The Transport Accident Investigation Commission of New Zealand (TAIC) is investigating a serious incident involving an ATR 72-600, registration ZK-MVQ, at Nelson Airport, New Zealand, on 27 November 2025.
On approach to Nelson Airport the flight crew received a landing gear warning and conducted a go-around. The aircraft diverted to Auckland Airport and landed safely.
The TAIC has requested assistance and the appointment of an accredited representative from the ATSB. To facilitate this support and to provide the appropriate protections for the information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of Annex 13 to the Convention on International Civil Aviation and commenced an investigation under the Australian Transport Safety Investigation Act 2003.
TAIC is responsible for the investigation and release of the final investigation report regarding this accident. Any enquiries regarding the investigation should be addressed to TAIC.
A Boeing 737 took off from Canberra Airport with incorrect performance calculations after a data input error led to 51 of the passengers on board not being accounted for, an ATSB final report explains.
On 1 December 2024, a Qantas 737 operating a flight from Perth to Sydney diverted to Canberra due to bad weather.
Prior to its subsequent flight from Canberra to Sydney, an error was made within the Qantas departure control system that meant 51 passengers were incorrectly listed as not on board the aircraft.
A loadsheet was then issued to the flight crew with an aircraft weight that was 4,291 kg less than the actual weight of the aircraft, resulting in performance calculations generating take-off speeds 3-4 kt lower than they should have been.
“This increased the risk of degraded performance and handling characteristics during the take-off,” ATSB Director Transport Safety Dr Stuart Godley said.
“Fortunately, the flight crew elected to use the full length of the runway for the take-off, and did not apply the headwind component, which added an increased safety margin for take-off performance.”
While the flight took place without further incident, Dr Godley said the occurrence demonstrated how a small error can cascade when unusual situations are not proactively identified, addressed, or escalated by those involved in a safety system.
“The initial error made was by a Qantas staff member who inadvertently input a smaller aircraft type into the flight plan, resulting in the system automatically removing passengers from the flight,” Dr Godley explained.
The staff member recognised the aircraft code error and corrected it, but this did not automatically reallocate the passengers back onto the flight. The lower number of passengers went unnoticed.
Qantas airport personnel then used the erroneous planning data within the scheduling system to close the flight. After being made aware of offloaded passengers in the system by another staff member, they attempted but failed to onboard those passengers within the system. They then took no further action to address the issue, assuming load control would be aware of the error and resolve it.
“Qantas load control was not aware of the error,” Dr Godley said.
“While they had concerns about the validity of the data, after liaising with the system manager, they issued the final loadsheet to the flight crew because the previous closure of the flight by airport staff indicated to them that the data had been confirmed as correct.”
Shortly after the loadsheet was issued, but before the aircraft had departed, the load control manager identified there were offloaded passengers within the system, and tried to call the flight crew via mobile phone, which went unanswered.
The issue was then handed over to Qantas movement control at Canberra Airport, who attempted to contact the flight crew via radio. But this was also unsuccessful, as the flight crew had deselected the radio to reduce distractions while they entered the loadsheet data into the aircraft computer.
Qantas movement control then radioed the Qantas gate agent to pass on the message about the error to the flight crew.
“This was not in line with procedure, which stipulated the movement control officer needed to liaise directly with the flight crew about the error,” Dr Godley said.
The gate agent then did not inform the flight crew themselves, instead believing the aircraft cabin manager, who was next to them at the time, had overheard the radio call and would tell the flight crew.
“After the incident, the cabin manager could not recall either being advised of the issue, or overhearing the radio,” Dr Godley said.
The flight crew were therefore not made aware of the loadsheet error until they had taken off.
As a result of the occurrence, Qantas will amend its procedures to allow load control personnel to contact flight crews directly via the aircraft communications addressing and reporting system, when a loadsheet error is identified.
The airline has also amended procedures to require airport personnel to conduct a headcount when a passenger discrepancy is identified.
“This incident highlights that It is not sufficient to rely on downstream controls or other functions to intervene or trap errors,” Dr Godley said.
Nonetheless, Dr Godley reiterated the uneventful take-off demonstrated the value of prudent flight planning.
“The safety margins built into the performance calculations by the flight crew meant that the incorrect data did not lead to a more consequential outcome,” he concluded.
The ATSB is investigating a midair collision involving 2 Van's RV-7 aircraft, registered VH-EWS, and VH-NMG, near Wedderburn Aerodrome, New South Wales, on 30 November 2025.
Four Van’s RV-7 aircraft were in formation and returning to Wedderburn Aerodrome when 2 of the aircraft collided in mid-air. One of the aircraft involved in the collision was able to safely land at the aerodrome. The other aircraft impacted with terrain and the pilot sustained fatal injuries.
The ATSB has commenced the examination and analysis of the initial evidence collected.
To date, the ATSB investigation has:
examined the wreckage and the other damaged aircraft involved in the collision
interviewed the pilots from the formation as well as witnesses to the accident
examined the available closed-circuit television footage
examined the pilot records
completed preliminary analysis of the available flight data.
A preliminary report, which detailed factual information established during the evidence collection phase, was released on 30 January 2026 - see below.
The investigation is continuing and will include:
examination of maintenance records
examination of pilot records and training
consideration of formation flying procedures and practices
further analysis of recorded data.
A final report will be released at the conclusion of the 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.
Preliminary report
Report release date: 30/01/2026
This preliminary report details factual information established in the investigation’s early evidence collection phase, and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.
The occurrence
Just before midday on 30 November 2025, a group of 4 aircraft were returning from a private formation flight, which had departed from the Wedderburn aeroplane landing area, New South Wales. The formation used the call sign ‘Acro Formation’ and consisted of 1 Van’s RV‑6A aircraft (registration VH-LMK), 2 Van’s RV-7 (VH‑EWS and VH‑VNZ), and 1 Van’s RV-7A (VH-NMG). Each aircraft’s respective pilots were the sole occupants.
During its return, Acro Formation was in a box formation (as shown in Figure 1). VH-LMK was formation lead in position #1, VH-NMG in position #2, VH-EWS in position #3 and VH‑VNZ was in position #4.[1] At 1205:08, #1 broadcast on the Wedderburn common traffic advisory frequency that the formation was 10 NM (19 km) from Wedderburn. At 1209:14, the pilot of #1 directed #3 and #4 to move their aircraft into the echelon right formation (as shown in Figure 1) and the formation then descended to about 600 ft above ground level (AGL). This was to facilitate the planned stream landing after entering the Wedderburn circuit via an initial and pitch manoeuvre.[2]
Figure 1: Box (left) and echelon right (right) formations
Source: ATSB
At 1209:58, the pilot of #1 broadcast that the formation was joining crosswind for runway 35. Shortly after, the pilot waved at the formation to signal that they were about to turn and leave the formation. The pilot in #1 then commenced a climbing turn to join crosswind and establish the aircraft at the normal circuit height of 1,000 ft AGL. The remaining aircraft would follow, but with a 3 second delay between each aircraft.[3]
According to a nearby eyewitness who was watching the formation from outside a hangar at the aerodrome, each aircraft turned into the circuit after similar time delays. They recalled that #3 continued the turn, tighter than the previous aircraft, which put it onto a converging heading with #2. An overlay of the flight tracks from the available flight data for each aircraft showing the initial and pitch sequence is shown in Figure 2.
A generic low wing aircraft is displayed. Pitch, roll and yaw data was not available to accurately depict aircraft orientation. Source: Cesium and individual aircraft flight tracking data, annotated by the ATSB
At about 1210:09, #3 (VH-EWS) collided with #2 (VH-NMG) at about 1,140 ft AGL (Figure 3), and about 350 m south-east of the northern threshold of runway 35. From the collision, the rear fuselage of #3, just rearward of the baggage compartment, separated from the aircraft. Almost immediately, #3 descended rapidly and impacted terrain in a near vertical trajectory, fatally injuring the pilot. Aircraft #2 remained flyable and the pilot, who was not injured, was able to land the aircraft at the aerodrome and taxi off the runway.
Figure 3: Flight track of the formation showing the collision point between #3 (VH‑EWS, in blue) and #2 (VH-NMG, in yellow) at about 1210:09
A generic low wing aircraft is displayed. Pitch, roll and yaw data was not available to accurately depict aircraft orientation. Source: Cesium and individual aircraft flight tracking data, annotated by the ATSB
Context
Pilot information
VH-EWS
The pilot of VH-EWS held a Private Pilot Licence (Aeroplane), which had been issued in 2010. They held flight activity endorsements, which permitted them to conduct aerobatics above 500 ft AGL, spins, formation flying and formation aerobatics. They also held an instructor rating specifically for teaching spins and formation flying. The pilot held a class 2 aviation medical certificate with a requirement to wear distance vision correction and have reading correction available when flying, which was valid until February 2026.
Their most recent logbook and flying records could not be located after the accident. They were reported as being very experienced in general aviation activities and had held their formation endorsement since 2016. At the time of their most recent medical examination in February 2024, the pilot reported a total of 2,500 flying hours. Their last flight review was in December 2023 and was valid until February 2026.
VH-NMG
The pilot of VH-NMG held a Recreational Pilot Licence (Aeroplane) that was issued in 2022. They held flight activity endorsements, which permitted them to conduct aerobatics above 1,500 ft AGL, spins, formation flying and formation aerobatics. The pilot’s class 2 aviation medical certificate was valid until May 2026, however, it was not valid for night flying.
The pilot reported a total of 509 flying hours of which 331 hours were on Van’s RV-7 aircraft. Their last flight review was in April 2024 and was valid until April 2026.
Aircraft information
VH-EWS
VH-EWS was a Van’s RV-7 amateur-built aircraft with a manufacture date of 2012. It was a piston-engine, 2‑seat aircraft with a low wing, and tailwheel landing gear (Figure 4 left).
VH-NMG
VH-NMG was a Van’s RV-7A amateur-built aircraft with a manufacture date of 2009. It was similar to VH-EWS except that it had a tricycle landing gear (Figure 4 right).
Figure 4: VH-EWS (left) and VH-NMG (right)
Source: Reuben Morison (left) and Clinton J Down Photography (right) via www.Jetphotos.com, modified by the ATSB
Meteorological information
Weather
The other pilots in the formation reported that conditions were good, although there was some turbulence during their flight. They did not express any concerns that the conditions were not suitable for their flight. Closed circuit television footage obtained from a hangar at the aerodrome showed that the sky in the immediate vicinity was clear, with cloud well above the circuit height.
There was no Bureau of Meteorology forecast or observations for the aerodrome, however, the graphical area forecast[4] valid for the time and area of the flight did not indicate any weather phenomena that may have impacted visibility. Moderate turbulence was forecast below 6,000 ft above mean sea level.
The aerodrome had a weather station that recorded numerous parameters including wind speed and direction. At the time of the accident, average winds were below 10 kt and generally westerly. Cloud and visibility data were not recorded parameters.
Daylight
At the time of the accident, Geoscience Australia recorded the sun position at an elevation of 75° 16’ 34’’ and azimuth of 33° 59’ 04”.[5] This was high in the sky towards the north‑north‑east. The 3 remaining pilots reported that the sun position did not present an issue for their visibility.
Aerodrome information
Wedderburn was a non-controlled aeroplane landing area[6] located approximately 3 km south of Wedderburn township and 19 km to the south-east of Camden Airport, New South Wales. It had an elevation of 850 ft with a paved and adjacent grass runway aligned 17/35,[7] which was 980 m long. The aerodrome was privately owned and operated.
Recorded information
None of the aircraft were fitted with, nor were they required to have, a flight data recorder or cockpit voice recorder. However, flight tracking data was obtained for each aircraft, from sources including third party flight tracking providers, electronic flight bag applications and onboard avionics. Generally, this data included latitude, longitude, ground speed, course and altitude, at variable rates between 1 and 5 seconds.
Although the pilots of VH-EWS and VH-NMG had frequently flown with onboard video cameras, neither pilot did so during the accident flight, nor did the other pilots in the formation.
Common traffic advisory frequency recordings for Wedderburn were retrieved, however, the discrete frequency used during their formation flying was not recorded.
Closed circuit television footage from one of the nearby hangars captured VH-EWS descending rapidly just prior to it entering the tree canopy but did not capture the subsequent collision with terrain. Another camera captured the other aircraft in the formation landing at the aerodrome after the accident. The collision between the aircraft was not captured.
Wreckage and impact information
VH-EWS
The main wreckage of VH-EWS was located in dense bush about 250 m west‑south‑west of the collision point. The rear fuselage was in similarly dense bush, 250 m north-east of the main wreckage (Figure 5).
Figure 5: VH-EWS wreckage site locations and its flight track adjacent to the aerodrome
Source: Google Earth, annotated by the ATSB
Observations of the site identified that the aircraft collided with trees prior to impacting terrain in a nose down attitude at an impact angle of about 65°. The main wreckage trail extended for about 5 m from the initial impact point towards the south. The aircraft was significantly disrupted, with the propeller buried into the earth at the point of impact (Figure 6).
Figure 6: VH-EWS main wreckage showing key parts of the aircraft
Source: ATSB
Due to the wreckage disruption a full flight control continuity check was not possible, but examination of the available controls did not identify any pre-collision defects. All aircraft parts were accounted for at the wreckage site. Examination of the propeller indicated that the engine was providing power at the time of impact.
The tail section showed damage consistent with contact with VH-NMG. Specifically, there was compression damage to the upper rudder and vertical stabiliser, and propeller strike marks from right to left at the rear fuselage separation point (Figure 7). The rear fuselage section was complete and there was no evidence of pre-collision defects in the flight controls or structure.
Figure 7: VH-EWS rear fuselage and tail assembly
Source: ATSB
VH-NMG
Examination of VH-NMG identified aircraft impact damage to the lower fuselage, nose wheel fairing, propeller blades and spinner. The lower fuselage damage consisted of skin and rib damage and a large intrusion into the aircraft structure just aft of the wing carry through structure and red paint transfer observed in several locations. The damage was consistent with the upper rudder and vertical stabiliser damage on VH-EWS with the orientation of the intrusion at about 30° left of VH-NMG’s longitudinal axis[8] (Figure 8). A flight control function check showed slight fouling of the ailerons and elevators due to the skin intrusion into the area of the flight controls.
Figure 8: VH-NMG lower fuselage and nose wheel fairing damage
Source: ATSB
Examination of the propeller and its spinner showed leading edge gouges, rotational scoring, tip bending and red paint transfer that was consistent with VH-NMG striking VH‑EWS several times during the collision sequence (Figure 9).
Figure 9: VH-NMG propeller damage
Source: ATSB
Aircraft to aircraft impact alignment
An assessment of the aircraft impact damage identified that VH-EWS collided with VH‑NMG from below and slightly ahead. VH-EWS was likely in a nose up attitude and 30° nose left relative to VH-NMG. The vertical stabiliser from VH-EWS intruded into the lower fuselage of VH-NMG, and the propeller of VH-NMG cut through the rear fuselage of VH-EWS. A depiction of the impact alignment is shown at Figure 10.
Figure 10: Aircraft to aircraft relative impact alignment
Source: ATSB
Further investigation
The investigation is continuing and will include:
examination of maintenance records
examination of pilot records and training
consideration of formation flying procedures and practices
further analysis of recorded data.
A final report will be released at the conclusion of the 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.
Acknowledgements
The ATSB acknowledges the significant assistance provided by the NSW Police Force during the onsite phase of the investigation.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
About ATSB reports
ATSB investigation reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines.
Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence.
The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
[1]For ease of reference, each aircraft and/or pilot will be referred to by their formation position number.
[2]Initial and pitch: a circuit entry technique for formation flights. This involved flying an upwind leg, aligned with the landing runway, commencing from a predetermined position (initial). At about halfway along the runway, the lead aircraft in the formation will then turn onto the crosswind leg (pitch) with each aircraft following in succession with a set time delay between them. Once complete, there should be sufficient lateral separation between each aircraft as they continue in the circuit to land in succession (stream landing).
[3]The 3 second delay was reported by the surviving pilots as being their standard time delay for a formation initial and pitch manoeuvre.
[4]Graphical area forecast provides information on weather, cloud, visibility, icing, turbulence and freezing level in a graphical layout with supporting text.
[5]The elevation of the sun is the angle between the direction of the sun and the observer's local horizon. The azimuth is the angle between North, measured clockwise around the observer's horizon.
[6]An aeroplane landing area is an aerodrome that has not been certified by the Civil Aviation Safety Authority. These aerodromes are non-controlled, unregulated facilities. It is the responsibility of pilots and operators to determine whether these aerodromes are suitable for use.
[7]Runway number: the number represents the magnetic heading of the runway.
[8]The longitudinal axis of an aircraft runs from its nose to its tail.
Occurrence summary
Investigation number
AO-2025-071
Occurrence date
30/11/2025
Occurrence time and timezone
12:10 Australian Eastern Daylight Time
Location
Near Wedderburn aeroplane landing area
State
New South Wales
Report status
Preliminary
Anticipated completion
Q2 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Evidence collection
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Collision
Occurrence class
Accident
Highest injury level
Fatal
Aircraft details
Manufacturer
Amateur Built Aircraft
Model
Van's RV-7
Registration
VH-EWS
Serial number
73226
Sector
Piston
Operation type
Part 91 General operating and flight rules
Activity
General aviation / Recreational-Sport and pleasure flying-Aerobatics
Departure point
Wedderburn Aircraft Landing Area, New South Wales
Destination
Wedderburn Aircraft Landing Area, New South Wales
Injuries
Crew - 1 (fatal)
Damage
Destroyed
Aircraft details
Manufacturer
Amateur Built Aircraft
Model
Van's RV-7A
Registration
VH-NMG
Serial number
73232
Sector
Piston
Operation type
Part 91 General operating and flight rules
Activity
General aviation / Recreational-Sport and pleasure flying-Aerobatics
The ATSB is investigating a midair collision involving two Van’s RV-7 light aircraft at Wedderburn, south of Sydney, on Sunday.
As reported to the ATSB, the two aircraft had been involved in a formation flight of four aircraft that was returning to land at Wedderburn Airport when the collision occurred. One of the aircraft involved in the collision landed safety but the other aircraft collided with terrain and its pilot was fatally injured.
A team of four transport safety investigators from the ATSB's Perth, Canberra and Brisbane offices, with experience in aircraft operations, maintenance and engineering, is preparing to deploy to the accident site to begin evidence-collecting activities.
Over coming days, investigators will undertake site mapping, examine aircraft wreckage and damage, and recover any relevant components for further examination at the ATSB’s technical facilities in Canberra.
Investigators will also interview the other pilots involved in the formation flight, as well as other witnesses and involved parties. They will also collect relevant recorded information including any air traffic control and flight tracking data, as well as pilot and aircraft maintenance records, and weather information.
The ATSB asks anyone who may have witnessed and has footage of the accident, or who has footage of either aircraft in any phase of their flights, to contact us via the witness form on our website at their earliest convenience.
The ATSB will release a preliminary report detailing factual information established in the investigation’s evidence-gathering phase in about two months. A final report will be released at the conclusion of the investigation and will detail analysis and findings.
However, if at any point during the investigation we uncover any critical safety issues we will immediately inform relevant parties so they can take safety actions.
The ATSB is investigating a collision with terrain involving a Van's RV-8, registered VH-YGY, 40 km west of Gladstone Airport, Queensland, on 23 November 2025.
During initial climb, the aircraft reportedly encountered a mechanical issue and the pilot attempted to land. The aircraft subsequently collided with a tree and was destroyed. The pilot sustained serious injuries.
The ATSB deployed a team of 4 transport safety investigators to the accident site with experience in aircraft operations, maintenance, and engineering. As part of the on-site phase of the investigation, ATSB investigators examined the aircraft wreckage and other information from the accident site, interviewed witnesses and involved parties, and examined maintenance records and recorded data.
The draft report internal review process has been completed. The draft report has been distributed to directly involved parties (DIPs) to check factual accuracy and ensure natural justice. Any submissions from those parties will be reviewed and, where considered appropriate, the draft report will be amended accordingly.
Following the external review process, any submissions and amendments to the draft report are internally reviewed. Once approved, the final report is prepared for publication and dissemination and released to DIPs prior to its public release.
The final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Last updated:
Occurrence summary
Investigation number
AO-2025-068
Occurrence date
23/11/2025
Occurrence time and timezone
09:00 Eastern Australia Standard Time
Location
40 km west of Gladstone Airport
State
Queensland
Report status
Pending
Anticipated completion
Q2 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Final report: External review
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Collision with terrain, Engine failure or malfunction, Forced/precautionary landing
Occurrence class
Accident
Highest injury level
Serious
Aircraft details
Manufacturer
Van's Aircraft
Model
RV-8
Registration
VH-YGY
Serial number
80605
Sector
Piston
Operation type
Part 91 General operating and flight rules
Activity
General aviation / Recreational-Unknown general aviation flying
The ATSB is investigating suspected rotor drive belt failures involving 2 Robinson R22s, registered VH-8H8 and VH-HFQ, near Argadargada Aerodrome, Northern Territory, and Chillagoe Aerodrome, Queensland, on 15 November 2025 and 23 November 2025.
During cruise for mustering, the pilot and passenger of VH-8H8 noticed a smell of burning rubber and the pilot thought the rotor drive belts had failed. The engine over sped and the pilot conducted an autorotation. The helicopter subsequently collided with terrain resulting in substantial damage.
During cruise on a private flight, the pilot and sole occupant of VH-HFQ detected an airframe vibration and observed an abnormal rotor RPM indication, before conducting an autorotation and forced landing. The helicopter landed hard and the pilot observed a rotor belt on the ground. The helicopter was subsequently destroyed by post‑impact fire.
The ATSB has examined and analysed recovered components, maintenance records, and information from the occurrence pilots, maintenance personnel and the helicopter manufacturer. The evidence collection and analysis phases of the investigation are now complete and the ATSB is drafting the final report.
The final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Occurrence summary
Investigation number
AO-2025-069
Occurrence date
15/11/2025
Occurrence time and timezone
08:30 Australian Eastern Standard Time
Location
Near Argadarga Aerodrome and Chillagoe Aerodrome
State
Northern Territory
Report status
Pending
Anticipated completion
Q2 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Final report: Drafting
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Collision with terrain, Forced/precautionary landing, Powerplant/propulsion - Other
Occurrence class
Accident
Highest injury level
None
Aircraft details
Manufacturer
Robinson Helicopter Co
Model
R22 Beta
Registration
VH-8H8
Serial number
3293
Aircraft operator
Georgina Pastoral Company Pty Ltd
Sector
Helicopter
Operation type
Part 91 General operating and flight rules
Activity
General aviation / Recreational-Aerial work-Observation and patrol
Departure point
Argadargada Station, Costello, Northern Territory
Destination
Argadargada Station, Costello, Northern Territory
Injuries
None
Damage
Substantial
Aircraft details
Manufacturer
Robinson Helicopter Co
Model
R22 Beta
Registration
VH-HFQ
Serial number
4279
Aircraft operator
Sunrise Helicopters Pty Ltd
Sector
Helicopter
Operation type
Part 91 General operating and flight rules
Activity
General aviation / Recreational-Own business travel
The ATSB is investigating a near collision involving a Bell 212, registration VH-JJR, and a Sling 2, registration VH‑FFZ, near Moorabbin Airport, Victoria, on 24 November 2025.
Both aircraft were engaged in training activities, and each had 2 persons on board. While returning to land at Moorabbin the Bell 212 crossed into the path of the Sling 2 which was on final approach to runway 13L. It was reported that the helicopter passed above the fixed wing aircraft with a separation of less than 60 meters. Both aircraft continued to land without further incident. There were no injuries to those on board, and no damage to either aircraft.
The ATSB has commenced the examination and analysis of the evidence collected.
To date, the ATSB investigation has included:
interviewing the flight crew and air traffic controllers
examination of pilot records
analysis of flight recorder and air traffic surveillance data.
In the course of the investigation, the ATSB considers there to be a reasonable likelihood of limitations in risk controls that potentially contributed to the occurrence. Examination of these factors represent a significant increase in the scope of this investigation, and it has been upgraded from Short to Defined as a result (the ATSB's different levels of investigation are detailed here).
The continuing investigation will include examination and analysis of:
operational documentation
related occurrences.
A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Last updated:
Occurrence summary
Investigation number
AO-2025-070
Occurrence date
24/11/2025
Occurrence time and timezone
12:05 Australian Eastern Daylight Time
Location
About 1.6 km north-north-west of Moorabbin Airport
State
Victoria
Report status
Pending
Anticipated completion
Q4 2026
Investigation level
Defined
Investigation type
Occurrence Investigation
Investigation phase
Examination and analysis
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Near collision
Occurrence class
Serious Incident
Highest injury level
None
Aircraft details
Manufacturer
The Airplane Factory
Model
Sling 2
Registration
VH-FFZ
Serial number
195
Aircraft operator
Learn to Fly Australia Operations Pty Ltd
Sector
Piston
Operation type
Part 142 Integrated and multi-crew pilot flight training
Activity
General aviation / Recreational-Instructional flying-Instructional flying - dual
Departure point
Moorabbin Airport, Victoria
Destination
Moorabbin Airport, Victoria
Injuries
None
Damage
Nil
Aircraft details
Manufacturer
Bell Helicopter Co
Model
212
Registration
VH-JJR
Serial number
31280
Aircraft operator
Microflite Aviation
Sector
Helicopter
Operation type
Part 141 Recreational, private and commercial pilot flight training
Activity
General aviation / Recreational-Instructional flying-Instructional flying - dual
The Statement of Intent 2025–2027 has been developed in response to the Statement of Expectations issued by the Minister for Infrastructure, Transport, Regional Development and Local Government for the period 1 September 2025 to 30 June 2027. It details how the ATSB plans to meet the expectations specified in the Statement of Expectations.
Overview
The ATSB’s vision is Transport without accidents.
Our purpose in pursuing that vision is:
To influence transport safety improvements for the greatest public benefit through independent no-blame investigations and fostering safety awareness.
The ATSB vision and purpose is informed by the ATSB’s primary function in the Transport Safety Investigation Act 2003 (TSI Act) which is to improve safety in the aviation, marine and rail modes of transport. The ATSB undertakes the following strategic activities in support of its legislative function and purpose to influence improvements to transport safety:
Investigations
Investigate transport safety matters by conducting independent, no-blame investigations. The ATSB may investigate transport safety matters involving the following:
Aviation
Civilian Australian-registered aircraft anywhere in the world, and foreign-registered aircraft operating in Australia. Investigations into aircraft without a VH- registration, or aircraft that are non-powered, will be on an exception basis, as resources permit, and where conducting such an investigation has the potential to highlight wider safety issues.
Rail
Rail operations in Australia, subject to Commonwealth and State and Territory resourcing arrangements.
Marine
Civilian interstate and overseas shipping involving:
Australian-registered ships anywhere in the world,
Foreign-registered ships in Australian waters,
Foreign-registered ships en route to Australian ports.
Safety data and reporting information
Collect, analyse and share safety data and reporting information including through administering the voluntary and confidential reporting scheme (REPCON), processing mandatory notifications of transport accidents and incidents, and sharing important safety messaging through the publication of occurrence briefs.
Influence safety improvements
Collect, analyse and share safety data and reporting information including through administering the voluntary and confidential reporting scheme (REPCON), processing mandatory notifications of transport accidents and incidents, and sharing important safety messaging through the publication of occurrence briefs.
Leadership
Provide leadership in transport safety investigation through building knowledge and education in the transport sector, utilising and sharing best practice investigation techniques, representing Australia in international transport safety forums, and providing expert assistance to investigations in other countries.
Governance
The ATSB remains committed to upholding high standards of governance in undertaking its role as Australia’s national transport safety investigator. In addition to adhering to the Public, Governance Performance and Accountability Act 2013 (PGPA Act) and the Australian Public Service Code of Conduct and Values, the ATSB approaches its work in accordance with 5 key principles:
Independence
Engagement
Rigour
Innovation
Relevance
The ATSB has established a governance framework that details the structures, systems, processes, policies and procedures that support us to pursue our purpose in accordance with these principles and maintain accountability to the government and wider public. In ensuring that high standards of governance are maintained, the ATSB will:
maintain clear and open communication with the Minister and the Department of Infrastructure, Transport, Regional Development, Communications, Sport and the Arts (the department), ensuring any issues are communicated promptly
continue to provide quarterly progress reports to the Minister detailing the performance of the ATSB and relevant activities undertaken during the reporting period
report publicly on its operations, including through the publication of its investigation reports and Annual Report
implement the elements of the ATSB Governance Framework to ensure that integrity, transparency and accountability is maintained
continue to manage both perceived and actual conflicts of interest appropriately by:
ensuring the ATSB Commission reports any material personal interests to you in accordance with the PGPA Act and the TSI Act.
publishing ATSB’s conflict of interest policy on its website
regularly reviewing the conflicts of interest policy, processes and procedures
maintaining a conflicts of interest register.
Strategic Direction
In fulfilling ATSB’s main function of improving transport safety, the ATSB will continue to adhere to applicable legislation and Government policies. The ATSB will continue to ensure our strategic approach to carrying out our function and delivering on our purpose is consistent with the Statement of Expectations and align with Australia’s international obligations, such as requirements of the International Civil Aviation Organization and the International Maritime Organization.
Consistent with the Minister’s Statement of Expectations, the ATSB will continue to:
foster safety awareness through publicising safety information from its investigations, research and data analysis in a timely manner and through mediums and forums that target key stakeholders for safety messaging and education
consistent with our jurisdiction outlined in the overview section, focus our resources on investigations that have the highest potential to deliver the greatest public transport safety benefit
while maintaining our independence, complement and add value to the work of transport regulators, policy agencies, Defence and industry in Australia’s transport safety policy and regulatory framework
through our engagement in international forums and partnerships with tertiary institutions, pursue global leadership in transport safety investigation, research and analysis
review, improve and promote best practice investigation policies and practices, benchmarking itself against like organisations.
Overall, the ATSB’s strategic focus is to maximise safety outcomes across the aviation, marine and rail sectors. The ATSB achieves this through influencing stakeholders to foster safety awareness, knowledge and action, as well as positioning ATSB as an enduring and adaptable organisation that invests in its people, systems and partnerships. The ATSB directs its resources to investigations and activities that have the ability to deliver the greatest improvements to transport safety. This strategic focus allows the ATSB to make the most effective use of resources and respond rapidly to changes in the environment.
Key Initiatives
The ATSB will continue to use the corporate plan, annual report and quarterly performance report to communicate key initiatives and progress to the Minister. Through the period of the Statement of Intent, the ATSB will focus on the following priorities, consistent with the Statement of Expectations:
Partnerships and collaboration – continue to invest in partnerships with educational institutions such as the RMIT University to enhance transport safety education and learning. Collaborate with other countries to improve accident investigation capability, including through the Australia-Pacific Partnerships for Aviation Program in partnership with the Department of Foreign Affairs and Trade.
Staff development – continue to focus on staff development and growth, including through effective workforce planning and training to ensure that ATSB has the skills and expertise to meet current and emerging challenges in transport safety investigation. This includes focusing on developing leadership capability and implementing transport safety investigator competencies to ensure we have a capable, technical and engaged workforce.
Research, data and communication – continue to invest in research activities, including collecting and analysing data on transport safety topics for the greatest public benefit. Focus on new and innovative communication mediums such as the use of video content to highlight safety messaging for the benefit of industry and the travelling public.
Fiscal sustainability – work closely with the department to develop options to address long term financial sustainability for the ATSB, whilst continuing to operate in an efficient and effective manner and ensuring our resources are utilised effectively for the greatest public benefit.
Stakeholder Engagement
The ATSB collaborates with a wide range of stakeholders in fulfilling its functions under the TSI Act. The ATSB participates in national and international conferences, industry events and other relevant forums to build awareness of safety messages and instil public confidence in aviation, marine and rail transport. The ATSB will continue to engage with:
the department and other government agencies to deliver comprehensive safety advice to government, industry and the public
industry organisations to communicate safety advice and influence improvements to safety practices
regulators and policy makers to ensure appropriate sharing and use of safety information
education institutions such as RMIT University to provide a centre of excellence for transport safety investigation education
the travelling public and wider community to foster public awareness and education of transport safety
state, territory and local governments to undertake collaborative investigations in those jurisdictions, where applicable
international counterparts, especially in the Asia Pacific region to build understanding and transport investigation capability.
The ATSB will use multiple channels and methods to influence safety action and instil public confidence in aviation, marine and rail transport.
ATSB Statement of Intent
PDF copy of the ATSB Statement of Intent 2025 – 2027
Air traffic control issued instructions to deconflict two aircraft on approach to the same runway at Moorabbin Airport after the pilot of an Aero Commander inadvertently turned onto the wrong final approach path, an ATSB final report details.
On 9 August 2025, the twin-engine Aero Commander was being ferried from Bacchus Marsh to Moorabbin Airport, in Melbourne’s south-east, with a single pilot on board.
The pilot, who was unfamiliar with Moorabbin Airport, intended to land on runway 17R, and configured their electronic flight bag and GPS navigation unit to provide guidance to that runway.
“During pre-flight planning, the pilot did not identify Moorabbin’s aerodrome reference point was not near the runway 17R centreline, nor that runway 17R’s magnetic heading of 164° differs slightly from that implied by its designation,” ATSB Director Transport Safety Stuart Macleod said.
Consequently, the inbound track showed by the pilot’s GPS, based on their inputs, was offset and deviated away from the runway centreline.
Approaching the airport from the west, the pilot turned right, attempting to join final targeting this selected inbound track. The aircraft passed the extended centreline for the intended runway 17R, and instead joined final for the parallel runway 17L.
Concurrently, a flying training operator’s Cessna 172 was conducting circuit training on runway 17L with an instructor and student pilot onboard.
Separation between the two aircraft reduced as they both proceeded on final for runway 17L, before air traffic control (ATC) observed the aircraft in close proximity.
“ATC quickly issued instructions to both pilots, deconflicting the aircraft and directing them away from other traffic,” Mr Macleod said.
Following ATC instructions, the Aero Commander climbed away as the Cessna 172 continued with its landing. The Aero Commander then conducted a visual circuit and landed.
Mr Macleod said the incident was a reminder for pilots of the importance of comprehensive preparation when planning a flight to an unfamiliar airport.
“This is particularly the case when flying into a Metropolitan Class D airport due to their typical high traffic volumes, complex runway layouts, and use of local landmarks and procedures,” he said.
“When arriving during tower hours, advising ATC that you are unfamiliar with the airport alerts them to the fact you may require additional guidance.”
As a result of the incident, the operator of the Aero Commander, 360° Aviation Group, disseminated information to flight crew about the potential for misleading indications when using the aerodrome reference point for navigation at Moorabbin Airport.
Additionally, the training operator, CAE Melbourne Flight Training, is incorporating ADS-B in/out capability into the Cessna 172s in its fleet that were not currently equipped.
Safety management system procedures were not effectively implemented when the Spirit of Tasmania I’s second engineer was seriously injured in a fall during engine maintenance earlier this year, the final report from an ATSB investigation details.
The accident occurred during a routine oil change on one of the ship’s main engine turbochargers, while it was berthed in Geelong, Victoria, on 6 March 2025.
Problems encountered during the work led to the decision to replace the turbocharger’s bearing housing cover plate. This required climbing on and off the engine several times.
While climbing off the engine during the work, the second engineer fell heavily and sustained a serious knee injury, which later required surgery.
The ATSB’s investigation found a standard safe route to access the top of the main engine was not defined or used, despite access being a regular requirement.
“After working on top of the main engine, the second engineer walked along its rocker covers before stepping across to the opening in the railing, slipping off the cover and falling,” ATSB Director of Transport Safety Stuart Macleod said.
Mr Macleod also noted the decision to replace the bearing housing cover plate represented a significant change to the scope of the work initially planned.
“Despite this significant change in scope, the existing Job Safety Analysis was not reviewed, nor was a new prestart safety checklist completed by those conducting the work,” Mr Macleod said.
“This was due to perceived time pressure, and a perception by those involved that the work was low risk. Consequently, the risk of slips and falls involved in the work was not properly considered.”
More broadly, the ATSB’s investigation identified Spirit of Tasmania I’s safety management system procedure for Job Safety Analyses (JSAs) was not effectively implemented at the time of the occurrence.
“This meant the JSA for replacing the main engine turbocharger bearing housing cover plate was not in place, and JSAs covering other work on top of the engine did not address the risks involved in accessing the work site,” Mr Macleod said.
The ship’s manager, TT-Line, reacted proactively to the accident and put in place several engineering and procedural measures to reduce the risk of falls from the engine top and general access risks.
The ship’s manager has provided a removable work platform for safe access to the top of the engines for Spirit of Tasmania I and sister ship Spirit of Tasmania II, and the JSAs related to work on turbochargers and the exhaust manifold have been updated to include the access risk.
“The ATSB has investigated numerous occurrences involving unsafe working practices on board ships,” Mr Macleod said.
“A recurring factor in such incidents is the people involved in the work not recognising the hazards involved and/or considering the work routine and low risk.
“This investigation highlights the importance of effective risk controls, which requires staff at all levels on board and ashore to contribute towards the effective implementation of the shipboard safety management system.”
