Investigation summary

What happened

On 12 November 2025, at around 2030 local time, the pilot of a Sharp Airlines Fairchild Industries SA227-DC, registered VH-HPE and using callsign ‘Sharp 161’, was preparing to conduct a scheduled freight operation from Mackay Airport to Brisbane Airport, Queensland. Mackay Airport was operating on a common traffic advisory frequency (CTAF) at the time. 

As the aircraft was taxiing, backtracking and lining up on runway 14, an airport safety vehicle, callsign ‘Car 1’, had been stationary at an adjacent runway holding point, with the intention to conduct a routine runway inspection after the preceding aircraft to Sharp 161 had departed. 

While both the pilot and the driver of the car made radio broadcasts, neither heard the other, and shortly after the car entered the runway to complete their runway inspection, the aircraft commenced its take-off run. 

When the car approached the midway point of the runway, the driver observed the approaching aircraft. In response, the driver manoeuvred the vehicle to the edge of the runway and accelerated towards a runway exit. Approximately 5 seconds after the vehicle exited the runway via a taxiway, the aircraft rotated adjacent to that taxiway. 

What the ATSB found

The ATSB identified that CTAF radio transmissions from the aircraft were of poor quality due to a combination of the pilot’s rapid speech, non-standard phraseology and interference caused by use of a radio with the ground‑facing antenna.

Additionally, while the pilot did not hear the broadcast from Car 1, likely due to the reduced reception strength of the transmission and concurrent broadcast on another frequency, the pilot did not confirm the runway was clear after seeing a flash of unidentified light prior to commencing their take-off run.

Finally, the airport safety officer did not scan for aircraft ground movements or keep a constant radio listening watch prior to entering the occupied runway, possibly due to being distracted while using a company-issued iPad and not expecting the aircraft at that time. 

The ATSB also found that the airport operator did not have specific guidance for the use of company-issued iPads and the aircraft operator had not formally risk assessed identified hazards at non-controlled aerodromes, as was required by their safety management system.

What has been done as a result

Following this occurrence Mackay Airport updated and reinforced existing human factors training and supplemented existing guidance on iPad use for operational demands.

Sharp Airlines issued a safety advisory to flight crew reiterating the requirement for clear and effective radio communication and introduced a procedure to ensure that any discussions around the identification and assessment of hazards are now documented in safety meetings. Sharp Airlines also conducted a formal assessment of the placement of antennas on its aircraft and pilot radio selection at non-controlled aerodromes, with detail incorporated into its risk register.

Safety message

This investigation reiterates how important it is for pilots and drivers operating at non‑controlled airports to actively listen to the CTAF and always maintain a vigilant lookout. Additionally, it is crucial for broadcasts on the CTAF to be clear, concise and accurate. 

According to CASA’s Be heard. Be seen. Be safe publication, when it comes to ensuring your radio call is effective, attention to detail is essential. This includes pausing at the beginning and end of a transmission to avoid ‘clipping’, using standard phraseology, and speaking slowly and clearly.

For operators, hazard identification and risk mitigation should be a continuous and ongoing activity. Safety performance needs to be monitored and re-assessed to assure the effectiveness of any risk control.

The occurrence

On 12 November 2025, the pilot of a Sharp Airlines Fairchild Industries SA227-DC, registered VH-HPE and operating as ‘Sharp 161’, was preparing to conduct a scheduled freight flight from Mackay Airport to Brisbane Airport, Queensland. The pilot was the sole occupant. 

The aircraft was scheduled to depart at 1955 local time, as it did 3–4 times per week. However, due to the flight plan being inadvertently cancelled, the pilot was required to liaise with Mackay Tower air traffic control (ATC) to rectify the issue, including re‑submission of flight details. This delayed their departure by around 30 minutes. 

When the aircraft was ready to depart, Mackay Tower had closed, and communication and coordination were now being conducted between airport users on a common traffic advisory frequency (CTAF).¹ 

The pilot had been communicating with Mackay Tower on the aircraft’s VHF COM 1 (COM 1) radio, and once the tower closed, the pilot selected the CTAF on VHF COM 2 (COM 2), and Brisbane Centre on COM 1. The pilot then used COM 1 to make a taxi broadcast to Brisbane Centre and was given traffic for their departure (see the section titled Readability of radio broadcasts). 

The pilot commenced taxiing for departure from the western general aviation apron, along taxiway ‘Juliet’ and made a taxiing broadcast on the Mackay CTAF (Figure 1 and Figure 3). A subsequent review of this broadcast identified that the quality of the transmission was poor and barely audible. In addition, the pilot did not state they were at Mackay, advised they would hold short of the incorrect holding point, and used the incorrect flight number. 

As the aircraft was taxied towards holding point Juliet, another scheduled aircraft (aircraft 2) backtracked on runway 14² and departed. 

Figure 1: Holding points and receivers at Mackay Airport

After being stopped at the holding point for about 1 minute and 30 seconds, the pilot made a broadcast on the CTAF advising they were entering and backtracking runway 14. Again, this broadcast was of poor quality and barely audible. While the pilot did state ‘Mackay’ at the end of the broadcast, it was difficult to hear. 

The aircraft then commenced backtracking on runway 14. As they were backtracking, the pilot was contacted by Brisbane Centre, questioning how long before they would be departing, to which they advised they were backtracking on the runway. Despite that broadcast from the pilot also being poor quality, the controller understood it. Neither the Brisbane Centre controller nor the pilot mentioned Mackay during the interaction. 

At 2029:45, as the aircraft was turning around at the runway threshold, the pilot advised Brisbane Centre, on COM 1, that they were lining up on runway 14 at Mackay. While the pilot again used the incorrect flight number, the broadcast was audible and stated ‘Mackay’ at the end. The aircraft then stopped at the threshold. Between 2030:01 and 2031:19 there were near-continuous broadcasts on the Brisbane Centre frequency from different aircraft, none of which were relevant to Mackay. 

At 2030:11, the pilot broadcast on the CTAF (COM 2) that they were rolling. This transmission was slightly better quality than the previous 2 broadcasts, although still difficult to understand. In it, the pilot did not mention Mackay at the start of the broadcast but did state ‘Mackay’ at the end.

The pilot then commenced their line-up checklist that consisted of 6 items, during which they detected a flash of light coming from the opposite end of the runway. They stopped the checklist to try to identify the source of the light but could not determine where it had come from. As they had been distracted and could not recall what items had been completed, they restarted the checklist. 

Shortly after Sharp 161 commenced taxiing, an airport safety vehicle, callsign ‘Car 1’, stopped at the taxiway ‘Bravo’ holding point. Car 1 remained stationary for approximately 5 minutes, including during the time that Sharp 161 taxied to, backtracked and lined up on runway 14. This holding point was 350 m from taxiway Juliet, on the same side of the runway (Figure 1). The driver of Car 1 advised that their intention was to conduct a routine runway inspection once aircraft 2 departed.

The driver did not recall seeing aircraft 2 take-off but advised that they heard their departure call. The driver used their company-issued iPad to pre-emptively open and start completing an installed runway inspection form prior to entering the runway (see the section titled Airport safety officer – electronic device usage).

They stated that there was another scheduled aircraft around 30 NM (about 55 km) away and inbound to Mackay, and that they would usually commence their runway inspection between the departure of aircraft 2 and the arrival of the inbound aircraft.  

A review of recovered information from the aircraft’s flight data recorder (FDR) identified that the pilot of Sharp 161 increased engine power at 2030:21. At the same time, the driver of Car 1 made a broadcast on the Mackay CTAF that they were entering runway 14. This broadcast was of good quality.

Approximately 20 seconds after the broadcast from Car 1, the car crossed the holding point and, about 10 seconds later, the FDR information and CCTV footage showed the aircraft began to move. 

As the driver commenced their runway inspection, they observed a light and queried to themselves if it was a vehicle from the road behind the threshold (see the section titled Visual limitations) but did not clarify on the radio if there was anyone on the runway. CCTV footage showed that when the car was about halfway between taxiways Bravo and Juliet, the vehicle’s speed noticeably increased. The driver stated this was when they detected the approaching aircraft, moved the vehicle to the edge of the runway and accelerated towards taxiway Juliet to exit the runway. 

The pilot advised that as they passed approximately 100 kt in the take-off run, they observed 2 lights. However, as they blended in with the runway edge lights, they were difficult to distinguish. They only realised they were car headlights as they approached rotation speed and the vehicle was exiting the runway.

Approximately 5 seconds after the vehicle exited taxiway Juliet, the aircraft rotated adjacent to taxiway Juliet. 

The pilot then contacted Car 1 on the CTAF to discuss the incident. There were a couple of exchanges, with all radio broadcasts from the aircraft being of good quality. 

Context

Pilot information

The pilot held a Commercial Pilot Licence (Aeroplane) and a class 1 aviation medical certificate. They had accumulated 3,035 flight hours, including 1,753 hours on the SA227‑DC.

Driver information

The driver had been an airside safety officer (ASO) at Mackay Airport for 12 years and had not previously been involved in an airside driving incident. Their most recent ASO proficiency check was successfully completed on 22 May 2025.

Aircraft information

The Fairchild Industries SA227-DC is a low-wing, pressurised, twin-turboprop aircraft. VH-HPE was manufactured in the United States in 1993 and issued serial number DC‑823B. It was registered in Australia as VH-HPE in 2002. The aircraft was fitted with 2 Garrett turbine TPE331 engines. 

Recorded data

The aircraft was fitted with a flight data recorder (FDR) and cockpit voice recorder (CVR). The CVR was not obtained by the ATSB, as the recording would have been overwritten. The FDR was downloaded and analysed by the ATSB. 

CCTV

The incident was captured on Mackay Airport’s closed‑circuit television camera located at the eastern general aviation apron. 

Radio recordings

Common Traffic Advisory Frequency (CTAF) recordings were obtained for the night of the incident from the aviation rescue and firefighting services (ARFF) receiver (Figure 1) and the Mackay Airport receiver. ATC recordings were also obtained for the Brisbane Centre frequency.

For comparison, the ATSB also obtained CTAF and ATC recordings for the same aircraft during operation (by different pilots) on other days and times. There were no readability issues identified in the other recordings. However, the ATSB did not verify the orientation of the aircraft to the receivers during these radio broadcasts. 

VHF radio antenna position 

VH-HPE had 2 VHF antennas installed (Figure 2), with the: 

• antenna for VHF COM 1 (COM 1) mounted centrally on the roof of the aircraft forward of the wings
• antenna for VHF COM 2 (COM 2) mounted centrally on the underside of the aircraft laterally in line with the wings.

The pilot confirmed they could hear received transmissions from both COM 1 and 2 at the same time when there were simultaneous transmissions on both frequencies.  

Figure 2: Antenna positions on VH-HPE

Post‑incident inspection

During a post‑flight inspection, the right landing light was found to be dull and was replaced.

An inspection was also conducted on the antennas, and the operator reported that corrosion was detected on the connectors for the coaxial cable for COM 1 and the cable was returning a higher than acceptable resistance. This likely reduced the transmission strength of the broadcasts. However, there was no reported corrosion present under the COM 2 antenna, which was likely the antenna in use for the CTAF transmissions. 

Vehicle radios

Car 1 was fitted with 2 separate radios, both outputting through separate loudspeakers in the cabin. The driver reported that it was their standard practice when the tower was not operating to have the CTAF tuned on COM 1, and a different frequency tuned on COM 2.

Normally, and on this occasion, COM 2 was tuned to Coral Approach (retransmitting the Brisbane Centre frequency) and was used to monitor for aircraft approaching the airport. Both receivers were active, and the driver would monitor transmissions on both frequencies. 

The driver advised that they deliberately configured the radios such that the volume on COM 2 (approach frequency) was set to a lower volume than COM 1 (CTAF). The driver reported that they did this to help distinguish between the 2 channels, however, COM 2 was still loud enough that the driver could clearly hear broadcasts to assist with their situation awareness.

Post‑incident inspection

A maintenance test of the vehicle’s radios was conducted after the incident, and they were determined to be fully functional. 

Readability of radio broadcasts

CASA’s radiotelephony manual outlined that readability of a broadcast should be classified in accordance with the scale in Figure 3.

Figure 3: CASA readability scale

The content and readability of the various radio broadcasts during the occurrence are shown below in Table 1.

The ATSB assessed that while the pilot made the required calls on the Mackay CTAF, it would have been very difficult to discern the word ‘Mackay’ in any of the broadcasts. In addition, individual words were very difficult to understand. The ATSB also assessed that the transmissions on the Brisbane Centre frequency, while slightly clearer, were still difficult to understand.

Table 1: Readability of the radio broadcasts recorded on the Mackay CTAF

The ATSB also reviewed the radio broadcasts made by the preceding departing aircraft on the CTAF and assessed the readability to be 5.

Mackay Airport

Mackay Airport is a certified airport at an elevation of 19 ft above mean sea level, with a sealed runway orientated in a north-west/south-east direction – 14/32. The runway was 1,981 m long and 45 metres wide (Figure 4).

Figure 4: Mackay Airport

Visibility

Last light at Mackay Airport on the date of the incident was at 1842 and CCTV footage showed a clear night with good visibility.

Similarly, weather forecasts and observations obtained from the Bureau of Meteorology showed there was no significant weather in the area, such as thunderstorms.  

Visual limitations

Car 1 was at holding point Bravo, approximately 1.3 km from the runway 14 threshold (Figure 1). A 4-way road intersection is situated behind the threshold, and Mackay Airport personnel advised that aircraft lights may be confused with vehicle lights from this intersection.

Vehicle 

While the car was parked at the holding point, it had both its headlights and an amber rotating beacon on the roof selected on. As it passed the holding point, 2 spotlights and a light bar were also selected on, and all were visible in the CCTV footage of the incident. The vehicle was not fitted with an ADS-B transponder, nor was it required to be. 

Aircraft lights

The aircraft’s navigation, rotating beacon and taxi lights were on during taxi. As the aircraft entered the runway the strobe lights were selected on. As the aircraft lined up the landing lights were also selected on as part of the line-up checklist. 

VHF receivers 

Airport 

At Mackay Airport, VHF radio transmissions on the CTAF frequency were received from an antenna on the main terminal. These transmissions were recorded and, due to its elevated position, this antenna was within line of sight of the entire runway environment.

An additional receiver, operated by Airservices Australia, was mounted on the aviation rescue and firefighting (ARFF) building, located on the western side of the airport, also in line of sight of the entire runway environment. This receiver also recorded the CTAF transmissions made by the pilot and the driver. 

The readability of all the transmissions were the same on both receivers, however, broadcasts made by the pilot were recorded at a higher volume on the ARFF receiver.

Airspace and traffic services 

Mackay Airport had an air traffic control tower that operated from 0620–2020 local time Monday to Friday. The tower provided class D services from surface to 1,000 ft above mean sea level (AMSL), with Coral Approach providing class D services from 1,000 ft to 4,500 ft.

Outside tower hours, the airspace within a 10 NM (18.5 km) radius of Mackay Airport operated on a CTAF. In addition, outside approach hours, the airspace around the Mackay CTAF became Class G airspace to 4,500 ft AMSL. Consequently, no air traffic control services were provided, and aircraft were responsible for their own separation. This was done by using ‘alerted see and avoid’ practices, using VHF communications and visual reference to other aircraft. Aircraft intending to operate within controlled airspace were required to contact ATC (Brisbane Centre) on the ground prior to take-off, to receive an airways clearance for the overlying airspace.

Procedures at non-controlled airports

Pilot positional broadcasts

Traditionally, VHF radio broadcasts are made at non-controlled aerodromes to provide situation awareness, traffic separation and deconfliction with other traffic. The effectiveness of these broadcasts relies on the accuracy of the information being broadcast and the ability of other traffic [or vehicles] receiving, comprehending and reacting to this information.

The Civil Aviation Safety Authority’s Advisory Circular, AC 91-14 v1.3 Pilots’ responsibility for collision avoidance, section 10 stated:

Pilots should be mindful that transmission of information by radio does not guarantee receipt and complete understanding of that information. Many of the worst aviation accidents in history have their genesis in misunderstanding of radio calls, over-transmissions, or poor language/phraseology which undermined the value of the information being transmitted.

Without understanding and confirmation of the transmitted information, the potential for alerted see-and-avoid is reduced to the less safe situation of unalerted see-and-avoid.

The Aeronautical Information Publication (AIP) Enroute 1.1 section 9.1.14 recommended pilot broadcasts to alert other traffic to their location and intentions:

• before take-off
• inbound to land at, or if intending to overfly a non-controlled aerodrome.

Included in the recommended broadcasts was when the pilot taxied with the intention to take-off and when the pilot intended to enter a runway. 

For non-controlled aerodromes, including Mackay, the standard broadcast format, as outlined in AIP En route 1.1 section 9.1.13 was:

a. {location} traffic

b. {aircraft type}

c. {call sign}

d. {position/level/intentions}

e. {location}

CASA’s advisory circular (AC) 91-10 Operations in the vicinity on non-controlled aerodromes also stated that pilots should speak at a normal pace, as rapid speech can make transmissions difficult to understand. It further stated that if calls are not made clearly and concisely, using standard phraseology, confusion can arise. 

An ATSB research report Limitations of the See-and-Avoid Principle (Hobbs, 1991) found that an alerted search is likely to be 8 times more effective than an unalerted search, because knowing where to look greatly increases the chances of sighting traffic.

Departures from a non-controlled airport

AIP En route 1.1 section 9.5.2 further outlined the standard ATC report required for IFR departures at a non-controlled aerodrome, as follows:

• Aircraft type

• [number] POB (for flights other than air transport operations)

• IFR

• location

• destination

• runway to be used.

Vehicle positional broadcasts

According to the Mackay Airport runway and taxiway operations standard work procedures (Figure 5), airport safety officers (ASOs) were required to make the following CTAF broadcasts when the airport was operating outside tower hours: 

Figure 5: Extract from Mackay airport standard work procedures

The airside driver’s handbook available to ASOs advised that ‘no acknowledgment is expected to this call’. 

The driver reported that they were not aware of the requirement to make a second broadcast prior to entering the runway, and a review of Mackay Airport CTAF recordings on other dates confirmed that it was common practice for ASOs to only make one broadcast when entering the runway. After the incident, Mackay Airport management made enquiries with other airport managers and found that they also did not require a second entering broadcast by a vehicle driver. 

The Mackay Airport runway and taxiway operations standard work procedures also required drivers to:

continue to scan air and ground for aircraft movements when operating on runway/taxiways.

Additionally, the Mackay airside driver’s handbook stated:  

Once you have entered the manoeuvring area, you must keep a constant radio listening watch, staying alert to what is happening around you by listening to radio communications.

VHF radio line of sight limitations

VHF radio requires line of sight between the transmitting and receiving stations to function effectively. If an aircraft does not have a clear visual path direct to another aircraft (or vehicle) in the vicinity, then the radio wave signal strength and clarity can be affected. In some cases, terrain, vegetation or buildings can create areas that may shield or substantially reduce radio wave propagation and adversely affect broadcast signal strength and clarity.

In areas where there are no physical obstacles on the airport, it has been found that using an antenna that is positioned underneath the aircraft may also affect the transmission or reception strength and clarity on the ground due to airframe shielding. 

As found in ATSB investigation AO-2023-050Aircraft separation issue during take-off involving Lancair, VH-VKP, and De Havilland Aircraft of Canada Limited DHC-8-315, VH‑TQZ, Mildura Airport, Victoria, on 29 September 2023:

While geographic obstacles and structures between the stations had the likelihood of reducing signal strength and readability in general, it was identified that a significant reduction in radio signal strength and consequent readability existed when VHF COM 2 was used for ground-based communications when compared with VHF COM 1, even when no geographical or man-made structures were present between the stations. 

Further, signal strength and shielding testing conducted by the ATSB found that:

the signal strength of VHF COM 2 was consistently less (greater than half strength) at all locations with the VHF COM 2 maximum loss (−10 dBm) at the front and right rear quarter most notable.

The testing identified that the closer and clearer the line of sight of the antenna on the aircraft to the receiver, the clearer the radio transmission. It also found that the orientation of the aircraft to the receiver affected the quality of the transmission. 

CASA guidance 

CASA released Advisory Circular AC 91-10 Operations in the vicinity of non-controlled aerodromes (Figure 6) (amended in September 2025) which strongly recommended the use of radios connected to the upper antenna for ground communications. 

Figure 6: CASA advisory circular

The aircraft type certificate holder advised that VHF COM 1 is normally used for more important communication functions while the VHF COM 2 can be used for arguably less important ones. They also advised that they were not aware of any communication issues due to the placement of the VHF COM 2 antenna. 

Operator procedures 

The operator’s standard operating procedure at the time of the occurrence, required communication with air traffic services to be conducted using COM 1 (upper antenna on Sharp 161) and communication within the CTAF to be conducted using COM 2 (lower antenna on Sharp 161).

Safety management system

Awareness of potential ground/airframe shielding

The ATSB discussed the potential for ground shielding to result in poor-quality radio transmission with Sharp Airlines throughout the course of the investigation. 

In November 2025, during a discussion with the safety manager and a senior maintainer, the maintainer advised that it was known best practice to make ground transmissions through the communication unit that had the antenna on the roof, i.e. VH COM 1. 

On 19 December 2025, a Sharp Airlines Fairchild Industries SA227-AC was involved in a separation issue at Flinders Island Airport, Tasmania, where the departing SA227 did not hear the radio broadcasts from a second departing aircraft on a crossing runway. At the time of writing, the second occurrence was being investigated by the ATSB.

In February 2026, the ATSB further discussed antenna ground shielding, including the value of making ground transmissions through COM 1 when operating in non-controlled airspace, with the operator. In response, the operator stated that if the procedures required the pilots to switch between COM 1 and COM 2 when on the ground were changed, it would introduce confusion, in addition, some of the fleet (2 out of 18 aircraft) had both COM 1 and COM 2 antennas mounted on the underside of the aircraft. 

Following receipt of the draft report, Sharp Airlines provided a written assessment of the benefits and risks associated with radio selection, concluding that:

the more appropriate risk control is to retain a clear and consistent radio-management procedure while expressly allowing either VHF system to be used whenever communication quality or operational circumstances require it. 

However, this assessment had not been internally documented in safety meetings, risk registers or the operator’s internal investigation.

Sharp Airlines advised that it also conducted a review of possible alternate antennas and/or alternate antenna location on its aircraft and determined that there were no viable options. Detail of that review was also not internally documented.

Sharp Airlines’ safety management system manual stated:

Hazard identification is a prerequisite to the safety risk management process.

Hazard identification is the first step in a formal process of collecting, recording, acting on and generating feedback about hazards and safety risks. Hazard identification is based on a combination of reactive, proactive and predictive safety data collection methods.

The scope of hazards in aviation is wide. Examples of the scope of factors and processes that should be looked into when engaging in hazard identification include:

• normal operations monitoring schemes

• investigation and follow-up of incidents.

Examples of external sources of hazard identification available to an organisation include:

• accident reports.

The safety management system required that an executive safety review meeting occur every 2 months and should:

• discuss new occurrences 
• review the hazard/risk register. 

The safety management system manual went on to state:

Safety risks are conceptually assessed as acceptable, tolerable or intolerable. Risks assessed as initially falling in the intolerable region are unacceptable under any circumstances. If the likelihood and/or severity of the consequences of the hazards are of such a magnitude and the damaging potential of the hazard poses such a threat to safety, then mitigating action is required to be implemented to reduce the level of risk to [as low as reasonably practicable] ALARP. The implemented mitigation measures should then be monitored to ensure that they have the desired effect.

Hazards identified as high risk required:

Perform risk review mitigation as necessary. Departmental approval of control measures required.

The risk can only be said to be ALARP when it can be demonstrated that all justifiable risk reduction measures have been considered and the remaining mitigation strategies cannot be justified.

The operator provided the ATSB with the agendas for a number of executive safety review meetings that occurred after the occurrence. These identified that the ATSB was investigating the incident. It was also reported that related hazards had been discussed. However, as there were no meeting minutes, it was not possible to identify any detail of the discussion, including outcomes.

Risk register

For routine operations at non-controlled aerodromes, the operator’s risk register had identified the following hazards and their assessed risk:

• CTAF communications affecting safety of flight - assessed as ‘low risk’
• Vehicle incursion on the runway resulting in aircraft accident - assessed as ‘low risk’

As both risks were deemed low risk, no further mitigation or treatment was deemed necessary. 

Following the incident, Sharp Airlines updated its risk register associated with non‑controlled aerodromes to include several additional previously‑unidentified hazards. However, although the operator had assessed the issue in documents sent to the ATSB, the potential risks of poor ground communications due to ground shielding were not identified or assessed in a risk assessment. 

Incident investigation 

Sharp Airlines SMS manual outlined that: 

An internal investigation shall be conducted following a [Sharp Aviation Group] SAG accident or serious incident that is the subject of an external investigation. It should be emphasised that any investigation focuses on the facts of an occurrence, to identify the causal factors, human interactions and systemic causes underlying the incident, and to facilitate the development of agreed actions to either prevent or reduce the probability of a recurrence.

In March 2026, in response to its investigation findings, Sharp Airlines issued a safety advisory to flight crew reiterating the requirement for clear and effective radio communication.  

Airport safety officer – electronic device usage 

Airport safety officers (ASO’s) were issued with iPads to enable completion of required runway inspection forms in the Airside Tracker application. The application login screen required the user to accept the conditions of its use, one of which included not using the application while driving. Mackay Airport also provided an induction program for the use of the application when it was first introduced in 2023.

The iPads were also installed with flight tracking applications to assist with scheduling runway inspections and for situation awareness. The FlightAware application was considered useful for this purpose, as the flights inbound to Mackay could be easily visually distinguished from other aircraft.

The airside driver’s manual stated that ‘mobile phones were not permitted by a driver on a manoeuvring area’, this included a taxiway. However, Mackay Airport did not have a specific policy for the use of iPads in the vehicles beyond the requirement not to use them while driving.

The driver of Car 1 reported that they planned their runway inspections around the scheduled movements of air transport operations at the airport by consulting the airport’s flight information displays and the FlightAware application on their iPad. The driver further advised that they routinely used their iPad to monitor the track of inbound aircraft before entering a runway and also to mark off departing and arriving aircraft in the Airside Tracker application. The driver could not specifically recall if they were using the iPad at the time of the occurrence, but stated they may have been. 

Records show that a runway inspection form was commenced by the driver at 2029:44, 1 second prior to the pilot of Sharp 161’s line up broadcast on the Brisbane Centre frequency and 27 seconds prior to their rolling call on the CTAF. 

As Sharp 161 was not a passenger service, it was not displayed on the airport flight information display, nor did the FlightAware application show aircraft on the ground at Mackay Airport. The driver also stated that as Sharp 161 was not displayed on these devices, and the Sharp flight normally departed prior to the tower closing, they did not expect the aircraft to be on the runway.

FlightAware advised that it did not have consistent ADS-B source data at Mackay Airport. As such, it was common for departing aircraft to only become visible on the application at around 100 ft AMSL.

Human factors 

Selective auditory attention

Research into human information processing has shown that auditory stimuli, such as radio transmissions, may sometimes be unconsciously supressed to allocate attentional resources to other tasks (Broadbent 2013, Treisman 2012). Stimuli may be automatically selected for attentional focus, or otherwise suppressed, based on their saliency. The threshold at which this automatic filtering occurs is dependent on the level of competition for attentional resources.         

In addition, Broadbent’s Filter model of attention (2013) proposed that because of limited information processing capacity, the human brain applies a filter to auditory information, based on physical properties, such as loudness and pitch. Treisman’s Strategies and models of selective attention (2012) proposed that any information that does not make it through the filter can be processed at some basic level if it is somehow meaningful to the listener i.e. a particular callsign or location is mentioned.

Similar occurrences

ATSB investigation (AO-2012-090)

On 29 June 2012, an ASO at Mackay Airport, Queensland, contacted Mackay Tower air traffic control (ATC) to request a clearance to enter the airport runway for a routine runway and lighting inspection. Mackay Tower cleared Car 2 to enter runway 14 and runway 05. Car 2 entered runway 14 at taxiway Alpha. 

At about this time, the pilot of a Piper PA-31 Navajo aircraft contacted Mackay Ground for a taxi clearance from the western general aviation apron and requested runway 05 for departure. Mackay Ground cleared the PA-31 to taxi for runway 05 via taxiway Hotel. Mackay Tower then instructed the ASO in Car 2 to hold short of runway 05. The ASO understood and correctly read back the instruction. They later reported that they were aware that an aircraft was about to depart off runway 05. 

As the aircraft backtracked on runway 05, the ASO proceeded to the threshold of runway 32. Between the time the ASO acknowledged the ATC instruction and positioning at the threshold of runway 32, the ASO received a mobile telephone call. The ASO accepted and continued with the call as they travelled to the threshold of runway 32.

Contrary to the ATC instruction to hold short of runway 05, the ASO continued through the runway intersection. The aircraft passed over Car 2 at the runway intersection, at about 30 ft above ground level.

The investigation highlighted the importance of remaining vigilant during airside operations, and to be mindful of the potential distraction presented by all portable communication devices, including mobile telephones.

ATSB investigation (AO-2023-025)

On 6 June 2023, a Piper PA-28 and a De Havilland Aircraft of Canada Limited DHC-8 (Dash 8) taxied at Mildura Airport for crossing runways. Both aircraft broadcast their intentions on the local CTAF. Despite that, while the pilot of the PA-28 was aware of the Dash 8, the crew of the Dash 8 were not aware of the PA-28. The Dash 8 commenced their take-off on runway 09 as the pilot of the PA-28 gave a rolling call on runway 36 with the Dash 8 crossing the runway intersection about 600 m ahead of the PA-28.

The ATSB’s investigation identified that the pilot of the PA-28 incorrectly identified the runway direction at Mildura Airport during their radio calls (saying ‘runway 35’ instead of ‘runway 36’). This led to an incomplete comprehension of traffic at Mildura by the Dash 8 crew (who believed that the PA-28 was not at Mildura) due to the Dash 8 crew’s focus on obtaining their pre-departure information from air traffic control, with the volume for the radio tuned to the CTAF frequency turned down, and only receiving certain elements of the PA-28 pilot’s radio calls due to an over transmission from air traffic control.

ATSB investigation (AO-2024-009)

On 19 March 2024, a Fairchild SA226 Metroliner taxied at Geraldton, Western Australia, for runway 03. About 1 minute later, a Beechcraft A36 Bonanza taxied for runway 14. After reaching their respective runway thresholds, both pilots attempted to contact the other, however, they did not hear or see each other. A third aircraft assisted by relaying information. Based on the information received, the Bonanza and Metroliner pilots commenced their take-off within 3 seconds of each other. The Metroliner crossed runway 14 about 400 m in front of the Bonanza, with a vertical separation of about 250‍–‍300 ft. 

The investigation found that, when aircraft were positioned at the thresholds of runway 03 and 14 (and 08), they will unlikely be visible to each other due to the position of the airport buildings. Further, they may not be contactable on VHF radio due to potential shielding effects. This resulted in the pilots being unable to verify each other’s position and intentions prior to commencing their take-off. 

While the pilot of the third aircraft was attempting to assist, the details provided were inaccurate and incomplete. This inadvertently resulted in misinterpretation by the Bonanza and Metroliner pilots and influenced their decision to take off.

ATSB investigation (AO-2024-041)

On 15 July 2024, a De Havilland Aircraft of Canada Limited DHC-8 (Dash 8) was taxied to reposition to a different bay at Wagga Wagga Airport, New South Wales. This repositioning required the Dash 8 crew to taxi out onto the runway and then return to a different bay. As the Dash 8 entered runway 05, the crew were unaware that a Piper PA‑28, operating on a training flight, had already commenced its take-off run from the opposite end of the runway. 

The instructor of the PA-28 was aware of the Dash 8 taxiing and assumed that the Dash 8 had received and understood their previous positional broadcasts. However, the crew of the Dash 8 were not aware of the PA-28 preparing for take-off.

Upon entering runway 05 the Dash 8 was notified, by a preceding aircraft that had landed, that there was another aircraft taking off from runway 23. The captain of the Dash 8 immediately stopped the aircraft and engaged reverse thrust to clear the runway. Simultaneously, the PA-28 pilot rejected their take-off. 

The Dash 8 operator’s radio procedure required crew to use the number 2 VHF radio to broadcast and receive on local frequencies during operations at a non-controlled aerodrome. This likely reduced ground-based reception strength and the likelihood of the Dash 8 hearing other traffic in certain circumstances.

ATSB investigation (AO-2025-074) 

The ATSB is investigating a near collision involving a Gippsaero GA8, and a Fairchild SA227, at Flinders Island Airport, Tasmania, on 17 December 2025. Passing 150 ft on take-off from runway 14, the crew of the Fairchild SA227 observed the Gippsaero GA-8 taking off on the crossing runway 23 in close proximity.

Safety analysis

Introduction

This analysis will discuss the readability of the radio broadcasts from the Sharp Airlines Fairchild Industries SA227 and why neither the pilot or the driver of the safety vehicle heard each other’s transmissions or saw each other, prior to the near collision. This section will further examine Mackay Airport’s procedures regarding the use of electronic devices for airside safety officers and Sharp Airlines’ hazard identification process.

CTAF radio transmissions 

The recordings of the CTAF broadcasts, made on the ground by the pilot of Sharp 161 using COM 2, ranged from unreadable to readable with considerable difficulty. However, once the aircraft became airborne, the transmissions were clear and readable and after the incident, no faults were found with the radio or the antenna.

While the reduced quality was due in part to the pilot’s rapid speech, the variation in quality between the ground and airborne transmissions indicated that the use of the ground facing antenna (COM 2) also contributed by reducing the signal strength. That conclusion was consistent with previous ATSB investigations that identified that using an antenna positioned underneath the aircraft may not allow optimal ground‑based transmission or reception strength and clarity due to airframe shielding. 

In addition, the information in the broadcasts from Sharp 161 was not transmitted in the expected order which required that the location be stipulated at the beginning and end of each call. 

Unidentified safety car 

The pilot taxied from the western general aviation apron to holding point Juliet without observing Car 1 at holding point Bravo. This may have been influenced by their focused attention on taxiway Juliet during the night manoeuvring followed by looking for any airborne traffic approaching runway 14 prior to backtracking that runway. In addition, they did not hear the driver of Car 1 transmit on the CTAF to advise they were about to enter the runway. While the recording of that transmission was of high quality, it is likely that the reception quality of this incoming broadcast was also reduced to the pilot of Sharp 161 due to it being received via the antenna on the underside of the aircraft. 

At the time of the driver’s broadcast, the pilot was increasing engine power and focusing on pre-take-off tasks. In addition, other transmissions were being made on the Brisbane Centre frequency. The pilot confirmed they could hear both transmissions in the aircraft when this occurred, however, the high overall transmission activity likely reduced the ability of the pilot to identify the driver’s broadcast.

While the pilot did not see the car, they saw a flash of light, which was likely the vehicle’s headlights turning on to the runway, however, they did not question on the radio if there was something on the runway prior to commencing the take-off.

Unidentified aircraft 

While the airport safety officer (ASO) was holding on Bravo for an extended period, they did not observe aircraft 2 depart or Sharp 161 enter runway 14 and backtrack to the runway threshold. 

The ASO heard the clear departure broadcast from aircraft 2 but did not hear any of the 5 radio broadcasts, made on both the CTAF and area frequency, by the pilot of Sharp 161. While the 3 broadcasts on the CTAF were of poor quality and key words were not audible, radio transmissions on the frequency could clearly be heard, indicating that an aircraft was operating within the CTAF area. Additionally, the 2 broadcasts made by the pilot on the Brisbane Centre frequency, which the ASO was also monitoring, were readable.

The evidence showed that the ASO opened the runway inspection form 1 second prior to the lining up call made on the Brisbane Centre frequency. While they could not specifically recall doing so on this occasion, they reported that they routinely used their iPad to gain situation awareness of the arriving and departing aircraft before entering the runway. As such, it is possible that the driver had also used the iPad prior to the lining up call. Further, the driver was not expecting the aircraft to be on the runway at that time, due to its delayed departure time.

Research has shown that when a person’s attention is diverted to a different task, unless a meaningful phrase is used, information such as that contained in a radio transmission, may not be processed. In this case, as:

• the radio broadcasts were very difficult to understand
• the pilot did not state the location at the beginning of the broadcasts
• they were likely received by the ASO at a lower volume than expected for a CTAF transmission 

they may have been perceived as irrelevant transmissions on the Brisbane Centre frequency and so did not break through the ASO’s attention filter.

Airport procedures

Mackay Airport provided iPads to ASOs and required that they were used to complete runway inspection forms. They advised that the iPads were also to assist with aircraft movement awareness. 

Despite their intended operational benefit, the airport had not provided specific guidance on iPad usage to ensure there were no unintended consequences, such as distraction. 

Safety management system application 

At the time of the incident, Sharp Airlines had completed 2 risk assessments that identified hazards at uncontrolled airports however, it had not identified or assessed the potential risks associated with poor ground-based communications due to interference from the ground facing (VH COM 2) antenna. After the incident, they conducted an internal investigation and updated the risk register. However, this did not include the potential risks associated with ground shielding, although they did risk assess communication issues at the CTAF.

Following receipt of the draft report, Sharp Airlines provided the ATSB with an evaluation of the use of VHF COM 2 at non-controlled aerodromes, however, this was not formally documented in any safety meetings, the internal investigation or its risk register. 

While Sharp Airlines advised that identified hazards were discussed and evaluated at its safety meetings, there were no minutes kept for the meetings.

In addition, there was no formal evaluation or documentation of those hazards via its safety management system. This is an important part of the process to ensure identified risks are managed appropriately and that any mitigations are consistently understood by all.

Findings

From the evidence available, the following findings are made with respect to the runway incursion and near collision involving Fairchild Industries SA227-DC, VH-HPE, and an airport safety vehicle at Mackay Airport, Queensland, on 12 November 2025.

Contributing factors

• Common traffic advisory frequency radio transmissions from the aircraft were of poor quality. This was due to a combination of the pilot’s rapid speech, non-standard phraseology and interference caused by use of the VHF COM 2, the radio with the ground‑facing antenna.
• While the pilot did not hear the transmission from the driver of Car 1, likely due to the reduced reception strength of the radio broadcast and concurrent transmission on the Brisbane Centre frequency, the pilot did not confirm the runway was clear after seeing a flash of unidentified light prior to commencing their take-off run.
• The airport safety officer did not scan for aircraft ground movements or keep a constant radio listening watch prior to entering the occupied runway, possibly due to being distracted while using an iPad for other operational tasks and an expectation that the aircraft would not be departing at that time. 

Other factors that increased risk

• Contrary to the requirements in its safety management system, Sharp Airlines did not formally assess known hazards for operations at non-controlled aerodromes in its risk register to ensure that the associated risks were adequately managed. (Safety issue)
• Mackay Airport provided its airport safety officers with iPads for operational benefits but did not provide any specific guidance on their usage to ensure there were no unintended consequences, such as distraction. (Safety issue)

Safety issues and actions

Sharp Airlines hazard identification

Safety issue number: AO-2025-067-SI-01

Safety issue description: Contrary to the requirements in its safety management system, Sharp Airlines did not formally assess known hazards for operations at non-controlled aerodromes in its risk register to ensure that the associated risks were adequately managed. 

Mackay Airport electronic device usage

Safety issue number: AO-2025-067-SI-02

Safety issue description: Mackay Airport provided its airport safety officers with iPads for operational benefits but did not provide any specific guidance on their usage to ensure there were no unintended consequences, such as distraction.

Safety action not associated with an identified safety issue

Following this occurrence, Mackay Airport: 

• arranged for testing of the radios in airside vehicles by an external communications technician and confirmed they were fully functional
• conducted an internal investigation immediately and implemented mitigation actions
• designed and delivered additional human factors training for all safety operations team members (annual refresher scheduled) to accompany existing training
• reviewed the standard work procedures relating to runway and taxiway operations for consistency with other aerodromes and discussed CTAF radio calls and situational awareness with wider safety team via toolbox talks.

Glossary

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of the incident flight 
• the driver of the airport safety vehicle
• Sharp Airlines 
• B2 maintainer of Sharp Airlines
• safety manager of Sharp Airlines 
• Mackay Airport
• Airservices Australia
• the flight data recorder
• CCTV footage of the incident flight 
• audio recordings from the CTAF 
• the aircraft certificate holder.

References

Broadbent, D. E. (2013). Perception and communication. Elsevier.

CASA, (2025) ‘Be heard. Be seen. Be safe - Radio procedures for non-controlled aerodromes and operations. 

CASA, (2025) ‘Operations in the vicinity of non-controlled aerodromes’ - Advisory Circular, AC 91-10 v.17, p.37

CASA, (2025) ‘Pilots’ responsibility for collision avoidance’,  Advisory Circular, AC 91-14 v1.3 

Hobbs (1991), Limitations of the see-and-avoid principle. ATSB.

Treisman, A. (2012). Strategies and models of selective attention. In J. W. L. Robertson (Ed.), From perception to consciousness: Searching with Anne Treisman (pp. 1–12). Oxford University Press.  

Submissions

Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report. 

A draft of this report was provided to the following directly involved parties:

• the pilot of the incident flight 
• the driver of the airport safety vehicle
• Sharp Airlines 
• Mackay Airport
• the aircraft certificate holder
• the Civil Aviation Safety Authority 
• the United States National Transportation Safety Board.

Submissions were received from:

• Mackay Airport
• Sharp Airlines
• the Civil Aviation Safety Authority.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations The objective of an ATSB safety investigation is to improve transport safety through: identifying safety issues for action by organisations with the responsibility for managing that safety risk influencing safety action through engaging with stakeholders, communicating findings, and fostering awareness of safety issues and concerns.  In accordance with the TSI Act, the ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action, and cannot apportion blame, assist in determining liability, or, as a general rule, assist in court proceedings.  About ATSB reports ATSB safety investigation reports are developed in accordance with ATSB procedures and guidelines, and with regard to applicable international standards and instruments. Reports must include factual material of sufficient weight to support the investigation’s 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.   Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2026 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. ^    CTAF: a designated frequency on which pilots make positional broadcasts when operating in the vicinity of a non‑controlled aerodrome
2. ^    Runway number: the number represents the magnetic heading of the runway.

Pilots and maintainers should also be aware of external and internal commercial pressures to continue a flight without fully researching and conducting an appropriate repair. 

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is Reducing passenger injuries in commercial ballooning operations.

The investigation

The occurrence

On 18 October 2025, a Kubíček BB142P hot-air balloon, registered VH-RRP, was being operated by Go Ballooning Gold Coast on a sightseeing flight from Beaudesert, Queensland. 

The pilot, who was also the operator and maintenance controller, obtained relevant weather information from the Bureau of Meteorology and via a phone‑based weather application, Rain Parrot, to assess the weather conditions and plan the proposed flight.

The pilot picked a familiar launch site location in a large open field adjacent to a supermarket car park, which they had operated from numerous times previously.

The pilot and a ground crew member arrived at the launch site (Figure 1) at about 0300 to unload and prepare the balloon for launch. The balloon basket was positioned close to the public road bordering the launch area. This position was within 10 m of a public road and about 20 m from nearby light posts bordering the shopping centre car park.

Figure 1: Location of balloon launch site

Source: Google Earth, annotated by the ATSB

As per Go Ballooning Gold Coast’s operational procedure the pilot released several helium pibal[1] balloons to observe wind conditions at different levels for the intended flight and confirmed the launch site suitability for the planned flight.

The pilot and ground crew member were preparing the balloon by cold inflation,[2] when the pilot described that the wind speed increased to about 6 kt and changed direction. At a time that could not be determined, the partially inflated balloon envelope moved from a north-east to a south-west position around the basket that was secured to the front of a 4-wheel drive car. The crew attempted to restrain the balloon by pulling on the crown line,[3] but were unable to stop the movement of the envelope. The balloon envelope continued to travel across the public road and struck 2 light posts (Figure 2) in the shopping centre car park. During recovery from one of the light posts, it sustained a tear to the upper section of the envelope. 

Figure 2: Photograph of balloon after striking light posts

Source: Supplied, annotated by the ATSB 

At about 0500 local time, the tour manager and 24 passengers, booked for the scheduled sunrise flight, arrived at the launch site on the operator’s bus. 

After the crew retrieved the balloon envelope it was deflated and packed up with the assistance of some of the passengers. 

The balloon was then repositioned away from the obstacles and laid out for the pilot to inspect for any damage. The pilot identified a tear in the upper section of the envelope, above the balloon equator.[4] The pilot estimated the tear to be about 45 cm in length (Figure 3), and no other damage was identified.

The pilot reported that they had previously carried out field repairs on balloons and was confident that the specialised adhesive tape provided from the manufacturer would temporarily fix the tear to allow the flight to proceed as planned.

After the pilot applied the tape, the balloon was fully inflated with hot air and was visually inspected. The pilot reported that they believed the repair was sufficient to continue with the flight. About 20 minutes after completing the repair and following an assessment that the wind speed was within the allowable limits for launch, the pilot decided to continue with the flight as scheduled. A safety briefing was given to the passengers before boarding, and the flight proceeded at about 0550. 

Figure 3: Photograph of damage to balloon envelope

Source: Supplied, annotated by the ATSB

The pilot reported that after take-off, the balloon tracked in a southerly direction, opposite to the intended direction of flight for about 30 minutes. The pilot reported that about 5‍–‍10 minutes before arriving at a newly planned landing site, heat at the top of the balloon likely caused the adhesive repair tape to weaken, partially re-opening the tear and allowing a small, uncontrolled venting of air. The pilot reported not being concerned and continued to the planned landing site. The balloon landed safely at 0620 at Kerry, Queensland, about 17 km south of Beaudesert.

Context

Pilot information

The pilot was the owner and operator of Go Ballooning, operating sightseeing balloon flights and private charters in south-east Queensland, since 2015. 

They held a Civil Aviation Safety Authority (CASA) Commercial Pilot (Balloon) Licence and had over 20 years of experience with 2,299 total flying hours at the time of the incident. In the previous 2 weeks the pilot had flown about 6.5 hours in VH-RRP. The pilot held a current CASA class 2 aviation medical certificate, a valid CASA maintenance authority (MA) for balloons and a valid Kubíček maintenance certificate.

The pilot reported having slept their normal 7–8 hours prior to the incident and self‑assessed as ‘1’ on a fatigue scale of 1–7 where 1 is fully alert and 7 is completely exhausted. 

Balloon information

VH-RRP was manufactured in 2022 by the Kubíček factory in Czechia and could operate with a maximum of 24 passengers and 1 pilot. The balloon was registered to Go Ballooning Australia on 9 December 2022. 

The BB142P balloon envelope had a volume of 14,158 m² and was about 30 m in diameter and almost 34 m in height which supported a maximum take-off weight of 4,500 kg (Figure 4). The balloon envelope was constructed of 32 gores[5] and was inflated by hot air from 4 burners connected to 4 independent fuel systems. 

Figure 4: Schematic of a Kubíček balloon

Envelope and basket not to scale. Source: Adapted from the Kubíček hot air balloon flight manual (section 1), annotated by the ATSB

A manned free balloon certificate of airworthiness was issued on 16 February 2023, and the balloon had accumulated a total time of 369.6 hours in service and the basket 942 hours at the time of the event. 

Meteorological information

The ATSB obtained relevant weather data from the Bureau of Meteorology. For Beaudesert, observations for wind were recorded at 1-minute intervals at ground level about 3 km to the north-west of the launch site. Between 0448 and 0515, surface winds were reported as west to north-westerly at approximately 3 kt, shifting through the west to a southerly, then south‑easterly at approximately 2 kt from 0516 through to the launch time of 0550. The forecast temperature for Amberly, (about 50 km to the north-west of the launch site) at the time of the launch was around 16°C.

The pilot recalled that, at the time of preparation, forecast conditions for the time of the launch were: 

• light and variable winds
• unrestricted visibility
• no low cloud, a few scattered high-level clouds.

Regulatory oversight

Operators require a Civil Aviation Safety Authority (CASA) Air Operator’s Certificate (AOC) to conduct balloon transport operations under Part 131 of the Civil Aviation Safety Regulations (CASR). 

The Part 131 Manual of Standards (MOS) sets out the specific requirements for these operations. The MOS does not specify size requirements for balloon launch sites, however an operator is required to keep records of launch and landing sites. This includes a description of each launch and landing site with maps, diagrams, and records of any hazards associated with the site and any limitations or restrictions. The documented information is required to form part of the operator’s exposition.[6]

CASA Advisory Circular (AC) 131-02 v4.0 specifies in section 8.2 Ground Handling: 

Operators and PIC [pilot in command] are recommended to consider the hazards or risks to persons or property that might arise during any of the following activities:

• laying out, inflation and preparation for launch

• take-off and climb 

• landing, normal deflation and pack up 

• relocation of inflated balloon on the ground 

• use of the handling line for hot air balloons 

• use of the trail rope for gas balloons.

Pre-flight damage assessment and repair

After contact with the light posts and inspection of the envelope, the pilot identified an estimated 45 cm tear, located above the equator of the balloon in gore 22, panel 26 (Figure 5) and no other damage. The pilot, who was also a maintenance authority, applied specialised adhesive tape to the tear as they had reportedly done on previous occasions for temporary field repairs on minor fabric damage.

Figure 5: Location of tear in balloon envelope VH-RRP

Source: Photograph supplied; diagram from Kubicek maintenance manual, annotated by the ATSB

Manufacturer instructions for envelope repair

The operator’s exposition outlined the pre-flight procedures with a list of pre-flight inspections and checks for the balloon which included verifying the envelope integrity in accordance with damage limitation in the Kubíček Hot Air Balloon Flight Manual (BFM). 

The BFM provides information on the damage limits applicable to various sections of the balloon. Different sections of the balloon envelope are subject to varying thermal loads, internal pressures and fabric tensions during operation. Therefore, the structural consequences of damage will differ depending on where the damage is located on the envelope. The hottest and highest structurally loaded area of the balloon envelope is above the equator. 

The operator accessed the BFM and the Kubíček Maintenance Manual(BMM) for the BB142P model.

The BFM stated that repairs above the first horizontal load tape are limited to:

…small holes or tears of no more than 5 mm (1/4 in) in any direction. The integrity of the panel must not be affected by the holes or tears. 

Any damage exceeding the above limits must be repaired prior the next flight according to the instructions given by the Kubicek Maintenance Manual

For damage limitation the BFM warning states:

Any damage to the fabric weakens the fabrics resistance to tear and causes localized heating of the fabric around that damage. Damage exceeding those listed above increase the potential of propagating a tear or hole and is unacceptable for flight.

The BMM (section 3.21) repair guidance for using an adhesive patch above the equator, stated:

Adhesive Patch without Overstitching:

If the damage is not more than 2.5 cm (1") in any dimension. There must be minimum of 10 cm (4") between any two damaged locations on a single panel.

Adhesive Patch with Overstitching:

If the damage is not more than 10 cm (4“) in any dimension. May not be used if the damage extends to within 2.5 cm (1“) of a load tape. There must be a minimum of 10 cm (4“) between any two adhesive patches on a single panel.

A further note also stated that:

Always check adhesion of the patch as the adhesive may adhere differently on different materials (polyester vs. polyamide, ripstop, etc.) and its adhesion may also be affected by outside temperature, age and dustyness of the fabric, and other factors. When in doubt, use sewn patch.

Balloon envelope damage

The size (45 cm) and location (above the equator) of the tear significantly exceeded the limit to use adhesive tape for repair. The BMM stated that a sewn partial panel or panel with the same material as used in the original panel was required for a tear of this size. The panel repair is designated as a category B repair which covers the common maintenance tasks that may be carried out by individuals who have undertaken a manufacturer maintenance course and hold a valid manufacturer maintenance certificate. The approved method to repair the damage, as detailed in the BMM, required the affected panel to be repaired in accordance with the manufacturer's directions before further flight.

Operational information

Launch site selection and preparation

The pilot reported that between 40 and 50 sites were used for launching and landing balloons, with agreements in place with landowners to access several private properties on the Gold Coast. The operator’s exposition included documented information for each site, including the Beaudesert launch site. The balloon basket was positioned close to the public road bordering the launch area. While this suited the southerly wind at the time for the balloon layout, it left little clearance from other obstacles in the circumstances of a wind shift.

Passenger briefings

The pilot reported that the passenger briefing was given prior to boarding the passengers. It was described as the operator’s standard briefing and included details on the brace position for landing, that passengers should not enter or exit the balloon until the pilot has given permission and that smoking was strictly prohibited.

Balloon envelope damage in-flight

The operator’s exposition referred to the manufacturer’s flight manual for emergency procedures. The Kubíček BFM stated that in the event of damage to the envelope in‑flight the balloon should be kept flying at a low altitude to avoid a hard landing and landed as soon as possible.

Safety risk

ATSB investigation 198900820 illustrated that damage to the envelope of a balloon that propagates to the point where it rapidly deflates can have disastrous implications for flight safety. 

On 13 August 1988, 2 hot air balloons, VH-NMS and VH-WMS, were operating tourist flights near Alice Springs Airport. VH-WMS departed about 2 minutes ahead of VH-NMS and climbed to about 4,000 ft AMSL (2,000 ft AGL) and drifted in a westerly direction. After reaching 4,000 ft, VH-WMS commenced descending as VH-NMS climbed towards it. VH‑NMS continued climbing until its envelope collided with the basket of VH-WMS, tearing a large hole in the envelope fabric. The disruption to the envelope of VH-NMS prevented the balloon maintaining inflation and it descended uncontrolled until it collided with terrain. The pilot and 12 passengers were fatally injured. 

Safety analysis

During the envelope pre-inflation for a scheduled sunrise sightseeing balloon flight, the wind suddenly increased and changed direction pushing the balloon envelope into contact with 2 nearby light posts. This caused a tear in a panel above the equator of the envelope greater than the manufacturer’s allowable limit. The pilot applied adhesive tape to repair the damage while passengers waited. After hot inflation and inspection of the repair, the pilot then decided to operate the flight as scheduled. The repair subsequently degraded in‑flight however a safe landing was made. 

This analysis will explore the assessment of the launch location, damage assessment and repair, as well as factors relating to the continuation of the flight.

Launch site 

The pilot selected a regular launch site and although the site had been used previously, the positioning of the basket and envelope layout for the flight did not provide sufficient available space to ensure clearance of surrounding obstacles at all times during the balloon’s preparation for flight, increasing the risk of envelope damage. 

A wind change occurred at a critical part of envelope inflation, causing the envelope to contact nearby light poles. During recovery from the light pole, the envelope sustained damage. 

Repair

The onsite repair did not comply with the operator’s exposition which required repairs to be conducted in accordance with balloon manufacturer’s instructions. 

Although adhesive tape was allowed for smaller tears up to 10 cm in that area of the envelope, this tear was at least 45 cm. The decision to apply adhesive tape for the repair indicated that the pilot, who was also the maintainer, did not fully understand the manufacturer’s requirements relating to envelope damage limits and did not review the manufacturer’s written requirements before proceeding with the repair. 

The absence of any other obvious deformation of the envelope, or further tearing after the tape was applied, was interpreted that the repair was sufficient. Previous experience repairing minor damage with the adhesive tape likely reinforced the perception that this was an adequate method for this repair, even though 45 cm was beyond admissible damage where such repair was permitted. 

Had the pilot consulted the hot air balloon flight manual, a sewn panel repair would have necessitated the postponement or cancellation of the flight. The pilot’s decision to repair the tear to enable the planned flight to continue without consulting the manufacturer’s envelope repair requirements increased the risk of further in-flight envelope tear propagation, potentially leading to catastrophic envelope failure and a subsequent uncontrolled descent.

Flight continuation 

Research has shown that many aviation accidents involve a ‘plan continuation bias’ or ‘plan continuation error’.[7] That is, pilots decide to continue with the original plan of action despite the presence of cues or information that suggests changing the course of action would be the safer option (Orasanu and others 2001; Orasanu 2010). Plan continuation bias is often associated with situations involving dynamically changing risk and pilots underestimating the risk level (Orasanu and others 2001; Wiegmann and others 2002).

The absence of any immediate deterioration in the tape repair after hot inflation likely reinforced the pilot's belief that the envelope was airworthy. The pilot’s expectation that the balloon was serviceable, supported the pilot’s desire to continue the flight. Improving stability in the surface wind direction and strength then provided an opportunity to launch the balloon.

With the 24 passengers already arrived and waiting, it was likely the pilot perception of the passengers’ expectations was also a strong motivator to continue and influenced the pilot’s decision to conduct the flight. The weight of the perceived passenger expectation would likely have the pilot searching for solutions to enable the flight to proceed, rather than cancelling and rescheduling the flight to conduct repairs.  

The manufacturer’s flight manual instructions were to land as soon as possible following in‑flight envelope damage. While the pilot reported awareness of the tape repair degrading in flight, they did not assess the need to land earlier.

Findings

From the evidence available, the following findings are made with respect to the flight with damaged envelope involving Kubíček BB142P, VH‑RRP, near Beaudesert, Queensland, on 18 October 2025.

Contributing factors

• The location in the launch area did not provide adequate clearance from obstacles during inflation.
• A change in the wind direction caused the partially inflated balloon envelope to move and strike 2 light posts, resulting in significant envelope damage.
• The pilot identified the tear and conducted a repair not in accordance with the balloon manufacturer’s requirements, increasing the risk of in‑flight envelope failure.
• The pilot continued with the intended flight, likely due to their confidence in the repair, improvement in the weather conditions and perceived passenger expectations. When the repair failed, the pilot continued for the remaining 5-10 minutes of the flight rather than landing immediately.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of the incident flight
• Civil Aviation Safety Authority
• Bureau of Meteorology
• balloon manufacturer
• witness
• video footage of the accident flight and other photographs taken on the day of the accident.

References 

ATSB (1989) Kavanagh Hot Air Balloon E-260, VH-NMS, 14 km SSE of Alice Springs Airport NT, 13 August 1989 198900820

Kubíček Balloons, Flight manual B3102 3^rd edition, revision 19, 2017.

Kubíček Balloons, Maintenance manual B3202 3^rd edition, revision 10, 2017.

Orasanu, J., Martin, L., & Davison, J. (2001). Cognitive and contextual factors in aviation accidents: Decision errors. In Linking expertise and naturalistic decision making (pp. 209-225). Psychology Press.

Orasanu, J. M. (2010). Flight crew decision-making. In Crew resource management (pp. 147-179). Academic Press.

Wiegmann, D. A., Goh, J., & O'Hare, D. (2002). The role of situation assessment and flight experience in pilots' decisions to continue visual flight rules flight into adverse weather. Human factors, 44(2), 189-197.

Submissions

Submissions were received from:

• the pilot of the incident flight
• Civil Aviation Safety Authority
• Bureau of Meteorology.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

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 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2026 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.

Investigation summary

What happened

At around 0655 local time on 7 November 2025, a Cessna 172N, registered VH-SCU and operated by Consolidated Pastoral Company (CPC), departed Newcastle Waters Airport, Northern Territory, on a training flight. On board the aircraft were the pilot and an instructor. The pilot was being trained to fly at low level, with the intention of obtaining a low-level operational rating. 

About one hour into the flight while flying at around 300 ft above the ground at an airspeed of 80 kts, and manoeuvring to follow a creek bed, the pilot initiated a steep turn to the right. During the turn, control of the aircraft was lost and it descended towards the ground. The instructor attempted to override the pilot’s control inputs but could not do so before the aircraft impacted terrain. The aircraft came to rest upright but was substantially damaged. The instructor received minor injuries, the pilot was uninjured.      

What the ATSB found

The ATSB found that while conducting a steep turn at low level, excessive aft control input was applied which almost certainly caused the aircraft to enter an aerodynamic stall. Subsequently, inappropriate recovery control inputs by the pilot limited the instructor’s ability to intervene before the aircraft collided with the ground.

The initial excessive control input was likely a combined result of the pilot being focused on maintaining a track over the ground feature and their inexperience in handling the aircraft during low-level flight. The subsequent application of an inappropriate stall recovery technique was likely caused by the pilot reverting to instinctive rather than learned behaviour under stress.   

The ATSB also found that the instructor's recovery control inputs likely prevented the aircraft from impacting terrain in a nose down attitude and reduced the severity of the collision. 

What has been done as a result

The flight training provider undertook a critical review of its training practices and risk mitigation measures. 

Safety message

This accident highlights the importance of understanding the relationship between the elevator control stick position and the aircraft’s angle of attack, to minimise the risk of an aerodynamic stall. The wing will stall when the control stick is moved beyond a fixed position, irrespective of airspeed and attitude. During steep turns at low airspeed, awareness of the stick position provides increased awareness of the aircraft’s performance relative to its limits. This is particularly important to consider when operating close to the ground, such as during take-off, landing, and when conducting low-level air work. Attention may become focused on positioning the aircraft relative to ground features rather than monitoring its aerodynamic performance, and the time available for recovery from an undesired state will be limited. 

The investigation

The occurrence

At around 0655 local time on 7 November 2025, a Cessna 172N, registered VH-SCU and operated by Consolidated Pastoral Company (CPC), departed Newcastle Waters Airport, Northern Territory, on a training flight. On board the aircraft were the pilot and an instructor. The pilot was being trained to fly at low level,¹ with the intention of obtaining a low-level operational rating and had completed 6 training flights with the instructor over the previous 3 days. The purpose of this flight was to consolidate the earlier training and prepare for the low-level rating flight test.

The aircraft was initially climbed to an altitude of approximately 2,000 ft above ground level (AGL), where the pilot demonstrated a sequence of flight manoeuvres. These included left and right turns at angles of bank up to 60° and minimum radius turns at angles of bank up to 45° (see the section titled Minimum radius turns). The pilot also demonstrated their ability to identify and recover from a stall during a minimum radius turn.

The pilot then proceeded to perform a pre-briefed low-level task, which simulated a typical airborne survey of station infrastructure. This task was flown at altitudes between 200 ft and 1,000 ft AGL and incorporated simulated contingencies such as system and engine failures. At the completion of this portion of the training flight, the aircraft was approximately 13 km south of Newcastle Waters Airport, just north of 9 Mile Yard (Figure 1).

The instructor then asked the pilot to return to the departure airport by following the Newcastle Waters Creek in a northerly direction, simulating a water course survey activity (Figure 1). The task commenced at an altitude of 300 ft and the pilot was reminded not to descend below the pre-briefed minimum altitude of 200 ft. At around 0750, a few minutes into the activity, the pilot observed that the creek bed ahead made a sharp turn to the right and they began to manoeuvre the aircraft to keep the ground feature directly below the aircraft. At the start of this manoeuvre, the aircraft was flying approximately 300 ft above the terrain at an airspeed of around 80 kt, with flaps retracted. 

Figure 1: Low-level flightpath over the Newcastle Waters Creek and the location of the collision with terrain  

Source: Google Earth, annotated by ATSB

The pilot rolled the aircraft right to a bank angle of around 45º. As the turn commenced, both the pilot and instructor noted that the aircraft’s nose was pitching down and the aircraft was beginning to descend. The instructor expected that the pilot would correct the pitch attitude by adding power, following the technique that had been taught and successfully demonstrated during the preceding training. 

In addition to the observed descent, the pilot also noted that the aircraft was not turning quickly enough to remain above the ground feature, and in response they rapidly applied more aft control column input to tighten the turn, recalling that they also added a ‘smidge’ more power, however the instructor advised no power was added. In response, the aircraft rolled further to the right and continued to descend. Immediately, the pilot attempted to level the aircraft’s wings and arrest its descent by applying left roll control input, however they maintained aft control input. They stated they did not hear the stall warning horn activate throughout the manoeuvre. 

The instructor could also not recall if they heard the stall warning, however they assessed that the aircraft was in an aerodynamic stall and attempted to intervene by making opposing corrective inputs through their own control column but they could not overcome the control forces being held by the pilot. They could not remember if they advised they were ‘taking over’ however, the pilot flying recalled that the instructor had announced that they were ‘taking over’ and they subsequently released the controls. The pilot advised that the aircraft was already below the tops of the trees before the instructor’s inputs could take effect. 

The instructor stated that they judged that the aircraft would now almost certainly impact the terrain, and that the rudder pedals and throttle were the only effective control inputs available. They applied full power and right rudder with the aim of raising the aircraft’s nose and inducing further right yaw. The instructor’s intent was to prevent the aircraft from impacting terrain nose first and therefore improve the likelihood of survivability. 

As the aircraft descended below the height of the treetops, its pitch attitude had almost levelled, its roll angle had reduced, and it was yawing to the right. The aircraft then impacted the trees, before coming to rest upright on its undercarriage, on relatively flat terrain. It had yawed during the impact sequence, such that it was facing back along its flightpath through the trees. The aircraft sustained extensive damage, particularly to its wings and tail section, with the latter being almost completely detached from the rear fuselage (Figure 2).

Figure 2: VH-SCU as it came to rest following impact with trees and terrain

Source: Supplied

Immediately after the aircraft came to rest, fuel began draining from a rupture in the right wing prompting the crew to exit the aircraft through the left door. During the impact, the instructor sustained minor injuries, while the pilot suffered no visible injuries but reported some neck pain. 

The pilot used a mobile telephone to report the occurrence to the operator, and a ground vehicle was dispatched, which arrived at the accident site at around 0835 and subsequently transported both crew members back to the Newcastle Waters station. Following an initial examination by medical staff, both crew were conveyed to a medical clinic for treatment. The instructor was later discharged, while the pilot was transported to a hospital in Alice Springs for further assessment and monitoring. The pilot was discharged from hospital the following day. 

Context

Flight crew

The pilot of VH-SCU held a Commercial Pilot Licence (Aeroplane) issued in 2024 and a class 1 aviation medical certificate. They had accumulated around 300 flight hours, mostly on single engine piston training aircraft, including the Cessna 172 and Diamond DA40. They had worked as a pilot on the station since October 2025.

The instructor held an Air Transport Pilot Licence (Aeroplane), a class 1 aviation medical, and a low-level rating, among other ratings and endorsements. They had accumulated a total of around 24,500 flying hours, with approximately 2,500 hours in the Cessna 172. They had flown 240 hours in the 90 days prior to the occurrence, with 25 of those in the Cessna 172. 

Aircraft

VH-SCU was a Cessna Aircraft Company 172N manufactured in the United States in 1977 and assigned serial number 17268700. It was equipped with a Textron Lycoming O‑320‑H2AD piston engine, fixed pitch propeller, and fixed tricycle undercarriage. Maintenance records indicated that the airframe had accumulated a total flying time of 15,995 hours prior to the accident flight and the engine had 927.6 hours since overhaul. The aircraft was being maintained under the Civil Aviation Safety Authority Schedule 5 and had flown 45 hours since its most recent maintenance event, which was a 100-hour inspection performed on 23 August 2025. 

The aircraft had no recording devices on board and nor was it required to.

Weather

No weather information was recorded for Newcastle Waters station, however the Bureau of Meteorology provided information for the nearest observation station at Daly Waters, approximately 123 km north. An observation issued at 0800 local time reported the temperature to be 29°, with a dew point of 21°, an atmospheric pressure of 1010 hectopascals, and a surface wind of between 8–10 kt from the north. This station did not provide a report of visibility or cloud cover.

Both flight crew provided consistent reports of the weather conditions at Newcastle Waters. They recalled a temperature of between 22–26°, winds of between 5–10 kt from the north-west, smooth air with no mechanical turbulence, and no cloud. There was light smoke haze but this did not significantly impair their visibility. The instructor estimated the density altitude² to be approximately 3,000 ft.  

Low-level training

The low-level flight training was being provided under the provisions of Part 141 of the Civil Aviation Safety Regulations (CASR). The instructor was qualified to deliver this training and had provided the same training to other pilots, employed at the station, on numerous occasions prior.

Part 61 of the CASR required an applicant for a low-level rating and aeroplane low-level endorsement to have, among other conditions: 

• undertaken at least 5 hours of dual flight training in an aeroplane while receiving training in low level operations

• pass a flight test defined in the Part 61 manual of standards.  

The Part 61 manual of standards prescribed a set of knowledge and flying competencies, which must be satisfactorily demonstrated during the low-level rating flight test. The specific activities and manoeuvres to be demonstrated during the flight test included:

• navigate at low-level

• conduct steep, max rate and min radius turns

• recover from approach to stalls – level and turning

• recover from unusual attitudes

• recover from wing drop at the stall

The training syllabus employed by the instructor planned for all airborne activities and manoeuvres to be taught over a period of 5 flying hours. The instructor reported that, in their experience, most students achieved competency within this period. 

At the time of the accident, the pilot flying had undertaken 10.1 hours of low-level training. Training records indicated that additional flying hours were required at the start of the course for the student to demonstrate competency in some manoeuvres, including maintaining altitude during steep turns, stall recognition and recovery. However, during a period of upper air work conducted earlier in the accident flight, the student had successfully demonstrated competency in all these manoeuvres. 

Aircraft stall behaviour

The angle of attack (AOA) is the angle at which the wing meets the relative airflow passing the aircraft. It is directly related to elevator position and therefore control stick position. The amount of lifting force produced by the wing increases with increasing AOA until a critical angle is reached. At the critical AOA (typically 16–18°), the wing aerodynamically stalls and lift production decreases abruptly. Recovering from a stall requires AOA be reduced below the critical angle by reducing aft control stick displacement. 

Should the critical AOA be approached during a turn, using aileron to level the wings increases the AOA of the inside wing and may cause it to stall prior to the outside wing. This can result in the angle of bank rapidly increasing rather than decreasing. Instead, it is recommended that rudder is used to level the wings when a stall is encountered. 

Minimum radius turns

A minimum radius turn achieves a change in aircraft direction over the smallest possible ground space. This technique is often used in low-flying operations where manoeuvring is made with respect to a ground feature and within confined terrain. Minimum radius turns are typically conducted at high angles of bank and lower airspeeds. Both conditions increase the AOA required to maintain level flight. The margin between required AOA and the critical (stalled) AOA is therefore reduced. 

Adding additional aft control stick displacement during a minimum radius turn can quickly result in the wing exceeding the critical AOA and entering a stalled condition. For this reason, pilots are often instructed to correct low attitude during minimum radius turns through application of power, rather than additional aft control stick input.

Related occurrences

There have been a number of recent ATSB investigations into fatal accidents that resulted from a loss of control while manoeuvring during low-level flight. 

ATSB investigation AO-2024-037

On 27 June 2024, the pilot of a Cessna 172N, registered VH-SQO, was mustering sheep at Mulgathing Station, South Australia. The aircraft was observed to dive to an estimated height of about 50 ft above the ground before climbing rapidly, turning to the left and then descending towards the ground. The ATSB found that, while mustering without the appropriate endorsement, the pilot lost control of the aircraft leading to an aerodynamic stall and spin from an altitude that was not recoverable.

ATSB investigation AO-2022-011

On 3 March 2022, the sole pilot of a Cessna U206G, registered VH-JVR, was conducting a low-level geophysical survey, about 120 km west of Norseman, Western Australia. At about 1430, the aircraft’s satellite tracking system stopped reporting its position. Wreckage was subsequently located 3.2 km west of the aircraft’s last recorded position. The ATSB found it was likely that, during a manoeuvre to intercept the next survey line, for undetermined reasons, control of the aircraft was lost at a height from which recovery was not possible. 

ATSB investigation AO-2021-016

On 13 April 2021, a Cessna R172K, registered VH-DLA, departed Canberra Airport, Australian Capital Territory, with a pilot and observer on board to conduct powerline survey work to the north of Sutton township, New South Wales. The aircraft was subsequently observed flying low above the trees before commencing a left turn that continued in to a steep descent and collision with terrain. The ATSB found that while manoeuvring to align the aircraft to inspect a powerline, the aircraft aerodynamically stalled and entered a spin at a height that was insufficient for recovery prior to the collision with terrain.

ATSB investigation AO-2021-052

On 4 December 2021, the pilot of an Air Tractor AT-400 aircraft, registered VH-ACQ, was conducting aerial spraying operations on a property 75 km west-south-west of Moree, New South Wales. During a right procedure turn, the aircraft was observed to climb then descend rapidly and collide with terrain. The ATSB found that the aircraft was too close to the start of the spray run during the turn, which probably resulted in the pilot tightening the turn. This almost certainly resulted in an aerodynamic stall at a height too low to recover before colliding with the terrain.

Safety analysis

The pilot and instructor were conducting a low-level navigation exercise, tracking along a ground feature at approximately 300 ft AGL and 80 kt. 

Accounts from both crew members indicated that while making a steep right turn to follow the ground feature, the aircraft’s nose dropped. Additionally, the pilot observed that the aircraft was not turning quickly enough to remain over the river. In response, they sharply increased their aft control stick input rather than increase the bank angle. This almost certainly placed the aircraft into an aerodynamically stalled condition rapidly increasing the rate of descent and further rolling to the right. 

The pilot did not follow the recommended method to address the nose drop at low level - application of power rather than increasing pitch, which they had demonstrated successfully earlier in the flight. The ATSB could not determine why the correct recovery technique was not applied. However, human factors research (Martin, Murray, Bates and Lee 2013) noted that when faced with a sudden unexpected aircraft condition, pilots may experience a rapid increase in stress and revert to instinctive behaviour over trained behaviour. 

After recognising that the pilot had applied inappropriate control inputs the instructor attempted to intervene. It is uncertain what verbal communication was made between the crew, but there was a period of confusion over who had control of the aircraft, and it is likely both crew members were making control inputs simultaneously resulting in the instructor being unable to override the control inputs of the pilot, delaying the effectiveness of the recovery actions. Due to the proximity to the ground, the aircraft descended into terrain before this confusion could be resolved. Despite this, the instructor’s inputs to the throttle and rudder likely prevented the aircraft from contacting the ground in a nose down attitude and reduced the severity of the impact.    

Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 172, VH-SCU, about 6 km south of Newcastle Waters, Northern Territory, on 7 November 2025. 

Contributing factor

• While training to follow a ground feature at low level, the pilot flying applied and held inappropriate control inputs, which led to an aerodynamic stall and limited the instructor’s ability to make corrective actions, resulting in the aircraft colliding with terrain.

Other finding

• The instructor's control inputs likely prevented the aircraft from impacting terrain in a nose down attitude and reduced the severity of the collision.

Safety actions

Safety action by flight training provider

The flight training provider undertook a critical review of its training practices and risk mitigation measures.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company
• Bureau of Meteorology.

References

Martin, Murray, Bates, and Lee (2015) Fear-potentiated startle: A review from an aviation perspective. The International Journal of Aviation Psychology, 25(2), pp.97-107.

Submissions

Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report. 

A draft of this report was provided to the following directly involved parties:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company
• Civil Aviation Safety Authority.

Submissions were received from:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

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 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2026  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. ^    CASA defines low-level flight operation as any flying conducted below 500 ft above ground level (AGL), other than for the purpose of take-off or landing.
2. ^    Density altitude is the pressure altitude corrected for non-standard temperature. It is the altitude at which the aircraft ‘feels’ it is flying regardless of its actual height above sea level.