Final report into fatal outback plane crash blames pressure issue for lack of oxygen, finds operator AGAIR was aware
The Gulfstream 695A aircraft took off from Toowoomba, west of Brisbane, on November 4, 2023 and was on its way to photograph fire zones north of Mount Isa.
But the plane crashed about 55 kilometres south-east of Cloncurry in open bushland and burned up after impact.
On board were a pilot and two camera operators, including 22-year-old William Jennings from the United States, all of whom died in the crash.
The flight was operated by operated by Victorian company AGAIR.
In its final report, released this morning, the Australian Transport Safety Bureau (ATSB) found the pilot was experiencing hypoxia when the crash occurred.
ATSB Chief Commissioner Angus Mitchell said the "aircraft's pressurisation system was not reliably maintaining the required cabin altitude", which had been in issue for "many months".
"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," he said.
On the day of the accident, the pilot had descended from 28,000 feet to 15,000 feet for about six minutes before climbing back up to 28,000 ft, he said.
"Later, while the aircraft was ... nearing Cloncurry at 28,000 ft, both power levers were probably reduced, possibly with the intention of undertaking a similar descent," the ATSB report found.
"This caused the aircraft's speed to decay, before it ultimately entered a steep, descending, anticlockwise turn.
Mr Mitchell said it was almost certainly due to pilot control inputs made in an unsuccessful attempt to regain control.
"The ATSB found the onset of hypoxia during the flight significantly degraded the pilot's ability to safely operate the aircraft, and it is possible that at stages the pilot also experienced some loss of consciousness," he said.
The ATSB said the pressurisation defect in the plane was known to senior AGAIR management, who attempted to have it rectified.
"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," Mr Mitchell said.
An online fundraiser to bring Mr Jennings home received over $92,625 US in donations — about $142,000 AUD.
In the fundraiser, his family said William was "a bright light extinguished too soon".
"William was a 22-year-old promising mechanical engineer who recently graduated from Northeastern University," his family said.
"He had an exciting life ahead of him, but tragically lost his life in a plane accident while surveying fires in Australia.
"William was known to bring light to any room he walked into, and his sense of humour was infectious.
"He was an avid hiker and lover of nature, always seeking new adventures in life."
The other two people on board the aircraft are yet to be publicly identified.
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