Pilot of a Cessna 172 was fatally injured when their aircraft contacted wires above a field adjacent to Coonabarabran Aerodrome during an intentional low-level pass;
Pilot was not wearing upper torso restraint, however it was not possible to determine whether this could have prevented fatal injuries.
A Cessna 172 pilot was very likely conducting an intentional low-level pass over a tractor before their aircraft struck a powerline, an Australian Transport Safety Bureau investigation details.
The Cessna, with a single pilot on board, had been conducting circuits at Coonabarabran Aerodrome on 18 April 2022, before it contacted powerlines and impacted terrain. The pilot was fatally injured and the aircraft was destroyed.
“After completing several touch-and-go landings, the pilot flew a low pass at 15–25 feet above the ground over a tractor, which was working in a field adjacent to the aerodrome,” ATSB Director Transport Safety Dr Mike Walker said.
In the vicinity of an airfield operations at low level are normal during take-off and landing, however, the aircraft’s flight path just prior to the collision did not align with the runways, and was not consistent with a normal circuit pattern.
“It was therefore very likely the pilot was conducting an intentional low-level pass over the tractor,” Dr Walker said.
“Operations at low height expose an aircraft to several hazards like powerlines, which are typically very difficult to see and present a critical hazard to any low-flying aircraft,” Dr Walker said.
In recognition of this and other specific risks and hazards of low-level flying, the Civil Aviation Safety Authority requires pilots to hold a specific low-level rating before flying at low level.
“Even with appropriate training, flying at low-level carries a significant risk and should be avoided when there is no operational reason,” Dr Walker continued.
“For most private pilots, there is generally no reason to fly at low levels, except during take-off and landing, or conducting a forced or precautionary landing.”
The investigation also notes the pilot was found to be wearing only the lap portion of their seatbelt. However, it was not possible to determine with certainty whether, if worn, the seatbelt’s upper torso restraint would have reduced the severity of injuries.
“Nonetheless, pilots should always wear upper torso restraints where available,” Dr Walker said.
“Research has shown that wearing an upper torso restraint significantly reduces the risk of serious or fatal injury.”
Pilot successfully conducted emergency autorotation landing on a beach after smelling burning rubber and noting the clutch warning light flicker;
The drive belt set had disengaged from the sheaves, preventing effective drive from the engine to the rotor system;
After installing new drive belts, the aircraft’s maintainers had used the then-recommended practice of extending the clutch actuator to stretch the new drive belt set.
Robinson Helicopter Company has removed a drive belt stretching practice from its R22 and R44 helicopter handbooks in response to an ATSB investigation into a drive system failure and forced landing incident in Queensland’s Whitsundays region.
On 3 February 2021, a Robinson R44 conducting a charter flight with a pilot and two passengers on board was cruising at 1500 ft between Long Island and Hamilton Island when the pilot smelled burning rubber and saw the clutch warning light flicker briefly.
Shortly afterwards, and observing a reduction in main rotor RPM, the pilot turned the helicopter back toward Long Island and made a successful emergency autorotation landing on a beach.
A post-incident inspection found two of the helicopter’s four drive belts were dislodged and moved forward of the upper sheave of the helicopter’s drivetrain.
“The other two drive belts had also shifted forward such that they were not effectively engaged within their sheave grooves,” ATSB Director Transport Safety Stuart Macleod said.
“This meant there was a complete loss of effective drive from the engine to the rotor system.”
The ATSB’s investigation determined maintenance checks had found drive belt stretching both before and after the incident, each time within a short time of new drive belt sets being installed.
The report notes the helicopter maintainer, after installing new drive belts, used the then-recommended practice of extending the clutch actuator to stretch the new drive belt set.
“However, in light of this incident and other reports, Robinson has now identified that this practice may lead to overstretching and looseness in the drive belts during operation,” Mr Macleod said.
“Looseness can in turn result in the drive belts coming out of the sheave grooves while the helicopter is shut down, and disengaging drive to the rotor system in flight.”
Robinson has subsequently removed from its pilot’s operating handbooks for R22 and R44 helicopters the procedure of stretching new drive belts by extending the clutch actuator, and leaving it engaged with the engine off.
“Following the helicopter manufacturer’s latest advice, R22 and R44 operators and maintainers should not stretch new drive belt sets using the clutch actuator,” Mr Macleod summarised.
“This will avoid overstretching and reduce instances of drive belt disengagement and subsequent loss of rotor drive.”
Mr Macleod noted the pilot’s actions in quickly reacting to the loss of rotor drive led to the incident’s safe outcome.
“The pilot’s handling of this incident highlights the importance of efficiently managing an in-flight emergency by following flight manual emergency procedures, and having a pre-planned course of action,” he said.
“These fundamentals enabled the pilot to make a safe landing with no injuries or loss of the helicopter.”
The requirements for reporting aviation accidents and incidents to the ATSB are detailed in the Transport Safety Investigations Regulations (TSI Regulations).
The TSI Regulations(Opens in a new tab/window) set out the ATSB’s safety occurrence reporting scheme and prescribe what occurrences must be reported to the ATSB, the timeframes those reports must be made in, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report.
Guidance for the aviation industry on what and how to report to the ATSB as prescribed in the TSI Regulations is provided below. This guidance is also available in in the Aeronautical Information Package (AIP)(Opens in a new tab/window), Enroute 1.14, AirTraffic Incidents, on the Airservices Australia website.
Reporting of accidents and incidents
The Regulations define occurrences that must be reported to the ATSB as “immediately reportable”, which must be reported by telephone as soon as reasonably practical, and “routine reportable” matters, which can be notified to the ATSB by a written report within 72 hours.
The Regulations define 4 categories of aircraft operations, each with different reporting requirements, while types of reportable matters are defined in 7 broad classifications based on International Civil Aviation Organization definitions. Whether an event is to be immediately reportable, routine reportable or not reportable at all, is based on a combination of the 4 aircraft operation categories and the 7 classifications.
Higher categories, in particular passenger-carrying and commercial operations, have a greater reporting focus due to the greater public safety benefit that could be derived. Non-commercial aircraft operations and uncrewed RPA and balloons have lower reporting requirements.
Aside from being the basis for starting safety investigations, all occurrences reported to the ATSB are maintained in Australia’s official aviation occurrence database and used for safety research and analysis.
For routine reportable matters, complete the ATSB's online form.
Aircraft categories for reportable matters
The four aircraft operations categories comprise Category A (passenger transport), Category B (commercial non-passenger, including medium to large RPA), Category C (non-commercial) aircraft operation, and Category D (small non-excluded RPA and certain uncrewed balloons) aircraft operation. Further detail is provided below.
Category
Kinds of aircraft operations covered
Category A (passenger transport) aircraft operations
What is included in Category A?
(1) Passenger transport operation (within the meaning of the Civil Aviation Safety Regulations 1998 (CASR)) being an operation in an aircraft that involves the carriage of passengers[1], whether or not cargo is also carried on the aircraft.
Examples include: air transport operations (scheduled or non-scheduled), balloon transport operations,[2] mining fly-in-fly-out operations, scenic flights/joy flights, parachuting operations, future advanced air mobility passenger carrying operations, and aerial work operations that carry passengers who are not crew members.
(2)Medical transport operation (within the meaning of CASR) being an operation with the primary purpose of transporting medical patients, medical personnel, or supplies (blood, tissue etc), or an operation prescribed by CASA in the CASR Part 119 Manual of Standards as a medical transport operation.
Examples include: flights formerly known as air ambulance operations, Royal Flying Doctor Service flights and patient transport/transfer services using aircraft operated by State and Territory ambulance services.
(3) Repositioning flights prior to conducting a substantive Category A operation (passenger transport or medical transport) will also be treated as a Category A operation for the purposes of occurrence reporting.
What is excluded from Category A?
Category A aircraft operations will not include an operation in an aircraft with a special certificate of airworthiness, or a cost-sharing flight[3], or operation of an aircraft (where the registered operator is an individual) that carries passengers without payment or reward.
For example, if a scenic flight involves ‘cost-sharing’ – then any occurrences during that operation would be reportable under Category C (non commercial) aircraft operations. It is important to note that cost-sharing is limited to an aircraft configuration of not more than 6 seats (including pilot’s seat) and requires the pilot in command to directly contribute to equal costs for the flight.
Category B (commercial non-passenger) aircraft operations
What is included in Category B?
(1) Operation conducted for a commercial purpose – any non passenger carrying aircraft operation that is conducted for a commercial purpose will be included in Category B. A ‘commercial purpose’ is intended to have a general meaning and includes, among other things, operations conducted for hire or reward.
Examples include: aerial work operations such as surveying, spotting, surveillance, agricultural operations, aerial photography; search and rescue operations; flying training activities (such as training under a CASR Part 141 or CASR Part 142 training organisation).
(2) Cargo transport operation (within the meaning of CASR) being an operation of an aircraft that involves the carriage of cargo and crew only (excluding operation for the carriage of possessions of the operator, or pilot in command, for business or trade).
Examples include: air freight, air mail, and parcel/package delivery using aircraft operated by logistics companies.
(3) operating Type 1 RPA (defined in section 6 of the TSI Regulations and adopting CASR definitions) being a large RPA[4], medium RPA[5] or RPA which is type certificated (and which is not an excluded RPA or micro RPA).
Examples include: package delivery using large RPA, agricultural operations, other kinds of aerial work.
(4) Repositioning flights prior to conducting a substantive Category B operation will also be treated as a Category B operation for the purposes of occurrence reporting.
What is excluded from Category B?
To avoid doubt, Category B aircraft operations do not include Category A (passenger transport) aircraft operations or Category D (type 2 RPA and certain unmanned balloons) aircraft operations.
This means in practice, Category A operations (if applicable) take precedence for the purposes of occurrence reporting – if the operation is not Category A, then responsible persons (pilots, operators and others mentioned in section 13 of the TSI Regulations) should consider if the operation would then fall within the scope of Category B for commercial purposes (unless it would be Category D), and if not, then whether the other two remaining categories would apply.
For example, if an operator is contracted to conduct crop spraying for a client’s farmland, this would be considered a commercial purpose (Category B). However, if an operator undertakes crop spraying on their own land, there is no commercial purpose in relation to the aircraft operation and this would be considered an operation covered under Category C (non-commercial).
Category C (non-commercial) aircraft operations
What is included in Category C?
(1) Operation of an aircraft that is not Category A, Category B or Category D – this broad description has the aim of covering non-commercial operations (with a pilot on board) generally. This means Category C includes recreational flying, general aviation, and flights where the pilot shares equally in costs with passengers (cost sharing).
Examples include: flying activities at local aero clubs, solo flying, community service flights, gliding activities.
What is excluded from Category C?
The purpose of Category C is to cover every kind of remaining aircraft operation (with a pilot on board) that is not excluded from the aviation occurrence reporting framework under subsection 7(3) of the TSI Regulations.
Subsection 7(3) provides that Part 2 (aircraft operations) of the TSI Regulations do not apply to ‘excluded aircraft’ – being an Australian defence aircraft, an exempt foreign aircraft, or an RPA that is not type 1 RPA or type 2 RPA. The Amendment Regulations also extend the exclusions listed in subsection 7(3) to model aircraft, small balloons and light balloons and tethered balloons.
Category D (type 2 RPA and certain unmanned balloons) aircraft operations
What is included in Category D?
(1) operating type 2 RPA (defined in section 6 of the TSI Regulations) being an RPA that is not a type 1 RPA, not an excluded RPA, and not a micro RPA.
(2) operating a medium balloon (defined in Part 101 of CASR) being an unmanned free balloon with, among other things, a payload with combined mass of at least 4kg but less than 6kg.
(3) operating a heavy balloon (defined in Part 101 of CASR) being an unmanned free balloon with, among other things, a payload with combined mass of at least 6kg.
Examples include: commercial and non-commercial operation of a very small RPA (more than 250g but under 2kg) such as the DJI Phantom 4 or a small RPA (more than 2kg but under 25kg) such as the DJI Agras MG-1. Unmanned balloons capable of reaching stratospheric heights would also be included in Category D.
What is excluded from Category D?
Category D covers a subset of unmanned aircraft operations that are not already covered under earlier categories. If the aircraft operation is not using a type 2 RPA, medium balloon or heavy balloon, then Category D would not apply.
The framework clarifies that occurrences during repositioning flights for the purpose of conducting Category A aircraft operations must be reported as a Category A (passenger carrying) aircraft operation, and similarly for Category B (commercial non-passenger) aircraft operations. The rationale for including Category A and Category B repositioning flights is to ensure that occurrences for those operations with greater public safety impact and interest are included in categories that provide proper visibility of safety matters leading up to conduct of the substantive operation. The requirement for reporting occurrences during repositioning flights does not apply to Category C (non commercial) aircraft operations or Category D (type 2 RPA and certain unmanned balloons) aircraft operations.
Responsible persons
Reportable matters known by responsible persons must be reported to the ATSB by that person unless that person believes, on reasonable grounds, that one or more other responsible persons:
have already reported the matter, or
will as soon as is reasonably practicable report the matter.
However, the ATSB still encourages all responsible persons with information about a reportable matter to report that information to the ATSB.
The following are responsible persons:
a crew member of the aircraft concerned
the owner or operator of the aircraft
a person performing an air traffic control service in relation to the aircraft
a person performing a dedicated aerodrome rescue or firefighting service in relation to the aircraft
a person who is licensed as an aircraft maintenance engineer and does any work in relation to the aircraft
a member of the ground handling crew in relation to the aircraft
a member of the staff of CASA
the operator of an aerodrome
a sport aviation body that administers aviation activities in relation to the aircraft.
Reportable matters
Reportable matters are defined in the TSI Regulations via a combination of the type of safety occurrences (see below), and the type of operation. The combination determines whether a safety occurrence is an immediately reportable matter, routine reportable matter, or not reportable.
The TSI Regulations refer to the following types of safety occurrences:
an aircraft accident
a reportable serious aircraft incident
a loss of a separation standard between aircraft
a declaration of an emergency in relation to an aircraft
a serious property damage incident (external)
an aircraft incident
an aircraft incident (external).
The TSI Regulations refer to 4 categories of aircraft operations, each with different reporting obligations (see section above, Aircraft that must report reportable matters).
Reportable matters for each type of operation category
Category A operations have the most reporting requirements and Category D have the least reporting requirements. The below table shows the types of safety occurrences that are either immediately reportable matters (telephone as soon as reasonably practicable and written report within 72 hours), or routine reportable matters (written report within 72 hours), for each type of operation category.
Category
Immediately reportable matters (IRM)
Routine reportable matters (RRM)
Section 11A: Category A (passenger transport) aircraft operations
The following kinds of occurrences reported as IRMs:
aircraft accident;
reportable serious aircraft incident;
loss of separation standard between aircraft;
declaration of an emergency in relation to the aircraft; and
serious property damage incident (external).
The following kinds of occurrences reported as RRMs:
aircraft incident; and
aircraft incident (external).
Section 11B: Category B (commercial non-passenger) aircraft operations
The following kinds of occurrences reported as IRMs:
aircraft accident;
loss of separation standard between aircraft; and
serious property damage incident (external).
The following kinds of occurrences reported as RRMs:
reportable serious aircraft incident;
declaration of an emergency in relation to the aircraft; and
aircraft incident (external).
Section 11C: Category C (non-commercial) aircraft operations
The following kinds of occurrences reported as IRMs:
aircraft accident – limited to fatal aircraft-related injuries, serious aircraft-related injuries, or missing aircraft;
loss of separation standard between aircraft; and
serious property damage incident (external).
The following kinds of occurrences reported as RRMs:
aircraft accident other than reportable as an IRM;
reportable serious aircraft incident;
declaration of an emergency in relation to the aircraft; and
aircraft incident (external).
Section 11D: Category D (type 2 RPA and certain unmanned balloons) aircraft operations
The following kinds of occurrences reported as IRMs:
aircraft accident – limited to fatal aircraft-related injuries or serious aircraft-related injuries; and
serious property damage incident (external).
The following kinds of occurrences reported as RRMs:
aircraft accident other than reportable as an IRM; and
loss of a separation standard between aircraft.
Reportable matters definitions and examples
Reportable matters are safety occurrences that involve the operation of an aircraft, including preparation for departure and during disembarkation. Specifically, in relation to a particular crewed aircraft, reportable matters must occur during the period:
beginning when the aircraft is being prepared for take-off; and
ending when all passengers and crew members have disembarked after the flight.
For uncrewed aircraft, reportable matters must occur during the period:
beginning when the aircraft is ready to move with the purpose of flight; and
ending when the aircraft comes to rest at the end of the flight and the primary propulsion system is shut down. In the case of an uncrewed aircraft without a primary propulsion system (such as a gas balloon), the end of flight is when the aircraft comes to rest at the end of the flight.
Emergency declaration
A declaration of an emergency, in relation to an aircraft, means:
a declaration, by a flight crew member of the aircraft, of an alert phase (PAN PAN) or a distress phase (MAYDAY); or
a declaration by an air traffic service provider of a distress phase (DETRESFA) in relation to the aircraft.
Note: a PAN MED (Medical emergency) is excluded from an emergency declaration. Refer to Reportable serious aircraft incidents – ‘incapacitation of a flight crew member’, and Aircraft incidents – ‘flight crew incapacitation’, and ‘cabin injuries’ for definitions of reportable incidents.
Loss of separation standard between aircraft
A situation where the recognised separation standard (vertical, lateral or longitudinal) between aircraft that are being provided with an Air Navigation Service Provider separation service is infringed. This includes any of the following:
loss of procedural or surveillance separation standards
loss of prescribed runway or wake turbulence separation standards
visual reference is lost during visual separation by a pilot or air traffic controller in controlled airspace.
Serious property damage incident (external)
In relation to the operation of an aircraft, damage to property outside the aircraft that would cost at least $25,000 to repair or replace, that is caused by:
contact with any part of the aircraft, including anything that is attached to the aircraft or that has become detached from the aircraft; or
direct exposure to jet blast, propeller wash or rotor downwash from the aircraft.
Aircraft accident
An aircraft accident is defined as:
A person suffers a fatal aircraft-related injury in relation to the operation of the aircraft; or
A person suffers a serious aircraft-related injury in relation to the operation of the aircraft; or
The aircraft sustains damage or structural failure, or there are reasonable grounds for believing that the aircraft has sustained damage or structural failure, which:
adversely affects the structural strength, performance or flight characteristics of the aircraft; and
would normally require major repair or replacement of the affected component;
except for any of the following:
engine failure;
engine damage limited to a single engine (including damage to its cowlings or accessories);
damage to propellers, wing tips, antennas, probes, vanes, tyres, brakes, wheels, fairings, panels, landing gear doors or windscreens;
damage such as small dents or puncture holes to the aircraft skin;
minor damage to main rotor blades, tail rotor blades or landing gear;
minor damage resulting from hail or bird strike (including holes in the radome); or
The aircraft is missing; or
The aircraft is completely inaccessible.
For further detail on determining injury and damage level, see below section Guidance for determining injury and damage.
Reportable serious aircraft incidents
A serious aircraft incident is an incident involving circumstances indicating that there was a high probability of an aircraft accident (that is, a high probability of a fatal or serious aircraft-related injury and/or the aircraft sustaining damage or structural failure); or
An incident in the following list of incidents that have the potential to be classified as a serious incident.
Note that a reportable serious aircraft incident includes a serious aircraft incident (as per the first point above) even when not in the list of examples below, as well as any incident in the list of examples below (with clarifying notes) even if it might not meet the definition of a serious aircraft incident.
Examples of reportable serious aircraft incidents
Reportable serious aircraft incident as defined by the TSI Regulations
Clarifying notes
A near collision requiring an avoidance manoeuvre to avoid a collision or an unsafe situation, or when an avoidance action would have been appropriate.
Immediate evasive action was required or should have been taken to avoid a collision.
Includes during flight and on the ground.
A collision with anything other than an animal or a bird.
Unless the resulting damage or injury qualifies it as an accident, an aircraft collides with another aircraft or collides with terrain (including water, trees and wires), a person, structure or object.
Where controlled flight into terrain was only marginally avoided.
Includes any legitimate terrain avoidance system warning ‘pull up’ type annunciation.
Excludes anticipated or spurious annunciations that occur in VMC.
An aborted take‑off on a closed, engaged or unassigned runway, or on a taxiway (other than an authorised operation by a helicopter).
A take‑off from a closed, engaged or unassigned runway, or from a taxiway (other than an authorised operation by a helicopter).
A landing or attempted landing on a closed, engaged or unassigned runway, on a taxiway (other than an authorised operation by a helicopter), or on an unintended landing location (such as a road).
Excludes helicopter landings on taxiways by authorised helicopter operations.
The retraction of a landing gear leg during landing, or a wheels‑up landing.
Unless the resulting damage or injury qualifies it as an accident.
The dragging, during landing, of a wing tip, engine pod or any other part of the aircraft.
Unless the resulting damage or injury qualifies it as an accident. Includes during a go-around. Dragging includes any contact with the surface.
A significant failure to achieve predicted performance during take‑off or initial climb.
Fire or smoke in the cockpit, the passenger compartment or a cargo compartment, or engine fire, even if the fire was extinguished by the use of extinguishing agents.
Includes explosions.
Excludes events involving fumes only.
An event requiring the emergency use of oxygen by a flight crew member.
Includes oxygen use for fumes, depressurisation.
Aircraft structural failure, engine disintegration or uncontained turbine engine failure.
Significant structural airframe failures, excluding dents, missing panels and minor skin damage.
Multiple malfunctions of one or more aircraft systems seriously affecting the operation of the aircraft.
Incapacitation of a flight crew member: - during a single pilot operation; or - during a multi‑pilot operation, if the safety of the operation is compromised because of a significant increase in workload for the remaining flight crew members.
Incapacitation for any reason to the extent that their ability to perform any flight management role is significantly impaired. Includes remote pilots.
Fuel quantity level or distribution situations (such as insufficient fuel, fuel exhaustion, fuel starvation, or inability to use all usable fuel on board) requiring the declaration of an emergency by the pilot.
Includes when declaration of emergency would be expected but not done.
A runway incursion where a collision is narrowly avoided.
Only includes runway incursions classified with severity index A as per the ICAO Manual on the Prevention of Runway Incursions (Doc 9870)
A take‑off or landing incident such as under‑shooting, overrunning or running off the side of a runway.
-Over-running refers to either a landing or a rejected take-off where the aircraft continues beyond the effective operational length available for use by aircraft for landing at certified or registered aerodromes or the distance available for landing on an aircraft landing area.
-Under-shoot refers to a landing that touches down prior to the designated landing area on a runway within the aerodrome perimeter.
Any of the following which caused, or could have caused, difficulties controlling the aircraft: - system failures (including loss of power or thrust) - weather phenomena - operations outside the approved flight envelope - any other occurrence.
Relates only those circumstances that require immediate intervention. Includes system alerts such as engine indications requiring inflight shutdowns, stall warnings during critical phases of flight.
Includes complete or partial loss of engine power.
Failure of more than one redundant system mandatory for flight guidance and navigation.
The unintentional or emergency release of a slung load or any other load carried external to the aircraft.
Aircraft incident
An aircraft incident is any event that is associated with the operation of an aircraft and affects, or could affect, the safety of the operation of the aircraft.
The degree to which an occurrence “affects or could affect” the safety of the operation of the aircraft should be understood to mean occurrences that, if not corrected, could endanger the aircraft or its occupants. To be clear, a responsible person is required to report an aircraft incident whether or not it was actually corrected or able to be corrected.
If an event, without correction, does not endanger the aircraft or its occupants, then the ATSB would consider that it has not affected or could not affect the safe operation of the aircraft (and therefore is an event that does not need to be reported).
Below are typical examples of aircraft incidents. For completeness, the list also includes occurrences that are aircraft accidents and/or reportable serious aircraft incidents, with notes to indicate this. However, the list is not exhaustive, and other operational events not in the list that meet the definition of an aircraft incident must be reported as aircraft incidents.
Incident
Definition
Clarifying note
Aircraft control incidents
Hard landing
The vertical deceleration operational limits for the aircraft set out in the aircraft's flight manual are exceeded during the landing.
(Note damage criteria for accidents.)
Airframe overspeed
The airspeed limit has been exceeded for the current aircraft configuration as published in the aircraft manual.
General airframe limits such as VNE; Extension speeds for flaps, slats, spoilers; Undercarriage extension speed.
Minor overspeeds are not incidents. In determining whether the overspeed is minor, both the degree and duration of the overspeed event should be taken into account.
Stall warning
Any cockpit warning or alert that indicates the aircraft is approaching an aerodynamic stall.
Warnings and alerts that are reportable include:
-aural stall warnings
-stick shaker activations
-stick pusher activations
-alpha protection or alpha floor activations.
-Stall warnings that are intentionally generated during flying training or flight testing operations are not reportable.
-Stall warnings are not reportable if the crew conclusively establish that the indication was false and provided that the false warning did not result in difficulty controlling the aircraft or a hazard arising from the response to the warning.
-Note criteria for reportable serious aircraft incidents for stall warnings during critical phases of flight.
Incorrect configuration
Where an aircraft system is incorrectly set for the current and/or intended phase of flight.
Landing gear not extended in preparation for landing;
Inadvertent retraction of landing gear after landing;
Incorrectly setting the flaps or slats;
Incorrect application of carburettor heat (when carburettor icing occurred or was likely to have occurred).
Incorrectly setting the auto flight system mode;
Raising the flaps instead of the landing gear after becoming airborne.
Minor configuration issues that are not reportable include:
- Momentary Enhanced Ground Proximity Warning System (EGPWS) flap and gear warnings related to incorrect settings in the EGPWS
- Configuration warnings on the application of take-off power that are resolved by the crew and the aircraft subsequently departs without incident.
Control issues
Occurrences where there were difficulties controlling the aircraft either airborne or on the ground.
Minor control issues arising from:
-Weather phenomenon (icing, severe turbulence, significant wind shear, thunderstorm encounter);
-Wake turbulence;
-Minor technical issues.
(Note criteria for reportable serious aircraft incidents.)
Weather events
Icing issue that affect the performance of the aircraft;
Lightning strikes;
Turbulence or windshear that affect aircraft performance;
(Note criteria for reportable serious aircraft incidents.)
Unstable approach
Flight crew continues an approach to landing when unstable (rather than conducting a go-around) when:
a. there is an approved operator-specific stabilised approach criteria and that criteria is not met; or
b. there is no approved operator-specific stabilised approach criteria, and one of the clarifying notes is not met under the following conditions:
(i) IMC at or below 1,000FT AGL;
(ii) VMC at or below 500FT AGL.
An approach is unstable when one or more of the following criteria is not met:
-the aircraft is on the correct flight path;
-only small changes in heading/pitch are necessary to maintain the correct flight path;
-the airspeed is not more than VREF + 20 kt indicated speed and not less than VREF;
-the aircraft is in the correct landing configuration;
-sink rate is no greater than 1,000 feet/minute;
-power setting is appropriate for the aircraft configuration and is not below the minimum power for the approach as defined by the operating manual;
-all briefings and checklists have been conducted;
-instrument landing system approaches flown within one dot of the glideslope and localiser;
-a Category II or III instrument approach flown within the expanded localiser band;
-a circling approach is flown with wings level on final approach when the aircraft reaches 300 feet above airport elevation.
Does not include when the approach was discontinued due to being unstable in the vicinity of 1,000 ft (IMC) or 500 ft (VMC).
Wheels-up landing
An aircraft contacts the intended landing area with the landing gear retracted.
Includes intentional and unintentional wheels-up landing.
Includes amphibious aircraft landing on water with landing gear not retracted.
(Note – all wheels-up landings are either accidents or reportable serious aircraft incidents.)
Aircraft loading incidents
Loading-related
Incorrect loading of an aircraft if the loading adversely affected, or could have affected, any of the following: (i) the aircraft's weight; (ii) the aircraft's balance; (iii) the aircraft's structural integrity; (iv) the aircraft's performance; (v) the aircraft's flight characteristics.
Incorrect load sheet provided to flight crew;
Incorrect weight data input into flight computers;
Incorrect passenger numbers or seating;
Incorrect freight or baggage or incorrect loading;
Freight shifting inflight or unrestrained freight;
Incorrect fuel quantity or tank usage.
Does not include events that were detected and corrected before flight.
Cabin safety incidents
Flight crew incapacitation
A flight crew member becomes incapacitated, such that their ability to perform normal flight duties is impaired.
Incapacitation may be due to illness, injury, physiological or psychological factors, or environmental or other factors. Incapacitations may be short term or persist for the duration of the flight, and includes both partial and total incapacitation.
(Note criteria for reportable serious aircraft incidents.)
Depressurisation
Air pressure inside the cabin of a pressurised aircraft reduces to an extent that requires action by the flight crew.
(Note criteria for reportable serious aircraft incidents.)
Cabin injuries
Crew and passenger injuries and incapacitations sustained as a direct result of an aircraft operation.
Injuries to flight crew, cabin crew or passengers if they are the result of:
- the movement of the aircraft due to a weather phenomenon like windshear or turbulence;
- an abrupt aircraft manoeuvre, either airborne or on the ground
- unrestrained objects.
Does not include workplace health and safety related injuries like slips, trips, falls, spillage of hot beverages, bumping head on overhead lockers or passenger illness unless the injury or illness is a direct result of the operation of the aircraft.
Unrestrained occupants / objects
Aircraft occupants, equipment or objects are not appropriately restrained for the aircraft operation or phase of flight.
Includes crew or passengers standing during take-off or landing, passenger not wearing seatbelts when required, and unrestrained galley equipment during critical flight phases.
Fire, smoke, and Fumes
Fumes
Smells, odours or odourless fumes not generally associated with normal aircraft operations.
Includes fumes from:
-dangerous goods
-post compressor wash
-oil / electrical smells
- carbon monoxide from engine combustion or heating.
Excludes (if no other consequences):
- fumes from galley oven contents or residual cleaning products
-bird ingestion through air conditioning
-passenger hand luggage contents.
(Note criteria for reportable serious aircraft incidents when incapacitation results from fumes.)
(Note separate reporting requirements for declaration of an emergency.)
Fire
Any fire that has been detected and confirmed in relation to an aircraft operation.
(All fire events are reportable serious aircraft incidents.)
Smoke
Smoke is reported to be emanating from:
a) inside the aircraft; or
b) an external component of the aircraft.
(All smoke related events are reportable serious aircraft incidents.)
Excludes passengers smoking inside the aircraft when the safety of the aircraft was not compromised.
Flight preparation / Navigation incidents
Lost / unsure of position
Uncertainty by flight crew in relation to an aircraft's position where the flight crew request assistance from an external source.
Applies to pilots that request navigational assistance from ATC, other aircraft, or other person outside the aircraft in determining their current position.
Pre-flight planning and preparation
Inadequate or incorrect pre-flight planning or preparation of an aircraft for flight that affected, or if not corrected, could have affected the safety of the operation of the aircraft.
Inadequate or incorrect fuel planning;
Navigation/flight planning issues including flight management computer data entry errors;
Deficiencies or erroneous data in navigation databases;
Inadequate pre-flight aircraft inspection.
Flight below safe altitude
An aircraft is operated below the designated or planned lowest safe altitude for the in-flight conditions and phase of flight.
Crew error to descend below the lowest safe altitude in IMC;
Aircraft operating below lowest safe altitude without knowledge of terrain in the vicinity;
ATC instruction to descend or operate below the lowest safe altitude;
Aircraft that continue the approach below minima with no visual reference to the runway;
Intentional unauthorised low flight.
VFR into IMC
An aircraft operating under the visual flight rules enters instrument meteorological conditions.
(Note criteria for reportable serious aircraft incidents.)
Fuel related incidents
Fuel contamination
The presence of a foreign substance in fuel loaded into an aircraft.
Fuel that is manufactured outside the technical specifications for the fuel grade or type;
Contamination of fuel in aircraft fuel tanks or aircraft fuel systems;
Incorrect fuel type for aircraft.
Fuel leak or venting
Unplanned loss of fuel from a fuel tank or fuel system.
Includes missing or insecure fuel cap.
Fuel starvation
Fuel supply to the engine(s) is interrupted although there is usable fuel on board the aircraft.
Mismanagement of the fuel system by the flight crew;
Mechanical failure involving the fuel system;
Unporting of the fuel standpipes during an aircraft manoeuvre.
(Note criteria for reportable serious aircraft incidents.)
Low fuel
The aircraft's supply of fuel becoming so low that the safety of the aircraft is compromised.
Any occurrence where fixed fuel reserves are compromised.
(Note the separate reporting requirements for a declaration of an emergency.)
Fuel exhaustion
When the engine stops because the aircraft has become completely devoid of useable fuel.
(All fuel exhaustion events are reportable serious aircraft incidents.)
Ground Proximity Warning
TAWS/GPWS
A Terrain Avoidance and Warning System warning or alert.
Any Terrain Avoidance and Warning System (TAWS) warning or alert, such as from a Ground Proximity Warning System (GPWS) and Enhanced Ground Proximity Warning System (EGPWS)
Excludes:
-expected or spurious terrain warnings in VMC
-momentary EGPWS flap and gear warnings related to incorrect settings in the EGPWS
-momentary EGPWS glideslope warnings where a safe approach is continued.
(Note criteria for reportable serious aircraft incidents.)
Ground operations’ incidents
Near collision on ground
An aircraft has a near collision with another aircraft, vehicle, structure, person or object while it is operating on the ground or water.
Near collision on taxiway or apron with another aircraft, vehicle, person or object.
(A near collision on the runway strip is a reportable serious aircraft incident.)
(Note criteria for reportable serious aircraft incidents for near collisions.)
(Note – all actual collisions are either an aircraft accident or a reportable serious aircraft incident depending on the level of damage.)
Foreign object damage / debris
Loose objects on a runway or in an aircraft that have caused, or have the potential to cause, damage to an aircraft.
Aircraft panels/parts that have dislodged from aircraft or vehicles and are a potential hazard to other aircraft;
Tools or equipment left in an engine or avionics bay (found during prefight preparation);
Loose objects in the cockpit/aircraft that result a hazardous condition.
Excludes foreign objects on a runway that have had no interaction with an aircraft.
Ground handling
Aircraft ground handling and aircraft servicing that have caused, or have the potential to cause, damage to the aircraft or injury.
Any hazardous condition such as vehicles colliding with a stationary aircraft or fuel spillages resulting from ramp operations (after the aircraft is being prepared for flight and before all passengers and crew have disembarked).
(Note separate reporting requirement for Aircraft loading incidents.)
Jet blast / prop wash / rotor wash
Air disturbance from a ground-running aircraft propeller, rotor, or jet engine that have caused or have the potential to cause damage or injury.
Jet blast or propeller wash that has the likelihood of causing injury to persons, or damage to aircraft or other objects. Also includes instances of helicopter rotor down wash where helicopters are hover taxiing or flying at low level.
Runway events
Depart, approach, or lands on wrong runway
An aircraft approaches an area other than that authorised or intended for landing or departure.
(Note all take-off, aborted take-off, landing and attempted landings on closed or engaged runway, on a taxiway, or an unassigned runway, or roadway, are reportable serious aircraft incidents.)
Runway incursions
Incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and take-off of aircraft.
Incorrect presence means: (a) anything within the confines of the runway strip, irrespective of having an appropriate clearance, which hinders the operation of an arriving or departing aircraft; or (b) an aircraft, vehicle or person entering the confines of the flight path without a clearance to do so, regardless of other aircraft operations.
(Note – a runway incursion where a collision is narrowly avoided is a reportable serious aircraft incident.)
Runway excursion
An aircraft veers off the side of the runway or overruns the runway threshold.
Over-running refers to either a landing or a rejected take-off where the aircraft continues beyond the effective operational length available for use by aircraft for landing at certified or registered aerodromes or the distance available for landing on an aircraft landing area.
Note - a runway veer-off or overrun incident during take-off or landing is a reportable serious aircraft incident.
Runway under‑shoot
An aircraft attempting a landing touches down prior to the designated landing area on a runway within the aerodrome perimeter.
Includes aircraft landing on the runway surface before a displaced runway threshold.
(Note – an aircraft touching down prior to the runway surface is a reportable serious aircraft incident.)
Terrain collisions
Collision with terrain and near collision with terrain
Any collision or near collision with terrain or water, including wirestrikes, or where controlled flight into terrain is only narrowly avoided
(Note – all collisions and near collisions (where avoidance manoeuvre was required or appropriate) are aircraft accidents or reportable serious aircraft incidents.)
Ground strike
Part of the aircraft drags on, or strikes, the ground or water in an unintended manner during take-off or landing.
A rotor or propeller makes contact with the ground during take-off or landing; An engine pod, wingtip, or tail contacts the ground during take-off or landing.
(Note criteria for accidents and reportable serious aircraft incidents.)
Miscellaneous warning devices
Warning device other
An aural or visual aircraft warning device activates to alert the flight crew to a situation requiring immediate or prompt corrective action.
Includes chip detectors, propeller/rotor low RPM horns, fire warning devices, carbon monoxide detection.
(Note separate reporting criteria for stall warnings, EGPWS/TAWS, TCAS/ACAS, abnormal engine indications or low fuel warnings.)
Mechanical related aircraft incident examples
Incident
Definition
Inclusions / exclusions
Airframe related incidents
Doors /exits
An aircraft door (passenger, cargo, or emergency), or its component parts, has exhibited damage or has failed.
Excludes internal doors, like cockpit doors or lavatory doors.
Landing gear
An aircraft’s landing gear, brakes, their component parts or tyres have failed.
Landing gear collapse due to mechanical malfunction;
Use of emergency gear extension;
Tyre deflation;
Overheated or smoking brakes;
Faults with float type undercarriages;
Faults with emergency flotation devices in helicopters.
Excluded:
-failure of landing gear indication bulbs
-flat tyres while standing or taxiing.
(Note criteria for accidents and reportable serious aircraft incidents for landing gear collapse, and smoke and fire.)
Windows
A window of the aircraft has exhibited damage or has failed.
Separation of windows from the aircraft in flight;
Shattering, cracking, crazing, or delamination of a window;
Window heat arcing.
Wing/fuselage /empennage
Part of the fuselage, wing, or empennage has structurally failed.
Cracks;
Debonding;
Delamination.
(Note criteria for reportable serious aircraft incidents for near collisions.)
Objects falling from aircraft
Objects that are inadvertently detached or dropped from an airborne aircraft.
Detached aircraft parts;
Inadvertent release of towed banner
Cameras or phones lost during open door operations.
Excludes objects deliberately detached or dropped from an aircraft.
(Note criteria for reportable serious aircraft incidents loss of a slung load or any other load carried external to the aircraft.)
Powerplant / propulsion related incidents
Abnormal engine indications
Any indications that an engine is malfunctioning or operating outside normal parameters.
Abnormal engine instrument readings, such as engine power output or temperature, oil pressure or temperature, fuel pressure;
Observation of abnormal sights or sounds by a crew member;
Engine overspeed or over-torque warnings.
Engine failure or malfunction
An engine malfunction that results in a total engine failure, a loss of engine power or rough running engine.
Partial power loss (loss of RPM, surging, coughing);
Inflight shutdown of a failing engine;
Full power loss to an individual engine.
(Note criteria for accidents and reportable serious aircraft incidents.)
Propellers and rotor malfunctions
A failure or malfunction of any part of a propeller, helicopter rotor, or associated components.
Failure of associated propeller accessories, such as feathering mechanisms, constant speed units, and reduction gearboxes;
General reports of damage to a propeller or rotor including delamination.
Transmission and gearboxes
The failure or malfunction of an aircraft transmission or gearbox or associated components.
Includes only when the operation of the aircraft was compromised or had the potential to compromise safety.
(Note criteria for reportable serious aircraft incidents for failure of more than one redundant system.)
Airspace related aircraft incident examples
Incident
Definition
Inclusions / Exclusions
Aircraft separation related incidents
Collision or near collision
A collision or near collision between aircraft, either airborne or on the runway strip.
Near collision is where immediate evasive action was required or should have been taken.
(Note all aircraft collisions and near collisions are either accidents or reportable serious aircraft incidents.)
Airborne Collision Alert System warnings
An airborne collision avoidance system resolution advisory alert or equivalent.
Includes all systems, such as TCAS.
Excludes traffic advisories.
Loss of separation
A situation where the recognised separation standard (vertical, lateral or longitudinal) between aircraft that are being provided with an Air Navigation Service Provider separation service is infringed.
(Note separate reporting requirements for all loss of separation incidents.)
Loss of separation assurance
A separation standard existed, however, planned separation was not provided by the ANSP separation service.
LOSA is an occurrence where separation existed but:
The potential conflict was not identified; or
Separation was not planned or was inappropriately planned; or
The separation plan was not executed or was inappropriately executed; or
Separation was not monitored or was inappropriately monitored.
Other separation issues
Aircraft separation is a concern but does not meet the definition of near collision.
Includes separation issues inside and outside controlled airspace.
Aircraft incident (external)
This is defined as an aircraft incident (any occurrence associated with the operation of an aircraft that affects or could affect the safety of the operation of the aircraft) that originates from any of the following outside the aircraft:
infrastructure
flying and other objects
animals or birds.
Aerodrome related aircraft incident (external) examples
Incident
Definition
Inclusions/exclusions
Aerodrome related
Where aircraft safety has been compromised due to the failure or inadequacy of any aerodrome infrastructure used in conjunction with aircraft operations, including: (i) runway lighting (including approach and slope guidance lighting); (ii) runway, taxiway or apron surface areas; (iii) signs and markings.
Must impact on the operation of an aircraft to be reportable.
Airways facility
Where aircraft safety has been compromised due to the failure or inadequacy of a facility used in connection with an aircraft operation, including: (i) a navigation aid; (ii) communications; (iii) radar/surveillance (including ADS-B); (iv) air traffic services; or (v) general operational services (e.g. briefing, Unicom, etc).
Must impact on the operation of an aircraft to be reportable.
Navigation aids include ground-based and satellite-based aids.
Environment related aircraft incident (external) examples
Incident
Definition
Inclusions/exclusions
Birdstrike or animal strike
A collision between an aircraft and an animal or a bird.
Includes birdstrikes (including when the pilot suspects a birdstrike) where the aircraft is in flight, or taking off or landing anywhere.
Birdstrike and animal strikes where a carcass is found on a runway.
Excludes near strikes.
Collision or near encounter with flying object
Collision or near encounter with a flying object when the object interrupts flight or is sighted in the proximity of an aircraft.
Includes collision or near encounter with any RPA or model aircraft or parachute.
(Note – if an RPA is known to be a type 1 or type 2 RPA, then reporting requirements for collision and near collision apply.)
Interference from ground
Near encounter between an airborne aircraft and an object when the object interrupts the aircraft’s flight path, or
a laser or spotlight being directed at an airborne aircraft that affects the flight; or
any unauthorised communication, signal or system interference directed at an aircraft, air traffic control or air navigation aid.
Must impact on the operation of an aircraft to be reportable.
Includes interference from laser pointer lights, kites, yacht masts, weather balloons.
Other
Other environmental issues that affect the safety of a flight.
Includes insect nests or bodies, or dirt/sand blocking pitot tubes.
Determining injury and damage
Fatal aircraft-related injury
A fatal aircraft related injury is one where the person dies as a result of the injury within 30 days after the injury occurs, and the person suffers the injury as a result of:
being in the aircraft during the operation; or
direct contact during the operation with any part of the aircraft, including parts which have become detached from the aircraft; or
direct exposure to jet blast during the operation.
Fatal aircraft related injuries do not include:
the injury results from natural causes;
the injury is intentionally self- inflicted;
the injury is intentionally caused by another person;
the injury is to a person who is a stowaway in a part of the aircraft that is not usually accessible to crew members or passengers after take off.
Serious aircraft-related injury
A serious aircraft-related injury is when a person suffers a serious injury as a result of:
being in the aircraft during the operation; or
direct contact during the operation with any part of the aircraft, including parts which have become detached from the aircraft; or
direct exposure to jet blast during the operation.
A serious injury is defined as an injury where any of the following apply:
the injury requires, or would usually require, admission to hospital, for more than 48 hours, within 7 days after the day when the injury is suffered;
the injury involves a fracture of any bone (other than a simple fracture of fingers, toes or nose);
the injury involves lacerations which cause severe haemorrhage or severe nerve, muscle or tendon damage;
the injury involves injury to any internal organ;
the injury involves second or third degree burns, or any burns affecting more than 5% of the body surface;
the injury involves exposure to hazardous chemicals, infectious substances or injurious radiation.
Serious aircraft related injuries do not include when:
the injury results from natural causes;
the injury is intentionally self inflicted;
the injury is intentionally caused by another person;
the injury is to a person who is a stowaway in a part of the aircraft that is not usually accessible to crew members or passengers after take off.
Guidance for the determination of aircraft damage
The following excerpt from ICAO Annex 13 Attachment E should be used for guidance when determining if aircraft damage is considered to be an accident:
If an engine separates from an aircraft, the event is categorised as an accident even if damage is confined to the engine.
A loss of engine cowls (fan or core) or reverser components which does not result in further damage to the aircraft is not considered an accident.
Occurrences where compressor or turbine blades or other engine internal components are ejected through the engine tail pipe are not considered accidents.
A collapsed or missing radome is not considered an accident unless there is related substantial damage in other structures or systems.
Occurrences of missing flaps, slats and other lift augmenting devices, winglets, etc., that are permitted for dispatch under the configuration deviation list (CDL) are not considered accidents.
Retraction of a landing gear leg or wheels-up landing, resulting in skin abrasion only, when the aircraft can be safely dispatched after minor repairs or patching, and subsequently undergoes more extensive work to effect a permanent repair, would not be classified as an accident.
If the structural damage is such that the aircraft depressurises, or cannot be pressurised, the occurrence is categorised as an accident.
The removal of components for inspection following an occurrence, such as the precautionary removal of an undercarriage leg following a low-speed runway excursion, while involving considerable work, is not considered an accident unless significant damage is found.
Occurrences that involve an emergency evacuation are not counted as accidents unless someone receives serious injuries or the aircraft has sustained significant damage.
Note 1.— Regarding aircraft damage which adversely affects the structural strength, performance or flight characteristics, the aircraft may have landed safely, but cannot be safely dispatched on a further sector without repair.
Note 2.— If the aircraft can be safely dispatched after minor repairs and subsequently undergoes more extensive work to effect a permanent repair, then the occurrence would not be classified as an accident. Likewise, if the aircraft can be dispatched under the CDL with the affected component removed, missing or inoperative, the repair would not be considered as a major repair and consequently the occurrence would not be considered an accident.
Note 3.— The cost of repairs, or estimated loss, such as provided by insurance companies may provide an indication of the damage sustained but should not be used as the sole guide as to whether the damage is sufficient to count the occurrence as an accident. Likewise, an aircraft may be considered a ‘hull loss’ because it is uneconomic to repair, without it having incurred sufficient damage to be classified as an accident.
Details to be reported
The TSI Regulations outline details of immediately and routine reportable matters that are required to be reported to the ATSB. Practically, the below details should be reported when they are known to the reporter.
Investigation decision making and research using details of occurrences included in the ATSB database benefit from reporting as much detail about the reportable matters as is known. Reporters are encouraged to report all details known and to provide detailed descriptions.
Details to report during telephone notification of immediately reportable matters:
The type, model, nationality, registration marks and flight number (if any) of the aircraft the subject of the immediately reportable matter.
The kind of aircraft operation (with reference to the CASR Part number), and aircraft activity, that the aircraft was engaged in at the time of the immediately reportable matter.
The name and contact details of the operator of the aircraft.
As much detail as is known about the nature of the immediately reportable matter.
A description of any damage to the aircraft or any other property.
A description of any dangerous goods on board the aircraft.
Whether a person died, or was seriously injured.
Where the immediately reportable matter occurred (including a description of the location, or the geographical coordinates).
The aircraft’s place of departure and destination.
The day and local time when the immediately reportable matter occurred.
A description of the following, in as much detail as is known:
what happened;
how and why it happened.
In relation to the responsible person reporting the matter, their name and a method of contacting the person that will enable the person to be promptly contacted for ATSB to conduct further enquiries into the matter.
Details to report in written reports for both immediately and routine reportable matters Note: for bird/animal strikes, see next section.
The name and contact details of the person making the report.
The person’s role in relation to the aircraft concerned.
The type, model, nationality, registration marks and flight number (if any) of the aircraft.
The name of the owner of the aircraft.
The name and contact details of the operator of the aircraft.
If the aircraft was under hire when the reportable matter occurred, the name of the hirer.
The name and nationality of each flight crew member, and the type and licence number of the licence held by each of them (for example, a Recreational Pilot Licence Number).
The Aviation Reference Number of each flight crew member if one has been issued by CASA.
The day and local time when the reportable matter occurred.
The place where the flight started (or intended to start); and the place where the flight was intended to end, and if different, the actual place the flight ended.
The purpose of the flight.
Unless the reportable matter occurred at an airport, the location of the aircraft immediately after the occurrence of the reportable matter, including the geographical coordinates of that location.
The number of persons on board the aircraft when the reportable matter occurred (separately for crew and passengers).
The nature of the reportable matter, including:
its outcome or effect on the flight of the aircraft;
the phase of the aircraft’s flight when the matter occurred;
the weather conditions;
the airspace designation;
the altitude at which the matter occurred;
if the matter occurred at, or in relation to, an airport—the name of the airport;
if the matter occurred on, or in relation to, a runway—the runway number;
the causes of the occurrence (if known), including any human performance issues;
any safety action carried out to prevent a recurrence of the matter; and
the nature and extent of any damage to the aircraft.
The physical characteristics of the area where the reportable matter occurred (e.g. the terrain, vegetation cover, and existence and location of any buildings, runways or aerodromes).
The flight rules under which the aircraft was operating at the time of the reportable matter.
The kind of aircraft operation the aircraft was engaged in at the time of the reportable matter (including the CASR Part number and general activity).
If the matter resulted in a death or serious injury, and the aircraft carried an emergency locator transmitter—whether the emergency locator transmitter was fixed or portable and whether it was activated at the time the immediately reportable matter occurred.
If the aircraft’s pilot has died (and if available, for all accidents):
the pilot’s date of birth; and
the pilot’s total flying hours on all aircraft and flying hours on the same type of aircraft.
If any crew members, passengers and/or other persons have been fatally or seriously injured:
how many;
their names and nationalities; and
descriptions of their injuries.
Details to include in written reports concerning bird/animal strikes
The name and contact details of the person making the report.
The day and local time when the reportable matter occurred.
The nature of the reportable matter, including:
if the matter occurred at, or in relation to, an airport, the name of the airport, and if it occurred on, or in relation to, a runway, the runway number; and
the nature and extent of any damage to the aircraft.
Any other information that the person making the report considers appropriate such as the species, number of birds/animals seen and struck, weather conditions.
Jabiru aircraft’s propeller separated in flight during circuit training
Inspection of the propeller showed extensive fatigue crack propagation to the propeller bolts
Incident highlights importance of following manufacturer’s requirements and recommendations for maintenance and inspections
A Jabiru aircraft’s wooden propeller separated in flight due to extensive fatigue cracking resulting in the fracture of the propeller bolts, an ATSB transport safety investigation details.
An instructor and student pilot had been conducting circuit training in the Jabiru J120-C aircraft at Devonport Airport, Tasmania on 16 January 2022.
While on the downwind leg of a circuit, the student pilot (seated in the left seat) saw a white flash and called ‘seagull’, believing they saw a bird. At the same time, the instructor felt a jarring and saw that the propeller had separated from the aircraft.
The engine RPM immediately increased as the engine was unloaded, however there was no other unusual noise, vibration or indications associated with the propeller separation.
The instructor immediately took control of the aircraft, closed the throttle and conducted an unpowered landing onto the runway. The propeller was subsequently found, on the beach adjacent to the airport, with the tip of one of the blades separated.
“The ATSB’s investigation determined that the propeller separation occurred as a result of fracture of the propeller bolts,” said ATSB Director Transport Safety Dr Stuart Godley.
Examination of the propeller found no evidence of a defect at the fractured tip, while there was no observed organic matter or smearing to indicate a bird strike.
“The propeller bolts showed extensive fatigue crack propagation. Regardless of whether or not the propeller struck a bird, the extent of cracking was such that the propeller could have separated without an external influence, or would have separated with continued operation.”
The investigation also found that propeller washers had not been installed in accordance with the maintenance manual, and this may have contributed to accelerated wear and subsequent cracking of the bolts.
“This incident and investigation highlights the importance of conducting maintenance and thorough inspections of hardware in accordance with the manufacturer’s requirements and recommendations, as deviations can have unintended, and potentially hazardous consequences,” said Dr Godley.
“Particular attention should be paid to evidence of abnormal contact or movement between components as indications of loose or fretting components.”
Dr Godley noted that the ATSB did not typically investigate accidents and incidents involved recreational aircraft registered with Recreational Aviation Australia (RAAus), however Australia is the state of design and manufacture for the Jabiru aircraft. As such the ATSB investigated this incident to determine if there were broader implications of the international Jabiru aircraft fleet.
Flight crews of two separate 737 flights misinterpreted NOTAMs at Darwin Airport and believed a displaced threshold was in operation for runway 11;
Both crews conducted displaced threshold landings on runway 11, unnecessarily reducing available landing distance;
Incidents highlight the critical importance NOTAMS can have for flight planning.
Two 737 passenger flights landed at Darwin Airport in September 2021 with unnecessarily reduced landing distances available to them after their flight crews misinterpreted NOTAMs detailing that a displaced threshold was in place due to runway works.
The incidents occurred on two flights operated by Virgin Australia Boeing 737-800s: the first on 3 September 2021, from Melbourne to Darwin, the second on 19 September 2021, from Brisbane to Darwin.
On both occasions, during pre-flight briefings, flight crews misinterpreted a NOTAM (notice to airmen) for Darwin Airport. The NOTAM stated that runway 29 (for landing from the east) had a displaced threshold of 765 metres due to works in progress and that the eastern end of the runway was not available due to the works.
Landing from the west on runway 11, however, did not require using the displaced threshold, although the landing distance available, due to the runway works at the eastern end, was reduced to 2,670 metres.
“On both occasions, the flight crews misinterpreted the NOTAM and conducted unnecessary displaced threshold landings, reducing the available runway for their landings.”
Both aircraft landed without incident.
“These incidents highlight the critical importance that operational information in a NOTAM can have for the planning and conduct of a flight,” ATSB Director Transport Safety Stuart Macleod said.
“Misinterpretation of NOTAM information can significantly affect flight safety.”
In addition, Mr Macleod noted correct and complete readback of air traffic control clearances are important to confirm information has been received and understood.
“Readbacks provide a valuable defence to detect and correct errors such as occurred during these incidents,” he said.
“Flight crews are also encouraged to seek clarification from air traffic control when there is uncertainty or ambiguity about the condition of a destination, such as a displaced threshold.”
After the first incident, Virgin Australia updated their Flight Crew Operational Notice for Darwin Airport. It then modified it further after the second incident, to specifically highlight the displaced thresholds.
The Australian Transport Safety Bureau (ATSB) has welcomed investigators from the United States to assist in the transport safety investigation into Monday’s large air tanker accident in Western Australia, in line with long-established international protocols.
The Boeing 737-300 was modified by the operator for aerial firebombing, and had conducted retardant drops in the Fitzgerald River National Park when it collided with terrain. Thankfully, both aircrew were able to self-extract from the aircraft without serious injuries before the aircraft was consumed by a post-impact fire.
ATSB transport safety investigators began arriving on site on Wednesday, staging from Hopetoun, to commence the on-site phase of the investigation.
On Friday they welcomed a team of six investigators from the National Transportation Safety Board (NTSB - the US accident investigation agency and equivalent to the ATSB), the Federal Aviation Administration (FAA - the US aviation regulator) and Boeing.
“We are pleased to welcome to Australia our colleagues from the NTSB, FAA and Boeing,” said ATSB Chief Commissioner Angus Mitchell.
“Boeing’s in-depth technical and operational knowledge of the 737, and the NTSB’s and FAA’s experience in investigating large aircraft accidents, will be of valuable assistance to the ATSB as we progress this investigation.”
Mr Mitchell noted that the international standards and recommended practices for conducting and cooperating on aircraft accident investigation are set out by the International Civil Aviation Organization’s Annex 13.
Under those provisions, as the United States was the state of design, manufacture and registration of the 737, the NTSB has appointed an accredited representative to the ATSB’s investigation, with the FAA and Boeing as technical advisors to the NTSB.
“While the investigation is the responsibility of the ATSB, we welcome the important contributions the NTSB, the FAA and Boeing will make.”
Mr Mitchell noted that international accident investigation agencies regularly work closely together, to assist each other with their investigations, and to share knowledge on best practice for conducting transport safety investigations.
“The ATSB enjoys close working relationships with our counterpart agencies across the globe. The assistance we can provide each other regularly leads to meaningful improvements in transport safety, worldwide.”
Cessna 441 charter flight diverted and landed safely after right engine malfunctioned;
Checks identified air/oil cooler return and air/oil separator vent lines had been incorrectly transposed during a recent engine swap;
ATSB reminds maintenance engineers to check relevant documentation, rather than relying on experience and memory.
A Cessna 441 Conquest II turboprop aircraft, operating a charter flight in the Northern Territory, diverted after the pilot observed abnormal engine indications, later found to be caused by oil lines that had been mistakenly transposed, an Australian Transport Safety Bureau investigation report notes.
On 7 September 2021, the twin-engined aircraft was flying from Sawfish Camp to Darwin with nine passengers on board, when during the cruise the pilot observed abnormal torque fluctuations, as well as high oil pressure and high oil temperature indications, from the right TPE-331 engine.
The pilot diverted the aircraft to Tindal Airport and landed uneventfully, with maintenance checks identifying that the air/oil cooler return line and air/oil separator vent line had been incorrectly transposed during a recent engine change.
“The oil lines could be easily transposed, given they were long and flexible enough to each reach either port, and they were the same size, used the same thread, and were almost identical in appearance,” said ATSB Director Transport Safety Dr Mike Walker.
Dr Walker noted that since there was no record of which engineer had done the work, it was not possible to determine whether there were any individual or environmental factors associated with the error, or the extent to which the available maintenance documentation had been checked.
After the oil line issue was rectified, there were further abnormal indications from the right engine, during a flight about 3 weeks after the initial occurrence. After landing, the reduction gearbox scavenge pump was found to be unserviceable.
The ATSB’s final report notes the incorrect oil flow resulting from the transposed oil lines had damaged the engine’s air/oil separator, which then increased the reduction gearbox scavenge pump pressure. This compromised the structural integrity of the pump housing.
“These additional problems had not been detected during the initial maintenance,” Dr Walker noted.
The ATSB’s final report into the incident notes that in 1990 the engine’s manufacturer, Honeywell, issued a service information letter (SIL) advising the oil lines had been transposed on several previous occasions on similar aircraft.
Following this occurrence, the operator, Chartair, commenced a fleet-wide program to add markings to engine oil tanks, conducted toolbox talks with engineering staff about distractions during maintenance, and began documenting each stage of engine changes.
In addition, Honeywell reissued the SIL with additional information and guidance.
“This investigation highlights to maintenance engineers that it is important to check relevant documentation rather than relying on experience and memory, and to remain familiar with other data such as manufacturer service information letters,” Dr Walker said.
“Further, since maintenance documents do not always provide advice on non-routine technical situations, operators and maintainers should seek technical advice from the manufacturer to ensure that non-routine problems are fully rectified prior to releasing an aircraft to service.”
On 27 January 2023 a Boeing 777 aircraft, registered ZK-OKN, was conducting a scheduled passenger flight from Melbourne, Australia to Auckland, New Zealand. Shortly after touchdown at Auckland airport, the aircraft briefly lost directional control and the aircraft veered away from the runway centreline. There was damage reported to 6 runway edge lights and to the aircraft’s undercarriage assembly, including deflation of one tyre, there were no injuries to passengers or crew.
The Transport Accident Investigation Commission (TAIC) requested assistance from the Australian Transport Safety Bureau (ATSB) to download the aircraft’s cockpit voice recorder (CVR) and flight data recorder (FDR) to assist their investigation.
To facilitate this support and to provide the appropriate protections for the information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of ICAO Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.
The recorders were downloaded at the ATSB Canberra facilities on 9 February 2023 and the voice and flight data from the occurrence flight were retrieved and provided to the TAIC investigators in attendance. ATSB staff assisted with further analysis of the data as required.
The TAIC was responsible for the investigation and released the final investigation report regarding this occurrence on 29 May 2025. The report is available here.
Pilot was not qualified for night flight and continued flying in a remote area after last light;
Helicopter collided with the ground after the pilot was likely flying at low-level following roads for navigation;
Accident highlights the inherent risk of night flying in remote areas due to the absence or degradation of visual references for establishing an aircraft’s attitude and position.
A fatal helicopter accident in North Queensland highlights the inherent risk of night flying in remote areas without the qualifications to do so, an Australian Transport Safety Bureau investigation details.
On the evening of 11 February 2021, the pilot of a Robinson R22 had flown from their station at Reedy Springs, south-west of Townsville to an area nearby to look for family members. Attempting to return to Reedy Springs, the pilot became lost, and landed at Camden Park Station, then Wongalee Station, to refuel and get directions.
“Different individuals at both stations suggested the pilot discontinue the journey, due to poor weather conditions and degrading light,” ATSB Director Transport Safety Dr Stuart Godley said.
“However, the pilot elected to continue to their planned destination, taking off from Wongalee five minutes before last light.”
Twenty-nine minutes after last light the helicopter contacted a powerline, which resulted in a loss of ground lighting in the direction of flight.
“Then, shortly after turning to follow an unsealed road in overcast, moonless conditions, the helicopter departed the road after a bend, before flying over open grassland and colliding with trees and terrain in a left bank, nose-down attitude.”
Conditions on the night of the accident were overcast, and just 1 per cent of the moon was illuminated. The severed powerline – which had been supplying electricity to a nearby station – further reduced the amount of ground lighting available to the pilot, who was already operating in a sparsely-populated area.
“Based on the nature and location of the wirestrike, and accident location, it was very likely that the pilot was flying at a low altitude, tracking over a sealed road, then an unsealed road, in an effort to navigate back to their property.”
Dr Godley said the accident highlighted the inherent high risk of night flying in remote areas, due to the absence or degradation of the visual references for establishing an aircraft’s attitude and position.
“Day visual flight rules (VFR) pilots need to plan to arrive at their destination at least 10 minutes before last light – and to not take off after this time under any circumstances.”
A transport safety investigation is underway into the collision and derailment of two trains in Port Botany on 13 January 2023.
At approximately 0605, Pacific National train 1150 (operated by Railtrain Services) and QUBE Logistics train T296 (operated by Sydney Rail Services) collided and derailed during a propelling movement. Both trains derailed and train 1150 came to rest in close proximity to a nearby building. There were no injuries but there was significant damage to both trains and local rail infrastructure.
This investigation is being led by the NSW Office of Transport Safety Investigations (OTSI). OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003.
OTSI has completed the evidence collection and analysis phases of the investigation and is drafting the final report.
The final report will be released at the conclusion of the investigation. However, should a critical safety issue be identified during the course of the investigation, OTSI and the ATSB will immediately notify relevant parties, so that appropriate and timely safety action can be taken.
