The ATSB welcomes the appointment by Minister for Infrastructure, Transport, Regional Development and Local Government Catherine King MP of the appointment of Vice Admiral (ret’d) Russell Crane, AO, CSM as our new Marine Commissioner.

VADM Crane had an extensive career in the Royal Australian Navy, culminating in serving as Chief of Navy between July 2008 and June 2011, during which time he initiated the New Generation Navy program and established the inaugural RAN Seaworthiness program. His Navy service also included three seagoing commands (including of HMAS Success, then the largest vessel in the Navy), and serving as Commander of the Navy Systems Command, Director General Coastwatch, and Deputy Chief of Navy.

Since retiring from the Navy, he has held a number of board and advisory positions.

VADM Crane commenced his three-year term as an ATSB Commissioner on 14 December.

“With VADM Crane’s extensive experience as a highly experienced mariner and senior leader he is exceptionally well placed to help shape and guide the ATSB, and I have no doubt he will make a significant contribution to improving transport safety,” said ATSB Chief Commissioner and CEO Angus Mitchell.

“I welcome his appointment and look forward to working with him.”

Mr Mitchell also took the opportunity to acknowledge and thank the service of Gary Prosser, whose term as an ATSB Commissioner concluded on 13 December.

“For the past six years Gary’s wealth of maritime industry expertise, along with his guidance, influence and support, has been a true enabler for the ATSB, during which time he has played a key role in several significant marine incident investigations which have led to safety improvements not just here in Australia but internationally,” he said.

“All of us at the ATSB wish Gary well for his future endeavours and thank him for his exemplary service as an ATSB Commissioner.”

As an independent Commonwealth Government statutory agency, reporting to the Minister for Infrastructure, Transport, Regional Development and Local Government, the ATSB is governed by a Commission comprising the Chief Commissioner and three part-time Commissioners.

An ATSB investigation of coordination and communication issues between firefighting aircraft near the NSW-Qld border on 31 October 2023 has led to extensive, systemic safety improvements.

The incidents occurred when up to 18 smaller NSW Rural Fire Service (RFS) aircraft were operating over multiple firegrounds in the Tenterfield region, and the state operations controller proactively dispatched three large air tankers (LATs) and their lead plane (known as a birddog) to the area.

The ATSB’s investigation found these new assets were dispatched without a target and without first coordinating with the local incident management team.

Further, the investigation found the NSW RFS did not have a procedure for ensuring the tasking of LATs by the state air desk would be coordinated with the incident management team, so the large assets could be integrated into the existing incident plan.

“It was likely the state operations controller had assumed the LATs would be coordinated by the local air attack supervisor, who was in a helicopter,” ATSB Chief Commissioner Angus Mitchell said.

“But this air attack supervisor was not actually aware the LATs were inbound, and was just about to leave the fireground for fuel when the LATs arrived unexpectedly. The air attack supervisor subsequently did not provide traffic or local radio information to the birddog crew.”

The crews of the LATs and the birddog were then unable to communicate and coordinate with other aircraft in the area, and reported coming into unsafe proximity with other aircraft several times.

The ATSB’s final report details findings relating to the NSW RFS’s aerial asset coordination, including the expectations placed on local air attack supervisors.

“The NSW RFS procedure required an air attack supervisor when three or more aircraft were deployed to a fireground, but there was no assurance aerial supervision would remain adequate as the size of the fire or aircraft numbers scaled up,” Mr Mitchell said.

Compounding the situation on the day of the incidents, Queensland Fire Department (QFD) also had aerial assets at an adjacent fireground on the NSW-Qld border.

“Neither the NSW RFS nor QFD had established cross-border coordination procedures for aerial firefighting activities to ensure reliable aircraft communication and separation,” Mr Mitchell said.

The report notes the NSW RFS has introduced “extensive systemic-level safety improvements” in response to the identified safety issues, including a new policy to ensure LAT pilots receive a briefing from the incident management team regarding incident strategy prior to departure.

There are also new procedures for state air desk and incident management team liaison, regular assessments of operational complexity and the number of aircraft deployed to a fireground, the implementation of temporary restricted areas, and the allocation of fire-specific radio frequencies.

In addition, in January 2024 the National Aerial Firefighting Centre released the national cross-border airspace management guideline, which establishes coordination measures between different jurisdictions, including procedures for frequency alignment, and liaisons between state air desks.

Mr Mitchell welcomed the safety actions taken, noting all seven of the investigation’s identified safety issues had been adequately addressed.

“Aerial firefighting is a critical capability for the management and suppression of bushfires in Australia,” he said.

“As the number of LATs and other aerial assets being used for firefighting increases, it is important that operators, tasking agencies and other relevant parties continue to develop and improve their safety systems to mitigate risk.”

Mr Mitchell noted this investigation was the third undertaken by the ATSB involving LATs, following that into the loss of a 737 air tanker in WA in 2023, and the fatal accident involving a C-130 air tanker in NSW in 2020.

“During aerial firefighting operations, non-standard procedures and practices may result in unforeseen risks emerging,” he said.

“It is therefore critically important for tasking agencies to take the lead, with the support of stakeholders, in developing the quality and safety standards they require for the firefighting effort to mitigate operational risks.”

Read the final report: Coordination and communication breakdown during aerial firefighting operations, near Tenterfield, New South Wales,on 31 October 2023

A pilot had to make significant control inputs to maintain level flight after a skydiver’s reserve parachute became snagged on the tail of their Cessna Caravan during a jump run over Tully Airport, in Far North Queensland, an ATSB final report details.

The Cessna took off from Tully on 20 September 2025 with a pilot and 17 parachutists on board, planning for a 16-way formation jump from 15,000 ft filmed by a parachuting camera operator.

Once at the desired altitude, the pilot slowed the aircraft to 85 kt, extended 10° of flap and signalled the jump to begin.

While the first parachutist was climbing out of the roller door, the handle for their reserve parachute snagged on the wing flap, deploying the chute inadvertently.

This dragged the parachutist suddenly backwards, and their legs struck the aircraft’s left horizontal stabiliser, substantially damaging it. The parachute then wrapped around the stabiliser, suspending the parachutist below the aircraft.

“The pilot recalled feeling the aircraft suddenly pitch up, and observed the airspeed rapidly decreasing,” ATSB Chief Commissioner Angus Mitchell explained.

“Initially unaware of what had occurred, the pilot believed the aircraft had stalled, and pushed forward on the control column and applied some power in response. But upon being told there was a skydiver hung up on the tailplane, they reduced power again.”

The pilot felt the controls vibrating, and reported significant forward pressure and right aileron input were required to maintain straight and level flight.

Meanwhile, 13 of the parachutists exited the aircraft and 2 remained in the doorway, watching as the snagged parachutist used a hook knife to cut 11 lines from their reserve parachute, allowing the remaining parachute to tear, freeing them from the aircraft.

Then in freefall, the parachutist was able to release their main parachute, which fully inflated, despite becoming tangled in the remaining lines and canopy of the reserve chute. The parachutist then landed safely, having sustained minor injuries in the accident.

“With all parachutists out of the aircraft, the pilot assessed they had limited pitch control, given the substantially damaged tailplane, which still had a portion of the reserve parachute wrapped around it,” Mr Mitchell said.

“With forward pressure they found they could achieve a gradual descent, and retracted the flap, which then allowed slightly more rudder, aileron and elevator control.”

The pilot maintained about 120 kt airspeed during the descent, and declared a MAYDAY to Brisbane Centre ATC, advising they had minimal control input.

The pilot, who was wearing an emergency parachute, prepared to bail out during the descent if they deemed they did not have sufficient control to land the aircraft. But, descending through about 2,500 ft, they assessed they would be able to land.

“In difficult circumstances, the pilot managed to control the aircraft and land safely at Tully.”

Mr Mitchell said the event reminds parachutists of the importance of being mindful of their handles, especially when exiting the aircraft.

“Carrying a hook knife – although it is not a regulatory requirement – could be lifesaving in the event of a premature reserve parachute deployment,” he said.

While it did not contribute to this accident, the ATSB’s investigation also found the pilot and aircraft operator did not ensure the aircraft was loaded within its weight and balance envelope.

“Fatal parachuting accidents have occurred in the past due to aircraft being loaded outside centre of gravity limits, which highlights the importance of conducting aircraft weight and balance calculations prior to each load,” Mr Mitchell concluded.

Read the final report: Premature parachute deployment involving Cessna 208, VH-DVS, over Tully Airport, Queensland, on 20 September 2025

The ATSB has published a preliminary report from its ongoing investigation into the collision with terrain of a Reims F406 Caravan II aircraft near Oakey Airport, west of Brisbane.

The twin-turboprop aircraft impacted the ground about 2.6 km from the threshold of Oakey Airport’s runway 14 on the afternoon of 20 July 2025 while being used for a multi-engine instrument proficiency check (IPC) flight.

On board the aircraft was a pilot undergoing assessment and an external flight examiner, with their planned route from Warwick Airport to Oakey Airport, then back to Warwick.

During an IPC, the pilot under assessment is required to demonstrate a range of specified standards including, for multi-engine operations, the satisfactory completion of a simulated one engine inoperative (OEI) departure and a simulated OEI approach. 

“This preliminary report outlines information gathered so far in the ATSB investigation, but does not contain findings or analysis, which will be developed for publication in a final report,” said ATSB Chief Commissioner Angus Mitchell.

The report details that at about 300 ft above ground level, while on approach for Oakey Airport, the aircraft was observed to commence a flat turn and yaw to the left, before it rolled left, pitched down, and impacted the ground in an open paddock.

The aircraft was destroyed in a post-impact fire, and both occupants were fatally injured.

“While the fire limited the extent to which ATSB investigators could identify any pre-impact defects, their on-site examinations accounted for all major aircraft components at the point of impact,” Mr Mitchell explained.

“Subsequent inspections of the engines found no indication of pre-impact mechanical anomalies.” 

Evidence indicated that at the time of impact the left engine was rotating and the right engine was developing power.

“About 4 minutes before the accident, the aircraft commenced the approach and the pilot made a radio broadcast to advise they were established on the Oakey Airport runway 14 ILS (instrument landing system),” Mr Mitchell explained.

“About a minute later, flight tracking data showed the aircraft began to deviate slightly from the horizontal profile for the approach, and later descended below the glideslope on two occasions. The aircraft’s groundspeed then began to decay, reducing to 85 kt, before the accident occurred.”

Recorded weather at Oakey at the time of the accident was clear, with a light southerly breeze of 6 kt.

The aircraft operator’s Head of Flying Operations recalled that the external flight examiner had in the past for IPCs typically conducted the required simulated engine failure departure after take-off from Warwick Airport and the simulated engine failure approach at Oakey Airport, the preliminary report notes.

“As the investigation progresses, it will include an examination of the recent history of both pilots, operational procedures and documentation, and of the requirements for conducting simulated one engine inoperative exercises at low heights,” Mr Mitchell explained.

“We will also continue to examine the aircraft’s propellers and its maintenance history, conduct further interviews, and continue our analysis of flight data and air traffic surveillance data.”

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

“In the meantime, should the ATSB identify a critical safety issue as the investigation progresses, we will immediately notify relevant parties so they can take appropriate safety actions.”

Read the preliminary report: Collision with terrain involving Reims Aviation F406, VH-EYQ, 3 km from Oakey Airport, Queensland, on 20 July 2025