The flight crew of a passenger 737 missed arming the speedbrake before landing at Melbourne, after their workload increased unexpectedly during the arrival, an ATSB investigation has found.

On 2 July 2025, a Virgin Australia 737 was arriving in Melbourne when it exceeded two speed limitations on the standard terminal arrival route, and its flight crew was instructed to reduce speed below 180 kt, and then 160 kt, by air traffic control (ATC), likely to provide separation from other aircraft.

The crew hastened the conduct of the approach actions after perceiving the ATC instructions to be urgent, and missed arming the speedbrake and performing the landing checks.

As the aircraft descended below 1,000 ft above airfield elevation, the crew assessed the approach to be stable and continued, resulting in the aircraft landing without its speedbrake armed, and thus without it automatically deploying.

Noticing this, the captain moved their hand to the lever to raise it manually. But before they could do so, the first officer selected reverse thrust, which automatically deployed the speedbrake. The aircraft then decelerated, and the flight concluded without further incident.

ATSB Director Transport Safety Stuart Macleod said the flight crew were put under a higher than usual workload when they allowed the aircraft to exceed speed limitations on the arrival.

“The crew were then slow to take positive steps to reduce speed requiring ATC to instruct them to slow further, and the crew’s attention became focused on achieving the requested speed reductions, likely resulting in them omitting to arm the speedbrake and conduct the landing checks,” Mr Macleod said.

Mr Macleod noted threat and error management principles state proactive management of workload throughout the flight is a key defence against capacity and attention-related errors by flight crew.

“Checklists are a vital defence against human error and are integral to maintaining flight safety,” he added.

“This occurrence highlights the importance of adhering to standard operating procedures and ensuring checklists are conducted at the appropriate times.”

Read the final report: Incorrect landing configuration involving Boeing 737, VH-YFZ, Melbourne Airport, Victoria, on 2 July 2025

The pilot of a King Air mistook taxiway edge lights and markings for centreline guidance before one of the aircraft’s propellers struck a light while taxiing at night at Hobart Airport, an ATSB final report details.

On the evening of 1 July 2025, the RFDS Beechcraft B200 King Air commenced taxiing at Hobart, for a planned flight to Launceston, with two pilots and a paramedic on board.

The pilot flying was operating under the guidance of a supervisory pilot, prior to their final line check. Conditions were dark, with little to no moonlight, and good visibility.

The aircraft entered and backtracked on runway 30 before reaching the threshold and commencing a 180° turn.

“The flight crew reported the common technique for taxiing and turning the King Air B200 is to make a wide arc turn to reduce stress on the undercarriage,” ATSB Director Transport Safety Dr Stuart Godley said.

“But during the turn in this case, the pilot flying steered the aircraft away from the centreline taxiway ground markings, toward the right runway edge, later reporting they had subconsciously mistaken the blue taxiway edge lights and double yellow line as taxi centreline guidance.”

During the turn, the aircraft struck one of the taxiway edge lights with its right propeller, and the flight crew taxied back to the apron.

A post shutdown inspection found damage to the right propeller, and the aircraft was grounded for repairs.

Dr Godley said the incident demonstrated how pilots need to be vigilant and maintain an awareness of their location.

“The airport environment contains numerous visual aids, markings, signals and signs to help pilots remain situationally aware of their location, traffic and intended ground tracks to avoid obstacles.”

The ATSB’s final report notes the supervising pilot noticed the aircraft deviating closer to the edge lighting, but did not intervene in time to avoid it striking the light.

“Effective monitoring in a multi-crew environment is paramount to aircraft safety,” Dr Godley said.

“Bringing deviations to the early attention of the pilot flying promptly ensures the aircraft remains on a desirable track.”

Read the final report: Propeller strike of a taxiway edge light involving Beechcraft King Air B200C, VH-RFD, Hobart Airport, Tasmania, on 1 July 2025

An XPT passenger train exceeded a temporary speed restriction by more than 60 km/h after its driver was provided with an ambiguous notice of the restriction, a transport safety investigation has concluded.

The investigation into the incident was conducted by the Office of the Chief Investigator, which investigates rail occurrences in Victoria in accordance with a collaboration agreement with the ATSB.

The investigation’s final report notes that, on the morning of 24 May 2022, a temporary speed restriction (TSR) of 40 km/h was in place for a section of track over Moonee Ponds Creek bridge. ARTC network controllers had applied the TSR in response to a rough ride report made by the driver of an earlier train.

While the TSR was in place, an XPT passenger service from Sydney to Melbourne travelled through the section at about 100 km/h.

Chief Investigator Mark Smallwood said the driver of the XPT train had been given a warning for the TSR that was ambiguous as it described the location using only kilometres, which contributed to the exceedance. 

“The driver was provided with a condition affecting network warning saying the TSR was applied between 24.0 and 24.4 km,” Mr Smallwood said.

“However, the standard gauge route to Melbourne contained two locations with these same kilometres in the path of the train.”

The driver slowed the train at the first 24.4 km location but did not do so as they crossed over Moonee Ponds Creek bridge, the second location of that kilometrage on their route where the TSR applied.

Mr Smallwood highlighted that the method of warning trains of a TSR was an administrative process. 

“The administrative processes used by the network operator, ARTC, to warn train crew about TSRs, were vulnerable to errors in creation and communication,” Mr Smallwood said.

“There were opportunities to improve existing processes and to adopt technology-supported solutions to reduce risk associated with the implementation of TSRs.”

In response to this issue, ARTC has implemented an electronic system for generating condition affecting network warnings that prompts train controllers to provide two types of location identification information. ARTC also advised of a longer-term action to implement digital transmission of speed warnings to trains by 2028. 

Mr Smallwood welcomed the safety actions by ARTC.

“In the Australian rail context, administrative processes have often been established for long periods of time while technology has improved,” he concluded.

“Opportunities exist for safety improvement in rail safeworking through the modernisation of administrative controls and adoption of technology-supported solutions.”

Read the final report: Exceedance of temporary speed restriction by XPT ST21, Merri-bek, Victoria, on 24 May 2022

Separation reduced between two aircraft above Jandakot Airport, south of Perth, after one of the pilots did not identify an amended instruction from air traffic control, and their incomplete readback was not corrected by the controller, an ATSB final report explains.

On 12 June 2025, a student pilot was returning to Jandakot at the conclusion of a solo navigation flight in a twin-engine Piper PA-44 Seminole. At the same time, a single-engine Cessna 172 was approaching the airport from the training area.

Air traffic control (ATC) directed the pilot of the faster Seminole to overtake the Cessna as they approached the circuit. However, when the Seminole did not pass the Cessna prior to joining the circuit, ATC amended the instruction, telling the Seminole to ‘follow the Cessna’.

“The Seminole pilot did not identify this final part of the amended instruction, likely due to receiving an unexpected cockpit traffic alert at the time the approach clearance was issued,” ATSB Director of Transport Safety Stuart Macleod said.

“Consequently, the Seminole passed the Cessna as per the original clearance, reducing separation between the two aircraft.”

Although a key element of the revised approach clearance, the pilot’s readback of ATC’s instructions was incomplete.

“This was not corrected by the controller as the Manual of Air Traffic Services did not explicitly require sequencing instructions to be read back,” Mr Macleod said.

“This was a missed opportunity to resolve the situation and, more generally, provided no assurance that this safety-critical aspect had been correctly understood.”

Airservices Australia has subsequently conducted a review, and says it will investigate a change to the Manual of Air Traffic Services, and the respective Aeronautical Information Publication reference, to include the instruction ‘follow’ in the list of items requiring readback.

“This incident highlights the importance of ensuring that pilots and air traffic control all have an accurate situational understanding, especially when plans change,” Mr Macleod summarised.

“Sequencing of aircraft is a safety critical component of assuring separation and needs to be unambiguous for all.

“Pilots should seek confirmation from controllers if they are unsure of what is required of them, and ATC should confirm that pilots have a correct understanding of sequencing requirements, if there is any doubt.”

Read the final report: Separation occurrence involving Piper PA-44, VH-KZJ, and Cessna 172, VH-ZER, near Jandakot Airport, Western Australia, on 12 June 2025

The ATSB has provided a substantive update on its ongoing investigation into a midair collision near The Oaks, south-west of Sydney, on 26 October last year, with the release of an interim report.

The 35-page report outlines in detail evidence gathered during the investigation as well as contextual information around the circumstances of the accident. It does not contain findings, which will be made in the ATSB’s final report, to be released at the conclusion of the investigation.

The two aircraft, a Cessna 182, which had departed Camden and a Jabiru recreational aircraft, which was returning to land at The Oaks, collided in-flight about 2.7 km west of The Oaks aerodrome. Both aircraft impacted heavily-wooded terrain and all three occupants were fatally injured.

“As we previously detailed in a preliminary report, the Jabiru was one of two aircraft that had departed The Oaks for a planned flight to Cessnock, but both decided to return to The Oaks after encountering turbulence en route,” ATSB Chief Commissioner Angus Mitchell outlined.

The Cessna, meanwhile, had been conducting circuits at Camden, as part of a commercial pilot licence flight test, having originally departed Shellharbour.

“The collision occurred when the Jabiru was flying to the north on the downwind leg of the circuit for The Oaks ahead of a planned landing, and as the Cessna was tracking to the southwest.”

Both aircraft were on near reciprocal headings and on relatively constant flight path trajectories at the time of the collision, with video from an onboard camera on the Jabiru showing it in straight and level flight and the Cessna climbing.

The collision occurred at an altitude of approximately 2,200 ft, about 1,300 ft above the runway at The Oaks.

“The video camera in the Jabiru has been instrumental in establishing the accident’s sequence of events and in allowing us to undertake extensive analysis of radio calls made prior to the collision,” Mr Mitchell said.

 The Oaks aerodrome is in non-controlled airspace, meaning pilots are responsible for maintaining separation from other aircraft using ‘alerted see-and-avoid’ principles – making required and recommended position and intention radio calls on a common traffic advisory frequency (CTAF) and maintaining a visual scan.

Camden Airport, meanwhile, about 6.5 NM (12 km) to the north-west, is in controlled airspace which extends over a 2 NM (3.7 km) radius, with separation provided by an air traffic control tower.

“While radio calls made on The Oaks CTAF are not recorded, the video showed transmissions being both made and received by the Jabiru on The Oaks CTAF radio frequency,” Mr Mitchell said.

The duration and timing of all radio calls received by the Jabiru in the six minutes prior to the collision were consistent with those calls being made by the two other aircraft in the group – a Sonex on the ground, and a second Jabiru which also returned to The Oaks.

Noting that The Oaks CTAF was not recorded, the last recorded radio call made by the Cessna was reading back a clearance to Camden air traffic control for a touch-and-go and an upwind departure from Camden.

The report also details that the Cessna and the second Jabiru aircraft passed each other while the second Jabiru was about to turn onto the final leg of the circuit to land at The Oaks. Analysis of flight data showed that this Jabiru passed in front of and about 400 ft above the Cessna on a near reciprocal heading.

The report notes that CASA guidance states that pilots should avoid flying over non-controlled aerodromes at an altitude that could result in a conflict with aircraft operations there, while a warning label on the relevant aeronautical chart (the Sydney VTC) recommends overflying The Oaks not below 2,500 ft. 

“This investigation has benefited from a wide range of data sources such as the video, ASD-B and transponder data, and from electronic flight bag apps to build a picture of the flight paths of both accident aircraft and radio transmissions,” Mr Mitchell noted.

“From here the investigation is looking at wider considerations, such as CPL flight test procedures and practices, and reviewing radio communications, electronic conspicuity and surveillance equipment for aircraft in non-controlled airspace.”

The investigation’s final report is anticipated to be released in 2026.

“We look forward to concluding our analysis of the circumstances of this tragic accident and sharing our findings to help prevent similar accidents in the future,” Mr Mitchell concluded.

Read the interim report: Midair collision involving Jabiru UL 450, 19-4079, and Cessna 182, VH-APN, 2.7 km west of The Oaks, New South Wales, on 26 October 2024

The operator of two R22 mustering helicopters which collided soon after take-off did not define appropriate separation standards for its helicopter operations, with pilots permitted to arrange their own separation, an ATSB investigation has found.

The investigation’s final report details that between first light and sunrise on 25 July 2024, the pilots of four Robinson R22s planned to take-off from the Mount Anderson Station homestead in WA’s Kimberley to transit to a mustering site about a 10-minute flight away.

Shortly after taking off, two of the helicopters, flown by the lead pilot and another experienced mustering pilot, collided about 150 ft above ground level. The helicopters departed controlled flight and collided with terrain, and both pilots were fatally injured.

An ATSB investigation established that the helicopters collided during initial climb, after the lead helicopter had manoeuvred to the right.

“Neither pilot detected their converging flight paths before the collision,” Chief Commissioner Angus Mitchell said.

“While limited data prevented a full visibility study to establish what each pilot could see, the wreckage examination indicated that at the point of collision the lead helicopter may have been in a blind spot for the second helicopter.”

The investigation’s final report considers what actions the helicopters’ operator, Pearl Coast Helicopters, was taking to manage aircraft separation in its operations.

“The tools used by the operator to consider and manage operational risk were not tailored to their main business of aerial mustering,” Mr Mitchell said.

“Further, the risk of collision had not been identified in operational risk assessments, and the operator’s manuals did not provide documented procedures to ensure pilots establish and maintain adequate separation between helicopters.”

Instead, the final report notes, company pilots were permitted to arrange their own separation based on personal preference.

“Pilots routinely flew with reduced vertical and lateral separation, and over time this became an accepted operating preference.”

Mr Mitchell said the accident was a demonstration of the need for risk management to identify, assess and mitigate risks.

“Aerial mustering plays a critical role in Australia’s agricultural sector,” he said. 

“This tragic accident should serve as a trigger for all mustering operators to consider their risk management practices, and whether they have scaled them adequately for their operation.”

The final report notes Australia’s Civil Aviation Safety Regulations for aerial work activities(Opens in a new tab/window) (Part 138) are intended to provide operators with flexibility through scalable risk management practices.

“We encourage operators to review available guidance to assist in their identification and management of hazards.”

Mr Mitchell also said the accident was another reminder of the fallibility of see-and-avoid as a primary means of identifying and managing the threat of collision.

“Defined separation minimums and pre-planned safe exits which provide an opportunity to identify and respond to emerging collision threats are important tools in assisting pilots avoid midair collisions,” he said.

“Additionally, airframe obstructions can limit visibility in even the most open cabins. This should be a key consideration when establishing how aircraft should be positioned when flying in close proximity.”

Read the final report: Midair collision involving Robinson R22 Beta II, VH-HQH, and Robinson R22 Beta II, VH-HYQ, 51 km south-south-east of Curtin Airport, Western Australia, on 25 July 2024