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The ATSB's final investigation report into the Piper Aztec accident which killed a family of five near Mareeba, Queensland on 1 October 2003, has found that the pilot was probably incapacitated as a result of a cardiac event.

The pilot, his wife and three children were conducting a private flight from Mareeba, to Roma, Queensland, in the Piper Aztec aircraft, registered VH-WAC. Witnesses reported that shortly after the aircraft took off from runway 28, it started to bank to the left. The left bank gradually steepened, after which the aircraft rapidly descended to the ground. Witnesses close to the aerodrome described engine noises consistent with normal operation. The aircraft was destroyed by impact forces and post-impact fire.

At the time of impact, the aircraft was inverted and in a nose-low, nearly vertical attitude. An intense post-impact fire resulted in significant melting and destruction of much of the aircraft structure and components. The examination of the wreckage by ATSB investigators did not identify any pre-existing defect that could have contributed to the accident.

Postmortem examination of the pilot identified significant narrowing of the coronary arteries (coronary atherosclerosis).

Control of the aircraft was lost at a height from which recovery was not possible. The reason for the loss of control could not be conclusively established, however the circumstances of the accident and the available evidence was consistent with pilot incapacitation associated with coronary artery disease. Other possibilities, either individually or in conjunction with pilot incapacitation could not be excluded.

The pilot held a valid medical certificate at the time of the accident. As a result of the accident, the ATSB has issued a safety recommendation to the Civil Aviation Safety Authority that medical certification standards be reviewed.

The full investigation report (200304091) is available from the Bureau's website, or from the Bureau on request.