A fly-away incident where a DJI Inspire 2 remotely piloted aircraft (RPA) collided with a hotel window, injuring an occupant, serves to remind operators to be familiar and well drilled in emergency procedures, an ATSB investigation notes.

On 15 January 2021, the DJI Inspire 2 was being used for aerial photography and videography above Cockle Bay in Darling Harbour, Sydney.

Shortly after take-off, the RPA unexpectedly accelerated away from the pilot, and became unresponsive to control inputs. It accelerated to its maximum speed and, a short time later, collided with the window of a hotel adjacent to Darling Harbour.

The RPA shattered the window but did not penetrate it. A person inside the hotel received minor injuries from flying glass, and the RPA was destroyed.

The ATSB investigation into the incident found the compass of the RPA failed due to electromagnetic interference during flight, leading to the fly-away.

“Occurrence data reported to the ATSB indicates RPA fly-away occurrences are not rare,” ATSB Director Transport Safety Stuart Macleod said.

In the four years from 2017 to 2020, 94 occurrences of partial or complete loss of transmission and/or reception of digital information from an RPA were reported to the ATSB.

The majority of these occurrences resulted in damage to either the aircraft, property, or both.

“It’s important RPA pilots ensure they are familiar and well drilled in emergency procedures, as well as being proficient in flying in all flight modes,” Mr Macleod said.

Mr Macleod noted that during an RPA fly-away, there may only be a few seconds in which a pilot can take avoiding action.

“In the event of a compass failure, switching to the fully manual attitude flight mode may assist regaining control of the RPA,” he noted.

Following a review of the occurrence, the RPA’s manufacturer, DJI, updated the user manuals for a number of its products, including the Inspire 2.

The changes provide additional guidance to users regarding the use of the fully manual attitude flight mode in the event of compass interference.

Although not contributory to this occurrence, the ATSB investigation also found the pilot did not follow the operator’s emergency procedures, or comply with the regulator’s operational permissions to fly in restricted airspace.

“Adhering to operational guidelines and limitations remains important for ensuring the safe operation of RPAs,” Mr Macleod said.

“This is particularly true in populated areas, where risks are potentially elevated.”

Adhering to the limitations and guidance provided by the regulator will ensure these risks remain as low as reasonably practicable, Mr Macleod concluded.

Read the final report: Loss of control and collision with terrain involving DJI Inspire 2, remotely piloted aircraft, Darling Harbour, Sydney, New South Wales, on 15 January 2021

The Australian Transport Safety Bureau’s systemic investigation into a fatal helicopter accident during a night flight to conduct a marine pilot transfer off the coast of Port Hedland, Western Australia, details 21 findings. 

Two pilots – an instructor and a pilot under supervision – were operating an EC135 twin-engine helicopter under night visual flight rules (night VFR) to collect a marine pilot from an outbound bulk carrier on the night of 14 March 2018. 

During a second approach to land on the ship, the helicopter descended rapidly and impacted the water. The instructor pilot was able to escape the cabin as it flooded, while the pilot under supervision was not able to escape, and did not survive. 

ATSB Chief Commissioner Angus Mitchell encouraged all helicopter pilots and operators to review the investigation’s final report, and consider the findings in the context of their own operations. 

“This was a complex investigation, which has already resulted in several safety actions being taken by the operator and the regulator,” Mr Mitchell said. 

While the meteorological conditions during the accident flight met the standards for a night VFR operation, the investigation found that low celestial lighting, and the lack of artificial lighting 37 km offshore, meant the helicopter was being operated in a degraded visual (cueing) environment. 

“Helicopter pilots operating in a degraded visual environment are exposed to a higher workload and a heightened risk of spatial disorientation,” Mr Mitchell said. 

The operator’s training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in these conditions, the investigation found. 

“The accident flight was a line training flight, with the pilot under supervision in the right seat, and the instructor in the left seat,” Mr Mitchell explained. 

“However, the helicopter’s instruments were set up for a single pilot in the right seat. This limited the instructor’s ability to monitor the flight path and take over control if necessary, particularly in the degraded visual environment. 

“For any operation that relies on the instrument flying skills of a second pilot, consideration should be given to the adequacy of flight instrumentation for that pilot.” 

Mr Mitchell noted the Civil Aviation Safety Authority (CASA) has, since the incident, updated two of its regulations (CASR 91 and CASR 138), stating cockpits designed for single pilot operations need to be carefully assessed for instrument readability before being used for training, checking or testing operations. 

Additionally, the ATSB’s investigation found the pilot under supervision probably experienced a level of fatigue known to adversely influence performance. While there was insufficient evidence to establish fatigue for the instructor pilot, it is likely they were experiencing a level of fatigue in previous days. 

“The investigation found technical and methodological flaws in the operator's fatigue risk management system, and that the operator did not conduct a formal risk assessment of its roster prior to commencing marine pilot transfer operations at Port Hedland,” Mr Mitchell said. 

“Flight crew fatigue is an insidious problem that is difficult to predict for each individual on an ongoing basis and can have subtle effects that undermine performance of critical tasks. 

“Management of fatigue risk is a shared responsibility between operators and pilots and relies on sound principles, effective systems, and accurate recording.” 

The investigation also found the pilot under supervision had not undergone helicopter underwater escape training (HUET) since 2011, seven years prior to the accident. 

“This lack of recency reduced their preparedness for escape once the helicopter hit the water and rolled over,” Mr Mitchell said. 

“HUET provides familiarity with a crash environment and confidence in an emergency, for this type of accident. 

“Interviews with survivors from helicopter accidents requiring underwater escape frequently mention they considered that HUET had been very important in their survival.” 

Read the final report: Collision with water involving twin-engine EC135 helicopter, VH-ZGA, 37 km north-north-west of Port Hedland Heliport, Western Australia, on 14 March 2018

An Australian Transport Safety Bureau investigation into a 19 June 2020 loss of control incident involving a remotely piloted aircraft (RPA) while it was taxiing following a maintenance flight highlights to RPA operators the importance of fatigue management and controller design.

After landing at Bruhl Airfield, Queensland after completing a successful autonomous test flight, the pilot of the RF Designs Mephisto RPA - a high-performance autonomous testbed which has a 2.6 m wing span and a 35 kg max take-off weight - toggled the controller’s automatic mode switch to disengage the aircraft’s automatic mode for taxi back to the hangar, the investigation report details.

The pilot then increased the throttle to provide the RPA with sufficient momentum to taxi. As the RPA turned towards the pilot, the pilot determined that it was not responding to commands to reduce the engine thrust. The pilot considered attempting to arrest the RPA by hand but determined it was moving too quickly and instead toggled the automatic mode switch to regain control and turn it away from bystanders.

The pilot then directed the RPA across the airfield and it came to rest against the perimeter fence, resulting in minor damage to the aircraft’s skin.

“The ATSB’s investigation into the incident determined that the pilot did not correctly disengage the RPA’s automatic mode,” said ATSB Director Transport Safety Stuart Macleod.

“Subsequently, when they increased the throttle to provide the aircraft with momentum to taxi back to the hangar the ‘abort landing’ function activated, increasing the throttle to maximum and overriding the pilot’s commands to decrease throttle.”

Mr Macleod noted this incident has 3 key learnings for RPA operators.

“RPA operators should be mindful of the risk of fatigue, particularly in high tempo commercial operations,” he said.

“Even when fatigue management is not mandated, operators should ensure that their fatigue management processes are robust and effective.”

The incident also highlights the importance of controllers being as simple and reliable as possible.

“If a control leaves room for human error, then it will increase the risk of this error occurring even if procedural controls are in place. Consideration should also be given to a system that allows the remote pilot to shut down the aircraft immediately in the event of an unexpected state or failure.

“Lastly, operators should be prepared for the RPA to do something unexpected and know and frequently practice emergency procedures.”

Read the final report: Loss of control during taxi, involving RF Designs Mephisto, remotely piloted aircraft, Bruhl Airfield, 2 km south-west of Tara, Queensland, on 19 June 2020

An ATSB transport safety investigation into an airspeed management event involving a Fokker 100 passenger aircraft has found the operator’s training did not prepare pilots for the activation of an automatic flight envelope protection mode – alpha mode – during critical phases of flight.

The investigation report details how the Alliance Airlines-operated aircraft’s airspeed reduced below the minimum allowable approach speed during final approach into Rockhampton Airport, Queensland, on 10 November 2019.

The aircraft, registered VH-UQN, was being operated on a regular public transport flight from Brisbane to Rockhampton, with 97 passengers and 4 crew on board.

“Aware of some bushfire activity to the north-east of the airport, the flight crew conducted a standard briefing prior to descent which included the speeds required for the approach, and identifying the threat of reduced visibility due to smoke,” ATSB Director Transport Safety Dr Michael Walker said.

The aircraft was slightly high on approach, and at 400 ft above ground level the flight crew encountered reduced visibility and moderate turbulence due to the nearby bushfire.

This added uncertainty, and delayed the flight crew’s identification of the high approach profile, the report notes.

“In the later stages, crew identified the high approach, and began an attempt to regain the correct profile, the aircraft’s airspeed reduced below the minimum allowable speed at about 300 ft,” Dr Walker said.

This automatically activated the aircraft’s alpha mode automatic flight envelope protection, overriding the thrust levers and accelerating the aircraft.

“The flight crew were unaware of the alpha mode activation, and the pilot flying encountered increased resistance in the thrust levers while trying to manually recover airspeed,” Dr Walker said.

After a short period, the pilot forced the thrust levers to the desired setting. The aircraft’s engines responded, airspeed increased accordingly, and the aircraft landed safely.

“The ATSB’s investigation found the operator’s initial type qualification for the F100 aircraft and cyclic training did not adequately prepare pilots to identify and respond to alpha mode activations during critical phases of flight,” Dr Walker said.

“The ATSB further identified that the aircraft’s rate of descent exceeded the operator’s stabilised approach criteria for a short period during the approach; however, it was also identified that there was no permissible exceedance criteria in the stabilised approach criteria for transient exceedances.”

Following the incident, Alliance issued an operations notice to pilots including guidance on the dangers of low thrust and low airspeed situations during performance decreasing conditions.

The notice also provided greater guidance about the activation of alpha mode within its fleet, and the operator updated its cyclic simulator training to include alpha mode activation scenarios.

“Flight crew awareness of automatic flight protections and their subsequent effect is paramount to the safe operation of passenger transport flights,” Dr Walker said.

“Effective initial and cyclic training, and assessments in these systems, is important to ensure that pilots respond appropriately to these situations during critical phases of flight.”

The ATSB investigation also identified Alliance’s acting safety systems manager at the time of the incident was unable to effectively conduct the role, due to limited experience in the role, increased workload, and remote working conditions during this time.

“This, along with other key changes, limited the operator’s capacity to provide effective safety assurance,” Dr Walker said.

Alliance has, since the incident, finalised its internal safety manual and standard operating procedures, developed a position handover checklist, and reviewed its company policy manual to detail the formal delegation of duties relating to key safety post holder positions.

“This incident highlights that effective change management is an essential part of any safety management system,” Dr Walker said.

“Changes to key safety management systems, key post holder positions, and the procedures and processes that support systems and personnel, need to be carefully managed in order to operate a robust and effective safety management system.”

Read the report: Airspeed management event involving a Fokker F28-0100, VH-UQN, Rockhampton Airport, Queensland, on 10 November 2019

The pilot of an AW139 emergency medical service helicopter received a TCAS ‘resolution advisory’ collision alert while transiting airspace above Mangalore Airport en route to Royal Melbourne Hospital when a Piper Seminole aircraft conducted an unanticipated missed approach to the airport, an ATSB investigation report details.

The report details that on the afternoon of 6 June 2021, as the Seminole aircraft tracked north along the RNAV-Z runway 36 approach to Mangalore, the AW139 helicopter was about 10 NM north of Mangalore and tracking south to overfly the airport at 3,100 ft. At about 1555, the Seminole commenced a missed approach resulting in the helicopter’s TCAS (traffic alerting and collision avoidance system) displaying a traffic advisory, followed by a resolution advisory.

Six seconds later, the aircraft passed in cloud 451 m (in a straight line) from each other with a minimum vertical separation of 543 ft and a minimum horizontal separation of 333 m. Both aircraft were in cloud throughout the occurrence.

"The ATSB’s investigation into this occurrence found that while the helicopter pilot was aware of the Seminole, they did not consider the possibility of the Seminole conducting a missed approach, which might conflict with the helicopter’s flight path,” said ATSB Director Transport Safety Stuart Macleod.

“The Seminole’s pilot, meanwhile, reported not hearing broadcasts from the helicopter and misinterpreted traffic advice from air traffic control, and consequently was not aware of the helicopter nearby and that an incident had occurred.”

The ATSB also found that the helicopter operator's traffic alert and collision avoidance knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.

“As such, this incident highlights the importance of effective flight crew TCAS training,” Mr Macleod said.

“TCAS is a complex system which serves as a ‘last line of defence’ in airborne collision avoidance. Thorough knowledge of the system is critical in ensuring that crews respond appropriately to TCAS resolution advisories.”

The Seminole was not equipped with with TCAS or Automatic Dependent Surveillance Broadcast (ADS-B) IN (nor was it required to be), the report notes.

“The ATSB stresses that in non-controlled airspace the effective use of radio remains a primary defence in avoiding mid‑air collisions, achieved by maintaining an effective listening watch and proactive communication,” Mr Macleod said.

“In addition, the ATSB strongly encourages equipping all aircraft with ADS‑B transmitting, receiving and display devices as they can significantly assist pilots in identifying and avoiding conflicting traffic.

“The continuous positional information ADS‑B provides can predict a developing situation many minutes before it becomes hazardous – a significant improvement on both point‑in‑time radio traffic advice and ‘see‑and‑avoid’.”

Read the final report: Airborne collision alert involving AgustaWestland AW139, VH-YXH and Piper PA-44-180, VH-HMQ, Mangalore Airport, Victoria, on 6 June 2021

The Australian Transport Safety Bureau has released a preliminary report from the ongoing investigation into an accident involving a geophysical survey aircraft west of Norseman, Western Australia on 3 March 2022.

The report details factual information established in the investigation’s early evidence collection phase, and contains no analysis or findings, which will be detailed in the investigation’s final report.

The aircraft, a Cessna U206G modified for low-level geophysical survey, had departed Kalgoorlie to a survey site about 120 km west of Norseman with the pilot the sole occupant on board.

The aircraft began its survey pattern at about 1252, tracking back and forth over the area at about 25 m (82 ft) above ground level. At 1343, the aircraft’s final GPS position showed it heading west at 116 kt, at about the intended survey height.

The alarm was raised when the aircraft did not return to Kalgoorlie by the expected time.

During subsequent search operations, the accident site was located in dense bushland 124 km west of Norseman, with the pilot confirmed to have been fatally injured.

On deploying to the accident site, ATSB transport safety investigators determined that the point of impact indicated the aircraft initially struck trees in an upright, but relatively steep nose-down attitude. The aircraft then impacted the ground on its left side and continued through the bush in a southerly direction, coming to rest about 45 m from the initial point of impact.

“ATSB investigators found no indications of pre-impact structural failures, and were able to establish continuity of the aircraft’s flight controls, while propeller damage and strike marks observed in the trees indicated the engine was producing power at the time of impact,” said ATSB Director Transport Safety Dr Mike Walker

“There was no indication of fire in the wreckage trail, either in the bushland or aircraft components, however the remainder of the aircraft was almost entirely destroyed by a post-impact fire.”

Along with its survey of the accident site and recovery of key components for further analysis, the ATSB has conducted interviews, and collected aircraft, operator and pilot records and documentation.

“As we progress, the ATSB will further review documentation and records, and the retrieved aircraft components,” Dr Walker continued.

The investigation will also further analyse the flight path information from the aircraft’s GPS tracking device, and review the risk controls in place for low-level survey work.

“A final report will be released at the conclusion of the investigation,” Dr Walker concluded.

“However, 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.”

Read the preliminary report: Collision with terrain involving a Cessna U206G, VH-JVR, 124 km west of Norseman, Western Australia, on 3 March 2022

The Australian Transport Safety Bureau has released a preliminary report from its on-going investigation into the breakaway and grounding of a product tanker in the Port of Brisbane during flooding on 27 February 2022.

The preliminary report outlines factual information established through the transport safety investigation’s early evidence collection phase. It does not include analysis or findings, which will be detailed in the ATSB’s final report.

The Hong Kong-flagged product tanker CSC Friendship was alongside the Ampol Products Wharf in Brisbane, loaded with 25,000 tonnes of diesel oil and 7,000 tonnes of gasoline for a voyage to Adelaide, on the evening of 27 February.

A low-pressure system and associated rain and wind was impacting the greater Brisbane area, resulting in significant flooding of the Brisbane River.

At about 2250, during an increased ebb tidal flow in the river, one of the ship’s stern lines parted suddenly. This increased the load on the 13 remaining mooring lines which, over the following 90 minutes, also failed.

During this time, the ship’s crew used the main engine and an anchor in an attempt to arrest the ship’s movement, and a number of harbour tugs attended to assist.

Despite these efforts, the ship broke away from the berth at about 0028 on 28 February, was swept downstream, and grounded to the east of Clara Rock beacon at Lytton Rocks Reach.

About half an hour later, a harbour pilot arrived by launch and boarded the grounded ship via the ship’s pilot ladder.

The pilot quickly established the ship was aground with the port quarter on the bank, bow slightly in the channel, and head down river.

Over the next four hours, the pilot attended the ship and, working with the ship’s crew and tugs, re-floated it at 0530. During the re-floating efforts, the ship grounded a second and third time.

After re-floating, CSC Friendship was moved downriver and anchored at Brisbane’s ship-to-ship transfer anchorage at about 0645. Subsequent inspections confirmed some shell plate damage, including buckling and medium to heavy abrasion of the hull, but no hull penetration or cracking of plate or welds.

The ship then travelled to Port Botany to discharge its cargo, before sailing to China for dry dock and repair.

The ATSB’s continuing investigation will examine weather and flood conditions prior to and during the breakaway and grounding, the effectiveness of the port procedures, operational guidance and inter-agency communications during a flood event, and the mooring arrangements relevant to this incident.

Investigators will also review internal and external shipboard communication systems, analyse relevant human factors, and verify, interpret, and analyse recorded data.

Read the preliminary report: Breakaway and grounding involving CSC Friendship, Port of Brisbane, Queensland, on 27 February 2022

After changing their flight plan in-flight without reviewing NOTAMs, the pilot of a Citation business jet landed on a closed runway which did not have the required number of unserviceability cones and crosses in place, an Australian Transport Safety Bureau investigation finds.

During pre-flight planning on 21 October 2021, the pilot of a Cessna 510 Citation Mustang checked the NOTAMs for Temora Airport, a planned refuelling stop for flight from the Sunshine Coast to Essendon Airport with four passengers on board.

“When checking the NOTAMs for Temora, the pilot dismissed notices that were deemed irrelevant to the planned flight, which was intended to land on runway 05 due to forecast weather conditions,” ATSB Director Transport Safety Dr Stuart Godley said.

“This included dismissing a NOTAM detailing that runway 18 at Temora was closed due to works in progress.”

During cruise, the pilot reviewed more up-to-date weather information and made the decision to land on runway 18, rather than 05, due to changes in wind direction and apron accessibility.

“Not hearing any broadcasts on the aerodrome’s Common Traffic Advisory Frequency (CTAF), the pilot elected to land straight-in with a 5-mile final approach to save on time and fuel,” Dr Godley continued.

On touchdown, the pilot noticed cones across the runway a long distance ahead of the threshold, but judged there was sufficient distance to stop safely before reaching them, and so elected to continue with the landing.

The pilot reported not seeing any other markings to indicate the closure of the runway.

During its investigation, the ATSB found while white crosses had been placed on the runway, they were not in locations visible to aircraft conducting a straight-in approach on runway 18. Further, the size and number of unserviceability marking cones along the runway were insufficient to fulfil the requirements of the Civil Aviation Safety Regulations Part 139 Manual of Standards (MOS) for closed runways.

“An essential component of pre-flight planning is to check all NOTAMs relevant to the planned flight, and potential changes to the plan. This includes all NOTAMs regarding all aviation facilities that a pilot plans to use,” Dr Godley said.

“Additionally, aerodrome operators must ensure all markings displayed for works are in accordance with the current MOS for aerodromes to ensure clear communication of changes that may affect the safety of aircraft operations.”

Read the final report: Landing on closed runway involving Cessna 510, VH-MSU, Temora Aerodrome, New South Wales, on 21 October 2021

Key points:

• Boeing 787 being used for freight operations flew from Melbourne to Los Angeles with tape covering its engine cowl fan static ports;
• While the flight was uneventful, the covered ports meant redundancy for the engine electronic control system was reduced;
• Job instruction card for restoring a 787 to service did not link to Boeing’s recommended procedures;
• Qantas has amended its engineering instructions to properly reference Boeing’s recommended procedures.

A Boeing 787 being used for a freight flight flew from Melbourne to Los Angeles with tape over four of its static ports, a new ATSB investigation report details.

After the Qantas 787-9 aircraft, registered VH-ZNJ, landed in Los Angeles on the morning of 22 September 2021, a Qantas engineer found tape covering the four static ports on the aircraft’s engine fan cowls.

Static ports provide important air pressure data to aircraft systems. Boeing recommends they be covered, to avoid contamination, when the aircraft is parked for periods up to 7 days, and Qantas incorporated this instruction into its ‘normal’ parking procedure.

The ATSB investigation details that on the day before the incident flight, an engineer undertook the parking procedure on the aircraft, which included covering the engine cowl static ports with ‘remove before flight’ barricade streamer tape.

“Later that day, another engineer was tasked to conduct the ‘restore’ procedure to return the aircraft to flight status,” ATSB Director Transport Safety Stuart Macleod explained.

“The tape on the engine fan cowls was not removed by that engineer, as per the manufacturer’s procedures, and this wasn’t identified by flight crew or dispatch during pre-departure checks.”

VH-ZNJ subsequently took off with the tape still on its engine fan cowl static ports.

“While the flight was uneventful, the covered ports meant redundancy for the engine electronic control system was reduced,” Mr Macleod noted.

The ATSB found that while the job instruction card (JIC) developed by Qantas for parking a 787 did link to Boeing’s recommended procedures, the JIC for restoring it back to service did not.

“This was a missed opportunity to assist engineers to readily access the current procedures and determine which ports were covered, and also allowed for different interpretations of which ports could be covered,” Mr Macleod said.

“When performing safety‑critical tasks like aircraft maintenance, it is very important that procedures are clear and unambiguous to avoid misinterpretation and error such as occurred in this incident.”

At interview, the flight crew’s second officer, who conducted an exterior inspection of VH-ZNJ before the flight, reported they were aware of the fan cowl ports, but not that they could be covered by tape.

The second officer also reported they were somewhat distracted during the inspection, as they had found a pitot tube cover on the ground, and were trying to hand it off to an engineering staff member at that time.

“The second officer also believed Qantas engineering had conducted a pre-flight inspection prior to the flight crew arriving at the aircraft,” Mr Macleod added.

Following the occurrence, Qantas distributed memos to engineering, and flight and ramp crew, highlighting the location of the fan cowl static ports and that they may be covered.

In addition, the airline amended its ‘park’ and ‘restore’ engineering instructions to both reference Boeing’s procedures.

The investigation report also notes the metre-long tail of the ‘remove before flight’ tape covering the static ports was stuck down, to prevent it being torn from the fuselage in strong winds, as per Boeing’s recommended procedure.

“This likely reduced the visibility of it covering the fan cowl static port covers,” Mr Macleod said.

“Targeted inspection of locations and components, rather than relying on streamers, which can detach, can help to identify when these covers or devices have not been removed.”

Read the final report: Aircraft flight preparation occurrence involving Boeing 787-9, VH‑ZNJ, Melbourne Airport, Victoria, on 22 September 2021