Transport safety investigators release report into deadly plane crash at Rowena, after taking off from Moree

The safety watchdog has released its report into the deadly plane crash west of Moree 15 months ago.

The Australian Transport Safety Bureau (ATSB) has been investigating the crash at Rowena on the morning of December 4, 2021.

In its final report, made public on Friday, the ATSB found a flight risk assessment for aerial spray application would have identified the risks for the pilot of the Air Tractor AT-400.

"The ATSB found that the aircraft was too close to the start of the spray run during the turn, which probably resulted in the pilot tightening the turn," ATSB Director Transport Safety Dr Stuart Godley said.

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"This almost certainly resulted in an aerodynamic stall at a height too low to recover before colliding with the ground."

The Air Tractor aircraft - which was operated by a local company - had taken off from Moree Airport about six o'clock that morning and headed for the property's airstrip where it was spraying.

The pilot was on his 11th load of chemical spraying and had completed the fourth run of spraying paddocks when at the end of the fifth run, the plane was seen to climb and "enter a right procedure turn".

But during the turn, the plane "descended rapidly".

Witnesses saw the yellow aerial spray plane crash into the ground behind trees on a property off the Moomin Road at Rowena about 11.50am.

The plane's fuel tanks ruptured during the impact, sparking the deadly blaze.

Neighbouring residents rushed to try and help the pilot before emergency services arrived, but he died at the scene.

Mishandling the turn was probably a result of the combined effects of the pilot experiencing high workload and fatigue due to long flight and duty times, inexperience, the complexity of the task and the weather conditions, Dr Godley said.

The combination of these factors would likely have identified an elevated flight risk, had an aerial application-specific flight risk assessment been conducted. However, there was no requirement for the operator or pilot to conduct a flight risk assessment or to have a flight risk assessment tool.

As part of the ATSB's final report, investigators said the operator has implemented "additional fatigue management measures, which include an assessment of other factors that may contribute to fatigue and flight risk, within the regulatory fatigue requirements".

The ATSB found the aircraft, although not required to, was not fitted with a crash-resistant fuel system.

Dr Godley said crash-resistant fuel systems have proven effective in other machines including helicopters.

"As such, the ATSB has issued a formal safety recommendation to the US Federal Aviation Administration to take action to address certification requirements for crash-resistant fuel systems for fixed wing aircraft to reduce the risk of post-impact fire," Dr Godley said.

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