Defence investigation finds Taipan pilot's actions possibly prevented further fatalities in crash
A defence investigation into an army helicopter crash that killed four soldiers has revealed more lives could have been lost, had the aircraft pilot not taken evasive action to avoid another collision.
The Defence Flight Safety Bureau (DFSB) report — which made 196 findings or observations and 46 recommendations to the Australian Defence Force (ADF) — was today released publicly, after it was finalised last month.
It concluded it was highly likely the crash, which claimed the lives of Captain Danniel Lyon, Lieutenant Maxwell Nugent, Warrant Officer Class 2 Joseph "Phillip" Laycock and Corporal Alexander Naggs in July 2023, was because of unrecognised spatial disorientation suffered by at least one of the aircraft's pilots.
"This refers to a situation where a pilot is unaware of their actual orientation in relation to the earth's surface and the surrounding environment," defence said in a statement.
The four men were on board an MRH-90 "Taipan" helicopter with the call sign "Bushman 83" as part of a defence training exercise in Queensland's Whitsunday region.
The report identified that, after making a turn while flying in a four aircraft formation, Bushman 83 climbed over 100 feet, before rapidly descending and crashing into the ocean.
It took all of 21 seconds for the pilots to lose their orientation, and crash.
The report described how the conditions they flew in that night — low level, over water, using night vision devices in a degraded visual environment, while likely fatigued — increased the risk of a person experiencing spatial disorientation.
The report stated the pilot, Captain Danniel Lyon, "almost certainly" lost sight of the aircraft ahead of him in formation — Bushman 82 — and tried to regain visual.
It stated Captain Lyon likely didn't know Bushman 83 was facing nose down at the time and accelerated quickly "which, combined with a lack of recognition of the aircraft's increasing airspeed, resulted in a very high and unrecoverable rate of descent towards the water".
The DFSB said it was more than likely that during this time, Captain Lyon regained sight of the other aircraft and realised he was closer than expected.
It said he took evasive manoeuvres to "avoid a mid-air collision" by conducting a "controlled flight into terrain", therefore potentially saving the lives of those on board the other aircraft.
The report also identified that the loss of spatial orientation was likely not because of night vision technology used by the pilots of Bushman 83, which had previously been deemed as posing an unacceptable risk.
The helmet mounted visor, known as TopOwl 5.10, has been at the centre of bombshell evidence as part of a separate independent inquiry into the crash.
The Inspector-General of the Australian Defence Force (IGADF) inquiry heard evidence that a defence testing organisation held grave concerns about the technology, as it had a tendency to display serious inconsistencies when compared with real readings.
"Regardless [of the risks previously identified], the investigation determined that it was very unlikely the known hazards relating to the HMSD v5.10 contributed to the loss of spatial orientation," the report stated.
The ADF described the aviation safety investigation as "one of the most complex conducted by defence in recent history", with the resulting report determining the crash was "not survivable".
Defence has faced criticism from the family members and loved ones of the four men during the IGADF inquiry, for how long it took to inform them they were likely dead.
It heard for three days, the families were "cruelly" led to believe their loved ones would be found alive, despite many believing very early on, there was next to no chance they would be.
"[To tell us they were dead would have been] far less cruel than having us hoping and praying for a miracle that was actually impossible," Captain Danniel Lyon's wife, Caitland Lyon, told the inquiry last year.
Corporal Alexander Naggs's partner, Sarah Loft also echoed the sentiment, saying "They knew hope was lost long before we were told hope was lost".
Fatigue has been a major focus of the IGADF inquiry, and the DFSB report made findings in relation to the issue.
It found Captain Lyon and Lieutenant Nugent were likely fatigued, as a result of disruptive work patterns, burnout and rough sleeping conditions during the defence training exercise.
The IGADF inquiry heard the crew were sleeping next to an active fire station and operational airport, in hot tents, while trying to switch their body clocks to night-flying mode.
The report found their levels of fatigue likely increased their risk of experiencing spatial disorientation.
In its recommendations, the DFSB urged army aviation to review its fatigue management policy, and provide training to pilots about how to recognise spatial disorientation.
All 46 recommendations have been accepted by defence, many of which are also being enacted.
Hearings as part of the IGADF inquiry wrapped up this month, with its findings and recommendations to be handed down at a later date.
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