After take-off and at a height of 80 feet, the pilot noticed
that the front baggage compartment door was open. With
approximately 2,500 feet of runway remaining he decided to land
immediately and, without changing the attitude of the aircraft,
closed the throttle. The aircraft sank rapidly and power was not
increased until just before the aircraft landed heavily in a level
attitude.
When the aircraft arrived over Hughenden it descended to a
height of about 400 feet over houses on the southern and
north-eastern areas of the town, then climbed slightly and flew at
a low height across the town towards the golf course. The aircraft,
on two occasions, flew at a height of about 300 feet over the golf
course, in the vicinity of the club house, then climbed, circled to
the left and descended to a very low height over a group of people
who were playing golf. The aircraft then climbed steeply to
approximately 200 feet at which height the pilot apparently lost
control of the aircraft and it stalled, yawed sharply and dived to
the ground. The Initial impact was taken on the nose and starboard
main wheel and the aircraft skidded for a distance of 169 feet
before coming to rest.
The pilot, who was not the holder of an Agricultural Pilot
rating, was about to spray a cotton field on his own property. He
was attempting a spraying run from the north into the south which
required passage over two separate power line arrays to the north
of the paddock. The two arrays converged to the east but were
separated by 220 feet at the points at which they crossed the
flight path, the one closer to the paddock being 26 feet high and
the other 18 feet high. The pilot did not make an examination for
possible obstructions before spraying, as he was familiar with the
area. He believed that the wires were only 40 feet apart on the
line of the first spraying run and he approached from the north
with adequate clearance over the lower wires then immediately
commenced a descent to spraying level. The landing gear assemblies
contacted with southern-most power line and the aircraft nosed down
and decelerated sharply. Impact with the ground, with virtually no
forward velocity, was made on the nose and undercarriage, which
collapsed. The aircraft came to rest upright, 150 feet beyond the
point of contact with the power line and there was no fire.
At 0830 hours Western Standard Time on 31st December, 1968, a Viscount 720C aircraft, registered VH-RMQ, was scheduled to commence a regular public transport service, designated Flight 1750, from Perth to Port Hedland in the State of Western Australia.
The aircraft struck the ground in open spinifex-grassed country. The aircraft was destroyed by severe impact forces and the major portion was also affected by an intense post-impact fire.
There were 22 passengers and 4 crew on board, none of the aircraft occupants survived the impact.
What are the Transport Safety Investigation Regulations?
The Transport Safety Investigation Regulations (TSI Regulations) set out requirements for reporting safety occurrences across the aviation, marine and rail transport modes to the ATSB. They prescribe, among other things, the kinds of matters that must be reported to the ATSB, the kinds of responsible persons who are required to make a report, and the particulars to be included in an occurrence report.
Amendments to the TSI Regulations came into effect from 1 January 2023. The amendments, developed after three rounds of consultation with industry between 2019 and 2022, establish a revised aviation occurrence reporting framework across 4 aircraft operation categories. 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.
The revised regulations also prescribe additional responsible persons in the aviation and marine industries who are required to provide reporting, in particular sport aviation bodies, marine pilotage providers and vessel traffic service authorities.
A number of other clarifications improve administration of the reporting scheme.
Guidance for the aviation industry on what and how to report to the ATSB as prescribed in the TSI Regulations is provided here. 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.
A detailed overview of the changes introduced with the TSI Regulations (2022 amendment) can be found below.
Overview of changes to the Transport Safety Investigation Regulations (2022 amendment)
The changes amended the TSI Regulations in the following manner:
establish four categories (Category A, B, C and D) of aircraft operations based on the types of accident and incidents to be reported, where higher categories (passenger carrying and commercial operations) would have a greater reporting focus due to the greater public safety benefit that could be derived;
ensure immediately reportable matters are consistent with those matters more likely to be considered for investigation based on ATSB methodology, while reducing the reporting requirements on industry for those matters the ATSB are less likely to consider for investigation;
align aircraft operation definitions with flight operations rules in civil aviation legislation administered by CASA which commenced in December 2021 – this includes replacing references to regular public transport and charter operations which are no longer used in the civil aviation regulatory framework;
align key concepts such as aircraft accident, serious aircraft incident, aircraft incident, fatal injury and serious injury, with International Civil Aviation Organization definitions;
simplify reporting requirements for industry by removing prescriptive lists of individual kinds of incidents and defining occurrence concepts more broadly, with guidance material published on the ATSB website and in the AIP to supplement examples of matters to be reported;
clarify that certain aircraft incidents are to be reported as serious aircraft incidents, due to their relative importance in identifying safety risks;
clarify that occurrences during repositioning flights prior to conducting a passenger transport operation (Category A) or non-passenger commercial operation (Category B) are reportable as part of the planned operation;
prescribe additional persons who are responsible for reporting in the aviation industry (sport aviation bodies) and marine industry (pilotage service providers and vessel traffic service providers) to increase the ATSB’s safety information coverage; and
improve ATSB’s administration of the occurrence reporting framework by making other minor, technical or clarifying changes.
Categories of aircraft operations
Each of the categories mentioned cover the following kinds of aircraft operations:
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.
Kinds of reportable matters
The amended reporting framework, based on categories of aircraft operations, facilitates ease of understanding what would be reportable as an immediately reportable matter (IRM) or routine reportable matter (RRM) to better align with the ATSB’s investigation methodology and reduce reporting anomalies. The following table summarises the different categories of aircraft operations with associated IRM and RRM to be reported. Each of the 7 classifications referred to in the table is defined in the Regulations and the Guidance, and the guidance also provide comprehensive examples of events that fall into each classification.
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
The ATSB investigates accidents and incidents solely to improve transport safety, and we share the findings and safety messages from our investigations on social media so that others may learn from them. Our investigations do not apportion blame nor provide a means for determining liability.
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The Australian Transport Safety Bureau (ATSB) is seeking views from the aviation and marine industry, and other interested stakeholders, on proposed amendments to the Transport Safety Investigation Regulations 2021 (TSI Regulations). The proposed amendments to the TSI Regulations are set out in the Exposure Draft for the Transport Safety Investigation Amendment (2022 Measures No. 1) Regulations 2022 (the Exposure Draft).
The Exposure Draft proposes to make the following changes to the TSI Regulations:
For the purpose of accident and incident notification, aircraft operations are put into four categories (Category A, B, C and D) based on the types of accident and incidents they will have to report. Consistent with the Minister’s Statement of Expectations to the ATSB, the greatest focus is on receiving reports where the information is most likely to be used for the greatest public safety benefit.
Align aircraft operation categories and updating definitions consistent with flight operations rules administered by the Civil Aviation Safety Authority (CASA) which commenced on 2 December 2021.
Align key concepts such as accident, serious aircraft incident and aircraft incident, as well as kinds of examples, with International Civil Aviation Organization (ICAO) equivalents as best as practicable.
Removing prescriptive lists of individual kinds of incidents and defining occurrence concepts more broadly, with guidance material supplementing examples of matters to be reported.
Clarify that certain aircraft incidents are to be reported as serious aircraft incidents, due to their relative importance in identifying safety risks.
Clarify that occurrences during repositioning flights prior to conducting a passenger transport operation or non-passenger commercial operation are reportable as part of the planned operation.
Prescribe additional persons who are responsible for reporting in the aviation industry (aircraft insurers and sport aviation bodies) and marine industry (pilotage service providers and vessel traffic service providers) to increase the ATSB’s safety coverage.
Improve ATSB’s administration of the occurrence reporting framework by making other minor, technical or clarifying changes.
To assist readers, an unofficial compilation of the TSI Regulations incorporating the Exposure Draft amendments – as if it had commenced – is provided for reference at
To provide a holistic view of the proposed changes and how it might be implemented, a draft version of updates to the Aeronautical Information Publication (the AIP) is also enclosed (at
). The AIP is guidance material published by Airservices Australia and the ATSB has responsibility for updating content on occurrence reporting.
In large part, it is not expected that the proposed changes will have significant impact on industry participants, which are already required to report occurrences to the ATSB by telephone and/or by written reporting. For the aviation industry, the alignment of aviation occurrence reporting terminology and concepts with CASA’s flight operations rulesets will provide more, rather than less, clarity on how different kinds of aircraft operations are treated for the purposes of occurrence reporting.
The amendments are proposed to be made by 30 June 2022, which aim to provide 6 months of lead time before commencement on 1 January 2023.
Proposed amendments to TSI Act
There are two complementary proposed policy changes also being consulted which relate to potential future amendments to the Transport Safety Investigation Act 2003 (TSI Act). These two proposals are not included in the Exposure Draft. Subject to decisions of the Parliament, they will be considered as part of future reforms to the TSI Act.
The first of these proposals is to extend the reporting timeframe for written reporting following an immediately reportable matter (IRM) and a routine reportable matter (RRM) from within 72 hours to within 7 days. The genesis of this proposal is upcoming reform (anticipated July 2022) of rail sector reporting requirements in State-based legislation, progressed by the Office of the National Rail Safety Regulator (ONRSR).
The second proposed change to the TSI Act is to clarify that the regulations may prescribe the means by which the written report is submitted. Presently, the TSI Act empowers the regulations to prescribe the particulars of written reports but it is unclear whether the means of their submission might also be prescribed (as is the case with similar provisions in sections 18 and 19 of the TSI Act). The purpose of this clarification to the TSI Act is to eventually enable an update to the regulations to describe how written reports must be submitted. Preferably, in the future, the regulations would prescribed electronically-compatible formats to allow ATSB systems to automatically ingest and process data.
The ATSB thanks readers of this consultation paper, the Exposure Draft and the draft AIP updates for their interest and participation in the legislative-making process.
Public Consultation Paper
Amendment to the Transport Safety investigatoin Regulations 2021 - Exposure Draft and related matters
Non-restricted documents in relation to an aircraft accident involving a Cessna 172M, VH-WTQ near Agnes Waters, Queensland on 10 January 2017 (ATSB investigation number AO-2017-005).
Any expert reports, aircraft maintenance and components reports, pilot information and training records, witness information and statements, meteorological reports, site and wreckage reports, reports on similar accidents involving similar aircraft, and any on-board audio and video analysis from any onboard recording device excluding non-restricted information (ATSB investigation number AE-2018-023).
In relation to the parting of Metro Trains Melbourne passenger train TD 3817 on 9 November 2018:
Copies of all documents relating to complaints, including requests for inspection, maintenance, repairs and works on X’Trapolis Units 959M-1680-960M and 882M- 1641T-881M from 9 October 2017 to 9 October 2019;
Copies of all documents relating to the inspection, maintenance, repairs and works on X’Trapolis Units 959M-1680-960M and 882M-1641T-881M from 9 October 2017 to 9 October 2019;
Copies of all documents, reports, incident reports, investigations, memoranda, letters, emails, correspondence and photographs with respect to the parting of Metro Trains Melbourne passenger train TD 3817 from 9 November 2018 to now;
Copies of all documents, reports, investigations, memoranda, letters, emails, correspondence and photographs with respect to the ATSB Transport Safety Report Rail Occurrence Investigation (RO-2018-019) dated 9 October 2019 from 9 November 2018 to now.
