PILOT error killed two people in an Australia Day airshow crash on Perth’s Swan River, the Australian Transport Safety Bureau says as it reprimanded the Civil Aviation Safety Authority for its oversight.

The Australian Transport Safety Bureau today released the findings of its investigation into the fatal 2017 Australia Day Skyworks crash.

Father-of-three Peter Lynch, 52 and Endah Cakrawati, 30, died when their twin-engine Grumman Mallard plunged into the river in front of thousands of spectators.

The ATSB report found the Grumman entered the flight area contrary to procedure and should not have been carrying a passenger.

It has called for better tools and guidance for airshow display approvals and oversight.

The Grumman G-73 Mallard amphibious aircraft stalled over the Swan River and crashed into the Swan River during the air display, which was part of the City of Perth’s Australia Day Skyworks event.

Camera Icon A police boat patrols the debris of a plane that crashed into the Swan River whilst displaying during an Australia Day Skyworks event in Perth on Thursday, Jan. 26, 2017. (AAP Image/Richard Wainwright) Credit: Supplied / AAPIMAGE

It had been approved to perform two circuits over the Swan River following a Cessna Caravan aircraft.

Mr Lynch was inexperienced with flying over the area and it was expected following the more experienced Cessna pilot would reduce any risk.

He then asked and received permission for a third flyover without the Cessna.

The ATSB report said it returned “contrary to the standard inbound procedure”, requiring turns at higher bank angles and lower altitudes, before stalling at an unrecoverable height.

“Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft,” it said.

“Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.”

Camera Icon A Facebook image obtained Friday, Jan. 27, 2017 of Peter Lynch. Mr Lynch was one of two people who died after a plane crashed into the Swan River in front of horrified onlookers during Australia Day celebrations in Perth yesterday. (AAP Image/Facebook) Credit: Supplied / PR IMAGE

ATSB transport safety executive director Nat Nagy said pilots should take part only in displays that were within their own and their aircraft’s capabilities and limitations.

“Pilots should not undertake any impromptu manoeuvres that have not been planned or practiced,” he said.

The Civil Aviation Safety Authority independently published a revised manual of guidance for air displays in September 2017.

“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said.

“But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”

Aerial displays were cancelled at the 2018 and 2019 Skyshows but are scheduled to return next year.

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