The main landing gear of an Airbus A320 could not be fully retracted due to the fatigue failure of a pin in the aircraft’s left main landing gear, an ATSB investigation report details.  

The Jetstar Airways-operated A320 was departing Sydney to operate a scheduled passenger service to the Gold Coast on the morning of 1 August 2019.   

After take-off and on selecting retraction of the undercarriage, the flight crew received multiple warnings of the undercarriage not retracting completely. The flight crew informed air traffic control of the issue and requested vectors to an area where they could troubleshoot the problem where they then cycled the undercarriage to the extended and then retracted positions, however, the issue remained. 

Meanwhile, the crew of another aircraft taxiing at Sydney Airport identified an object on the ground which they reported to the air traffic control (ATC) Ground controller.  

The debris was collected by an airport ground car and determined to be an aircraft part that was subsequently identified as an A320 main landing gear component. 

The ATC Departures controller notified the A320’s flight crew that an aircraft part had been found on the runway, subsequently informing them ‘they believe it might be a part of the landing gear’. Separately, Jetstar engineering communicated to the flight crew that the part had not yet been positively identified and advised them to follow their standard operating procedures.  

When all appropriate checks were completed, the flight crew elected to return to land at Sydney, requesting the airport’s emergency services be put on a local standby.  

While the landing was uneventful, further damage to the left main landing gear occurred including the loss of brakes and the severing of electrical sensors. 

The flight crew had made the decision to return and land after seeking and assessing information relating to the landing gear malfunction, the ATSB’s investigation notes. 

However, at that time the operator’s engineering personnel were gathering and analysing additional information about the failed component.  

“Despite the failed part and aircraft being positively identified by elements within Jetstar, a message was unable to be conveyed to the flight crew before they returned for landing,” said ATSB Director Transport Safety Stuart Macleod. 

“As such, the flight crew was unaware of the true nature of the undercarriage defect and the associated risks, and that additional information would have better informed crew decision making.” 

Without the apex pin in place, the main landing gear axle could rotate out of alignment. This both prevented the landing gear from retracting, and caused damage to other landing gear components and systems during the taxi, take-off and landing, including disabling the left side main landing gear’s brakes. 

While the disconnected torque link reduced the directional stability and braking performance, the degradation was manageable and the aircraft landed safely. 

“Investigations determined that the fatigue failure of the apex pin was the result of a crack that initiated during the quench step of the heat treatment process at manufacture,” Mr Macleod noted.  

The failed apex pin shank was sent to A320 aircraft main landing gear manufacturer Safran Landing Systems, which concluded the cracks were initiated during the manufacturing process and were not caused by environmental effects in service. 

Following the incident Airbus issued an alert to A320 operators requiring the recall or inspection of 1,988 apex pins – as a result 19 pins were removed from service due to cracking. 

Safran had previously revised its manufacturing processes for the apex pin. 

Also in response to the incident, Jetstar clarified its non-normal operational communication guidance for ground crews in the Airport Operations Manual. This included dedicated phraseology for gaining priority on airband frequencies to relay high priority messages. 

“This investigation highlights the importance of ensuring that operational processes permit coordinated, accurate and timely flow of information between ground personnel and flight crew to assist airborne decision making,” said Mr Macleod. 

Read the final report: Landing gear malfunction involving Airbus A320, VH-VFN, Sydney Airport, New South Wales, on 1 August 2019

The Australian Transport Safety Bureau (ATSB) has issued a Safety Advisory Notice that strongly encourages all pilots conducting low-level operations to wear a properly fitted and maintained flight helmet to improve their survivability in the event of an accident. 

The advisory comes as the ATSB releases the final report from its investigation into a wirestrike and collision with terrain accident involving a Robinson R44 helicopter conducting low-level aerial spraying at a property south-east of Hay, NSW in July 2020. 

Before commencing spraying at Steam Plains Station, the helicopter pilot received a pre-flight briefing from their chief pilot (who was performing the role of loader that day). The briefing involved a review of hazards on the property including an unmarked 19.1 kV single wire earth return powerline that crossed the perimeter fence line once in the spraying target area. The powerline was also highlighted on the pilot’s map during initial planning with the station manager two days earlier.  

When spraying operations commenced, the pilot flew to the property boundary to spray a track adjacent to the fence line from about 2.5 to 5 m above the ground.  

On the fifth spray run of the day, and when about 370 m before the position of the identified powerline, recovered data from the helicopter showed that the pilot turned the spray off and manoeuvred the helicopter over a stand of trees 12 to 15 m high. The helicopter then descended, most likely to recommence spraying, when the top of its left skid struck the powerline. 

The helicopter then entered uncontrolled flight and collided with the ground about 120 m beyond the wire. The pilot was fatally injured, and the helicopter was substantially damaged. 

Post-accident imagery taken by an ATSB remotely piloted aircraft of the helicopter’s flight path found the wire would have been extremely difficult to detect.  

“Powerlines, particularly unmarked wires, are normally impossible to see due to the size of the wire, camouflage with the background and limitations of the eye,” ATSB Chief Commissioner Angus Mitchell said. 

“Without an aerial hazard check, the pilot was reliant on remembering the location of the wire from earlier briefings and seeing the wire during the flight.” 

A review of GPS data found that while the pilot overflew a small section of the spraying area earlier that morning, there had been no aerial inspection to identify potential hazards and to confirm the location of the powerline on the accident flight.  

“Even with a map of known powerlines, no matter how many hours of aerial application experience you have, and whether the target area is new to you or you flew it yesterday, a pre-application aerial survey from a safe height should be a non-negotiable piece of your personal commitment to safety.” 

The ATSB notes that pilots are increasingly able access to the latest powerline mapping data via applications on their mobile devices. For operations in Queensland, New South Wales and South Australia, pilots can access the location and height of powerlines via the Look Up and Live app, which is available for iOS and Android devices.  

In other states and territories, pilots and operators can check with their local energy provider for available powerline information. 

The ATSB also encourages landowners who engage pilots to conduct aerial application operations to mark powerlines that may pose a hazard to aircraft. 

“As more up-to-date mapping and powerlines data is made available, and more wires carry visible markers, pilots have improved access to tools for planning and strike prevention,” Mr Mitchell noted.  

“However, only by conducting an aerial inspection at a safe height can the pilot be assured of the location of hazards.”  

During its investigation, the ATSB also found the pilot was not adequately restrained by the seat belt’s shoulder sash, resulting in their head impacting the left side of the helicopter during the initial impact. The pilot either slipped out of, or was not wearing, the shoulder sash portion of their 3-point harness, further increasing the risk of injuries.   

“The use of a 4- or 5-point pilot restraint harness, which provides lateral stability to the upper torso in both directions, would have the reduced the risk of strike injuries, particularly to the head as well as reducing the risk of deceleration injuries,” said Mr Mitchell.  

“Although the pilot was wearing a flight helmet, it came off after the initial impact and did not attenuate the impact forces to a survivable level.” 

Either the impact forces exceeded the helmet design specifications, or the helmet was not fitted, worn or maintained correctly, the investigation notes. 

The ATSB has released a Safety Advisory Notice to strongly encourage all pilots conducting low-level flight operations to wear a correctly fitted, secured, and maintained flight helmet to improve their survivability in the event of an accident.  

“A correctly fitted and secured flight helmet can significantly reduce injuries and save lives in the event of a serious incident or accident but to be fully effective it must be adjusted to fit the head and the chin strap must be fastened securely,” Mr Mitchell said.  

“In addition, helmets must be serviced regularly, routinely inspected for damage, and replaced immediately if it has sustained a major impact.” 

Lastly, the investigation also found that the pilot had also been diagnosed with a high risk of severe obstructive sleep apnoea (OSA) in the months before the accident, but it was not reported to a Civil Aviation Safety Authority designated aviation medical examiner and was not being effectively managed in the two weeks before the accident.   

It could not be determined whether the pilot was experiencing any impairments associated with the condition. 

Read the report: Wirestrike and collision with terrain involving Robinson R44, VH-HNF, 69 km south-east of Hay Airport (Steam Plains), New South Wales, on 31 July 2020

To find the latest information on powerline locations in Queensland, New South Wales and South Australia use the Look Up and Live(Opens in a new tab/window) app or your contact the local electricity provider.   
 
For more information on the management of obstructive sleep apnoea read the Civil Aviation Safety Authority’s Obstructive sleep apnoea and aviation safety fact sheet(Opens in a new tab/window).

An improperly-secured insulation blanket became lodged in a 737 freighter’s main pressurisation outflow valve resulting in the aircraft cabin depressurising during descent, an Australian Transport Safety Bureau investigation report outlines.

On 6 July 2021, the Boeing 737-376SF operated by Express Freighters Australia – a subsidiary of Qantas – was operating a freight flight from Perth to Melbourne with a flight crew of two on board.

While descending through 8,000 ft, the flight crew received pressurisation system cautions and the cabin depressurised.

“In response, the flight crew performed the first four steps of the relevant non-normal checklist,” ATSB Director Transport Safety Stuart Macleod said.

“As they descended through 4,000 ft, and with the cabin already depressurised, they elected to suspend that troubleshooting process and landed the aircraft at Melbourne without incident.”

An engineering inspection determined that an insulation blanket from the aft cargo bay had been partially ejected from the aircraft’s main outflow valve, preventing it from closing.

“The engineering inspections revealed multiple aft cargo bay insulation blankets were either missing, installed incorrectly, or unsecured,” Mr Macleod said.

“A heavy maintenance check about 15 months prior to this occurrence necessitated the disturbance and partial or complete removal of the insulation blankets in the aft cargo bay, and it is probable that after this check, the blankets were installed incorrectly, and an inadequate area inspection was carried out.”

As a result of the incident, the operator conducted an inspection of all aft cargo compartment pressurisation components and insulation blankets in their 737 fleet, and discovered multiple unerviceabilities, which were all rectified.

Following these inspections, Express Freighters Australia implemented a 4,000 hour or 36 month insulation blanket visual inspection task for the 737-300, and a 4,000 hour or 18 month visual inspection take for the 737-400.

“Aircraft periodic inspection tasks often require equipment or covering removal to access inspection areas,” Mr Macleod explained.

“Maintenance crews are reminded of the importance of ensuring that any items removed for access are thoroughly inspected for serviceability and securely reinstalled. Items must be refitted in accordance with the maintenance manual to prevent unsecured items inhibiting flight critical systems.”

Read the final report: Uncontrolled pressurisation change involving Boeing 737, VH-XMO, near Melbourne Airport, Victoria, on 6 July 2021

A pilot’s high workload, including data entry difficulties, while conducting an approach to land at Adelaide Airport in instrument meteorological conditions likely affected their situational awareness resulting in their aircraft descending below the assigned minimum altitude.

An Australian Transport Safety Bureau investigation into the incident details that on the morning of 12 August 2021, the twin-engine Aero Commander 500-S was conducting a private flight from Port Lincoln to Adelaide with a pilot and passenger on board.

After descending to 3,800 ft during the approach, the pilot was cleared by air traffic control to track direct to the GPS waypoint GULLY, the initial waypoint for the area navigation (RNAV) instrument approach into Adelaide.

However, the pilot reported having difficulties entering the RNAV approach into the aircraft’s touchscreen multi-function display due to turbulence.

“Several factors including the environmental conditions, data entry difficulties, and the timing of the clearance for the GULLY waypoint, likely led to the pilot experiencing a high workload,” ATSB Director Transport Safety Dr Stuart Godley explained.

By the time the pilot correctly input the approach into the system, the aircraft had just overflown the GULLY waypoint. This meant when the pilot then selected the ‘Direct-To’ option on the display, the autopilot commanded a sharp turn to the right, to commence an orbit to attempt to overfly the waypoint to recapture it.

The controller then began giving the pilot instructions, intending to vector the aircraft back to the waypoint, but a short time later, communications were lost.

“The ATSB found that during the approach the pilot had inadvertedly selected the incorrect radio frequency,” Dr Godley said.

For about 4 minutes before contact was re-established, the aircraft continued on its assigned heading, but began descending below its assigned altitude.

“During this time, the approach controller attempted to contact the pilot and issued three terrain safety alerts. The lowest altitude the aircraft descended to was 2,480 ft, close to the highest point within 5 NM of the aircraft’s track, which was 1,913 ft.”

Once communications were re-established, the approach controller issued the pilot a terrain safety alert and instructed the pilot to climb immediately to 5,000 ft.

The aircraft then tracked to Adelaide Airport and landed without further incident.

Dr Godley said the event highlights the heightened workload pilots experience during the approach and landing phases of flight.

“Pilots must continuously monitor aircraft and approach parameters, and the external environment, to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing,” Dr Godley said.

“Distractions and unanticipated events can further increase a pilot’s workload leading to undetected errors and a loss of situational awareness.

“During high workload phases of flight, pilots should remain focused on monitoring the aircraft instruments and avoid fixating on a problem.”

Read the final report: Flight below minimum altitude involving Aero Commander 500 S, VH-LTP, near Adelaide Airport, South Australia, on 12 August 2021

A Cessna 172 aircraft conducting powerline inspections near Canberra stalled and entered a spin at a height too low for recovery before it collided with the ground, an Australian Transport Safety Bureau investigation details.

In the early afternoon of 13 April 2021, the Cessna R172K departed Canberra Airport to conduct powerline surveying to the north of Sutton township, NSW. On board was a crew of two comprising a pilot and an observer.

About three hours into the flight, while manoeuvring to inspect a powerline adjacent to Tallagandra Lane, nearby witnesses observed the aircraft flying low above the trees before it commenced a left turn that continued into a steep descent before colliding with the ground.

The pilot and the observer were fatally injured in the accident, and the aircraft was destroyed.

During the accident flight, according to recorded data and witness accounts, the Cessna transitioned from a level, right turn to the north-north-east into a tighter, possibly climbing, left turn.

From the ATSB’s analysis of the turns conducted by the pilot earlier in the flight, it was estimated that the final turn was likely conducted at a comparatively high angle of bank and closer to the stall speed of the aircraft.

As the manoeuvre continued, the aircraft likely exceeded the critical angle of attack for the wing, causing the wing to aerodynamically stall.

“This investigation reinforces to pilots the importance of managing airspeed and bank angle to minimise the risk of stalling,” ATSB Director Transport Safety Stuart Macleod said.

“This is particularly important when operating in close proximity to the ground, such as conducting low-level air work, as well as during take-off and landing, as recovery may not be possible.”

Mr MacLeod noted the Pilot’s Operating Handbooks for most light aircraft, including the accident Cessna R172K’s, provides stall speed guidelines to avoid a wings level stall.

However, pilots should be cognisant of the raised stall speed when operating turns.

“In a bank the vertical lift component is reduced, and so pilots must pull back on the control yoke to maintain altitude,” noted Mr Macleod.

“This increases the angle of attack of the wing, and if the angle of attack reaches a critical angle, loss of lift and increased drag occurs, and the wing will aerodynamically stall.”

Following the accident, the operator amended the training and checking section of its Operations Manual to incorporate Threat and Error Management and Situational Awareness training modules for powerline low-level survey operations. The amendments enhanced existing topics in the operator’s crew resource management training and stipulated learning outcomes and assessment criteria specific to Threat and Error Management and Situational Awareness.

“The operator also provided detail of intended additions to its low-level procedures to implement an airspeed ‘manoeuvre margin’ that will take into account the increased stall speed associated with steep turns,” Mr Macleod said.

Further, the operator plans to modify its aircraft to include an angle of attack indicator and a g-meter with recording and data download capability.

“These will not only supplement the aircraft’s stall warning device by providing additional warning of an impending stall, but will allow for a record of the maximum and minimum in-flight readings to be downloaded post flight for review,” Mr Macleod said.

Read the report: Loss of control and collision with terrain involving Cessna R172K, VH-DLA, near Sutton, New South Wales, on 13 April 2021

Key points: 

• Aircraft was conducting low-level aerobatics prior to colliding with water;
• ATSB encourages witnesses, particularly those in the aviation industry, to report concerns regarding unsafe behaviour through confidential reporting channels;
• Investigation found a pre-existing fatigue crack in the aircraft’s elevator bellcrank, although this did not contribute to the accident.

A Yak-52 warbird aircraft had been conducting low-level aerobatics at a height of less than 500 ft above the ground before it collided with water at high speed, fatally injuring the pilot and passenger, an Australian Transport Safety Bureau investigation report details.

The two-seat Yak-52, an ex-military trainer aircraft, departed Southport Airport, on Queensland’s Gold Coast, on the morning of 5 June 2019 for a private aerobatic flight expected to last about 30 minutes. The pilot had owned the aircraft since 2018, and held an endorsement to conduct aerobatics at no less than 3,000 ft above ground level.

When the aircraft did not return to Southport as planned, a search and rescue operation commenced, with part of the aircraft’s propeller located on South Stradbroke Island later that afternoon. The pilot and passenger, who had sustained fatal injuries, and additional wreckage, were recovered from the waters near Jumpinpin channel in the following days.

“The ATSB’s investigation established that prior to the accident the pilot had conducted a number of aerobatic manoeuvres below 500 ft above ground level,” ATSB Director Transport Safety Dr Stuart Godley said.

“While the absence of recorded data for the last phase of flight or witnesses to the accident meant we could not determine with certainty that the pilot was conducting an aerobatic manoeuvre immediately prior to the aircraft’s impact with the water, the ATSB considered it a possibility.”

Dr Godley said the ATSB was able to build a detailed understanding of much of the accident flight, including from air traffic control surveillance radar, which recorded an aircraft over South Stradbroke Island conducting operations with significant track and speed fluctuations, consistent with aerobatic manoeuvres, and witness reports.

Witnesses on South Stradbroke Island reported that they observed an aircraft consistent with the accident aircraft conduct a “loop, cut right, and dive below the tree line”.

“During the accident flight and previous flights, the pilot conducted low-level aerobatics without having completed the required training or having the appropriate endorsement to do so,” noted Dr Godley.

“This would have potentially limited the pilot’s appreciation of the inherent risks associated with low-level aerobatics.”

Dr Godley noted that research shows that pilot perceptions of risk may decrease with repeated successful outcomes, and if a pilot has a history of flights without incident, then they may perceive that they have a lower likelihood of an adverse outcome based on their prior incident-free experiences.

“This accident highlights the inherent risks associated with performing low-level aerobatics where there is a reduced safety margin for recovery,” Dr Godley said.

“Even more so, it demonstrates the importance of being suitably-trained and qualified to conduct these operations.”

The investigation noted that people with aviation experience and knowledge had witnessed the pilot undertake previous low-level aerobatic flights.

While there had been some attempts to communicate concerns about risk-taking behaviour to the pilot, the investigation did not find evidence that the pilot’s behaviour had been formally reported.

“We encourage witnesses, particularly those within the aviation industry, to report any concerns regarding unsafe behaviours through mechanisms such as confidential reporting systems, such as the ATSB’s own REPCON, or the Civil Aviation Safety Authority’s online reporting portal,” Dr Godley said.

“Confidential reporting provides a means to escalate concerns about pilot behaviour while providing protections for the source of the report.”

Dr Godley also noted that the investigation found a pre-existing fatigue crack in the aircraft’s elevator bellcrank, which had the potential to fail in-flight, leading to a loss of control.

Although this crack did not contribute to the accident flight, the finding prompted the ATSB in November 2020 to issue a safety advisory notice to Yak-52 maintainers and owners, emphasisng the importance of dye penetrant inspections to remove defective elevator bellcranks from service.

Read the final report: Collision with water involving Yakovlev Aircraft Factories Yak 52, VH-PAE, near South Stradbroke Island, Queensland, on 5 June 2019

The runway incursion of a Beech Baron aircraft onto an occupied runway at Bankstown Airport highlights the potential effect of expectation bias and the importance of pilots focusing on specific instructions given by air traffic controllers, a new Australian Transport Safety Bureau investigation report says.

On the morning of 26 October 2021, the Baron aircraft, registered VH-NSK, and operated by Little Wings, was conducting a post-maintenance flight to test its stall warning system, the investigation report details. Prior to this flight the pilot had not conducted a VFR flight from the airport for some considerable time and had only departed Bankstown from runway 29C for flights over the last previous 18 months. 

Following pre-flight checks, the aircraft was cleared to taxi to holding point A8 for a departure from runway 29R. Once there, the pilot contacted air traffic control (ATC) and advised they were holding short of runway 29R for departure and were advised to hold position. Just prior to this, an Embraer 190 received clearance to enter runway 29C at holding point A2, for high-power engine runs.

Moments later ATC instructed VH-NSK to line-up and wait for runway 29R. The pilot read back their instruction and seeing VH-NSK commence taxiing the Tower controller began assisting two helicopters operating north of the airport. During this time VH-NSK crossed runway 29R and entered and lined up on runway 29C.

Turning back to VH-NSK, the Tower controller issued an instruction for take-off.  When VH-NSK was detected on runway 29C, the Tower Controller immediately called for VH-NSK to ‘hold position, hold position you are lined up on Centre, hold position’ and issued repeated instructions to stop. At the same time, the pilot of VH-NSK saw the Embraer conducting high-power engine runs on runway 29C and did not commence the take-off.

ATSB Transport Safety Director Stuart Macleod said this incident highlights the importance of pilots focusing on the specific instructions given by air traffic controllers and how expectation bias can affect how they receive and understand verbal instructions

“As the pilot of the Baron aircraft had only conducted IFR flights departing from Bankstown’s runway 29 centre for the last 18 months it is likely their focus had narrowed to the actions for the unfamiliar VFR departure and despite confirming their instructions back to ATC they reverted to what they had done previously.

“When issued instructions by air traffic control, pilots need to focus on listening and then repeat what was said in your head and then actively apply that information,” said Mr Macleod.

For more information on runway safety and avoiding errors that lead to runway incursions go to Airservices Australia’s A pilot’s guide to Runway Safety and their specific publications for Bankstown(Opens in a new tab/window), Moorabbin(Opens in a new tab/window), Parafield(Opens in a new tab/window), Jandakot(Opens in a new tab/window) and Archerfield(Opens in a new tab/window) airports.

Read the final report: Runway incursion involving Beech Aircraft Corp. 58, VH-NSK, Bankstown Airport, New South Wales, on 26 October 2021

The Australian Transport Safety Bureau has not had a formal involvement in any search for the missing aircraft MH370 since the conclusion of the first underwater search in 2017, has not recommenced a search for the aircraft, and notes that any decision to conduct further searches would be a matter for the Government of Malaysia.  

“The ATSB is aware of the work of Mr Richard Godfrey and acknowledges that he is a credible expert on the subject of MH370, but the ATSB does not have the technical expertise to, and has not been requested to, review his ‘MH370 Flight Path’ paper and workings. As such the ATSB cannot offer an assessment of the validity of Mr Godfrey’s work using WSPR data,” said ATSB Chief Commissioner Angus Mitchell.

“The ATSB does acknowledge that Mr Godfrey’s work recommends a search zone for MH370, a significant portion of which covers an area searched during the ATSB-led underwater search,” Mr Mitchell continued.

“When the ATSB was made aware that Mr Godfrey’s zone incorporates an area of ocean surveyed during the ATSB-led search, out of due diligence the ATSB requested Geoscience Australia review the data it held from the search to re-validate that no items of interest were detected in that area.”

The ATSB expects that review to be finalised in coming weeks, the results from which will be made public on the ATSB’s website.

“The ATSB acknowledges the importance of locating the aircraft to provide answers and closure to the families of those who lost loved ones,” Mr Mitchell said. “The ATSB remains an interested observer in all efforts to find the missing aircraft."

Mr Mitchell reiterated that any decision to conduct further searches for MH370 would be a matter for the Government of Malaysia, and that the ATSB was not aware of any requests to the Australian Government from Malaysia to support a new search for the missing aircraft.

The Australian Transport Safety Bureau has discontinued its investigation into a light aircraft accident in which a passenger was fatally injured during a forced landing on a beach at Ball Bay, Queensland on 24 December 2021. 

 “The Australian Transport Safety Bureau conducts independent ‘no-blame’ investigations into accidents and incidents for the purpose of identifying safety issues and actions and to help prevent the occurrence of similar future accidents, and we do not investigate for the purpose of taking administrative, regulatory or criminal action,” said ATSB Chief Commissioner Angus Mitchell. 

 “In this tragic accident ATSB investigators established quite quickly that the aircraft, an amateur-built two-seat Jodel D11, was being operated outside of aviation regulations.  

“The pilot was not licenced to fly aeroplanes and the aircraft and engine had not been maintained in accordance with the appropriate regulations for about 10 years. 

“On that basis, the ATSB has determined that there was limited opportunity that continuing to direct resources at this investigation would uncover safety learnings for the broader aviation industry.” 

Mr Mitchell said investigators also determined during their examination of the aircraft wreckage that the passenger’s seat belt had completely failed at 2 locations. 

“Both the pilot and passenger’s seat belts were manufactured in May 1973 and were required to be removed from service prior to 1 January 1990 in accordance with a Civil Aviation Safety Authority airworthiness directive. 

“When owners operate outside of the rules, they remove the built-in safety defences and undetected problems are more likely to emerge,” he concluded. 

Further details on the accident flight, information determined from the ATSB’s examination of the aircraft wreckage, and the reasons for the ATSB’s discontinuation can be found on our website here.