ATSB releases aerial firefighting occurrences safety analysis.

The ATSB has published a statistical report of aerial firefighting accident and incident occurrence data spanning a near 20-year period, in response to a request for information from the Royal Commission into National Disaster Arrangements.  

The safety analysis forms a central element of the ATSB’s response to the Royal Commission, commonly referred to as the Bushfire Royal Commission, which requested information on “key operational and safety challenges encountered in coordinating and responding to fires associated with the use of aircraft and aerial firefighting techniques”.

ATSB Director Transport Safety Dr Stuart Godley noted the report details both the number of occurrences and, where data was available, the rate of occurrences per hours flown and number of flights, for aircraft conducting aerial firefighting operations, including water-bombing, surveillance and air attack tasks, for the period 1 July 2000 to 31 March 2020.

The ATSB could only draw upon limited exposure data to determine the rates of occurrences.

“Aviation activity relating to aerial firefighting has increased over recent bushfire seasons. Estimates for the most recent season, 2019 to 2020, have been that there was a four-fold increase in aerial firefighting activity compared to other recent bushfire seasons.” Dr Godley noted.

“More occurrences involving aerial firefighting aircraft were reported to the ATSB this financial year (between July 2019 and March 2020) than in any prior financial year in the study period. Further, there were two fatal aerial firefighting accidents between August 2018 and March 2020, whereas in the previous 17 years there were only three fatal accidents,” Dr Godley noted.

“However, given the amount of recent bushfire activity in Australia, an increase in reported occurrences could be expected, so this does not indicate an increase in risk per flight.

Since 2018 the ATSB has commenced six investigations involving aerial firefighting aircraft, including into the Lockheed C‑130 large air tanker collision with terrain near Cooma, New South Wales, on 23 January 2020, in which three flight crew were fatally injured. This number represents about one third of all investigations involving aircraft conducting aerial work commenced by the ATSB since 2018.

Dr Godley stressed that while the number of occurrences does give some indication of overall risk, the ATSB could only draw upon limited exposure data to determine the rates of occurrences, either on a per hours flown or numbers of flights basis.

“The ATSB was only able to draw upon Bureau of Infrastructure Transport and Regional Economics (BITRE) exposure data for Australian-registered aircraft conducting aerial firefighting from 2014 to 2018, while data was not available for hours and flights flown by foreign-registered aircraft operating in Australia.”

Foreign-registered aircraft accounted for about 16 per cent of reported aerial firefighting occurrences in Australia, the report notes. Foreign-registered aircraft were also significantly larger in comparison to Australian-registered aircraft, with an average maximum take-off weight around 10 times higher.

The statistical review also sought to identify any risks associated with aerial firefighting in addition to those inherent with low‑level flying by comparing the occurrence rates for Australian-registered aerial firefighting aircraft to the combined occurrence rates for other aircraft undertaking low-level aerial work flying in Australia between 2014 and 2018.

“Generally, the rates for incidents, serious incidents and accidents are relatively low for aerial firefighting compared to other aerial work activities,” Dr Godley noted.

“Further, it is highly likely that the rate of reported terrain collisions was lower for Australian‑registered aerial firefighting aircraft than other low‑level flying aerial work activities,” Dr Godley said.

The review did find that it is highly likely that the rate of reported occurrences involving Australian‑registered aerial firefighting aircraft, compared to other low‑level flying aerial work, was greater for communications‑related occurrences; encounters with remotely piloted aircraft; airframe‑related technical issues; flight preparation/navigation operational occurrences; aircraft separation occurrences; and operational non‑compliance occurrences.  

Read the research report AR-2020-022: A safety analysis of aerial firefighting occurrences in Australia, July 2000 to March 2020

The collision with rising terrain of an FU24 Stallion aerial application aircraft highlights the importance of pre-flight planning of application runs to account for nearby terrain, an ATSB investigation notes.

The Pacific Aerospace FU24 Stallion, registered VH-EUO, was conducting aerial agricultural application operations from an airstrip 40 km north of Bathurst, New South Wales, to apply fertiliser and seed to grazing land.

At about 2:05pm, the Stallion (a TPE331 turboprop conversion of the FU24 Fletcher) took off from the airstrip for the second flight of the second job of the day. When the aircraft did not return as expected, the loader raised the alarm and a search for the aircraft was launched. Early the next morning, the wreckage of the aircraft was found in dense scrubland to the east of the application area. The pilot had sustained fatal injuries as a result of the accident.

The ATSB investigation found that shortly after the end of the third application run, the aircraft was flown into an area of rising terrain that was outside the normal operating area for the job site. While repositioning the aircraft for the fourth application run, it was likely that the aircraft stalled at a low altitude, resulting in a low-speed, low-energy collision with wooded terrain part way up an approximately 28˚ slope rising to the north.

This accident highlights the importance of pre-flight planning of application runs to account for nearby terrain.

With no evidence of any defect with the aircraft that would have contributed to the loss of control, the investigation explored several possible factors that may have contributed to the loss of control, including birdstrike, pilot distraction and mishandling of a procedure turn. However, the ATSB investigation was unable to determine the reason for the loss of control, based on the available evidence.

“The ATSB is reminding operators and pilots of the dangers of aerial application near rising terrain,” ATSB Director Transport Safety Stuart Macleod said. “This accident highlights the importance of pre-flight planning of application runs to account for nearby terrain.”

An on-site visual inspection of the aircraft’s hopper identified that the hopper was approximately half full. The position of the hopper outlet control and dump control levers and the half-load in the hopper were indicative of the hopper’s contents not being dumped or applied in the lead-up to the collision with terrain.

“Although it could not be established that not dumping the hopper contributed to this accident, in an emergency, reducing the aircraft’s weight by dumping the hopper load will optimise an aircraft’s flight performance,” Mr Macleod said.

“As the Aerial Application Association of Australia (AAAA) pilot’s manual states, ‘The only safe rule is ‘if in doubt, dump’.”

Read the final report: Loss of control and collision with terrain involving FU24 Stallion, VH-EUO, 40 km north-east of Bathurst, New South Wales, on 16 June 2017

R22 helicopter’s collision with terrain highlights the risks of low-level flying in hazardous weather conditions.

A Robinson R22 helicopter collided with terrain when it likely encountered a downdraft with insufficient height to recover while unnecessarily flying at low level through the Northern Territory’s MacDonnell Ranges, an ATSB investigation has found.

The R22 had departed a cattle station’s homestead’s helipad to inspect bore sites and then assist with the recovery of a vehicle at Quartz Hill. After completing a bore inspection, the helicopter took-off and was levelled off at 150 feet above ground level, which was below the peaks of the surrounding terrain as it tracked into the MacDonnell Ranges to continue towards Quartz Hill.

Shortly after entering the MacDonnell Ranges, the R22 collided with the ground on a downslope, about 125 kilometres east of Alice Springs. The helicopter’s last recorded data point indicated it was at about 142 feet above ground level with an estimated ground speed of about 79 knots. The pilot sustained fatal injuries and the passenger was seriously injured.

Even if a pilot has been trained and approved to conduct low-level operations it should be avoided when there is no operational need to do so.

ATSB analysis of the helicopter’s GPS data and other available evidence suggested the pilot was likely operating the helicopter at low level and possibly contour flying. For the prevailing winds, the helicopter’s final track placed it on the lee side of higher ground. Bureau of Meteorology anaylsis indicated that broadscale moderate turbulence was especially likely at the time of the accident in the lee of the ranges and as a result of stronger upper winds mixing with lower winds.

ATSB Director Transport Safety Dr Godley said the investigation determined it was very likely the pilot was operating at low-level when the helicopter encountered a downdraft with insufficient height to recover, leading to the collision with terrain.

“When flying at low altitude there is a lower margin for error for obstacle avoidance. Even if a pilot has been trained and approved to conduct low-level operations it should be avoided when there is no operational need to do so,” Dr Godley said.

The investigation also found a number of other factors that increased risk, including incomplete pre-flight planning, overloading, a forward centre-of-gravity, and the pilot’s elevated blood alcohol level.

“Examination of the pilot’s iPad and iPhone found it was unlikely that flight planning data, such as meteorological information, had been accessed in the lead-up to the flight,” Dr Godley said.

“Thorough pre-flight planning is essential for avoiding hazardous weather conditions. It is not only important to obtain the relevant weather information to develop a mental picture of the conditions that may be encountered, but also to assess and understand how it relates to the planned flight.”

The investigation report also notes that it was very likely that the helicopter was overweight on departure and its centre-of-gravity was beyond the forward limit for the entire flight.

“Weight and balance have the potential to influence aircraft handling characteristics, and so it is critical that the loading remains within the prescribed operating limits for the entire flight,” Dr Godley said. “Otherwise, as the safety margin steadily erodes, even an experienced pilot may not be able to recover from a rapidly developing unsafe condition.”

The report also notes that alcohol was also present in the pilot’s blood at a level capable of impairing performance. However, evidence of previous low flying suggested the pilot’s actions may have been normal behaviour and not influenced by alcohol. Therefore, the investigation could not conclude that the pilot’s elevated level of alcohol contributed to the accident, but considered that it increased the likelihood of risk-taking behaviour and mishandling the helicopter in an emergency. 

“This accident is an important reminder that blood alcohol can persist the day after significant alcohol consumption, and the residual effects of alcohol may impair performance, especially in demanding situations,” Dr Godley said.

Read the final report: Weather event and collision with terrain involving Robinson R22, VH-KZV, 125 km east-north-east of Alice Springs Airport, Northern Territory, on 24 November 2018

ATSB Chief Commissioner reappointed chair of the International Transportation Safety Association.

The Australian Transport Safety Bureau’s Chief Commissioner, Greg Hood, has been reappointed as the chair of the International Transportation Safety Association (ITSA) for a second 12-month term.

The unprecedented reappointment was confirmed during a virtual meeting of ITSA members on Monday evening (Australian time) on what would have been the opening day of the ITSA 2020 forum, to have been hosted by the ATSB in Sydney on May 4-5. This year’s forum was deferred earlier in the year due to the international travel restrictions and social distancing requirements made necessary in response to the COVID-19 pandemic.

“ITSA is an international network of heads of agencies of independent transport safety investigation authorities from 17 nations, covering aviation, marine, rail and road transport, as well as pipelines and underground infrastructure,” Mr Hood explained.

This is a great responsibility at a time when the world is navigating the COVID-19 pandemic, and when safe and efficient transport networks are needed like never before.

“I feel privileged to have been re-elected chair of ITSA for a second term. This is a great responsibility at a time when the world is navigating the COVID-19 pandemic, and when safe and efficient transport networks are needed like never before.”

Mr Hood said the ITSA 2020 forum in Sydney would have been a valuable platform for sharing safety information and pursuing best practices in independent “no blame” transport safety investigations.

“During our virtual meeting members agreed to the desirability of rescheduling the deferred ITSA 2020 forum to a yet-to-be determined date in Sydney next year so that information sharing can be continued, should that be safe and plausible to do so,” Mr Hood said.

“The mission of ITSA is to improve transport safety in each member country by learning from the experiences of others,” said Mr Hood.

“It is our hope that that mission can be furthered with our next forum in Sydney some time in 2021.”

ATSB releases Aviation Occurrence Statistics from 2010 to 2019.

The Australian Transport Safety Bureau has released its latest Aviation Occurrence Statistics report, covering the 10-year period from 2010 to 2019.

“Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the ATSB,” said Dr Stuart Godley, ATSB Director Transport Safety.

“This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector.”

This latest Aviation Occurrence Statistics report notes that there have been no fatalities in scheduled commercial air transport in Australia since 2005, while that over the 10-year 2010-2019 period, the number of general aviation fatalities and fatal accidents decreased, and the number of fatalities and fatal accidents within the recreation aviation sector remained relatively constant.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety, Dr Godley explained.

“For example, since 2016, remotely piloted aircraft have surpassed helicopters to become the second most common aircraft type involved in an accident. Further, the number of manned aircraft experiencing near encounters with an RPA also increased significantly over the study period.”

Dr Godley also noted that for the first time, statistics in this report have been organised around the type of aircraft activity being conducted, rather than the operational regulation.

“An activity type reflects the activity the aircraft was engaged in, while an operation type reflects the legal regulation that the aircraft was flown under,” he said.

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

The report incorporates interactive web versions of all tables and graphs to allow the user to display aviation occurrence data in the format of their choice.

Read the report AR-2020-014: Aviation Occurrence Statistics 2010 to 2019

Mid-air collision preliminary report released. 

The Australian Transport Safety Bureau has released the preliminary report from its ongoing investigation into the mid-air collision involving a Piper Seminole and a Beech Travel Air aircraft south of Mangalore Airport in Victoria on 19 February 2020.

The preliminary report details basic factual information established in the investigation’s early evidence collection phase, and outlines the collision’s sequence of events using a number of sources including ADS-B transponder data and information from an iPad with an electronic flight bag app installed. The report also outlines weather information at the time and notes that there was no recording of the Common Traffic Advisory Frequency (CTAF) frequency.

The Travel Air aircraft, registration VH-AEM, had departed Tyabb Airport for a return Instrument Flight Rules (IFR) training flight to Shepparton via Mangalore with an instructor and student pilot on board at 10:55 am. Meanwhile the Seminole, registration VH-JQF, advised Air Traffic Control (ATC) at 11:11 am they were taxiing for departure from Mangalore for a round-trip IFR flight via Essendon and Shepparton. An authorising testing officer and pilot were on board.

Six minutes later, the Travel Air began its descent from 6,000 ft for airwork at Mangalore between 4,000 ft and ground level. ATC advised the Travel Air of the departing Seminole from Mangalore. The Seminole then made a departure call, advising ATC of a planned climb to 7,000 ft. ATC passed details of the Travel Air’s intended airwork to the Seminole.

The two aircraft collided at 11:24 am approximately 8 km south of Mangalore Airport at an altitude of about 4,100 ft. The Seminole travelled for about half a kilometre to the east before impacting an open field, while the Travel Air  continued north and impacted a lightly wooded area 1.4 km from the collision point. Debris was found in area ranging from 1.6 km to the north-north-east and about 200m to the west of the Hume Highway. The two pilots on board each aircraft were fatally injured.

Examination of the recovered radios, weather conditions at the time of the accident, as well as recorded area frequency calls and recollections of CTAF radio broadcasts will be the focus as the investigation moves forward.

ATSB Chief Commissioner Greg Hood noted preliminary reports do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final and any interim reports.

“Examination of the recovered radios, weather conditions at the time of the accident, as well as recorded area frequency calls and recollections of CTAF radio broadcasts will be a focus as the investigation moves forward,” Mr Hood said. 

“Other areas for investigation include air traffic services actions, procedures and practices, traffic density in and around Mangalore Airport and classification of its airspace, and Class G* and CTAF operational and communication processes and procedures at the airport. Visibility from both aircraft will also be examined.”

A final report is expected to be completed next year.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken,” Mr Hood said.

* In class G airspace, air traffic controllers provide traffic information to IFR aircraft about other conflicting IFR and observed VFR flights, but do not provide separation services.

Read the preliminary report: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF and Beech D95A Travel Air, VH-AEM, 8 km south of Mangalore Airport, Victoria, on 19 February 2020

Important safety notice issued to helicopter winching operators.

Improper stowage of helicopter winch hook assemblies can lead to excessive movement and accelerated wear of the cable, which if undetected, can lead to catastrophic failure of the winch cable, an Australian Transport Safety Bureau (ATSB) Safety Advisory Notice advises.

The Safety Advisory Notice comes after an incident involving an Airbus Helicopters AS350 B3 helicopter on 5 February 2020 near Bulga, New South Wales. While conducting winching operations of personnel and equipment during the recent bushfires, the helicopter crewman detected the outer strands of the hoist cable toward its termination into the hook assembly had loosened. Such loosening is known to occur during repeated short length winch deployment and retrieval cycles.

The crewman attempted to reset the cable strands using an accepted maintenance practise known as cable conditioning, however the following day the cable strands had not reset and remained loose, which prompted a second cable conditioning operation. During that operation, and while under load, the cable fractured at the hook assembly, releasing the dummy weight to the ground. There was no damage to the helicopter or injuries to personnel.

As part of an ATSB investigation into the incident, an examination of the helicopter’s winch system found that the cable failed near to the swaged ball-end that terminated into the hook assembly. The ATSB identified that the wear associated with the cable failure probably occurred due to improper stowage of the hook assembly following hoisting operations.

“A hook that is not firmly seated or with the bump stop spring not sufficiently compressed can move during exposure to airframe vibrations and rotor downwash buffeting during normal helicopter operations, which can lead to accelerated wear of the hoist cable close to the ball-end fitting where it enters the hook assembly” ATSB Director, Transport Safety, Stuart Macleod said.

“Should the cable fail while under load during operation, personnel being winched may sustain serious or fatal injuries.”

The ATSB is advising all helicopter operators and flight crew involved in rescue hoist operations to review their current operational practices to ensure hoist operation and hook stowage are in accordance with the hoist manufacturers’ published procedures.

“In addition, the ATSB advises those operators, flight crew, and maintainers, to closely review the pre- and post-flight inspection requirements of the hook and cable assembly, along with any recurring scheduled maintenance of the hoist system to ensure that they are completed in accordance with the manufacturers’ instructions,” Mr Macleod said.

In response to the failure, on 6 April 2020 winch system manufacture Breeze-Eastern published a Service Information Letter to operators, hoist maintainers and personnel working on the BL-29700 series rescue hoist. The letter reinforced the requirement for proper homing of the hook assembly following operation of the hoist, the importance of pre- and post-flight inspections of the hook assembly, and the recommended maintenance practises for the hoist system.

The Service Information Letter can be accessed from Breeze-Eastern’s website.

The Civil Aviation Safety Authority has also issued an Airworthiness Bulletin (AWB-25-034(Opens in a new tab/window)) warning of accelerated winch cable wear.

The ATSB’s investigation into the rescue hoist cable failure (AO-2020-013) is continuing.

Read the Safety Advisory Notice: Rescue hoist cable failure

Paying tribute to the extraordinary contributions to aviation by Senja Robey.

The Australian Transport Safety Bureau (ATSB) recognises and pays tribute to the extraordinary contribution made to aviation by Senja Robey, who passed away on 14 April at home, aged 93.

Senja was an Australian aviation icon, professional pilot, and extraordinary instructor, who in November 2017 was inducted into the Australian Aviation Hall of Fame.

“On behalf of the ATSB, I would like to extend my sincere condolences to Senja’s family, her friends and the wider aviation community who are mourning her passing,” ATSB Chief Commissioner Greg Hood said. “I have known Senja for several years having been introduced to her through the Australian Women Pilots Association - she exuded an aura of yesteryear – of having been there and done that before many of us were born, but with modesty and humility.”

Senja, influenced to fly by her father, a physics teacher and who started the Air Training Corps Flight at  Sydney Technical High, began her flying training at the Royal Aero Club of NSW in March 1949. Having flown solo within a month of commencing her training, Senja obtained her private pilot licence six months later.

One of a handful of original members of the Australian Women Pilots’ Association (AWPA), Senja worked at the then de Havilland Aircraft Company in Sydney, where she studied part-time to gain her Commercial Pilot Licence in 1953. Obtaining her flight instructor rating nine years later, Senja became an instructor at the Illawarra Flying School located at Bankstown Airport, where her husband, Keith, was the Chief Flying Instructor.

At the time, the Illawarra Flying School was one of the largest commercial schools in Australia. By 1969, Senja had accrued around 3,500 hours of instructing, with some of her students going on to become airline captains.

Rising to National President of AWPA in the 1970s, Senja assisted fellow aviator Deborah Wardley to challenge Ansett Airlines for her right to become an airline pilot. The Wardley case opened the door for other women pilots in Australia.

“Senja was renowned for her ability to fly with extraordinary accuracy and steadiness,” Chief Commissioner Hood said. “She held endorsements on approximately 60 aircraft types, both single-engine and multi-engine, ranging from the Tiger Moth to Aero Commanders and Aerostars. Senja Robey was a remarkable aviatrix whose life, achievements and almost 14,000 flight hours needs to be remembered, savoured and celebrated.”

In a career spanning more than 60 years, Senja was awarded the Order of the British Empire Medal (BEM) for her contribution to aviation in 1976. Giving a lifetime of service to aviation, Senja will be remembered throughout the industry for her high level of professionalism and unstinting generosity in providing practical guidance to less experienced and potential aviators.

ATSB releases Wallan XPT derailment preliminary report.

The Australian Transport Safety Bureau has released the preliminary report from its ongoing investigation into the derailment of XPT passenger train ST23 at Wallan, Victoria on 20 February 2020, in which the driver and assisting qualified worker were fatally injured.

The preliminary report details basic factual information established in the investigation’s early evidence collection phase, including the sequence of events, track information, and data downloaded from the train’s data logger.

“ATSB preliminary reports do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report,” ATSB Chief Commissioner Greg Hood noted.

The preliminary report confirms that the train, which was travelling from Sydney to Melbourne with six crew, the assisting qualified worker (who joined the train near Kilmore) and 153 passengers onboard, entered a passing loop at Wallan at a speed of more than 100 km/h when the speed limit for entering the loop was 15 km/h.

“Earlier that afternoon, the points at either end of the Wallan loop had been changed from their ‘Normal’ position to their ‘Reverse’ position, which meant that rail traffic, in both directions, would be diverted from the Main Line into the loop track,” Mr Hood noted.

“A Train Notice reflected this change and also specified a 15 km/h speed limit for entry into the loop.”

The train’s data logger showed an emergency brake application was applied a short distance from the points before entering the passing loop.

“This slowed the train a small amount before it entered the turnout travelling at a speed in excess of 100 km/h. The train was not able to negotiate the turnout to the loop track at this speed and derailed. All vehicles derailed excepting the rear power car.”

During the derailment sequence, the lead power car rolled onto its left side and the XPT driver and the accompanying qualified worker sustained fatal injuries. Three passengers were seriously injured and 36 received minor injuries, while five train crew who were in the passenger cars also sustained injuries.

Mr Hood said the preliminary report notes that due to damaged signalling equipment a 24 km section of track between Kilmore East and Donnybrook incorporating Wallan was being managed by an ‘alternative safe working system’, and that the accompanying qualified worker boarded the lead power car near Kilmore and joined the driver as part of the alternative safeworking system.

“The continuing investigation will explore a range of factors, including a detailed examination of the alternative safeworking systems; the operation of the train; the conditions of the track and rolling stock; and crew and passenger survivability including a passenger survey,” Mr Hood noted.

Mr Hood said the investigation is being led by Victoria’s Chief Investigator, Transport Safety (CITS), under delegation from the ATSB, with support from the ATSB as well as New South Wales’ Office of Transport Safety Investigations (OTSI). CITS conducts rail investigations in Victoria on behalf of the ATSB under the Transport Safety Investigation Act 2003.

“I would like to acknowledge the efforts of CITS in particular in working diligently to build a detailed understanding of this accident, and to recognise the support the ATSB and CITS have received from a broad range of stakeholders who have contributed to this investigation’s early phases,” he said.

Mr Hood noted an investigation of this nature and complexity may take more than 18 months to complete.

“However, should any safety critical information be discovered at any time during the investigation, we will immediately notify operators and regulators, and make that publicly known.”

Read the preliminary report: Derailment of passenger train ST23, Wallan, Victoria, on 20 February 2020

Recorded data and recovered components focus of ongoing investigation of fatal collision with water.

Recorded data and recovered components are among the areas of focus for the ongoing investigation into the fatal collision with water of a Cessna 182 light aircraft near Moreton Island in south-east Queensland on 22 January 2020.

The ATSB preliminary report details the aircraft’s flight path in the lead-up to the dual fatality accident. The Cessna 182, registration VH-WNR, had departed Caloundra Airport at 3.30 pm as a private sightseeing flight with the pilot and a passenger on board.

The aircraft flew south over Bribie Island and onto Moreton Island. At 4.06 pm, when the aircraft was overhead Tangalooma, the pilot radioed that he intended to head south to the end of the island and then north up the eastern side of the island.

The ATSB’s preliminary examination of the flight path indicates the aircraft passed the northern tip of the island at about 1,100 ft in a shallow descent and continued towards Flinders Reef. The aircraft’s airspeed and descent remained stable until about 4.25 pm when the descent rate began to gradually increase. The pilot made a MAYDAY call at 4.26 pm east of Flinders Reef while descending through 300 ft at a groundspeed of 115 kt. Air traffic control attempted to establish contact but no further transmissions were received from the aircraft.

Examination of underwater footage of the aircraft showed damage to the cabin indicating the impact with water was unlikely to be survivable.

Initial analysis of radar data points to the aircraft continuing north-east for another 15 to 20 seconds after the transmission before colliding with the water.

An aerial and marine search was initiated, and the aircraft was located on 29 January 2020, north-east of Flinders Reef in about 30 metres of water. The pilot and passenger were not located.

“Examination of underwater footage of the aircraft showed damage to the cabin, indicating the impact with water was unlikely to be survivable,” ATSB Director Transport Safety Dr Mike Walker said.

“Some aircraft components, including the engine and propeller, were recovered with the assistance of the Queensland Police Service and the Queensland National Parks and Wildlife Service. The ATSB is grateful for their valuable assistance.”

Dr Walker said no pre-existing defects were identified during workshop examinations of the engine and propeller but there remains much work to do.

“In addition to the examination of the recovered components, the ongoing investigation will include the examination of the aircraft’s maintenance and operational records as well as video footage of the wreckage, pilot qualifications and medical history and further analysis of recorded radio, radar and engine monitoring data.”

The investigation is still in early phases and that the ATSB’s safety analysis and findings will be published in the final investigation report.

“Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken,” Dr Walker said.

Read the preliminary report: Collision with water involving Cessna 182, VH-WNR, 6 km north-west of Moreton Island, Queensland, on 22 January 2020