Mangalore mid-air plane crash report reveals errors that led to the disaster

Four people died after two planes collided mid-air near Mangalore, north of Melbourne, in February 2020. (ABC News)

Four pilots who were killed in a mid-air crash in Mangalore two years ago were unlikely to have seen the other's aircraft in time to prevent the collision, the final report into the tragedy has found..

The fatal crash at Mangalore in Victoria was the first mid-air collision in Australia for many decades between two civilian aircraft operating under instrument procedures.

Just before 11am on February 19, 2020, a Beech Travel Air aircraft with pilots Ido Segev and Peter Phillips on board departed Tyabb Airport for an instrument flight rules return training flight to and from Mangalore Airport, south of Shepparton.

Around the same time, pilot Chris Gobel, instructing a 27-year-old female trainee pilot from West Melbourne on board a Piper PA44-180 Seminole, was at Mangalore Airport preparing for an instrument rating flight test.

The two aircraft collided while the Beech Travel Air plane was on the descent and the Piper PA44-180 Seminole was on the climb at an altitude of 4,100 feet, about 8 kilometres south of Mangalore Airport, killing all four pilots.

Chris Gobel was one of the pilots killed in the collision. (Supplied: Bendigo Flying Club)

Australian Transport Safety Bureau (ATSB) chief commissioner Angus Mitchell said all pilots were provided with traffic information about the other aircraft before the crash.

"After air traffic control provided aircraft with traffic information on the other aircraft, the pilots did not successfully manoeuvre or establish radio communications with each other to maintain separation, probably due to not recognising the collision risk."

The ATSB has strongly encouraged the fitment of and use of automatic dependent surveillance-broadcast (ADS-B) avionics in its final report into the crash. 

The report found that while there was extensive cloud cover in the area at the time, even in clear weather the pilots of both aircraft were unlikely to have seen the other aircraft in time to prevent the collision.

Peter Phillips (left) and Ido Segev (right) were both killed when the planes collided. (Supplied: Peninsula Aero Club)

Mr Mitchell said the available evidence in the investigation did not support a conclusion that the present system of self-separation in Mangalore airspace was unsafe, but the ATSB noted there were opportunities to reduce safety risks further.

ADS-B is a system that transmits GPS-derived position data, aircraft identification, and other aircraft performance parameters.

The report said both aircraft were fitted with ADS-B OUT, but neither aircraft was fitted with a system to receive ADS-B information directly from other aircraft, known as ADS-B IN, nor were they required to be.