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Figure 14 is a graph of the last 50 seconds of flight showing the time of autopilot engagement in the various modes, the flight director pitch commands, and actual aircraft pitch attitude.The aircraft nose down pitch angle continued to increase and the aircraft continued to descend. The aircraft manufacturer stated that: In addition, multiple pitch modes were selected throughout the flight, though ALT (altitude hold) mode was used the most. However, there are three negative vertical speed increases. During those times the pitch of the aircraft does not match the pitch command recorded. This occurs while the autopilot was activated. During all three occurrences, a negative pitch command is recorded. At the “peak” of each negative vertical speed increase the autopilot is disconnected by the pilot and the aircraft’s descent rate is decreased. In each of the pitch down sequences the pitch of the aircraft exceeded the pitch command recorded (which would seem to indicate pilot input). It is also interesting to note that after each of those disconnects the autopilot is reengaged almost immediately and a positive pitch command is recorded. After this sequence, the autopilot is disconnected while the ALT mode is still engaged. This would seem to indicate pilot input. If the pilot was experiencing some type of autopilot malfunction we would assume the pilot would follow the autopilot failure checklist and disable the autopilot. The data file also shows the autopilot was disconnected by the pilot before the recording stopped. This occurred when the aircraft was approximately 700 feet AGL and approximately 0.5 NM from the accident site. They indicated that it was a possibility that the pilot had overpowered the autopilot. Those sequences were on the sector between Swan Marsh and Ballarat.

Further, there was no evidence in the data to show any separation between the aircraft pitch attitude and pitch command on any phase of the flight with the autopilot on in a vertical mode other than just prior to the accident. The ATSB considered that it was also possible that the pilot did not have a sound understanding of the difference between PIT and ALT modes. During the three highlighted climbs and descents, PIT was set with a positive attitude reference, meaning that the aircraft climbed at the set positive pitch attitude. The autopilot was then switched off and the aircraft manually descended. That indicated that the pilot may have been unaware that when PIT is selected it will hold an aircraft attitude rather than altitude.This included possible factors that may have contributed to a rapid pitch down, which began with the autopilot engaged in a vertical mode. The flight training organisation advised that they were unsure why the autopilot reacted the way it did, but suspected it may have been due to manual manipulation of the flight controls. Some of the conditions varied, such as the autopilot vertical mode, which was constant during the verification flight but not for the accident flight. The initial increase in pitch was also greater in the verification flight and the power was reduced to decrease the airspeed in the descent. However, a comparison between the data of the two flights showed significant similarities which included: With the autopilot engaged in a vertical mode, backpressure was applied to the control column with the following results: The trim activation and rate of movement was similar to the nose down trim scenario. This was exacerbated if the seat was moved further forward, as would be required by relatively short pilots (such as the pilot of ZEW). When compared to the aircraft’s downloaded GPS track, the SSR track was found to match in location and altitude.

The final location points were not considered accurate enough to be useful to the investigation. The instructor left a note in the authorisation sheet that stipulated that the pilot must maintain a height of 1,000 ft above ground level (AGL). That gave the pilot a ground clearance of 270 ft AGL in the vicinity of the accident site at the flight planned altitude. The flight plan conflicted with the minimum altitude AGL as stipulated by the flight instructor. It was also below the minimum regulatory requirement of 500 ft over unpopulated areas. It should be noted that despite the flight plan, the flight data showed that the pilot was maintaining a height of about 3,000 ft AMSL (770 ft AGL) on the Ballarat Milton Reservoir sector before the rapid descent. When questioned about ground clearance in line with the Black Mount high terrain feature, the flight training organisation indicated that students usually flew to the right or left of track in order to improve ground clearance.This included instruction on changes made as part of flight planning to include consideration of that requirements. The accident flight was flown at 3,000 ft AMSL and its flight path was directly over the top of Black Mount. That gave the aircraft a ground clearance of about 800 ft over the high terrain at the aircraft’s cruise altitude. The RPL knowledge standards did not include topics related to aircraft systems and autopilot knowledge. However, those knowledge standards were included at the PPL level and are as follows: There was no requirement included in that section for pilots to have knowledge of, or have demonstrated use of the aircraft’s auto flight systems. The handbook referenced knowledge standards and units of competencies included in the MOS. At the time of the accident, the flight examiners handbook did not include a requirement for examiners to test student pilot auto flight systems knowledge.

The RPL (A) assessment scope and conditions section included: In December 2017 the ATSB asked CASA if the MOS should reflect the changes made in the flight examiners handbook. CASA stated that: The standards will align between the MOS, the flight test forms, and the examiners handbook. CASA stated that. This standard is elaborated in the examiners handbook. CASA stated that: The standards do not mandate knowledge and the use of autopilot systems. Competency using any system in an aircraft is finally regulated by regulation 61.385. CASA expects a flight training operator would ensure trainee pilots are competent using the systems in an aircraft he or she is assigned to fly. Additionally, it was reported by the flight training organisation that basic autopilot modes could be used at times of high workload. Observations of the pilot’s ability to use basic auto-flight modes such as heading, and altitude hold were conducted prior to pilots obtaining a RPL and the conduct of solo navigation flights. The accident pilot had successfully completed training using the aircraft’s autopilot system and flight trainer. The instructor advised the pilot that it was only to be used during high workload situations. The following time delays have been acceptable: The manufacturers did not have information that was similar to the VH-ZEW event. The ATSB also conducted a search of the National Transportation Safety Board (NTSB) database. One accident, two incidents and a recommendation highlighting several others accidents were identified. The autopilot manufacturer advised that the aircraft flight manual contained a warning that manual pilot input was not be applied with the autopilot engaged. The report indicated that with the autopilot engaged the aircraft had a violent pitch-up which required extreme forward pressure on the control yoke to keep the aircraft from pitching up and stalling.

The report stated that: The pilot noted that he did not attempt to use the manual trim wheel to change the airplane’s pitch attitude because that would have required him to release hand pressure on the control yoke. He was uncertain when or how the autopilot was disengaged. However, contributing to the accident was the pilot’s failure to use the manual trim wheel to reset pitch trim. No problems were identified in the trim or autopilot systems, however, manual control inputs with the autopilot ON were considered to have been a likely cause of those incidents. Both aircraft had the KAP140 autopilot systems fitted and the pilot’s guide for that autopilot contained a warning that manual pilot input was not be applied with the autopilot engaged. Eight of the accidents resulted in a total of 14 fatalities. In addition, from January 1, 1986, to June 10, 1994, 175 service difficulty reports were submitted to the FAA concerning various autopilot systems installed in Beech airplanes. These may result from a runaway electric trim, or pilot attempts to oppose or overpower the autopilot pitch axis. For example, if a pilot attempts to overpower the pitch axis for more than several seconds, the autopilot trim servo, in most cases, will move the elevator trim tab in a direction that will countermand the pilot’s input. If the pilot continues to restrain the control wheel, the trim tab will continue to operate and the wheel control forces may eventually become overwhelming. The NTSB recommended that Beech Aircraft Corporation issue a safety communique regarding the function, operation, and limitations of autopilot systems installed in Beech airplanes, and the need for strict adherence to the prescribed operating and procedural instructions contained in the respective airplane flight manual supplements and autopilot operating manuals.

The recommendation also stated that the communique should: During the ATSB’s investigation two Beechcraft POHs (Beechcraft Baron and Bonanza) that were reviewed had limitations and warnings about manual manipulation of the controls with the autopilot on. These problems may result from a runaway electric trim or pilot attempts to oppose or overpower the autopilot pitch axis. In most situations when a pilot attempts to overpower the pitch axis for more than several seconds, the autopilot trim servo will move the elevator trim tab in a direction that will countermand the pilot's input.These may include, but are not limited to: insufficient pilot training, pilot lack of an underlying model of autopilot behavior, misdiagnosis of malfunction, organizational policies, pragmatic considerations, human performance limitations, and system designs that do not capitalize on human factors principles. There is presently no regulation stating that a pilot must receive training in the use of an autopilot before flying with one in an aircraft. Although such training is the rule in Part 121 operations for flight management systems, General Aviation is yet another story. Theoretically, one could fly any aircraft that one was checked out in, and if a model of that aircraft happened to have an autopilot, the pilot would be free to use it without specific instruction. The same is true for GPS and other systems that one could conceivably add to the aircraft. The tempering factors, one would expect, would be that a prudent pilot generally would learn everything possible about the airplane to be flown, particularly if it were owned or regularly flown by that pilot. Additionally, if the aircraft were leased, it would be expected that all potential lessees would be thoroughly checked out in aircraft systems operations prior to being allowed to lease the aircraft, usually for insurance purposes. This is often not the case, however.