Pilots did not discuss a manoeuvre that led to a deadly mid-air plane crash before taking to the sky, the national transport safety investigator has found.
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Stephen Gale, 56, and cameraman James Rose, 30, were killed when one of two Viper S-211 Marchetti planes on November 19 during a formation flight.
They were filming a Jetworks Aviation promotional video about 12km west of Mount Martha when the planes collided.
Their bodies were later found off Mornington in the wreckage of their plane, submerged in 22 metres of water.
The second aircraft and the two people on board landed safely at Essendon Airport.
In its final report into the crash, the Australian Transport Safety Bureau (ATSB) confirmed the manoeuvre involved the formation lead aircraft, known as Viper 1, rolling inverted before the second jet, Viper 2, passed directly beneath it.
"This manoeuvre had not been specifically briefed before the flight, and was conducted without the prior knowledge of the crew of Viper 1," the investigation found.
Following a first attempt, both pilots discussed repeating the move over the radio.
"This in-flight discussion did not allow the pilots to fully consider the risks associated with the manoeuvre before it was attempted for a second time," Chief Commissioner Angus Mitchell said.
The right wing of Viper 2, piloted by Mr Gale, struck the right wing of the inverted jet during the second attempt.
The second jet sustained "substantial damage", resulting in the immediate loss of control.
"Pre-briefing of in-flight manoeuvres is critical to safe formation flying to mitigate the risks of increased pilot workload and distraction," Mr Mitchell said.
"Minimising the risk of these flights requires pilots to prioritise operational safety, in particular through in-depth briefings, pre-flight planning of manoeuvres, and strict adherence to procedures and the agreed plan.
Further, the ATSB investigation found the aircraft operator did not hold the required certificate to film flights and the S-211s were not legally permitted to be used for that purpose.
The surviving pilot also did not follow medical restriction requirements to operate aircraft with a side-by-side seating configuration and a type-qualified safety pilot.
Those factors did not directly contribute to the aircraft handling or decision-making that led to the crash but operating outside of the limits removed in-built safety defences and structures designed to identify and mitigate risks, Mr Mitchell said.
Australian Associated Press