Key points

• Aircraft likely stalled following a retardant drop when flying in hazardous conditions that included windshear and an increasing tailwind;
• Crew very likely did not know that other smaller firefighting aircraft had ceased flying in the area, and the assigned birddog aircraft had turned down the tasking, due to the hazardous conditions;
• Aerial firefighting operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that is shared between the tasking agency and the aircraft operator.

A Lockheed C-130 large air tanker that impacted the ground following an aerial firefighting retardant drop likely aerodynamically stalled when flying in hazardous conditions that included windshear and an increasing tailwind, an Australian Transport Safety Bureau investigation has found.

All three crew on board were fatally injured when the aircraft impacted slightly rising terrain while conducting a climbing left turn away from the drop site at the Good Good fire-ground near Peak View, north of Cooma, in the NSW Snowy Mountains region, on 23 January 2020.

Strong gusting winds and mountain wave activity, producing turbulence, were both forecast and present at the drop site. The fire and local terrain at the fire-ground likely exacerbated these hazardous conditions, the investigation report notes.

“The ATSB recognises the critical importance of aerial firefighting, where aircraft are flown at low altitudes and low airspeeds, often in challenging conditions, in the management and suppression of bushfires in Australia,” said ATSB Chief Commissioner Angus Mitchell.

“These operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that, in the Australian operating context, is shared between the tasking agency and the aircraft operator.

“As part of this investigation we have sought to understand the risk mitigations in place at the time of the accident, and have identified a number of safety issues that if resolved through actions will further mitigate risks for large air tanker aerial firefighting in the future.”

The investigation details that the C-130 was being operated by Coulson Aviation under contract to the New South Wales Rural Fire Service (RFS).

On the morning of the accident, the RFS State Operations Centre had tasked two large air tankers operating from RAAF Base Richmond, a Boeing 737 and the C-130, to conduct retardant drops at Adaminaby. The 737 departed first, and after conducting a drop at Adaminaby its crew reported that conditions precluded them from returning to the fire-ground.

The investigation notes that the RFS continued the C-130’s tasking to Adaminaby despite an awareness of the extreme environmental conditions and that all other fire‑control aircraft were not operating in the area at the time. (All smaller fire-control aircraft had ceased flying, a ‘birddog’ lead aircraft initially assigned to support the 737 and C-130 had declined the tasking, and the 737 was returning to Richmond, having declined further tasking to Adaminaby.)

This information was not communicated by the RFS to the C-130’s crew.

Instead, the ATSB notes that the RFS relied on the pilot in command to assess the appropriateness of the tasking to Adaminaby without providing them all the available information to make an informed decision on flight safety.

When the C-130 arrived overhead Adaminaby, the crew assessed the conditions were unsuitable and instead accepted an alternate tasking to the Good Good fire at Peak View, about 58 km to the east, which was subject to the same conditions.

Shortly after conducting a partial drop at Peak View, the aircraft commenced a climbing left turn. Following this, climb performance degraded and while at a low height and airspeed, it was likely the aircraft aerodynamically stalled, resulting in the collision with the ground.

The investigation notes that acceptance of the taskings was consistent with the operator’s practices to depart and assess the conditions to find a workable solution rather than rely solely on a weather forecast, which may not necessarily reflect the actual conditions at the fire-ground.

“The investigation found that Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations, in that there were no operational risk assessments conducted or a risk register maintained,” Mr Mitchell said.

“In addition, the operator did not provide a pre-flight risk assessment tool for their firefighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, and would take into account elements such as crew status, the operating environment, aircraft condition, and external pressures and factors.”

Separately, the RFS had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision, the investigation found.

The RFS also did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.

“The responsibility for the safety of aerial firefighting operations has to be shared between the tasking agency and the aircraft operator,” Mr Mitchell said.

“This accident highlights the importance of having effective risk management processes, supported by robust operating procedures and training to support that shared responsibility.”

Mr Mitchell noted Coulson Aviation has taken proactive safety actions in response to the accident, including the introduction of a pre-flight risk assessment tool, a new three-tiered risk management approach, and windshear procedures and training.

Separately, the RFS has committed to undertake a comprehensive review of RFS aviation doctrine and undertake detailed research to identify best practice (nationally and internationally) relating to task rejection and aerial supervision policies and procedures as well as initial attack training and certification.

Mr Mitchell welcomed that commitment but noted the ATSB has issued three safety recommendations to the RFS to take further action to reduce the risk associated with three safety issues identified in the investigation. These concern managing and communicating task rejections, aerial supervision requirements, and initial attack certification.

The ATSB has also issued two safety recommendations to Coulson Aviation. These are to further consider the fitment of a windshear detection system to their C-130 aircraft, and to incorporate foreseeable external factors into their pre-flight assessment tool.

Read the report: Collision with terrain involving Lockheed Martin EC130Q, N134CG, 50 km north-east of Cooma-Snowy Mountains Airport (near Peak View), New South Wales, on 23 January 2020

The Australian Government has launched a new $30 million Automatic Dependent Surveillance Broadcast (ADS-B) rebate program to support more general and recreational visual flight rules (VFR) aircraft owners to install the technology into their aircraft.

ADS-B transmits GPS-derived position data, aircraft identification and other aircraft performance parameters, which can provide pilots near real-time locational data to enhance their situational awareness of other ADS-B equipped aircraft near-by. This can aid self-separation from other aircraft, particularly in non-controlled airspace, helping to reduce the risk of collisions.

In Australia, all aircraft operating under instrument flight rules (IFR) are required to be fitted with ADS-B, with its fitment to aircraft operating under VFR voluntary.

To increase the uptake of ADS-B in VFR aircraft, the government is now providing a 50% rebate of the purchase cost of eligible ADS-B devices and, where applicable, the installation, capped to $5,000. Low-cost portable ADS-B devices will also be eligible for the grant.

“Ensuring the safety of our pilots, other aviation workers, passengers and those on the ground is of the utmost importance each and every time a plane takes off, which is why the funding of this technology will make a huge positive impact,” Infrastructure, Transport, Regional Development and Local Government Minister Catherine King said in announcing the scheme.

The rebate program, which opened on 12 August 2022, directly responds to calls from industry to encourage the uptake of ADS-B technology to realise its many benefits.

“The ‘see and avoid’ principle has known limitations, and the use of ADS-B with a cockpit display or an electronic flight bag application showing traffic information greatly improves a pilot’s situational awareness and enhances the safety of their flight,” Australian Transport Safety Bureau Chief Commissioner Angus Mitchell said.

“ATSB transport safety investigators can also use ADS-B data to help build a detailed picture and better understanding of an aircraft’s flight path* and performance in the lead up to an incident or accident, which can lead to better safety outcomes for the aviation community.”

The precise positional data available from ADS-B can also assist in managing life-saving search and rescue (SAR) operations undertaken by the Australian Maritime Safety Authority (AMSA).

“ADS-B data is another valuable tool used for SAR operations in Australia which helps to improve our ability to save lives,” AMSA’s Chief Executive Officer Mick Kinley said.

“For aircraft in distress, that are equipped with ADS-B, AMSA’s Joint Rescue Coordination Centre Australia will use the aircraft’s ADS-B data to refine a distress location and provide enhanced traffic conflict data in a search area that may involve multiple SAR aircraft.”

The ADS-B rebate program will be open until 31 May 2023 or until funding is exhausted, whichever occurs first.

For more information, including on how to apply, visit https://business.gov.au/grants-and-programs/automatic-dependent-surveillance-broadcast-rebate-program(Opens in a new tab/window).

* The above Google Earth image was generated by ATSB transport safety investigators using ADS-B data to show the flight path of Bell UH-1H helicopter, registered VH-UVC, which lost of control and collided with water 5 km south-west of Anna Bay, New South Wales, on 6 September 2019 (AO-2019-050).

An Australian Transport Safety Bureau investigation preliminary report has detailed that an Airbus A350 passenger aircraft was about to be pushed back for departure from Brisbane Airport before it was observed that covers were still in place on its pitot probes.

Aircraft are fitted with pitot probe covers when parked at Brisbane Airport to prevent mud wasps building nests within and blocking their pitot probes, which are used to measure air pressure to calculate airspeed.

The preliminary report on the 27 May 2022 occurrence, released to provide timely information to industry to highlight the importance of pitot probe covers being removed, notes that an aircraft refueller on an adjacent bay observed the pitot probe covers were still in place when the aircraft appeared ready for pushback.

“A known hazard at Brisbane Airport, mud wasps can rapidly build nests in aircraft pitot probes,” noted ATSB Director Transport Safety Dr Michael Walker.

“An aircraft being cleared to commence taxiing and then commence take-off with all pitot probe covers still fitted is a serious event.”

Two maintenance contractor ground crew engineers – a licensed aircraft maintenance engineer (LAME) supervising an inexperienced aircraft maintenance engineer (AME) – had been assigned to conduct scheduled receipt, dispatch, certification, and maintenance duties for the Singapore Airlines A350 aircraft during a two-hour turnaround at Brisbane.

As pushback approached, the covers remained in place until an aircraft refueller, working at an adjacent bay, observed them and alerted the supervising LAME.

The pitot covers were then removed two minutes before expected departure, and pushback occurred shortly afterwards.

As part of its investigation, to date the ATSB has interviewed the LAME, AME and the refueller, and reviewed airport security video, which did not show that the required final walk-around of the aircraft was conducted by either the LAME or the AME prior to dispatch.

“From here, the investigation will include examination of flight crew pre-flight inspection procedures, engineering final walk-around procedures, and induction training procedures,” Dr Walker said.

“It will also examine the engineers’ training records, policies and procedures around fatigue and change management, and more security video recordings.”

The ATSB has previously highlighted the risks of pitot probe covers not being removed prior to departure with its investigation into a March 2018 incident where an Airbus A330 took off from Brisbane with covers still in place, meaning the flight crew were faced with unreliable airspeed indications.

That ATSB investigation (AO-2018-053) identified safety factors across a range of subjects including flight deck and ground operations, aircraft warning systems, air traffic control, aerodrome charts, and risk and change management.

“The loss of airspeed data due to mud wasp ingress can occur even after brief periods, and the use of pitot probe covers for aircraft turnarounds at Brisbane is largely an effective defence,” Dr Walker said.

“However, as that earlier ATSB investigation identified, their use introduces another risk, which is the potential for aircraft to commence a take-off with pitot probe covers still fitted.”

Read the preliminary report: Flight preparation event involving Airbus A350-941, 9V-SHH, Brisbane Airport, Queensland, on 27 May 2022

Read the final report: Airspeed indication failure on take-off involving Airbus A330, 9M-MTK Brisbane Airport, Queensland, 18 July 2018

Key points:

• Two passengers sustained serious injuries during the hard landing of a hot-air balloon during a Yarra Valley scenic flight;
• The passengers had received an incomplete pre-flight briefing, probably resulting in them adopting a deep squat position during the hard landing, contributing to their injuries;
• Despite deteriorating wind conditions, the pilot rejected several suitable landing fields to avoid possible post landing logistical and operational difficulties, and eventually conducted a hard landing in a field to avoid contact with powerlines.

An ATSB investigation into a hard landing of a commercial hot air balloon in which two passengers sustained serious injuries highlights the importance of pre-flight briefings being completed and understood by all passengers.

On 31 December 2021, a Kavanagh B-350 balloon with 16 passengers and a pilot on board took off from near Glenburn, just north of Victoria’s Yarra Valley, for a planned one-hour scenic charter flight.

About 42 minutes later, the balloon pilot learned via a radio call that the wind was increasing near the intended landing area at Yarra Glen. Over the next 17 minutes, with the wind increasing, the pilot assessed multiple landing options before making an approach to land in a field.

During the approach the pilot manoeuvred the balloon to clear a fence before descending rapidly to avoid contact with nearby powerlines, and then landing hard. The basket then tipped onto its side and dragged for 30-40 metres. Two passengers sustained serious leg injuries.

The ATSB’s investigation found that, just prior to the landing, three passengers adopted a deep squat position.

“This was not in accordance with the prescribed pre-flight passenger safety briefing,” ATSB Director Transport Safety Stuart Macleod said.

“However, not all required actions were completed during the pre-flight briefing, probably due to time pressure and the pilot’s assumption that all passengers would understand an abbreviated briefing.”

“This incomplete briefing probably resulted in these three passengers adopting an inappropriate deep squat position prior to the hard landing, causing two of them to be seriously injured.”

Mr Macleod said the hard landing is a clear reminder for balloon pilots and operators of the importance of the pre-flight briefing being thorough and clearly understood.

“The pre-flight briefing is critical in ensuring passenger preparation, particularly as opportunities to reinforce that information during the flight may be limited.”

The investigation found that although wind conditions were deteriorating, the pilot rejected several suitable landing fields to avoid post-landing logistical and operational difficulties.

“While some landing options may not be ideal due to the impact on landowner relations, or the ease of access to the site after landing, pilots are reminded to prioritise occupant safety over such considerations, when faced with deteriorating wind conditions,” Mr Macleod said.

With safe landing sites progressively reduced as the flight continued, the balloon was landed in a field which presented high risks in the prevailing windy conditions.

The field contained fences, had powerlines downwind, and was the last landing field known to the pilot along the balloon’s track.

“The landing was complicated by the balloon descending faster than intended, bouncing off the ground back into the air, and then due to manoeuvres to clear fences,” Mr Macleod noted.

“These factors, in combination with the prevailing winds and nearby powerlines, led to the pilot descending the balloon rapidly from an excessive height, resulting in the hard landing.

“While undesirable, the hard landing was the safer option instead of risking contact with the power lines. However, hard landings still increase the risk of pilot and passenger injury.”

Although not contributing to the passenger injuries, the investigation also found that the maximum number of passengers that the balloon operator allowed to be carried on the balloon meant that there was insufficient room in the basket for passengers to adopt the backwards-facing landing position specified in the operator's procedures.

Read the final report: Hard landing involving Kavanagh Balloons B-350, VH-BSW 2 km south of Lilydale Airport, Victoria, on 31 December 2021

Key points:

• Instructor and student were conducting an aerobatic training flight in a Cessna A150 Aerobat to introduce and practice spin entry and recovery;
• Instructor likely intended to practice two spin recovery techniques, one of which has been shown to not recover a Cessna A150 Aerobat established in a spin to the left;
• While experienced in other aerobatic aircraft, the instructor likely had no experience conducting spinning and/or spin instruction in the accident aircraft type or similar variants;
• ATSB has issued a Safety Advisory Notice alerting aerobatic pilots and instructors of the limitations of the Meuller/Beggs spin recovery method for some aircraft types.

he Australian Transport Safety Bureau is advising aerobatic pilots and instructors of the limitations of the Meuller/Beggs spin recovery method for some aircraft types, after an investigation into an aerobatics training flight accident on Queensland’s Sunshine Coast.

During the accident flight on 23 June 2021, an instructor and student were likely intending to practice two methods of spin recovery. One of those techniques, broadly known as the Meuller/Beggs method, has been shown to not recover a Cessna A150 Aerobat established in a spin to the left.

Both occupants were fatally injured when the aircraft collided with bushland near Peachester.

Air traffic control radar data showed that about 20 minutes after take-off the aircraft entered a spin to the left 5,800 ft above ground level, and then impacted the ground 55 seconds later.

The ATSB’s analysis of the accident site established that the aircraft’s forward movement and low angle of entry indicated it was most likely in the process of recovering from the spin when it impacted with terrain.

The aerobatics instructor was experienced in conducting spins, primarily in the Pitts Special aircraft type, for which the Mueller/Beggs method is effective. However, it was likely that they had no experience in spinning a Cessna A150 Aerobat or any similar variant.

“The instructor likely intended to practice two spin recovery techniques, including the Mueller/Beggs recovery method, which has been shown to not recover a Cessna A150 Aerobat established in a spin to the left,” ATSB Director Transport Safety Dr Michael Walker said.

The other method planned to be demonstrated, the generic PARE method typical of most small single-engine aeroplane types, aligned closely with the aircraft’s pilot’s operating handbook (POH) and, if utilised, would recover the aircraft from a spin.

“A second student, who was also to fly the same training flight with the instructor in the Aerobat aircraft later that day, told the ATSB they believed they would be conducting both methods of spin recovery,” Dr Walker said.

“The ATSB therefore concluded it was likely the instructor was either not aware, or did not recall, that the Aerobat would not recover using this method in a spin to the left.”

Dr Walker noted that, based on the available evidence, the ATSB was unable to ascertain which recovery technique or techniques were being utilised at the various stages of the spin recovery preceding the accident. For this reason, the ATSB could not conclude if the use of an inappropriate recovery technique contributed to the accident.

“Nevertheless, this investigation presents a timely reminder that pilots should review the POH of the aircraft type that they intend to operate, and obtain instruction and/or advice in spins and recovery techniques from an instructor who is fully qualified and current in spinning that model,” Dr Walker said.

To highlight this message, the ATSB has issued a Safety Advisory Notice to aerobatic pilots and instructors, flying training organisations and aerobatic aircraft owners to raise awareness of the limitations of the Mueller/Beggs spin recovery method.

“Prior to intentionally spinning an aircraft, pilots should obtain instruction and/or advice in spins and recovery techniques from an instructor who is fully qualified and current in spinning that model,” Dr Walker said.

“All aircraft types do not spin and recover in the same way. Know your aircraft type, what recovery techniques will work and what recovery techniques will not work.”

Read the final report: Collision with terrain involving Cessna A150M, VH-CYO, 5 km west-south-west of Peachester, Queensland, on 23 June 2021

The derailment of a freight train after heavy rainfall near Charters Towers highlights to rail infrastructure managers the importance of adequate and well-maintained drainage, according to the Australian Transport Safety Bureau investigation of the incident.

Eleven wagons derailed on a loaded Aurizon freight train while it was travelling over a drainage culvert about 110 km south-west of Townsville, in the early morning of 30 December 2020.

While the locomotive stayed on the track and neither of the crew were injured, damage to the track and rolling stock was substantial.

The ATSB’s investigation found the derailment occurred after a series of rainfall events the day prior.

“While the rainfall was heavy, the ATSB’s calculations did not indicate it exceeded the design flow of the culvert itself,” ATSB Director Transport Safety Dr Stuart Godley said.

“It is therefore likely the pipe’s throughput was restricted.”

Dr Godley noted the culvert had been cleaned and cleared on 6 December, just over three weeks prior to the derailment.

“The throughput restriction could have been due to sinking, debris blocking the pipe, collapse of the pipe itself due to an exceedance of its service life – or a combination of the three,” he said.

The pooling of rainwater on the upstream side of the culvert led to it over-topping the track, which very likely undermined the track infrastructure, such that it could not support the weight of the train early the next morning.

Since the incident the track owner, Queensland Rail, has significantly improved drainage at the site, with the single 1,050 mm pipe now replaced with three new 900 mm pipes.

Queensland Rail has also had a contractor conduct a hydrology study along the rail line from Stuart, through Hughenden to Cloncurry, Mount Isa and Flynn to Phosphate Hill.

It has also identified a further 44 sites for new and upgraded weather monitoring equipment, and progressed a business case for required capital expenditure.

“To minimise the risk of system inundation and track over-topping, rail infrastructure managers should ensure their drainage systems are fit for purpose, and are clear, open, and in a serviceable condition,” Dr Godley said.

Read the final report: Derailment of freight train 9281, near Charters Towers, Queensland, on 30 December 2020

The Australian Transport Safety Bureau has released a preliminary report from its ongoing investigation into a Bell LongRanger helicopter accident in Kosciuszko National Park on 3 April.

The report, which details factual information from the investigation’s evidence collection phase to date, notes the helicopter collided with terrain at Kiandra Flats, 4,501 ft above sea level, after a steep left descending turn from 7,400 ft, fatally injuring the pilot and passenger.

Earlier on the day of the accident, the helicopter had departed from Majura, north of Canberra Airport, operating under visual flight rules (VFR). It was one of seven helicopters on a flying tour, following a common itinerary but operating independently of one another.

The six other helicopters landed on a property near Wee Jasper after encountering deteriorating weather, while the pilot of the accident helicopter continued further south before landing alongside Long Plain Road in the Brindabella region.

When the LongRanger didn’t arrive at Wee Jasper, the other pilots contacted authorities, who launched a search.

“With the help of a passing motorist, the pilot of the LongRanger was able to reach mobile reception and contact other members of the tour group, and the search was called off,” ATSB Director Transport Safety Stuart Macleod said.

Almost three and a half hours after landing beside Long Plain Road, recorded flight tracking data showed the LongRanger took off again at 1453 local time.

“Police officers dispatched to locate the helicopter as part of the earlier search arrived at the site just after it took off, and observed the helicopter depart to the south at low level, in overcast conditions with low cloud and light rain,” Mr Macleod said.

The forecast for the area at the time of this second flight indicated broken cloud between 2,500 ft and 10,000 ft above sea level.

Tracking data, reviewed by the ATSB, showed the helicopter progressed below 500 ft above ground level, following geographical features along lower lying terrain.

“About 10 minutes into this second flight, the pilot turned north-west and took up a track towards Tumut, which they had indicated to the tour group as their intended refuelling destination,” Mr Macleod said.

“They then encountered higher terrain and turned around to head southward, again following lower lying terrain for another 10 minutes, before reaching Anglers Reach, at which point they turned back on a track towards Tumut.”

The helicopter climbed to 7,000 ft above sea level – about 2,500 ft above ground level – and continued for about six minutes, before descending to 6,800 ft, and almost immediately climbing again.

“After climbing to 7,400 ft, the helicopter commenced the steep turn, its ground speed increased to 134 kt, and its descent rate exceeded 3,800 ft per minute.”

The helicopter impacted terrain at 1526 in an area of tussock grass, interspersed by bare protruding rock.

The following morning, in response to the LongRanger not meeting the tour group as planned at Mangalore, Victoria, a second search was initiated. Assisted by aircraft tracking data, a ground team located the accident site that evening.

The ATSB’s subsequent examination of the site indicated the helicopter’s engine was providing power at impact, and there was no evidence of an in-flight break-up or a pre-existing defect with the drive train or flight controls.

“As the investigation progresses, the ATSB will further review and analyse pilot and maintenance records, recovered wreckage components, the flight tracking data, witness information and meteorological data,” Mr Macleod said.

A final report, which will detail analysis and findings, will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified at any time as the investigation progresses, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: Collision with terrain involving Bell Helicopter 206L-4, VH-PRW 33 km north west of Adaminaby, New South Wales on 3 April 2022

The Australian Transport Safety Bureau has released a preliminary report from its on-going investigation into a fatal accident involving a Piper Pawnee aerial application aircraft at Seaview, Victoria on 23 February 2022.

The report, which details factual information established in the early evidence collection phase of the investigation, notes the aircraft was flown from Leongatha to a private landing area 25 km north at Seaview, landing at about 0700 local time, in preparation for aerial spreading of superphosphate pellets.

A loader driver arrived shortly afterwards and, finding the loader already pre-filled with superphosphate pellets by the pilot, transferred them into the aircraft’s hopper.

The landing area was normally used for cattle grazing, and was prepared for aerial application operations once a year. It had been mowed into a ‘Y’ configuration by the pilot in the days before the accident.

“Data from the aircraft’s onboard GPS showed the pilot commence the take-off at about 0711,” ATSB Director Transport Safety Dr Mike Walker said.

“According to witnesses and video, the aircraft accelerated along the strip and traversed the right branch of the ‘Y’ and briefly became airborne at a point at the end of the strip, where the terrain dropped away.”

The outboard section of the aircraft’s left wing then struck trees, and the aircraft rolled to the left, pitched down, and impacted the ground.

The pilot was fatally injured, and the aircraft was destroyed.

“The ATSB’s on-site examination of the aircraft wreckage indicated no pre-impact defects with the aircraft’s flight controls or aircraft structure,” Dr Walker noted.

“Damage to the propeller indicated the engine was driving it with significant power at impact, and preliminary audio analysis of a witness video indicates the engine was at or close to its maximum rotational speed throughout the take-off.”

Based on local weather observations and the witness video, the weather at the time was fine with the wind likely calm.

Dr Walker noted that while the aircraft’s hopper was capable of carrying about 700 kg of pellets for aerial application, its maximum permissible load was 544 kg.

“The exact volume or weight of superphosphate loaded into the aircraft prior to the accident could not be determined, and the loader driver could not later recall how much superphosphate had been loaded,” he said.

Dr Walker said the investigation is continuing and will include examination of pilot and aircraft records and further analysis of the witness video and the aircraft’s GPS data.

“In addition, consideration of aircraft weight and balance and take-off performance is a central theme of this investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

A final report will be released at the conclusion of the investigation.

Read the preliminary report: Collision with terrain involving Piper PA-25-235/A9 aircraft, VH-SEH, near Seaview, Victoria, on 23 February 2022

A Safety Advisory Notice has been issued to rollingstock operators as part of an ongoing investigation by the Office of Transport Safety Investigations (OTSI), into the derailment of a grain train near Wollongong.

The Notice has arisen from an ongoing investigation being conducted by OTSI on behalf of the Australian Transport Safety Bureau, into the derailment of a loaded grain train on the 1 in 30 grade rail line between Robertson and Unanderra, NSW, on 15 December 2020.

“During the descent, the train driver lost control of the train,” OTSI Chief Investigator and CEO Dr Natalie Pelham explained.

“The driver did not apply the emergency brake as the train continued to gain speed, as they believed the emergency application of the air brake would disengage the dynamic brake.”

The investigation identified, however, the locomotive’s electronic braking system did allow the dynamic brake to remain active while the emergency brake was applied.

“This feature was unknown to the operator and the train driver,” Dr Pelham said.

The investigation has identified that had the driver been fully aware of the braking functionality, it is likely they would have applied the emergency brake which may have slowed the runaway train and lowered the risk of derailment.

“Today’s advisory instructs all rail operators to review specifications and test locomotives under their control to understand how the braking systems are configured,” Dr Pelham said.

“Operators must have a complete understanding of the operation of their locomotives. Identifying safety critical information from technical specifications and testing locomotive operations must be completed and used to inform the organisation’s procedural and training material.”

OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003.

The investigation into the Dombarton incident is due to be finalised in the third quarter of 2022.

Read the Safety Advisory Notice: (RO-2020-022-san-002) Unknown functions in locomotive braking systems

Addendum 6 July 2022: some wording in this statement updated to more accurately reflect the wording in the SAN