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

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