A coroner's inquest into the death of a "talented and conscientious" pilot has failed to establish why her aircraft crashed into a mountain in remote southern Tasmania but has heavily criticised Australia's air safety investigator over its "worthless" report on the tragedy.
Nikita Walker, 30, was in control of a Pilatus Britten-Norman BN2A-20 Islander after departing Cambridge, near Hobart, on December 8, 2018 at about 7:48am.
She was scheduled to arrive at Bathurst Harbour about 45 minutes later to pick up five passengers for the return flight.
At about 8:29am, the Australian Maritime Safety Authority was informed the emergency locator transmitter on the aircraft had activated and advised Tasmania Police.
In its report on the crash, the Australian Transport and Safety Bureau (ATSB) said when search and rescue aircraft arrived at the scene, they were "unable to visually identify the precise location" of the plane.
The ATSB report noted the pilot of a rescue helicopter "reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the Western Portal" while at the scene.
In findings handed down on Thursday, coroner Simon Cooper said the evidence identified "no particular factor as especially causative or contributory" to Ms Walker's fatal crash.
"The evidence, viewed as a whole, does not point to any particular factor as especially causative or contributory to Ms Walker's fatal crash," Mr Cooper said.
"The aircraft was serviceable. Ms Walker was sufficiently experienced and appropriately qualified. She was well rested and unaffected by either drugs or alcohol.
"Why she flew into the Western Portal is not something the evidence enables me to determine with any real certainty.
"I consider the clear evidence relating to her flight path immediately before the crash makes it obvious Ms Walker was attempting to avoid crashing by trying to find a break in the weather.
"It follows that I am satisfied that her death was due to misadventure, that is, an accident."
ATSB report into crash 'worthless'
Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."
“One other obvious problem with the report … is that there is no indication of the author or author’s qualification to express the opinions and conclusions contained in it. In fact, there is even no indication as to the identity of the author or authors."
Mr Cooper said: "Perhaps most surprisingly, despite the fact that it was investigating an aircraft crash, the ATSB report does not appear to attempt to establish, at all, the reason for the crash.
"In short, the ATSB report was of so little use as to be, from my perspective, in the performance of my obligations under the Coroner's Act 1995, worthless. I have no regard to it, other than in a general sense, and specifically disregard the findings it contains."
In a statement, the ATSB said it offered to provide an investigator to give evidence at the inquest but was told by the Coroner's Court that this was not required.
"All investigators have training, qualifications and experience in applying the ATSB's recognised best practice transport safety investigation methodologies," it said.
It said the inquest misunderstood the ATSB's role in making findings "in relation to safety matters that were not contributory to the accident".
"It is apparent that the ATSB's role in advancing safety messaging around these factors was not understood at the inquest," the statement said.
"The ATSB notes the coroner's report does not include any new and significant evidence that would lead the ATSB to review its findings.
"Indeed, the entire sequence of events surrounding the collision outlined in the coronial report corresponds with the ATSB investigation report."
Ms Walker had moved from Queensland to Tasmania to pursue her career as a commercial pilot with Tasmanian airline Par Avion in 2016.
She had been flying for two years at the time of her death in December 2018.
In his report, Mr Cooper noted her housemate said he and Ms Walker "had a cup of tea" the night before, with her going to bed at "around 8:30 to 9pm" and getting up at about 6:30am to make her way to work.
Mr Cooper cited Par Avion's submission that Ms Walker was "flying visually and under control" immediately before impact.
"In my view, the evidence enables a conclusion that until the very last moment of the flight, immediately before colliding with the Western Portal, Ms Walker remained in complete control of her aircraft," he found.
"What happened in the immediate moment before colliding … can only be speculation."
Mr Cooper said the evidence related to the crash also "does not reveal any systemic issue" in relation to the airline, Par Avion, or the weather forecasting by the Bureau of Meteorology.
Mr Cooper described Ms Walker as a "talented and conscientious pilot, popular with her colleagues and trusted by her employer".
He expressed his sincere condolences to all who knew and loved Ms Walker for their loss.
Par Avion has been contacted for comment.
