Overview

• ATSB’s final report identified a long-term intermittent pressurisation defect as the primary cause of pilot hypoxia on the November 4, 2023 aerial surveillance flight
• Investigators found AGAIR management knew of the defect but did not formally record it, communicate risks, or issue pilots explicit procedures for its management
• A six-minute call between AGAIR’s head of flying operations and Airservices Australia minutes before the crash missed the chance to relay the defect and command a descent
• Hypoxia impaired the pilot’s control inputs at around 10,500 ft, causing the Gulfstream 695A to enter an unrecoverable spin and crash, killing two camera operators and the pilot
• AGAIR has accepted the ATSB’s safety recommendations, implemented many changes and will undergo an independent review of its structure and oversight