Engine failure incident highlights importance of following procedures.

The flight crew of an AirAsia X Airbus A330 did not follow proper procedures when faced with an engine oil pressure warning, attempting to restart the affected engine even after it had failed, as well as electing to divert to Melbourne when the aircraft was considerably closer to two other airports.

The engine oil pressure warning and subsequent engine failure occurred during a 16 August 2016 scheduled flight from Sydney to Kuala Lumpur, with two flight crew, eight cabin crew and 234 passengers on board. While in cruise near Alice Springs the flight crew received an ‘Engine 2 oil low pressure’ failure alert message, which the ATSB’s subsequent investigation of the event established was due to a shaft failure in the engine’s oil pressure pump.

That alert required immediate crew action comprising of reducing thurst on the affected Rolls-Royce Trent 700 engine to idle and then, in accordance with the Airbus procedure, ‘if [the] warning persists’, shutting down the engine.

Procedures need to be designed with clarity

However, the flight crew probably misinterpreted the term ‘persists’ as requiring they wait a certain period of time to determine if the condition was persisting. As a result, they continued to troubleshoot the failure, rather than shut down the engine.

After monitoring the engine the flight crew formed the view that the warning was the result of a gauge failure. With the intent of further trouble shooting, the crew then increased the engine’s thrust. This led to the engine stalling and ultimately failing.

However, despite evidence to the contrary, the flight crew determined that the failed engine was not damaged and could be restarted. Consequently, and contrary to the operator’s procedures, the flight crew made two attempts to restart the failed engine, even though there was no safety risk to the aircraft that demanded a restart attempt. Both attempts failed.

Also contrary to the operator’s procedures, the flight crew elected to divert to Melbourne following the engine failure, rather than to closer suitable airports in Alice Springs and Adelaide. Although twin-engined airliners such as the A330 are designed to fly safely on a single engine, this decision increased the time that the aircraft was operating in an elevated risk environment of single-engine operations.

“There are three key safety messages from this investigation,” noted ATSB Director Transport Safety Dr Stuart Godley.

“Not only does this occurrence demonstrate the importance of flight crews adhering to standard operating procedures when responding to aircraft system alerts, it also highlights that those procedures need to be designed with clarity,” Dr Godley said.

“Further, the investigation report identifies that where there is not a need for an immediate response, that flight crews look at the full contextural and available information before deciding on a plan of action.”

Since the incident, AirAsia X restated the operational requirements for flight crews for engine restarts and diversion decision making. Further, the airline has also used the occurrence as the basis for a training package for responding to engine failures, restarting failed engines, and diversion decision making.

Read the final report: Engine failure involving Airbus A330, 9M-XXD, 445 km south-east of Alice Springs, South Australia, on 16 August 2016

The ATSB and the Australian Air Force Cadets’ ‘Pathways to an Aerospace Future’ program in 2020.

The Australian Transport Safety Bureau (ATSB) has signed an agreement of intent to support the Australian Air Force Cadets’ (AAFC) ‘Pathways to an Aerospace Future’ program in 2020.

The AAFC Pathways program, overseen by the AAFC Foundation on behalf of the AAFC, seeks to provide opportunities and experiences for cadets with a desire for a career or connection within the civil and military aerospace industries to help that become a reality.

Signing the agreement with AAFC Foundation Chair, Air Vice-Marshal (AVM) Kym Osley AM, CSC, following the Canberra based AAFC units’ annual parade at the Burgmann Anglican School Forde Campus on 30 November, ATSB Chief Commissioner Greg Hood said the Bureau intends to provide opportunities and access that supports four of the program’s six pillars.

“There are around 8,000 young people in the AAFC nationally because they have a keen interest in aerospace,” Chief Commissioner Hood said. “Many of them aspire to a career in the industry, and the ATSB is delighted to support the program and offer cadets opportunities focusing on leadership and personal development; technology and innovation; pathways to an aerospace career; and aerospace experiences.”

During a number of planned visits to the ATSB’s offices next year, cadets will learn about the role of the ATSB and how the agency works to improve safety for the travelling public, and will be given an overview of career opportunities at the ATSB and the entry requirements.

Both Greg Hood and AVM Osley are former Air Training Corps cadets (the predecessor organisation to the AAFC), and several ATSB staff and family members are also either current or former members of the AAFC.

Multiple brake applications failed to slow the train to avoid a collision with a rake of wagons.

Multiple brake applications by the driver of an empty bauxite train failed to slow the train to avoid a collision with a rake of wagons, an ATSB preliminary* report says.

On 22 September 2019, the empty bauxite train was travelling the 19.5 km track between Lorim Point and Andoom, near Weipa in Queensland. At the 17.5 km mark, the driver made a service brake application to the slow the train for the 25 km/h turnout as it neared Andoom, but the brake application did not slow the train. The driver then released the brake, applied the locomotive’s dynamic brake, and applied a service brake application for the second time.

Realising the train was not slowing, the driver made an emergency brake application, which was not effective. At 59 km/h, the driver applied the locomotive independent brake on the train. The independent brake only applies to the locomotive, but it did result in a slight decrease in the train’s speed.

The driver was aware that a train collision was imminent but was unable to prevent it.

The train passed through the turnout at 54 km/h. At the same time, a rake of wagons was being loaded at the automated loading point at Andoom, 635 m away. The driver was aware that a train collision was imminent but was unable to prevent it.

The train collided with the partially-loaded rake of wagons at 37 km/h. The locomotive of the moving train, and four empty wagons at the rear of the partially-loaded rake, derailed on impact.

The collision resulted in the modular driver operating cab separating from the main structure of the locomotive, coming to rest on the ground. The cab sustained substantial damage. The driver was initially trapped inside the cab but sustained only minor injuries.

The ATSB’s ongoing investigation will focus on the the crashworthiness of the modular operating cab design, factors associated with the function and use of the train brakes, and further analysis of the train’s event recorder and the operator’s policies, procedures and guidelines.

Read the preliminary report: Collision with rake of wagons and derailment of ore train R1006, Andoom (near Weipa), Queensland, on 22 September 2019

*Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report.

Pilots without a current instrument rating should be prepared to amend plans, and not to push on.

Following the release of two preliminary investigation reports into multiple fatality accidents where the aircraft involved were operating under visual flight rules (VFR), the Australian Transport Safety Bureau (ATSB) is again highlighting to pilots the actions they can take to avoid a weather or low-visibility related accident.

Today, the ATSB has released the preliminary* reports for the collision with water of Bell UH-1H ‘Huey’ helicopter VH-UVC, and the collision with terrain of Mooney M20J VH-DJU.

Five people were killed in the accident involving VH-UVC, which impacted the ocean after last light at a time of reported severe weather near Anna Bay, NSW, on 6 September 2019. Then on 20 September 2019, a father and son died when VH-DJU collided with heavily-wooded terrain in the Dorrigo National Park near Coffs Harbour, NSW, in forecast weather conditions of low broken cloud.

Both accidents are unrelated, but in both instances the flights were operating under visual flight rules, and neither pilot had qualifications to operate in instrument meteorological conditions (IMC) or at night, the preliminary reports establish. Further, both investigations will continue to look at the weather and environmental conditions at the time of the accidents, among a number of other factors.

“It is important to stress that both investigations are still in their early stages, and the ATSB will not publish its findings until the final investigation reports are released,” said ATSB Executive Director Transport Safety Nat Nagy.

“But the ATSB notes that weather and environmental conditions are a focus for both investigations, and weather-related general aviation accidents remain one of the ATSB’s most significant causes for concern in aviation safety.

Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather conditions, and not to push on.

“Weather and low visibility-related accidents often have fatal outcomes, which is all the more tragic because they are almost always avoidable.”

To remind VFR pilots of the dangers of flying into IMC, and to highlight the actions they can take to avoid a weather-related accident, the ATSB is currently running a safety promotion campaign titled ‘Don’t push it, DON'T GO – Know your limits before flight’.

“‘Don’t push it, DON'T GO’ highlights three key messages: the importance of thorough pre-flight planning and having alternate plans, that pressing on where there is the possibility of entering IMC carries a significant risk of spatial disorientation, and the value of using a ‘personal minimums’ checklist to help manage flight risks,” Mr Nagy said.

“Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather and environmental conditions, and not to push on,” he said.

“Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather.

“Finally, setting expectations for your passengers beforehand can take the pressure off continuing with the flight if the conditions exceed your personal minimums.”

Source: ATSB

A total of 101 occurrences of VFR pilots inadvertently flying into IMC in Australian airspace were reported to the ATSB in the decade from 1 July 2009 to 30 June 2019. Of those occurrences, nine were accidents resulting in 21 deaths.

Findings from ATSB previous investigations into aircraft accidents where a VFR pilot flew into IMC makes for sobering reading. A selection of those findings are published in the ATSB’s recently updated Accidents involving pilots in Instrument Meteorological Conditions publication.

“The ATSB encourages VFR pilots to learn from the experiences of others, to help build a robust understanding of the risks of flying into IMC and just how rapidly such accidents can happen,” Mr Nagy said.

‘Don’t push it, DON'T GO’ follows on from a similar campaign the ATSB launched in 2018, titled ‘Don’t push it, LAND IT’, which was directed at helicopter pilots.

‘Don’t push it, LAND IT’ encouraged pilots to use their helicopter’s unique ability to make precautionary landings almost anywhere if faced with flying into IMC, fading day light or if something concerns them with their aircraft.

 “Know your limits before flight,” Mr Nagy said. “If you’re faced with deteriorating weather or if something just doesn’t feel right, don’t push it, make a precautionary landing. If you do decide to push on, it could be the beginning of an accident sequence.”

*Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report.

Read the preliminary report: Loss of control and collision with water involving Bell UH-1H, VH-UVC, 5 km south-west of Anna Bay, New South Wales, on 6 September 2019

Read the preliminary report; Controlled flight into terrain involving Mooney M20J, VH-DJU, 26 km west of Coffs Harbour Airport, New South Wales, on 20 September 2019

ATSB policy provides for identifying most organisations in its transport safety investigations. Most organisations directly involved in any aviation occurrence investigated by the ATSB are identified in the report and on the investigation web page.

The policy ensures the ATSB’s compliance with the International Civil Aviation Organization’s recommended practices. It also ensures that the ATSB has a consistent and transparent approach across all of its aviation, rail and marine safety investigations.

Operators and other organisations can be assured that it is not a function of the ATSB to apportion blame or determine liability. Including the name of the organisation does not imply any adverse inferences.

Which organisations are identified

For aviation, all operators and regulators are identified.

For marine, all ship owners, ship management companies and the regulator are identified.

For rail, rail transport operators (rail infrastructure managers and/or rolling stock operators) and regulators are identified.

Other large organisations that contributed substantively to the occurrence will also be mentioned. The exception to the above policy will be where the operator is an individual or an individual’s name is the company name. Consistent with the Transport Safety Investigation Act 2003, the ATSB does not name individuals in its final reports.

Are there any exceptions?

If an operator or organisation had a passive or third-party involvement in an occurrence, the ATSB will not name that operator in the investigation report or published information.

Operators and other organisations will not be named in investigation report titles.

This policy applies to safety occurrences investigated by the ATSB from 1 July 2017. Any incident or accident that occurred before 1 July 2017 was treated under the previous policy.

How will an organisation know if they’re named?

The ATSB provides advance copies of its investigation reports to all organisations involved in a transport safety occurrence. This ensures organisations are aware of, and have the opportunity to provide feedback on, the report’s contents before it is made public.

ATSB commends Jandakot air traffic controller for assisting student pilot 

The ATSB has commended the air traffic controller who was successfully able to guide a student pilot to a safe landing after the student’s instructor became incapacitated due to a medical episode.

ATSB Chief Commissioner Greg Hood presented the controller from Perth’s Jandakot Airport Tower with a Certificate of Commendation during a presentation at the Safeskies conference in Canberra on Thursday to acknowledge the controller’s calm professionalism in guiding the student to a safe landing.

“The controller worked with Airservices Australia’s highly capable team in Jandakot Tower to effectively manage the emergency situation," Chief Commissioner said.

“He calmly and competently provided instructions and advice to ensure the student pilot was able to make a safe landing at Jandakot. The controller, along with his colleagues in the tower, are commended for their professionalism and commitment to aviation safety.”

The student and instructor had departed Jandakot at about 5pm local time on 31 August 2019 for a training flight in the local training area, the ATSB’s Occurrence Brief report on the incident details. The student had a total of 2.4 hours flying experience but did not have experience flying the Cessna 152. It was the student pilot’s third flying lesson as his wife and three children watched from the ground.

While returning to the airport, the instructor experienced a medical episode due to an unknown and previously undiagnosed condition, and subsequently lost consciousness. The student took over control of the aircraft and contacted Jandakot Tower.

Under the guidance of the controller, the student was instructed to conduct a number of flyovers of the runway to gain situational awareness. The controller arranged for an instructor to assist the student from the tower, while ensuring all other aircraft remained clear of the airport while the student was able to practice approaches.

Once the student felt confident, the controller remained in contact to assist the student with landing the aircraft. Upon landing, emergency services vehicles attended the aircraft to assess the instructor.

“At all times, communication between ATC and the student was concise, informative and positive,” Chief Commissioner Hood said.

“During the time the flying instructor was incapacitated, both ATC and the student pilot communicated clearly, calmly and proactively, resulting in a safe landing.”

Commissioner Hood said the incident clearly highlights just how important effective communication is to aviation safety.

View an ABC News clip on YouTube featuring the radio transmissions between the Jandakot air traffic controller and student the student pilot here.(Opens in a new tab/window)

The ATSB has released its Annual Report, outlining its performance during 2018-19.

The Australian Transport Safety Bureau (ATSB) has released its Annual Report, outlining its performance during 2018-19.

ATSB Chief Commissioner Greg Hood said the Bureau continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports, which contained valuable safety learnings for the aviation, rail and marine transport modes.

“There was much attention on the agency in September 2018 with the publication of the final report from our investigation into a King Air aircraft’s collision with a building in a retail precinct at Melbourne’s Essendon Airport in 2017,” Chief Commissioner Hood said.

“The investigation drew upon the ATSB’s world-leading human factors capabilities, which resulted in safety messaging around the use of checklists as an essential tool for overcoming limitations with pilot memory and ensuring action items are completed in sequence without omission. This messaging highlights the ATSB’s approach to safety investigation, which is to ensure that all relevant lessons can be learnt to help stop accidents in the future.”

The ATSB’s significant contribution to safety internationally during the year was highlighted by the release of the final report from the investigation into a serious incident involving an ATR 72 turboprop airliner, which experienced an inadvertent pitch disconnect following an in-flight upset.

“The investigation into this complex event identified a number of safety factors, including some in relation to the continuing airworthiness of the aircraft, and aircraft certification standards,” Chief Commissioner Hood said.

“As a consequence, the ATSB issued Safety Recommendations to the European Aviation Safety Agency to review the current design standards in consideration of the effect that dual pilot control inputs may have on the safe operation of an aircraft.”

Another key highlight outlined in the annual report is the ATSB’s entering into a strategic partnership with RMIT University, which is a central element of the ATSB’s vision to create a centre of excellence for accident investigation and transport safety in the Asia-Pacific region.

"If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then they will have confidence in the safety of the transport system"

“If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then they will have confidence in the safety of the transport system,” Chief Commissioner Hood said.

“A significant achievement to realising this objective is the partnership between the ATSB and RMIT University. The ATSB is focused on ensuring its own people have the highest investigative capabilities and in educating others to achieve the same.”

Also during the year the ATSB’s operational efficiency was audited by the Australian National Audit Office (ANAO), which found the Bureau has established key elements of an overall framework to promote efficient investigation processes.

“The ANAO found that our efficiency had been declining, but that we have been focussing our attention improving investigation timeframes and moving to benchmark our performance against transport investigation entities in other countries” Chief Commissioner Hood said.

“The ANAO acknowledged a number of actions had already been taken by the ATSB to make improvements, including formalising aspects of our program-managed approach to investigations.”

The ATSB was notified of 17,454 incident and accident notifications across the aviation, rail and marine transport modes in 2018-19, and completed 44 complex investigations during the period.

Chief Commissioner Hood said the ATSB is well-positioned to continue making its important contribution to improving transport safety.

“The ATSB has been through significant organisational change over the last few years, all directed towards enhancing our productivity and building on our shared vision of being a world-leading transport safety investigation agency,” Chief Commissioner Hood said.

“The ATSB’s staff are dedicated, hard-working experts in their field, and their contribution to safety is highly valued and internationally recognised. I intend to ensure they are empowered and enabled to continue to make this contribution well into the future.”

Read the ATSB’s Annual Report 2018-19

ATSB calls for upper torso restraints for all light aircraft

(Source: ATSB)

The Australian Transport Safety Bureau (ATSB) is recommending that all light aircraft be fitted with upper torso restraints after a fatal passenger charter flight accident raised accident survivability questions.

During the January 2017 accident, one passenger was fatally injured, and two other passengers and the pilot were seriously injured when a Cessna 172 operating a passenger charter flight impacted a Queensland beach after its engine experienced a total power loss at low altitude (read more).

“The aircraft was not fitted with upper torso restraints for the rear passenger seats, which very likely increased the severity of the injuries sustained by the two rear-seat passengers,” ATSB Chief Commissioner Greg Hood stated.

An upper torso restraint (UTR) is a shoulder strap or harness, and when fitted in addition to a lap belt makes an aircraft’s passenger restraint similar to a normal seat belt in a car. UTRs are not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including those used for passenger transport operations.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints for all seats in small aeroplanes and helicopters.

Although options for retrofitting UTRs are available for a number of models of light aircraft, many of these aircraft manufactured before the applicable dates being used for passenger transport have not yet been retrofitted.

“As a consequence, the ATSB recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints for all seats in small aeroplanes and helicopters,” Mr Hood said.

“The recommendation is particularly aimed at those aircraft being used for air transport operations, and where the aircraft manufacturer has issued a mandatory service bulletin to fit UTRs for all seats, or such restraints are readily available and relatively easy to install.”

The ATSB is also issuing a Safety Advisory Notice to all operators of small aircraft and helicopters.

“The ATSB strongly encourages operators and owners of small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992 to fit upper torso restraints to all seats in their aircraft, if they are not already fitted,” Mr Hood said

The investigation also highlights that there was no requirement for operators of passenger transport flights in aircraft with six or fewer seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.

Further, the investigation also established that the operator did not routinely carry life jackets on its two Cessna 172 aircraft, despite Civil Aviation Order (CAO) 20.11 stating that life jackets are required for all charter flights when ‘in the event of a mishap occurring during the departure or the arrival it is reasonably possible that the aircraft would be forced to land onto water’.

“Accordingly, life jackets were required for the accident flight,” Mr Hood noted.

The report also found that the Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Read the final report: Collision with terrain following an engine power loss involving Cessna 172M, VH‑WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland, on 10 January 2017

Read the ATSB's safety advisory notice: Upper torso restraints can reduce injuries and save lives. Are they fitted to all seats in your aircraft?

New ATSB publication outlines proceedures following an on-airport aircraft accident

A new ATSB publication details the requirements of the national transport safety investigation agency following an on-airport aircraft accident or incident.

Launched today at Canberra International Airport’s celebrations to mark the start of Airport Safety Week, the Information and guidance for aerodrome operators publication outlines airport and aerodrome operators’ incident and accident reporting requirements to the ATSB, what to expect once an occurrence has been reported, and how to help preserve evidence for an ATSB investigation.

Emergency services and airport personnel have a critical role in responding to aircraft accidents and incidents, however this Airport Safety Week the ATSB is reminding them the importance of wreckage and ground scars being as little disturbed as possible.

“Airport operators having a thorough understanding of the role of the ATSB and the investigation process in the event of an aviation accident will help minimise disruption to airport operations,” ATSB Chief Commissioner Greg Hood said.

“This Airport Safety Week we are reminding airport operators of three key responsibilities in the event of an aviation accident: respond, report and preserve. Respond with their aerodrome emergency plan, report the accident to the ATSB, and along with emergency services preserve the accident site.”

Over the 10 years from 1 October 2009 to 1 October 2019, the ATSB’s National Aviation Occurrence Database shows approximately 25,500 incidents, serious incidents, and accidents have occurred within a one kilometre radius of Australia’s 31 towered civil and military airports. Of these, the ATSB has or is currently investigating 262 serious incidents and accidents.

Evidence preservation and collection is the first phase of any of our investigations,” Chief Commissioner Hood said.

“Critical evidence such as witness marks or small debris can be located some distance from the main accident site and spread over a very large area" 

"So it is imperative that all first responding agencies and airport operators proactively preserve all evidence at an accident site until our investigators arrive. This will greatly assist our investigators in their task of determining the factors that contributed to the occurrence.”

ATSB Transport Safety Investigators are based across the country and are on call 24 hours a day to deploy to an accident site as soon as practical, but the ATSB is not a first responder agency and it may take several hours before investigators arrive on scene.

“As we deploy, the ATSB will provide advice to first responders and airport operators to secure the accident site until we arrive,” Chief Commissioner Hood said.

“The ATSB is mindful of the effects an investigation can have on airport operations, however our priority will always be on conducting of a thorough and meticulous investigation to ensure that any safety issues are identified and addressed.

“Having a thorough understanding of our roles and requirements will greatly assist the ATSB accident investigation process, and help us to prevent similar accidents and incidents in the future.”

The Information and guidelines for aerodrome operators can be downloaded from the ATSB’s website, or printed copies can be ordered by emailing atsbinfo@atsb.gov.au

Prepare to land straight ahead following a low-level power loss

(Source: ATSB)

Pilots should plan to land straight ahead when conducting an emergency landing following an engine failure or power loss at low height, a new ATSB Investigaton reinforces.  

One passenger was fatally injured, and two other passengers and the pilot were seriously injured when a Cessna 172 operating a passenger charter flight suffered a total power loss at a height of about 60 feet while assessing a beach landing area to ensure it was suitable for a planned landing.

After conducting initial engine checks, the pilot had elected to conduct a “significant” left turn to the beach, the investigation into the 10 January 2017 accident at Middle Island, Queensland, established. During the continued turn, the aircraft impacted the beach with little or no control and at a significant descent rate.

Despite a detailed inspection of the engine and related systems, the ATSB was unable to identify the reason for the loss of engine power. Nevertheless, the ATSB found that the operator’s procedures and practices for conducting airborne inspections of the Middle Island aeroplane landing area (ALA) did not effectively manage the risk of an engine failure or power loss when at a low height.

The operator’s inspections were generally flown at 50-100 feet above sea level while flying at normal cruise speed towards an area of water at the end of the beach, with no planned consideration of what to do in the event of an emergency.

Regardless of the reasons why it occurred, an engine failure or power loss should not necessarily lead to very serious consequences, even in a single-engine aircraft.

“This tragic accident reinforces standard pilot training and guidance that, following an engine power loss at a low height, an emergency landing should, in most cases, be planned straight ahead with only small changes in direction to avoid obstructions,” ATSB Chief Commissioner Greg Hood said. 

“Operators and pilots should review their flight procedures to ensure that straight-ahead emergency landings are possible when their aircraft are at a low height. If such landings are not possible, then the suitability of the flight should be evaluated.”

Mr Hood also stressed that operators and pilots that conduct airborne inspections of landing areas should also ensure that the risk of an engine failure or power loss is considered when planning and conducting such inspections at a low height, particularly when below 500 feet.

“Regardless of the reasons why it occurred, an engine power loss should not necessarily lead to catastrophic consequences, even in a single-engine aircraft.”

All options facing the pilot after the power loss were likely to result in at least some level of damage and/or injury, the investigation noted. However, the option likely to result in the least damage or injury was to land the aircraft ahead on the remainder of the beach heading north.

The investigation also found a number of other issues with the operator’s activities, although these were not found to be contributing factors to this accident.

These included under-recording of aircraft flight hours, the aircraft being overweight for the accident flight with baggage and supplies not effectively secured, issues with the operator’s calculations of weight and balance, and the conduct of near-aerobatic manoeuvres during passenger charter flights with limited controls in place to manage the risk of such manoeuvres.

“Broadly speaking, the operator had no effective assurance mechanisms in place to regularly and independently review the suitability of its activities,” Mr Hood said.

The accident also identified a number of issues regarding occupant survivability, including the lack of upper torso restraints (seatbelts) for rear seat passengers, not briefing passengers on the brace position and the non-carriage of life jackets. It also found further scope for the Civil Aviation Safety Authority (CASA) to improve its surveillance activities of small operators.

Read more: ATSB calls for upper torso restraints for all light aircraft  

Read the final report: Collision with terrain following an engine power loss involving Cessna 172M, VH‑WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland, on 10 January 2017