Dean Neal, 32, was killed along with four passengers when the Microflite helicopter he was flying crashed at Mt Disappointment north of Melbourne on March 31, 2022.
The Australian Transport Safety Bureau's final report on the crash released on Thursday has found Mr Neal lacked experience and training in instrument flying - when a pilot relies on cockpit instruments rather than visual cues to monitor the aircraft's position through cloud or fog.
The helicopter crashed into a large tree at Mt Disappointment north of Melbourne in March 2022. (James Ross/AAP PHOTOS)
Mr Neal's helicopter had been following a second aircraft when he passed through cloud cover and crashed into a large tree at Mt Disappointment, about 60km north of the Victorian capital.
The two aircraft were initially flying between a layer of scattered cloud about 3500 feet but the pilot of the leading helicopter turned around upon seeing a "wall of cloud".
The pilot initially broadcast to Mr Neal they would backtrack, before repeating again, "U-turn, U-turn, U-turn", as they performed a sharp left-hand turn about 7.56am.
The pilot saw Mr Neal's helicopter pass below them and continue towards the mountain about 30 seconds later.
Mr Neal was killed in the crash along with First AG Capital co-founder Nicholas Vasudeva, AXIchain founder Linda Woodford, finance consultant Ian Perry and meat industry boss Paul Troja.
The safety bureau report found while Mr Neal did not have instrument flying training or experience, he was not required to by the regulations.
The helicopter was also not fitted with autopilot or a stability augmentation system, but those too are not required by the regulations.
"This equipment would have reduced the risk of a loss of control when the pilot attempted to exit from instrument meteorological conditions," the report stated.
The ATSB report highlights a lack of automatic controls and pilot training in 'instrument flying'. (Mick Tsikas/AAP PHOTOS)
Microflite did not publish a procedure to its pilots on how to recover from unexpected weather conditions, although voluntary training was available.
The company also did not require pilots to have instrument flying experience, nor did it ensure pilots underwent a pre-flight risk assessment.
The regulations did not require Microflite to have such procedures in place, the report noted.
The bureau accepted that Microflite has taken steps to address the safety issues since the crash, including introducing a pre-flight risk assessment tool.
Helicopters used by Microflite were also being upgraded to include autopilot features and more up-to-date cockpit instruments, the report noted.
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