Originally Posted by
hoss
Blind Freddy can see that the primary cause was a mis-handled escape manoeuvre from flying into a one way valley. Did the ATSB even consider poor pilot judgement and handling.
Maybe (and by a long shot) air contamination might have been a factor.
I was thinking along the same lines earlier, but I realised this.
You're right. The ATSB did consider poor pilot judgement and given that the pilot had flown this trip more than 700+ times before, they started to look deeper as to why he used poor judgement on this occasion. He did indeed make a wrong turn and should have turned hard left at that altitude, or continued to climb and then turn west, but he didn't. Then, low and behold, they dug deeper and found something that could have directly contributed to his poor decision making on that fateful day. Then it turns out that other aircraft may also be affected and thus may save the lives of other pilots and passengers in the future.
Job well done by the ATSB you'd have to say, wouldn't you?
So yes, it was poor pilot judgement. Why? Maybe because of CM, but maybe not, but by uncovering those defects they may have saved other lives by by bringing it to other operators attention.
I was in that area shortly after the crash in my boat and considering options as to why it happened and I can certainly tell you that those valleys really do all look the same and it would be very easy to fly into the wrong one after a minor distraction or a late night out. The part of the report that makes me believe it was CM was that he did not continue to climb when he should have. It should have been a continuous climb, but it didn't happen. That being said, they do climb incredibly slowly out of the area and the takeoff is very long, but that could be SOP by the operator, so if you hadn't witnessed one, the climb-out would look very gradual, highlighted at how the passenger was taking pictures at 100 ft long after the takeoff.