Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, having investigated the death of

Simon Francis BOURKE


Find That:

• died on 24 April 2011 at Bridport Airport in Tasmania,

• was born in Cobram, Victoria on 05 September 1955 and was aged 55 years,

• was the father of two young adult children and his occupation at the date of death was as an enrolled nurse.

I find that the deceased died from multiple blunt traumatic injuries as a result of an ultra-light aircraft crash.

Circumstances Surrounding the Death:

The following circumstances are taken from the sworn evidence of witnesses and available written records.  I adopt them as my findings of fact surrounding the preliminary circumstances to the crash.

Simon Francis Bourke was the son of Richard Francis and Marjorie Bourke, being the second of five sons and one daughter.    The deceased was in a long term defacto relationship with Judy Lawler and approximately 21 years ago their son Jordan Ryan Lawler was born.    In 1990 the family moved to Tasmania from Victoria and in 1993 their daughter Madison Lawler was born.   In 2004 Judy Lawler passed away and in 2006 Mr Bourke commenced a relationship with Jeanette Sheehan (Ms Sheehan).

Mr Bourke developed an interest in flying from his father, a WWII pilot.  As a young adult he began to fly hang gliders and thereafter continued his interest in flying.  Around 2010 the deceased became interested in flying ultra-light aircraft.  On 8 May 2010 Mr Bourke commenced flying lessons with E. Reid out of Devonport and George Town in a Jabiru, 3 Axis aircraft.  He undertook 10 lessons and accumulated 7.9 hours of flying time.   On 4 August 2010 Mr Bourke became a student pilot member of Recreational Aviation Australia Incorporated (RA-Aus), the governing body for ultra-light aircraft in Australia.  It registers aircraft and issues pilots licences through approved flight training facilities under delegation from the aviation regulator, the Civil Aviation Safety Authority (CASA).  He obtained student licence No. 028072, due to expire on 4 August 2011.

Andrew Gyenge, aged 54 years, is a certified flying instructor with 30 years experience flying aircraft.  Mr Gyenge has considerable experience in flying numerous aircraft including hang glider, powered hang glider, microlight aircraft, ultralight aircraft, home built aircraft, general aviation aircraft (commercial and private), seaplanes (commercial), helicopters (commercial and private - including low-level endorsement),  and twin engine aircraft (private and commercial). 

Advice from Ra-Aus is that Mr Gyenge gained his Instructor ratings and Chief Flying Instructor (CFI) approval with that organisation on 6 September 1999.  According to Mr Gyenge he also held a ‘Level 2 aircraft maintainer’ qualification.  He had attained about 4200 hours as a pilot. His title at the time of the crash was ‘Chief Flying Instructor and Senior Instructor’ as well as ‘Pilot Examiner’.  He held an appropriate medical clearance at the time of the crash.  He had owned and used “trike” ultra-light aircraft since 1984, with about 1600 flying hours in such aircraft, including 900 hours as instructor.

Mr Gyenge had experience in flight below 500 feet. As an instructor he was required to train student pilots in Precautionary Search procedures to prepare a pilot with experience and skills in inspecting and eventually landing on or off airfield locations, especially in cases of unforeseen circumstances such as: mechanical problems, deteriorating weather, health issues, disorientation, low fuel, low cloud et cetera. Those procedures required precautionary search starts at a height of 500 feet, with progressively lower passes made to further assess the suitability of the chosen landing place before attempting to land.
On 20 October 2010 Mr Bourke purchased his own ultra-light aircraft, a Microlight Trike, Airbourne Edge X Classic, Streak wing-weight shift, registered number 32-7182.  The aircraft had been manufactured in 1999. Mr Bourke completely refurbished the engine and the aircraft and it was reported to be in excellent condition at that time. He registered it for 12 months with RA-Aus on 14 January 2011.  Prior to registration CFI Andrew Gyenge assisted him with a condition report in relation to the aircraft to enable its registration.  He described the aircraft as being “well maintained and in excellent condition.”

At all relevant times the aircraft was reported to be properly maintained and in good condition.  It was kept at either Mr Bourke’s home address or at Bridport airstrip in a private hangar.

Mr Bourke commenced flying lessons in the Microlight Trike with Mr Gyenge on 31 March 2011, following an initial 1hr 45 min control familiarisation flight with Mr Rob Gill on 27 February 2011. Between 31 March 2011 and 17 April 2011 Mr Bourke logged 8.6 hours of flying during 10 flights.  According to the evidence of Mr Gyenge, he and Mr Bourke had flown microlight aircraft at the Bridport airstrip on only 2 prior occasions and Mr Gyenge had a total of only 6.4 hours microlight flight experience at the Bridport airstrip.

On Friday 22 April 2011 Mr Bourke contacted Mr Gyenge by text message to arrange some flying on 24 April 2011 for himself along with two other student pilots, Brian Collingham and Michael Groccogna.  Mr Gyenge advised that he thought it might be too windy, according to the forecast.  He later checked the forecast and was certain it would not suit training so he telephoned Mr Bourke and Mr Collingham and was advised that they were still going to Bridport Aerodrome to conduct maintenance on their planes at a shed where they stored them.  Mr Gyenge spoke to them again and stated that he would also go to the aerodrome.

Circumstances on the date of the Death of Mr Bourke:

The following circumstances are taken from the sworn evidence of eye-witnesses and available written records.  I adopt them as my findings of fact surrounding the circumstances involved in the crash.

On Sunday 24 April 2011Mr Collingham and Mr Groccogna arrived at the aerodrome first and contacted Mr Gyenge to inform him that the weather was good for flying, despite the earlier forecast.  Mr Bourke arrived at the airport around noon and Mr Gyenge arrived about 12.30pm.  He described the weather as being very good with about 6-8 knots of sea breeze.  After meeting with the 3 men, it was decided that Mr Bourke and Mr Gyenge would fly first.  A pre-flight safety check and inspection was undertaken and at 1pm they took off in Mr Bourke’s ultra-light, undertaking a one-hour flight doing circuits including take off, climb and turn, straight and level, descending turn, landing or fly over.   Mr Gyenge was in control of the flight until they reached an altitude of 1000ft at which time he handed control to Mr Bourke under helmet intercom instruction.  Mr Gyenge again took control for the landing.

After this flight Mr Gyenge conducted training flights with both Mr Groccogna and Mr Collingham.  He noted that the wind remained consistent and that there was a nearby tea-tree fire burn-off and when he looked at the smoke plume there was no movement.

A further pre-flight safety check, inspection and briefing were conducted by Mr Gyenge and Mr Bourke and at about 4.10pm they commenced another flight of ‘circuit training’ to include practice landing by Mr Bourke.  Prior to this they had determined that there was about one hour of flight time prior to dark. 

Mr Gyenge initially had control of the aircraft and took off east down runway 27 doing a right hand circuit to the south.  He then handed control of the plane to Mr Bourke who then flew West, then North, then East at 1000ft above sea level.  Mr Bourke remained in control as they descended for a circuit landing when they both noticed that ‘it had got bumpy’ and it became obvious to Mr Gyenge that the wind had changed.  Eye-witnesses, experienced in flying, noticed that at that time the wind had just started to gust to 10-15 knots to the north-east, but otherwise the weather was fine.

Mr Gyenge noticed that the wind had definitely changed to more northerly at that location; however the waves on the ocean appeared to be the same.  Mr Gyenge sought weather information from nearby locations other than at Bridport and contacted Paul Scott via aircraft radio at the Cranbourne Airfield at Mount Direction and he was told conditions were perfect there.  Nevertheless, Mr Gyenge considered the changed conditions were no longer conducive to meaningful flight training and decided to land. Mr Gyenge asked Mr Bourke via helmet intercom if he wanted to give it up for the day.  Mr Bourke agreed.  Mr Gyenge is unsure whether he informed Mr Bourke that he was taking control of the aircraft at that point, or not.

They were continuing with the approach to land at a height believed by Mr Gyenge to be approximately 150 feet, when he realised that they were not lined up and he decided to abort the landing.  By using the hand throttle, he put on full power to climb ahead and he reached up and took control of the aircraft.  It was his intention to turn away from the turbulent wind and re-position the aircraft for a landing in the opposite direction on runway 28, into the greatest component of headwind.  On the available evidence this seemed to be an appropriate action in the circumstances.

It was his intention to execute a “P” turn. I find this to be a sound aeronautical decision.  At approximately 150 feet above ground level he initiated a 30 degree bank turn to the right at full power.

Mr Gyenge states that he told Mr Bourke they were going around (re-fly the circuit) and he could see and feel that Mr Bourke was following him on the controls. Mr Gyenge was in control at the time and was aware that the air turbulence level was beyond the experience level of Mr Bourke.

During the bank or go-around the turbulence continued to the point where Mr Gyenge could not release his hands from the control bar. 

After the aircraft was turned away from the runway heading to the right, the wing was briefly returned to mostly level full power ascending flight in preparation for a turn to the left to bring the aircraft back to the runway for landing.  Mr Gyenge states that the aircraft required a full controlled deflection to maintain straight and level ascending flight and avoid a premature left turn.  At this point Mr Gyenge was attempting to fly straight and was about 150ft above ground level; however the aircraft continued its uncommanded roll to the left.  It continued to roll until the wings went beyond vertical, beyond the more normal 30 degree to 40 degree bank angle.  The aircraft lost height rapidly.   Mr Gyenge believes that a strong gust of wind/turbulence caused the roll to the left movement, he was trying to regain control and the aircraft had started to, in his words – “side-slip.” It is also possible that the left roll might have been exacerbated by a sudden increase in lift on the right side of the wing.

Full controlled deflection was continued by him in an attempt to level the aircraft and the aircraft started to recover when the left wing tip impacted the ground first, followed by the nose of the aircraft. The aircraft came to rest on its left side and in line with its intended flight path, in a flat open paddock on a property adjacent to the Bridport aerodrome.

A witness, Alan Mountney was driving along Bridport Road when he observed the ultra-light aircraft.  He stopped to watch as the aircraft approached the aerodrome as if to land.  He described: ‘it looked like it was approaching the airfield to land. It got to about 20 feet above the runway then started to lift as it turned to the right for a short time.  They then started to turn to the left. It appeared that all of a sudden it banked hard to the left like a strong gust of wind had caught them. They appeared to be only 30-40 meters above the ground. The ultra light appeared to tip over and nose down into the paddock’.  Mr Mountney did not see the crash impact but knew something bad had happened as he believed the aircraft had been too close to the ground.  Other evidence is clear that the aircraft did not impact nose-down.

More precise evidence is available from another witness, Roger McLennan who resides at 1800 Bridport Rd, Bridport. He is a microlight pilot and keen flying enthusiast. He was with a friend, Jeff Jennings and both had seen the ultra-lights flying intermittently during the afternoon, only one aircraft in the air at a time.  Mr McLennan states that the wind had been constant during the day and it had been good training weather as the wind had been north easterly at 5-7 knots, however just before the crash the wind began to gust and came up to 10-15 knots.  Mr McLennan describes seeing Mr Bourke’s ultra-light fly in an easterly direction over the top of the commercial airstrip, and he thought he saw the plane turn left however it then turned right turning down-wind.  The aircraft was banked at an angle he would describe as steeper than a normal turn, at which point it side-slipped down to the ground.  He states that the aircraft was about 150ft above the ground at the start of the turn.

Witnesses attended the crash scene on Mr McLennan’s property.  Mr Bourke was found to be seatbelted in the front seat unconscious with Mr Gyenge seatbelted and conscious behind him.  Mr Gyenge had attempted to help Mr Bourke by removing his helmet to assist clear his airway as he was gasping for air.  He requested Mr McLennan to help Mr Bourke and do CPR.  Mr McLennan and Mr Jennings had to untangle Mr Bourke’s feet from the aircraft; they then lay him on the ground and commenced CPR.   Emergency services subsequently attended with fire service personnel continuing CPR.   Peter James from Ambulance Tasmania also attended, however Mr Bourke was not able to be revived and treatment was ceased at 5.22pm. Mr Gyenge sustained serious injuries.

The aircraft was destroyed in the accident.

Tasmania Police investigators and SES secured the crash site and SES personnel stayed on site for the night.  The next morning an investigator with RA-Aus attended the site with police investigators and a full investigation took place on site over the next two days.

It is the evidence of Mr Gyenge that the air turbulence encountered immediately prior to the crash was of an extreme nature and the most violent ever encountered by him whilst flying a microlight aircraft.  It is his evidence that the suddenness and magnitude of the changed conditions could not reasonably have been predicted by him and the turbulence continued to a point where he could not relax his hands on the control bar for any period of time but was able to maintain full power to attempt to climb out of the turbulence to make the necessary turns to return for a landing, before the other extreme events unfortunately intervened to lead to what he and other witnesses described as a side-slip to the ground.  Mr McLennan had a windsock on his property and he observed that just prior to the crash and he described it as jumping around from the gusting component of the wind.

Post Mortem Examination:

A post mortem examination was conducted at the Royal Hobart Hospital on 27 April 2011 by Forensic Pathologist, Dr Donald Ritchey.  The result of the post mortem showed that the Mr Bourke died as a result of severe multiple blunt trauma injuries to the arms, legs, pelvis, thorax, abdomen, head and neck.  I adopt those opinions and make those findings.

Toxicology on the deceased showed caffeine and nicotine/cotinine present, but no other drugs or alcohol to be present.

Mr Gyenge also submitted to a blood test at the Launceston General Hospital on the evening of the crash, which returned a negative result for alcohol or drugs.

The Aircraft:

Mr Bourke’s aircraft was a factory built, high wing, cable braced, Microlight aircraft, constructed primarily from aluminium tubing and fibreglass fairings. The wing frame was covered by a Dacron fabric.

The engine was rear mounted, built in Austria for use in ultra-light aircraft. The engine was the type approved for the airframe and there was no evidence to suggest that any modifications had been made to the engine.

The throttle could be operated by the person in the rear via hand throttle mounted near the person’s right leg or by a foot control operated by the person in the front. The foot control defaulted to idle when released. The hand throttle stayed at a pre-set setting.

The propeller was in a pusher configuration.

The aircraft had an open cockpit with two seats mounted in tandem (one behind the other) with the two-axis controls operated by weight shift, allowing a pilot to manipulate the aircraft in pitch by moving the control bar fore and aft, and roll by moving the control bar left and right. The resultant input on the control bar change the position of the trike base’s mass in relation to the centre of gravity of the wing, effecting a change around the corresponding axis.

A set of training bars had been attached to the control bar to allow the certified flying instructor to operate the controls. The training bars are a factory item and did not affect the operation of the controls.

A hand held VHF radio was fitted to the airframe and wired to the occupants helmets. This permitted the Chief flying instructor to communicate with other aircraft and Air Traffic Services if required. An intercom was also fitted to allow communication between the pilot and student.

Recreational Aviation Australia Investigation:

An extensive investigation was conducted by RA-Aus in relation to the crash of Mr Bourke’s aircraft. It has no mandate or requirement to investigate fatal aircraft accidents; however it often utilises its significant expertise in an investigation with the intention of preventing similar occurrences.

In this case I requested RA-Aus to assist me in the inquest and investigation, especially to provide a safety report into all aspects of the crash. Investigators form RA-Aus attended the crash scene soon after the crash and also interviewed witnesses.

Full details of the crash investigation undertaken by Tasmania Police on behalf of the coroner were forwarded to RA-Aus and a detailed, comprehensive safety report has been received.  I have accepted and adopted the contents of that specialist safety report on the aircraft and the incident generally.

After examining all witness statements and all other available evidence, RA-Aus investigators reported –

‘After evaluation of the notes taken from the accident site, RA-Aus photographs, a review of the eye witness accounts and especially the statement given by the CFI, it was accepted that a mutual decision was made to terminate the flying lesson.

The above decision was prompted by an apparent change in wind direction and strength. The wind change was felt in the form of turbulence that buffeted the aircraft on approach to land. That turbulence interrupted the approach, which the CFI reacted to by conducting a go-around. (A go-around is the application of full power to climb away from the ground to rejoin a circuit to conduct an approach again).

After initiating the go-around, the CFI made an assessment of the wind and determined that the wind had changed direction significantly enough to warrant changing the runway to RWY28, from RWY10.

The CFI initiated a left turn believed to be made whilst on right crosswind on RWY10, intending to place the aircraft on a left downwind for the opposite runway (RWY28). The angle of the bank of the aircraft continued to the point of becoming excessive. Attempts to return the wings to level proved difficult and the aircraft began to lose height rapidly.

With the aircraft being at such low altitude, it is likely that the CFI did not have sufficient height to recover from the manoeuvre and the aircraft impacted the ground.

Damage to the wing and Trike base was consistent with the aircraft contacting the ground in a left bank (turning to the left). The lack of damage evident to the nose wheel is indicative of a high nose attitude at the point of impact. This is supported by the amount of damage evident to the main undercarriage.  All flight surfaces and control linkages were deemed to be in a serviceable condition prior to the crash.  Breaks and fractures were inspected at the crash site for signs of fatigue, corrosion or pre-existing faults.  There were none evident.  All breaks and fractures were consistent with a sudden force overload.

The relatively small amount of damage to the wing, combined with the majority of damage around the main undercarriage area suggests that the CFI was attempting corrective actions up to the moment before impact’.

I adopt the following findings from the investigation reports:

• All of the flight surfaces and control linkages were deemed to be in serviceable condition prior to collision and the aircraft was appropriately registered.
• Breaks and fractures were inspected at the crash site for signs of fatigue, corrosion or pre-existing faults. There were none evident. All breaks and fractures were consistent with sudden overload force.
• There was no evidence that the aircraft had been modified or had undergone any major repairs.
• There was sufficient evidence to indicate that the propeller blades were rotating under power from the engine prior to making contact with the airframe at the time of the crash.
• Airworthiness and maintenance of the aircraft was not a causal factor in the crash.
• The gross weight of and the balance of the aircraft was not a contributing factor to the crash.
• Fuel exhaustion or starvation was not a contributing factor to the crash. Examination of the engine switches and fluids indicated that there was sufficient fuel and oil and that the master in ignition switches was in the “on” position.
• At the time of the crash the conditions were suitable for daytime visual flight.
• That the Chief Flying Instructor (Andrew Gyenge) was a current member of Recreational Aviation Australia Inc., and his Pilot Certificate, ratings and approvals were valid.
• Mr Bourke held a valid Student Pilot Certificate.

Further Findings, Comments & Recommendations:

I have decided not to hold an inquest into the death because the lengthy and comprehensive investigation into the death has sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.

Having conducted the investigation I do not consider that the holding of a public inquest would elicit any information further to that disclosed by the enquiries conducted.

What is entirely clear from eye-witness accounts describing the final moments of the aircraft’s flight, is that the weather conditions were generally good for flying during the afternoon although wind strength and gusts had increased markedly and changed direction immediately before the crash. 

It is also clear that both pilots decided to terminate the flying lesson because of the increasing wind gusts and to land, but in doing so the aircraft was buffeted by extreme turbulence which interrupted the approach when it was very close to the ground and a decision was made by Mr Gyenge to go around to the right by way of application of full power to climb and again approach landing from the opposite direction and into the wind.  In doing so and at a height of approximately 150 feet, the aircraft banked excessively to the left following a sudden gust of air turbulence and it then crashed. 

It is also clear from all available evidence that Mr Gyenge applied full control inputs in an attempt to oppose the aircraft tendency to roll left but the aircraft began to lose height rapidly, more likely than not because of buffeting wind turbulence applying an extreme left roll force to the aircraft. 

There is no evidence to suggest the airplane was being operated in any reckless manner by a very experienced and qualified instructor pilot.  There is evidence it was being operated in difficult wind conditions quite close to ground level and a combination of events outside the effective control of the pilot lead to the crash. Evidence the engine was in a high power setting and the lack of damage to the nose of the aircraft and the amount of damage to the main undercarriage, is highly likely indicative of a high nose attitude at the point of impact and supportive of the evidence of Mr Gyenge that he was attempting appropriate corrective actions to the point of impact.

While Mr Gyenge may not necessarily agree with the following comment, I accept the opinion of RA-Aus of the possibility that from the rear seat with wings level, Mr Gyenge could apply full strength to inputs on the control bar, however once the wing is banked into a tight and urgent turn, in the outstretched position his ability to apply the same amount of strength to inputs on the control bar might be reduced. Under normal operating conditions this would be unlikely to pose any control issues but in the instance of a strong, rolling gust of turbulent wind it is possible that the pilot’s strength might be overcome hence increasing the bank angle of the aircraft into a position whereby being at such a low altitude, the aircraft did not have sufficient height to recover and it impacted with the ground while executing the left bank, or what has been described as a left side-slip. 

There is insufficient evidence to make any precise finding, however I adopt the report of RA-Aus that in the circumstances of the evidence available it is a possibility the aircraft was subject to a sudden increase in tailwind which could have contributed to a reduced amount of total lift force being produced by the wing, resulting in less lift being produced than that required to maintain an appropriate path and turn and compounding the other developing problems towards a significant vertical downward movement to the left with insufficient height to recover.

I have considered the possibility that Mr Bourke may have also been attempting to control and correct the flight path immediately prior to crash, whilst working against the control direction being imposed by Mr Gyenge. However, it is the evidence of Mr Gyenge that he had full control of the aircraft at the relevant time and that Mr Bourke was merely only following on the controls.

What is more probable is that there was a strong gust of wind which has caused the over-control or over-bank or side-slip in the turn to the left. There is no evidence that the aircraft had any mechanical problems or malfunctions which could have caused it to over-bank or roll during the intended left turn.

I have considered Regulation 166A of the Civil Aviation Regulations 1988 which provides the general requirements for aircraft (including ultra-light), on the manoeuvring area or in the vicinity of a non-controlled aerodrome.
Sub-regulation (2)(f) provides –

 subject to sub regulation (4), if the pilot takes off from the aerodrome, the pilot must maintain the same track from the take-off until the aircraft is 500 feet above the terrain;

(4) The rule in paragraph (2) (f) does not apply if a change to the track is necessary to avoid the terrain.

Further consideration of those regulations suggests that generally speaking, manoeuvres in and around such airports should be conducted at a height of no less than 500 feet above ground level.  It seems the main purpose for this regulation is to ensure a certainty of flight path and thus the safety of all aircraft in the vicinity of the aerodrome.

On this occasion the aircraft was not taking off as such, it was going-around after an aborted near landing in difficult wind circumstances whereby extraordinary actions were necessary.  Further, there were no other aircraft in any relevant vicinity of the aerodrome. It is then unclear whether sub-regulation (2)(f) is relevant in the circumstances of this case. 

The only clear evidence comes from Mr Gyenge that after aborting the attempted landing, he did a right turn and attempted a level power ahead climb to gain sufficient height to turn left to the runway and land safely, but in doing so wind turbulence prematurely forced the aircraft to its left at an unsafe angle leading to the crash.  There is no acceptable evidence to find that Mr Gyenge purposely executed a left turn at approximately 150 feet whereby the effects of the turbulent winds increased the effect of that turn to a disastrous degree.

I find it probable that Mr Gyenge, having encountered the unexpected and severe air turbulence during the aborted attempt to land, then considered it an urgency to land and was conducting a power ahead climb to an altitude where smoother air might be found before executing subsequent left turns to land safely into the wind.

What is clear from all of the evidence is that the efforts and skill of Mr Gyenge were starting to take positive effect by the aircraft starting to level out immediately before impact, but there was insufficient height to fully recover and avoid the impact.  It is also clear that he was undertaking appropriate and previously described Precautionary Search procedures and I could not find that on the balance of probabilities any of his actions were not aeronautically sound in all of the circumstances. Had the aircraft been at 500 feet rather than 150 feet then maybe the crash might not have occurred, but of course the apparent unpredictability of the wind turbulence at the time and its effect on a relatively small and light aircraft in fact occurred at that lower height.

There were a number of difficult circumstances presented to both pilots in the minute or two preceding the crash and a number of difficult and almost contemporaneous events immediately prior to impact were the main causes of the crash. 

Mr Bourke was clearly a very loving and caring parent of two children and was a highly regarded member of the community and in his employment.  The impact of his death which occurred tragically when participating in flying which gave him personal joy will continue to be felt by his family and friends for a very long time. Before I conclude this matter, I wish to convey my sincere condolences to the family of Mr Bourke. 

This matter is now concluded.

DATED :      24 December 2013 at Hobart in the State of Tasmania

Glenn Hay