbrook, in September 2015 after she manipulated the controls while the autopilot was engaged.

CRASH: Investigators and emergency service workers at the site of the Millbrook plane crash in September, 2015. Picture: Kate Healy

CRASH: Investigators and emergency service workers at the site of the Millbrook plane crash in September, 2015. Picture: Kate Healy

The Air Transport Safety Bureau released their final report in to the accident, which raised concerns about student pilot instruction on the use of autopilot systems in modern aircraft.

“The ATSB investigation determined that the pilot made control inputs while the autopilot was engaged,” said ATSB transport safety executive director Nat Nagy.

“As a result of that, the autopilot made control inputs against those pilot inputs which caused the aircraft to enter a nose-down steep descent. Due to that steep descent and rising terrain, the pilot had insufficient time to recover the aircraft prior to it colliding with terrain.” 

The 19-year-old pilot, who had a total flying experience of 53.8 hours, all in the same type of aircraft she was flying on the day, was training to become a commercial pilot with RMIT Flight Training.

The report found there was no advice, limitation, or warning in the aircraft pilot operating handbook or avionics manual to indicate that if a force is applied to the controls while the autopilot is engaged, that the autopilot will react against the force which could lead to the plane making unexpected movements.

Investigators also found that training requirements for autopilot systems were “rudimentary” in the early levels of pilot training and there was no regulatory requirement for pilots to show autopilot competency at recreational pilot licence level.

 About 2.10pm on September 8, 2015, the pilot took off from Point Cook Airfield on a solo navigation training flight via waypoints including Ballarat Airport before hitting the hill at Millbrook, near Gordon, about 2200ft above mean sea level.

Low cloud in the area meant the pilot was flying lower than usual above the ground giving her little time to diagnose the problem, react, and recover before the crash.

“The site and wreckage inspection identified that the aircraft impacted terrain in a level, slight right-wing low attitude. That indicated that the pilot likely stopped the aircraft’s descent and started to initiate a manoeuvre to avoid the terrain,” the report stated.

The ATSB issued safety recommendations to the aircraft and autopilot manufacturers about providing limitations, cautions and warnings for autopilot systems and audible alarms for pitch trim movement.

RMIT Flight Training updated their operations manual, as a result of flight testing they conducted, to include warnings about the operation and function of the autopilot system absent in the manufacturer’s documentation.

Student pilots were also warned of the hazards of manual manipulation of flight controls with the autopilot engaged.

“The ATSB has again determined as a part of this investigation the importance of pilots and students fully understanding the systems on board their aircraft. It is also important that students consolidate their manual flight handling skill and other skills such as navigation prior to engaging and utilising more complex systems such as the autopilot on board their aircraft,” Mr Nagy said.