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The Australian Transport Safety Bureau today released the final report into the plane crash after an eight-month investigation.
The report confirmed the manoeuvre involved the formation lead aircraft, known as Viper 1, rolling inverted before the second jet, Viper 2, passed directly beneath it.
“This manoeuvre had not been specifically briefed before the flight, and was conducted without the prior knowledge of the crew of Viper 1,” the ATSB investigation of the accident found.
After the first attempt at the manoeuvre, the pilots of both aircraft discussed repeating the manoeuvre over the radio.
“This in-flight discussion did not allow the pilots to fully consider the risks associated with the manoeuvre before it was attempted for a second time,” Chief Commissioner Angus Mitchell said.
During the second attempt, the right wing of Viper 2 struck the right wing of the inverted Viper 1, resulting in an immediate loss of control.
Viper 2 suffered substantial damage, leading to the failure of its front wing spar and the deformation of the outboard wing section, before the aircraft crashed into the water.
“Pre-briefing of in-flight manoeuvres is critical to safe formation flying to mitigate the risks of increased pilot workload and distraction,” Mitchell said.
Both Rose and Gale were killed, with their bodies later found among the wreckage off Mornington.
The second aircraft carrying two other people landed at Essendon Airport.
The crash occurred as they were filming a Jetworks Aviation promotional video.
Rose’s father David questioned whether the flight should have occurred.
“Everyone trusts a pilot when they get into an aircraft, and with three pilots involved that day, you would imagine being in safe hands,” he said in a statement.
“James was just a passenger on that flight, doing a paid job he had been assigned to at the last minute, due to another camera operator being unwell. But that trust was broken by poor decisions from those who should have known better.
“As James’s family, we are left with these questions: where is the accountability from those overseeing this TV project? Where is the duty of care? Did James die due to a poorly regulated air safety system in one of the most dangerous forms of aviation, formation aerobatics?
“The loss of our beautiful James is something that we will never recover from. We urge the Coroner and CASA to ask more questions.”
The investigation also found the aircraft operator did not hold the required certificate to undertake the filming flight.
It was also revealed the surviving pilot did not follow medical restriction requirements during the flight, as they were required to only operate aircraft with a side-by-side seating configuration and with a type-qualified safety pilot.
