A VICTORIAN coroner has found a malfunctioning global positioning system led a pilot off course ahead of a 2004 plane crash near Benalla that killed all six people on board.
Benalla timber company D&R Henderson’s executive Robert Henderson, his daughter Jackie, her husband Alan Stark and their friends Belinda Andrews and Geoff Brockie were killed when the twin-engined Piper Cheyenne slammed into a tree-covered ridge at Myrrhee in bad weather.
The pilot, Kerry Endicott, was also killed in the July 28, 2004 crash.
He had flown the Sydney-to-Benalla route weekly since 1988.
The inquest had previously heard the GPS had moved into “dead reckoning mode” for an unknown reason by the time Mr Endicott had announced his approach to Benalla Airport at 10.45am.
Coroner Paresa Spanos found Mr Endicott had been flying in cloud with no visual cues that he was flying off track and/or into terrain.
Ms Spanos said he had begun an approach relying on GPS and no land-based navigational aids.
“It is reasonable to infer that he believed that operations were normal and that in ‘scanning’ the array of instruments before him he focused on information from the GPS unit,” she said.
“Taking all evidence before me into account, I find that the accident which took the lives of all six deceased was caused by navigation with the GPS in dead reckoning mode.”
Ms Spanos also found Mr Endicott was not made aware of two previous alerts activated with air traffic controllers that the aircraft had deviated from its planned flight path.
Instead the inquest heard an air traffic controller had twice rerouted the plane from its current position without communicating with Mr Endicott about his track deviation, believing he had chosen a different approach to the Benalla airport.
“In doing so, he contributed to the accident as there was a lost opportunity for avoidance of the accident,” Ms Spanos said.
She said evidence regarding Mr Endicott’s cardiac history did not support a finding that any existing coronary condition, heart disease or any other disease in Mr Endicott, had either caused or contributed to his death or the accident.
“While the possibility of a causally relevant cardiac episode cannot be entirely excluded, it is a mere possibility, given other circumstantial evidence,” she said.
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