The aviation watchdog has found pilot error was responsible for a devastating crash that killed all five people onboard on a Far North Queensland beach.
The men, all from Cairns, died when the Cessna 404 Titan they were flying in hit sand dunes near Lockhart River in Cape York on March 11, 2020.
The victims included QBuild workers Wayne Ganter, 63, Henry Roebig, 62, and Wayne Brischke, 57, as well as contractor Mark Rawlings, 49 and pilot Stuart Weavell, 36.
They had been flown in to the area for the day to carry out work on a school.
The Australian Transport Safety Bureau (ATSB) has released its final report in to the crash.
It found Mr Weavell was attempting to land using an instrument approach on a cloudy and wet morning and appeared unaware he was flying about 300 metres lower than recommended.
An image taken by a passenger moments before the crash, which formed part of the ATSB investigation, shows heavy clouds as a tropical low hovered off the coast.
Inside the investigation
ATSB chief commissioner Angus Mitchell said the plane crashed on its second approach to the Lockhart River Airport.
"Misreading the altimeter by 1,000 feet appears to be the most likely scenario [for the crash] although there was insufficient evidence to provide a definitive conclusion," Mr Mitchell said.
"Regardless, it is evident from the continued descent that the pilot did not effectively monitor the aircraft's altitude and descent rate for an extended period, and that they were probably experiencing a very high workload."
The report found an examination of the wreckage had found both engines were operating "normally" and there was "no evidence of any structural or mechanical defects with the aircraft".
The report said the aircraft left Cairns at 7:19am and attempted to land at the Lockhart River aerodrome at 9:06am.
One minute later, Mr Weavell advised he was conducting a missed approach and again attempted to land before crashing into dunes at 9:19am.
The report said the aircraft was not fitted with a cockpit voice recorder or a flight data recorder, but nor was it required to be.
Mr Mitchell said the ATSB's investigation highlighted the importance of a terrain avoidance and warning system (TAWS) in preventing accidents, and urged operators of smaller aircraft conducting passenger operations to consider fitting them.
"Given the aircraft's descent profile on the second approach, a TAWS would have provided the pilot with both visual and aural alerts of the approaching terrain for an extended period," he said.
Crash continues to have impact
The crash had an enormous impact on the Lockhart River and Cairns communities.
Three months after the crash, Mr Weavell's partner, Liz Thomas, told the ABC he had clocked up 3,000 hours in the air.
"He was the friend, partner, son, and brother you could always count on, and there is a profound absence in our lives now," Ms Thomas said.
Lockhart River Mayor Wayne Butcher said he knew some of the QBuild workers killed in the crash.
"It sends shockwaves through the community when we have big tragedies such as this," Cr Butcher said at the time.
