Investigators did not know the content of conversations in the cockpit due to a lack of usable audio from the cockpit voice recorder.

The weather was hazardous, with gusting winds exacerbated by the fires and local terrain. The crew assessed the conditions were unsuitable at their original task and were sent about 58 kilometres to the east, where conditions were much the same.

The ATSB found the aircraft likely stalled as it climbed after dropping fire retardant on the fireground.

The RFS and the aircraft operator, Coulson Aviation, shared responsibility for risk mitigation in firefighting operations, which necessarily take place in a high-risk environment, the ATSB said.

The RFS had limited policies and procedures for tankers and their supervision, and no procedures for deployment without supervision.

There was also no policy to manage task rejections or to communicate those internally or to other crews.

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The RFS advised the ATSB it would commission reports on airspace management, establish a coordinator for air tankers, audit records on qualified pilots, and review its safety doctrine among other measures.

However, the bureau said the RFS had not yet committed to adopting any safety precautions that would reduce the risks associated with issues identified in its report. It recommended the agency address its absence of policies on aerial supervision and the communication of task rejections.

DeMorgan’s sister, Virginia DeMorgan, told The Sydney Morning Herald her brother was hysterically funny, a loving father, and loyal friend.

“He’s missed more than words can express by colleagues, friends and most of all his family. There’s not a day that goes by that I don’t think of him, wishing he was still here,” she said.

In a statement, the RFS said it would accept the recommendations that were relevant to it and seek to implement them before the coming fire season.

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The agency’s commissioner Rob Rogers said while the report recognises the dangerous environment that pilots operate in while undertaking firefighting operations, safety remains the highest priority.

“Aerial firefighting, including the use of large air tankers, makes a significant contribution to protecting communities during bushfires, however, it is an inherently dangerous environment and workplace,” he said. “On our busiest day during the 2019-20 season, we had more than 130 aircraft working on bushfires, and across the season there were more than 2500 taskings of aircraft.

“While there will always be a risk involved, our challenge is to balance this risk with the protection of the community, especially during extreme conditions.”

Commissioner Rogers said the service is committed to putting measures in place to address the ATSB’s recommendations.

“Work is already underway to put systems and processes in place, including improving notifications to pilots, and strengthening our policies and procedures based on the recommendations. ”

Coulson Aviation CEO Wayne Coulson said the loss of Tanker 134’s crew continues to be deeply felt by the company.