Australia Day fatal crash from pilot error

Pilot error killed two people in an Australia Day airshow crash on Perth's Swan River, an Australian Transport Safety Bureau report has confirmed as it reprimanded the Civil Aviation Safety Authority for its oversight.

Experienced pilot Peter Lynch, 52, and his Indonesian partner Endah Cakrawati, 30, were killed when his Grumman G-73 Mallard flying boat "stalled at an unrecoverable height" during a positioning turn and broke up on impact in front of horrified families in 2017.

ATSB executive director of transport safety Nat Nagy said pilots should not undertake any impromptu manoeuvres.

"The manner in which the pilot returned to the display area after the second pass was not in accordance with the display procedures and increased the risk of mishandling the aircraft in an area of relatively close proximity to the public," the ATSB said in its final report released on Tuesday.

The ATSB found Mr Lynch should not have been carrying a passenger and CASA did not have an effective framework to approve and oversee air displays.

In September 2017, CASA published a revised manual of guidance.

"While these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight," Mr Nagy said.

The ATSB has recommended CASA enhance its tools and guidance for air display approval and oversight, and procedures to ensure the suitability if those responsible for organising, coordinating and participating.

The City of Perth recently announced the Australia Day Skyworks event will return in 2020.