Investigation summary

What happened

At 1851 local time on 24 July 2025, the crew of an Alliance Airlines Embraer ERJ 190, registered VH‑A2T, departed Cairns, Queensland, for a passenger transport flight to Brisbane. For the departure, the crew took off from runway 15 with a clearance to follow the AKROM 1 standard instrument departure (SID). 

As the aircraft became airborne in darkness, the captain, acting as pilot monitoring, announced ‘pitch rate’ to alert the first officer, who was pilot flying, that the aircraft’s rotation had slowed. Both crewmembers then focused on the aircraft flight path, and the retraction of the landing gear was inadvertently omitted.

As the aircraft continued climbing and turning left to follow the SID, the flight crew received 2 radio altimeter annunciations and observed the flight director unexpectedly command a right turn. After completing the left turn to follow the SID, the first officer engaged the autopilot, and the aircraft started a right turn toward terrain. The captain identified the turn and instructed the first officer to turn left back to the required track.

As the aircraft then continued along the SID, the captain recognised that the landing gear was still extended and quickly retracted it. The landing gear completed retracting when the aircraft had reached a speed of 252 kt, 17 kt above the maximum landing gear retraction speed.

The flight continued and the aircraft landed at Brisbane without further incident at 2044. Following the flight, the aircraft was inspected and found to be undamaged.

What the ATSB found

The ATSB found that the 'pitch rate' announcement was made at a time when a ‘positive rate’ announcement would normally be expected. This resulted in both flight crewmembers focusing on the pitch angle and the first officer was not prompted to call for landing gear retraction.

As the aircraft turned left to follow the SID, the crew were presented with radio altimeter alerts and unexpected flight director indications. These distractions increased the flight crew's workload and delayed their identification of the extended landing gear. Upon recognising the still extended landing gear, the captain reflexively retracted it without first checking the aircraft speed.

What has been done as a result

Alliance Airlines accelerated its program to upgrade E190 aircraft from load 25 avionics to load 27 and at the time of the release of this report, all E190s in the Alliance Airlines fleet have been upgraded. This should prevent recurrence of the unexpected flight management system indications presented to the crew during this incident.

In addition, the load 27 avionics upgrade incorporated electronic checklists that require associated actions to be undertaken before the electronic checklist is completed. 

Safety message

This incident highlights the impact a combination of omitted actions and distractions can have on aircraft operations, during what is often a high workload period. Such situations can create challenges in responding to the unexpected with potential for a reduction in safety when pilots act rapidly and reflexively. In these situations, pilots may not be able to effectively process information or consider all relevant factors, which reduces the ability to make good decisions. 

Crews of Embraer ERJ 190 aircraft equipped with load 25 avionics should also be aware that, on occasion, these systems may provide unexpected indications. This has been observed on multiple occasions on the Cairns AKROM 1 SID. When faced with unexpected indications, crews should use primary instruments to ensure that flight path requirements are adhered to.

The investigation

The occurrence

On the evening of 24 July 2025, the crew of an Alliance Airlines Embraer ERJ 190, registered VH‑A2T, prepared to operate a passenger transport flight from Cairns to Brisbane, Queensland. For the flight, the captain acted as pilot monitoring (PM), and the first officer as pilot flying (PF).[1] For the departure, the crew were provided with clearance to follow the AKROM 1 standard instrument departure (SID) (see the section titled Cairns runway 15 AKROM 1 standard instrument departure). While preparing for the flight, the captain advised the first officer that on previous flights, the first officer’s rotation[2] rate was slower than required and, as adherence to the SID climb requirements was essential for terrain avoidance, the rotation rate would be a point of focus for the departure.

In darkness at 1851 local time, the aircraft commenced a take-off from runway 15 with the lateral navigation flight guidance mode selected. After passing the rotation speed of 143 kt, the first officer commenced the rotation to the target pitch attitude of about 15° nose up. The aircraft became airborne, and the captain assessed that as the aircraft passed 10° pitch angle, the rotation rate slowed. To alert the first officer, the captain announced, ‘pitch rate’.

This announcement came at about the same time that the PM would normally announce ‘positive rate’ after checking that a positive rate of climb was indicated on the aircraft instrumentation. This ‘positive rate’ announcement would then trigger the PF to request the retraction of landing gear. On this occasion, the lateral navigation mode activated and, after the captain announced ‘pitch rate’, both crewmembers then focused on the aircraft flight path and the retraction of the landing gear was inadvertently omitted.

The aircraft continued climbing and turning left to follow the SID. As the aircraft climbed through about 840 ft above mean sea level (AMSL), the primary flight displays presented 2 radio altimeter alerts in quick succession and the engine indicating and crew alerting system (EICAS) presented ‘RADALT MISCOMPARE’ and ‘APPR 2 NOT AVAIL’ messages (see the section titled Radio altimeter). The crew noted these indications and determined that they were not relevant to that phase of flight and therefore took no action.

As the first officer manually turned the aircraft left to follow the SID, the aircraft followed a turn radius smaller than the flight management system’s (FMS) precalculated turn (see the section titled Flight instrumentation) and turned onto the SID 030° track[3] to the left of the FMS calculated track position (Figure 1). As the turn continued, the FMS targeted the wider track and the crew observed the flight director indications on the primary flight display unexpectedly command a right turn. The first officer briefly followed the right turn command by reducing the angle of bank from 24° left to 10° left before then increasing the angle back to 20° left to complete the turn.

Once the first officer established the aircraft on a 030° track, the autopilot was engaged while the flight director continued to indicate a right turn. The autopilot then started a right turn to intercept the FMS calculated 030° track position. At about the same time, air traffic control instructed the crew to change radio frequency. As the aircraft commenced the right turn, the captain identified the turn away from the SID track toward the high terrain and instructed the first officer to turn left to follow the 030° track. The first officer then engaged the autopilot heading mode and selected 030° and the aircraft turned left to a heading of 030° and continued climbing.

Figure 1: Departure flight path (initial)

Source: Recorded data from VH-A2T and Google Earth, annotated by the ATSB 

The aircraft then continued along the SID and after climbing above 4,000 ft AMSL, turned right toward the waypoint AKROM. As the aircraft continued climbing toward AKROM, the captain, whose headset was not noise-cancelling, noted that the ambient noise was louder than expected and recognised that the landing gear was still extended. At about the same time, the first officer noted the landing gear extended indication on the EICAS. In response, while the aircraft was accelerating through 243 kt – 8 kt above the maximum landing gear retraction speed of 235 kt – the captain retracted the landing gear without first checking the indicated airspeed. The landing gear completed retracting when the aircraft had reached a speed of 252 kt, 17 kt above the maximum retraction speed (Figure 2).

Figure 2: Departure flight path

Source: Recorded data from VH-A2T and Google Earth, annotated by the ATSB

The flight continued and, at 2044, the aircraft landed at Brisbane without further incident. Following the flight, the aircraft was inspected and found to be undamaged.

Context

Flight crew details

The captain held an Air Transport Pilot Licence (Aeroplane) and a class 1 aviation medical certificate. The captain had 15,192 hours of flying experience, of which 1,680 hours were on the Embraer 190 aircraft type, with 137 hours accrued in the previous 90 days. 

The first officer held an Air Transport Pilot Licence (Aeroplane) and a class 1 aviation medical certificate. The first officer had 6,131 hours of flying experience, of which about 1,353 hours were on the Embraer 190 aircraft type, with 213 hours accrued in the previous 90 days.

The ATSB found no indicators that the flight crew were experiencing a level of fatigue known to adversely affect performance.

Operational information

Cairns Airport runway 15 AKROM 1 standard instrument departure 

High terrain partly encircles Cairns Airport from the north-west through south-west and to the south-east. To avoid the high terrain, the AKROM 1 standard instrument departure (SID) required aircraft departing runway 15 to make a left turn at the earlier of either reaching 400 ft AMSL or passing the departure end of the runway (DER) (Figure 3). During the turn, flight crew needed to maintain a bank angle of at least 25° and a speed of no more than 190 kt until the aircraft was established on a track of 030°. The location of the 030° track was dependent upon both the position that the left turn was commenced and the radius of the turn. The departure required maintenance of the 030° track until intercepting the 080° radial of the Cairns very high frequency omni range navigation aid (VOR) and then followed that track until the aircraft climbed above 4,000 ft AMSL. The departure then turned to the waypoint AKROM.

Figure 3: Runway 15 AKROM 1 standard instrument departure

Source: Airservices Australia, annotated by the ATSB 

Take-off standard operating procedures

The operator’s standard operating procedures manual (SOPM) required the pilot monitoring (PM) to verify a positive rate of climb immediately after take-off and then announce ‘positive rate’. After that announcement, the pilot flying (PF) confirmed the positive rate of climb and called for the landing gear to be retracted, and the PM then selected the landing gear ‘up’. 

The SOPM also specified a normal rotation rate of 3° of pitch angle per second.

Aircraft information

The aircraft was an Embraer ERJ 190‑100 IGW, manufactured in Brazil in 2008 and issued serial number 19000179. It was registered in Australia as VH-A2T on 19 July 2024. The aircraft was fitted with 2 General Electric Company CF34-10E5 turbofan engines. 

The maximum indicated airspeed at which the landing gear could be retracted or extended was 235 kt and the maximum airspeed with the landing gear in the extended position was 265 kt.

Flight instrumentation

The ERJ 190 was equipped with an integrated avionics system. VH-A2T was equipped with a ‘load 25’ version of the avionics. At the time of the incident, Alliance Airlines operated ERJ 190 aircraft equipped with both ‘load 25’ and upgraded ‘load 27’ avionics.

The flight management system (FMS) in ‘load 25’ equipped aircraft was designed to dynamically calculate the location of down path tracks, but only when these paths were inactive. Once the path became active, their location was fixed. The system should have predicted the 030° track leg of the AKROM 1 SID relative to where the system sequenced the 400 ft altitude crossing or departure end of the runway point. The avionics manufacturer, Honeywell, advised that in this case, the FMS sequenced the termination of the 400 ft altitude leg early and appeared to fix the location of the 030° track leg before it could be updated based on the position of the commencement of the left turn. 

Subsequently, and as intended by design, the FMS did not recalculate the location of the 030° track during the turn. As a result, when the crew turned to the 030° track to the left of the FMS precalculated track, the FMS, still targeting the wider track, commanded a right turn to intercept that track (Figure 4).

Figure 4: Representation of primary flight and navigation displays during the left turn

Note: The figure is based on an animation of the incident. The flight director representation is different to actual aircraft, and indications are included that are not presented in the actual aircraft. Negative roll values indicated a left turn, positive a right turn. Source: Embraer, annotated by the ATSB 

Recorded automatic dependent surveillance broadcast (ADS-B) data from previous AKROM 1 departures flown by VH-A2T identified 2 additional flights where the FMS had precalculated the 030° track at a wider location. On those occasions, the ADS-B data indicated that the flight crews followed the flight director commands and intercepted the wider track (Figure 5).

Figure 5: Departures of VH-A2T equipped with ‘load 25’ avionics

Source: Recorded data from VH-A2T and Google Earth, annotated by the ATSB

For ‘load 27’ equipped aircraft, the flight path was continuously updated as FMS track legs were flown and while in transition between them. This resulted in more accurate tracking of departure paths (Figure 6). 

Figure 6: Departure paths of an E190 equipped with ‘load 27’ avionics

Source: Recorded data from VH-UYY and Google Earth, annotated by the ATSB

Radio altimeter

The Embraer ERJ 190 was fitted with 2 radio altimeters. These provided each crewmember with an indication of the height of the aircraft above underlying terrain measured using radio waves. When a difference in the height measured by the 2 radio altimeters exceeded a dynamic threshold, an ‘RA’ alert was presented on the primary flight display (Figure 7) and the RADALT MISCOMPARE alert was presented on the EICAS. Whenever this condition was detected, the associated EICAS message APPR 2 NOT AVAIL was also displayed.

Figure 7: Radio altimeter alert

Note: The figure is based on an animation of the incident and indications (such as the radio altimeter readings) are included that are not presented in the actual aircraft. Source: Embraer, annotated by the ATSB 

United States Federal Aviation Administration Advisory Circular AC 25-7D Flight Test Guide for Certification of Transport Category Airplanes stated the following guidance and measurement conditions for radio altimeter certification:

32.1.5.5 Radio Altimeter System. 

32.1.5.5.1 The radio altimeter system should display to the flightcrew, clearly and positively, the altitude information that indicates the airplane main landing gear wheel height above terrain.

32.1.5.5.2 Verify that the altimeters display altitude without loss of signal indications or excessive fluctuations, under the following measurement conditions: 

• Pitch angle ±5° about the mean approach attitude. 

• Roll angle zero to ±20°. 

On departure from Cairns, the alerts were generated while the aircraft was operating over relatively flat terrain and when the aircraft’s pitch angle was about 14° nose up and the roll angle about 23° left. While the investigation did not determine the reason for the different radio altimeter readings that led to the radio altimeter alerts, the aircraft’s pitch and roll values at the time exceeded the guidance and measurement conditions specified in the FAA circular.

Light and meteorology

The departure was conducted in night visual meteorological conditions. The sun had set at 1802, 49 minutes before the departure, and the moon was below the horizon.

At the time of the departure, the Bureau of Meteorology automatic weather station at Cairns Airport recorded the temperature as 23°C and the wind as 9 kt from 161° magnetic. There was no recorded cloud, and visibility was recorded as 58 km.

Recorded data

Analysis of flight data from the flight data recorder fitted to VH‑A2T showed that the rotation rate during the take‑off was 1.49 degrees per second until the aircraft was pitched 9.7° nose up and then 1.73 degrees per second until 14.9° nose up. The pitch attitude stabilised at about 16° nose up during the turn.

As the aircraft turned left through a heading of 080°, the flight director began commanding a right turn (Figure 8). At 1853:08, the autopilot was engaged in the lateral navigation mode and while the flight director continued to command a right turn. The aircraft then rolled right, following that command. At 1853:20, while flying a heading of 058° the autopilot mode changed from lateral navigation mode to heading mode with 030° selected. The aircraft then began rolling left to turn to that heading.

At 1856:35, the landing gear was selected up at a speed of 243 kt. The landing gear completed the retraction sequence at 1856:47 as the aircraft accelerated to 252 kt.

Cockpit voice recorder data capturing the incident was not available as it had been overwritten.

Figure 8: Recorded flight data

Source: ATSB 

Safety analysis

Non-retraction of landing gear

During the take-off, the first officer rotated the aircraft slower than required, prompting the captain to call for an increase in pitch rate. The captain’s attention then remained focused on monitoring the pitch attitude of the aircraft throughout the rotation manoeuvre to ensure the required pitch attitude targets were being achieved. Because of this, the captain likely did not have sufficient opportunity to move onto the next task, verifying the aircraft’s positive rate of climb, before it passed through 400 ft – the point at which the terrain avoidance turn was to be initiated. Consequently, the task step of verifying and announcing positive climb performance was not fully completed and the captain did not make the ‘positive rate’ announcement. 

In the absence of the captain’s announcement, the first officer was not prompted to request landing gear retraction, and the landing gear remained extended. The captain’s announcement of ‘pitch rate’ at about the same time that the acoustically and semantically similar ‘positive rate’ announcement would normally be made, potentially caused interference in working memory (Lentoor 2023) and possibly gave both flight crew a false sense that the latter action had been successfully performed.

Delayed identification and overspeed

During the initial climb, which was a high workload phase of the flight, abnormal radio altimeter alerts and unexpected flight director indications further increased the flight crew’s workload. In particular, when the autopilot was engaged, it commenced a right turn toward high terrain in response to an unexpected flight director indication. This prompted the captain’s intervention and the crew’s attention then narrowed to focus on parameters which would enable them to verify the aircraft’s lateral tracking performance. Wickens (2009, 2021) notes that attentional tunnelling occurs under conditions of elevated stress and deliberate task focus and can cause other task-relevant stimuli to be ignored.

Consequently, increasing flight deck wind noise and abnormal engine indicating and crew alerting system (EICAS) indications, both of which provided an indication of the landing gear’s extended state, were not initially detected. Furthermore, the turn and speed restrictions of the departure also likely masked the performance degradation due to the extended landing gear, further reducing the likelihood of identifying that it was still extended.

As the flight crew’s workload decreased in the latter portion of the departure, the effects of attentional tunnelling reduced, and the noise from the landing gear increased as the aircraft accelerated. The captain (whose headset was not noise-cancelling) then detected the increased cockpit wind noise and was alerted to the misconfiguration of the landing gear. At about the same time, the first officer identified the landing gear extended indication on the EICAS.

As the aircraft had travelled well beyond the normal gear retraction point and was accelerating, the captain likely perceived some urgency to act upon noticing that the landing gear was still extended and experienced associated increased stress. Under such conditions research has shown that people often do not make optimal decisions and may act more reflexively (Dismukes and others, 2007). 

Under time pressure and stress, experts may revert to a recognition primed decision mode (Klein, 2014), making rapid and intuitive interpretations of a situation and selecting actions based on their most familiar experiences.

The landing gear was normally retracted well below the retraction limiting speed, and this speed was not normally checked by the other crew member. Therefore, the captain reverted to their most familiar experience and initiated gear retraction without first confirming the action with the first officer and did not check the gear retraction limiting speed. Consequently, the landing gear retraction was initiated 8 kt above the 235 kt retraction limit speed and the retraction completed 17 kt above that speed.

Findings

From the evidence available, the following findings are made with respect to the landing gear overspeed involving Embraer E190, VH-A2T on 24 July 2025.

Contributing factors

• After take-off, the pilot monitoring made a 'pitch rate' announcement at a time when a 'positive rate' announcement would normally be expected. This resulted in both flight crewmembers focusing on the pitch angle and the pilot flying was not prompted to call for gear retraction. Subsequently the crew's attention was focused on following the departure flight path and the landing gear was not retracted.
• As the aircraft turned left to follow the standard instrument departure, abnormal radio altimeter indications were presented, and the flight management system unexpectedly commanded a right turn. When the autopilot was engaged, the aircraft briefly followed the commanded turn before the captain intervened. These distractions increased the flight crew's workload and delayed their identification of the extended landing gear.
• After recognising that the landing gear was still extended, the captain reflexively retracted the landing gear at a speed above the maximum landing gear retraction speed.

Safety actions

Safety action by Alliance Airlines

Alliance Airlines has accelerated its program to upgrade E190 aircraft from load 25 avionics to load 27 and at the time of the release of this report, all E190s in the Alliance Airlines fleet have been upgraded. This should prevent recurrence of the unexpected flight management system indications presented to the crew during this incident.

In addition, the load 27 avionics upgrade incorporated electronic checklists that require associated actions to be undertaken before the electronic checklist is completed.  

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the flight crew
• Alliance Airlines
• the aircraft and avionics manufacturers
• Bureau of Meteorology
• recorded data from VH-A2T.

References

Dismukes, R., Goldsmith, T. E., & Kochan, J. A. (2015). Effects of acute stress on aircrew performance: literature review and analysis of operational aspects. National Aeronautics and Space Administration Technical Memorandum, NASA/TM-2015-218930.

Klein, G. (2014). The recognition-primed decision (RPD) model: Looking back, looking forward. In Naturalistic decision making (pp. 285-292). Psychology Press.

Lentoor, A. G. (2023). Cognitive and neural mechanisms underlying false memories: misinformation, distortion or erroneous configuration? AIMS neuroscience, 10(3), 255.

Wickens, C. D., & Alexander, A. L. (2009). Attentional tunnelling and task management in synthetic vision displays. The international journal of aviation psychology, 19(2), 182-199. 

Wickens, C. D., & Carswell, C. M. (2021). Information processing. In Handbook of human factors and ergonomics (pp. 114-158). John Wiley & Sons.

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 flight crew
• Alliance Airlines
• the aircraft manufacturer
• the avionics manufacturer
• Civil Aviation Safety Authority
• the United States National Transportation Safety Board.

Submissions were received from:

• the flight crew
• Alliance Airlines
• the aircraft manufacturer
• 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 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 2025 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

On the morning of 16 June 2025, a Cessna 182T departed a private aircraft landing area south of Emerald, Queensland, with a pilot and a passenger on board for a private flight to Atherton, Queensland.

Prior to their departure the pilot had obtained the weather conditions for Mareeba Airport, about 22 km to the north of their intended destination of Atherton, and assessed the conditions as acceptable for visual flight. 

When the aircraft was about 95 km north of Charters Towers, the pilot assessed they would be unable to continue their direct track towards Atherton due to the cloud height over the terrain ahead. The pilot diverted west to avoid higher terrain and planned to divert to Mareeba due to its lower elevation by approaching from the west. 

About 35 minutes after the diversion, the pilot descended the aircraft to about 500 ft above ground level, following a road. As they tracked towards rising terrain, their height reduced to about 200 ft above ground level. The pilot recalled that suddenly conditions ahead became a ‘white-out’ and they commenced a left turn and reduced the aircraft’s power in an attempt to avoid flying into the cloud. 

During the turn the aircraft entered cloud and the pilot lost visual reference with the ground. Recorded data indicated the aircraft conducted a 360° left turn with several changes in altitude and coming in close proximity to terrain before the pilot could engage the autopilot to attempt to stabilise the aircraft.

The pilot then commanded a 180° left turn using the autopilot, intending to return to visual meteorological conditions. However, as the aircraft climbed, the air speed reduced and the aircraft likely stalled, leading to a rapid descent.

The pilot received a terrain warning and immediately applied recovery actions; as they eased out of the dive, the pilot momentarily became visual with terrain before the aircraft contacted tree-tops but continued to remain airborne. 

The pilot was able to maintain control and became visual again on top of the cloud layer and, with the aircraft significantly damaged, diverted to Charters Towers Airport.

What the ATSB found

The pilot’s pre-flight planning was inadequate for the intended flight. The pilot had planned the second leg of the flight at a height that would not have allowed sufficient safe margin from terrain. While they obtained the forecast weather for a location close to their destination, which identified local conditions were suitable for visual flight, the pilot did not obtain the required graphical area forecast which indicated cloud height below terrain level on the flight planned track. Had the pilot obtained the area forecast this likely would have influenced their decision to commence the flight or plan an alternate route.

After encountering low cloud, the pilot continued flight towards the destination and into rising terrain, this forced them to descend below safe terrain clearance altitudes to a height of about 200 ft above ground level, rather than divert or return.

In an attempt to turn around, the aircraft entered cloud. The pilot was not rated for instrument flight, became spatially disorientated, resulting in a near collision with terrain.

While still in instrument meteorological conditions and disorientated, the pilot initiated a climbing turn and engaged the autopilot at reduced power. This resulted in the aircraft being unable to maintain airspeed and it likely entered a stall and rapidly lost height. During the recovery, the aircraft then impacted trees however continued to fly.

The pilot used the aircraft instruments to navigate out of cloud, regain visual reference to the ground and track south. Although the pilot was aware of the potential for damage sustained to the aircraft during the impact with the tree, they continued flight in the damaged aircraft for about 1.5 hours to Charters Towers (a familiar airport with a longer runway) rather than seek the nearest suitable landing area.

Safety message

Thorough information gathering is an essential part of a pilot’s pre-flight preparation. This is especially important in a single-engine aircraft and includes studying maps and routes to establish appropriate flight heights over terrain where forced landing areas may be limited. Weather conditions often vary over large distances and this is more likely over areas of elevated terrain. Although individual locations may indicate favourable conditions, other more widespread weather conditions, unsuitable for visual flight, may exist outside of the forecast location. Use of all available resources to ensure accurate knowledge of the expected conditions will assist pilots with informed decision‑making, both before and during flight.

It should be accepted that flying under visual flight rules will not always enable you to reach your planned destination. Making an early decision to land or divert and to resist the urge to ‘press on’ may prevent flight into marginal weather conditions and ultimately disaster.

The investigation

The occurrence

On 16 June 2025, at 0634 local time, a Cessna 182T, registered VH-TSS, departed a private aircraft landing area (ALA) about 16 NM south‑south-east of Emerald, Queensland, for a private flight to Atherton, Queensland. On board the aircraft were the pilot and one passenger.

Electronic flight data showed the aircraft departed and climbed to 4,500 ft above mean sea level (AMSL) where it initially held a steady track towards Atherton (Figure 1).

Figure 1: VH-TSS flight track between 0828 and 1115

Source: Google Earth, overlaid electronic flight data, annotated by the ATSB

At 0848, the aircraft descended to 3,000 ft AMSL, about 35 NM north of Charters Towers. The pilot then assessed that cloud and reduced visibility would affect continued visual flight direct to Atherton. The pilot stated they elected to continue, however diverted around weather to Mareeba Airport which they had planned as an alternative destination due to the lower elevation. They stated that they were familiar with the area, having flown a similar route 7 or 8 times previously and reported that they assessed the weather for Mareeba several times during the flight. At 0855 the aircraft was about 50 NM north of Charters Towers at an altitude of about 2,900 ft AMSL, about 1,650 ft above ground level (AGL). 

The pilot recalled altering their heading to avoid weather and flying over higher terrain. The aircraft tracked generally in a north-west direction with numerous adjustments to the heading and altitude for about 35 minutes. 

At 0930 the aircraft was recorded at about 530 ft AGL. The pilot recalled following Kennedy Developmental Road to the north. They reported this decision was due to the low cloud ceiling and advised that, in their experience, the road usually avoided the areas of highest terrain.

At 0932, the aircraft was recorded at about 410 ft AGL and the pilot made several heading adjustments to maintain visual reference with the road due to reducing visibility under heavy cloud cover. 

At 0933 and about 90 NM south-west of Mareeba, the aircraft was recorded at about 240 ft AGL, with the pilot continuing to track following the road in a northerly direction.

About a minute later at about 200 ft AGL and 140 kt airspeed (Figure 2), the pilot recalled commencing a left turn and reduced the aircraft’s engine power to try to avoid flying into ‘white-out’ conditions ahead. However, during the turn, the pilot recalled that they entered cloud.

Figure 2: VH-TSS flight track between 0932 and 0946

Source: Google Earth, annotated by the ATSB

In the following minute, the aircraft continued a left turn and completed an orbit with several significant altitude changes, descending and climbing twice then descending again. The recorded altitude, which may not be an accurate representation of the aircraft’s actual altitude during manoeuvres, varied between 0 ft AGL on the second descent (the pilot did not report any impact occurring at this point) and 700 ft about 20 seconds later.

At 0936, having descended a third time to about 200 ft, the aircraft began to maintain a constant heading for about 20 seconds during which time it had a high rate of climb consistent with the engagement of the autopilot (see Autopilot). The aircraft climbed from about 200 ft to 700 ft AGL and reduced groundspeed to 54 kt. The pilot recalled they engaged the autopilot after entering cloud (this was likely after about 1–2 minutes after entering cloud) and then commanded a 180° left turn, in an attempt to reverse their track and navigate out of the instrument meteorological conditions (IMC) (Figure 3). During the next 10 seconds, the aircraft turned sharply left and descended rapidly. The pilot recalled the aircraft instrument panel went red and displayed a terrain warning and immediately applied right rudder and attempted to level the aircraft during the recovery, as it descended almost to ground level.

Figure 3: VH-TSS flight track between 0934 and 0938

Source: Google Earth, annotated by the ATSB

The pilot reported that they momentarily became visual and heard the aircraft impact trees. They pulled back on the control column and commenced a climb, entering IMC again. The pilot climbed to an altitude of about 1,000 ft AGL and was able to stabilise the aircraft and navigate out of IMC using the instruments. They became visual again once on top of the layer of cloud.

At 0942 the pilot descended from 1,000 ft to about 300 ft AGL. They then navigated back to Kennedy Developmental Road at a height of 200–350 ft AGL. 

The pilot reported that they were unable to see the leading edge of the wing and unaware of the extent of the damage to the aircraft after the collision, however recalled the aircraft required more right rudder application than usual and that this prevented autopilot engagement. As a precaution, the pilot chose to follow major roads so that they could land if required and navigated the aircraft back to Charters Towers due to the runway length and their familiarity with the airport. The aircraft landed safely at 1114 local time.

As a result of the impact with the tree, the aircraft sustained substantial damage to the left wing (Figure 4), with minor damage to the left wing strut and both landing gear struts. No injuries were reported by either occupant.

Figure 4: Left wing damage

Source: Pilot

Context

Pilot information

The pilot held a valid Private Pilot Licence (Aeroplane) with a single engine aircraft rating since 1992. Their last flight review was conducted on 30 June 2023 and was valid to 31 July 2025. At the time of the occurrence, the pilot had about 3,580 hours total aeronautical experience of which 3,340 hours were reported to be on the Cessna 182. The pilot also reported that they had flown 48.5 hours during the last 90 days. 

The pilot did not hold an instrument rating and was only rated to fly in visual meteorological conditions (VMC).[1] 

The pilot held a valid class 2 medical certificate that was issued on 3 November 2023 and was valid until 12 November 2025. The class 2 was issued with a restriction requiring that reading correction must be available in flight and that the pilot must not fly within 24 hours of medical therapy.

Fatigue

The pilot reported that at the time of the occurrence they felt fully alert and wide awake. They indicated that they had slept 8 hours in the last 24 hours and 17 hours in the last 48 hours prior to the occurrence.

The ATSB considered that fatigue was unlikely to have affected the pilot’s performance at the time of the occurrence.

Instrument flight

As part of the pilot’s initial flight training for their licence, they recalled conducting 2‍–‍3 hours instrument flying with no visual references. However, since that time, they reported that they had not conducted any further instrument flight since their initial training. 

Aircraft information

The Cessna 182T is a 4-seat, single engine, high-winged aircraft and is powered by a 6‑cylinder fuel-injected 235 hp (175 kW) Lycoming TIO-540-AK1A piston engine.

VH-TSS was manufactured in the United States in 2005 and was first registered in Australia to the pilot in April 2010. The aircraft was certified to be flown by day and night under visual flight rules (VFR)[2] and was only operated for private operations.

The pilot recorded the total time in service of the aircraft as 2,761.8 hours after arriving at Charters Towers. 

Cessna 182 stall speeds

The Cessna 182T pilot operating handbook (POH) indicated the following stall speeds for the aircraft.

 - flaps up, power idle 54 knots calibrated airspeed[3] (KCAS)

 - flaps full, power idle 49 KCAS

The POH indicated that 54 KCAS would show as 50 kt indicated airspeed (IAS) to the pilot with no flap selected.

The POH also stated the stall speeds at known angles of bank at the aircraft’s maximum all up weight of 1,406 kg. The POH indicated that the stall speeds increased as the aircraft’s angle of bank increased.

Garmin G1000 terrain proximity 

The aircraft instrument panel contained the Garmin G1000 display unit, which consisted of a primary flight display and multifunction display.

Colours are used to represent obstacles and aircraft altitude when the terrain proximity page is selected for display. Terrain proximity uses black, yellow, and red to represent terrain information relative to aircraft altitude. The colour of each obstacle is associated with the altitude of the aircraft (Figure 5):

• black indicates terrain more than 1,000 ft below aircraft altitude
• yellow indicates terrain between 100 ft and 1,000 ft below the aircraft altitude
• red indicates terrain is above or within 100 ft below the aircraft altitude.

Figure 5: Garmin terrain proximity caution and warning 

Source: Garmin G1000 pilot’s guide Cessna NAV III

Autopilot

VH-TSS was fitted with a KAP 140 2-axis autopilot system, which provided both lateral and vertical modes and allowed the pilot to preselect an altitude.

The KAP 140 manual stated that when the autopilot was initially engaged, it activated the basic roll mode which levelled the aircraft wings and also engaged the vertical speed hold mode. This would capture the aircraft’s current vertical speed at the time of the autopilot engagement.

The manual provided a warning on the use of vertical speed mode stating:

When operating at or near the best rate of climb airspeed, at climb power settings, and using vertical speed hold, it is easy to decelerate to an airspeed where continued decreases in airspeed will result in a reduced rate of climb. Continued operation in vertical speed mode can result in a stall.

The engagement of the heading button would arm the heading mode, which would command the aircraft to turn to and maintain the heading selected on either the horizontal situation indicator[4] (HSI) or the directional gyroscope.

Figure 6: KAP 140 autopilot control panel

Source: KAP 140 manual, annotated by the ATSB

The pilot identified a key safety message from CASA seminars on ‘VFR into IMC’ that they had attended was to use the autopilot if available in case of inadvertent entry to IMC. 

Meteorological information

The pilot had obtained the TAF[5] for Mareeba Airport, about 22 km north of Atherton Airport and elevation of 1,564 ft above mean sea level (AMSL). The TAF was issued at 0328 on 16 June and valid between 0500 and 1800 local time. The forecast indicated the wind at 150° at 10 kt, with visibility greater than 10 km and broken[6] cloud cover at 2,000 ft above airport elevation. From 1000, the wind was forecast to increase to 12 kt, with visibility greater than 10 km and scattered[7] cloud cover at about 2,500 ft.

The Bureau of Meteorology does not provide an aviation forecast or recordings for Atherton Airport. 

The pilot did not obtain a graphical area forecast (GAF) for the flight planned route (Appendix – Graphical Area Forecasts). The GAF for surface to 10,000 ft for the area in North Queensland was issued at 2013 on 15 June and was valid between 0300 and 0900 on 16 June. Cloud heights were forecast down to 1,500 ft AMSL with isolated fog reducing visibility to 500 m in areas along the pilot’s flight planned track.

A further GAF for the same area was issued at 0224 on 16 June, it was valid between 0900–1500 the same day and indicated broken cloud down to 2,000 ft AMSL and to 1,000 ft AMSL with isolated rain showers reducing visibility to 4,000 m. It also indicated broken cloud cover down to 2,500 ft, becoming scattered after 1000. The GAF covered both the flight planned track and the aircraft’s diversion track (See Appendix – Graphical Area Forecasts).

Satellite image taken at 0930 provided by the Bureau of Meteorology indicated cloud cover in the flight planned area and the area the pilot intended to use as a diversion (Figure 7).

Figure 7: Satellite image 0930 local time 

Source: Bureau of Meteorology, annotated by the ATSB

The pilot recalled that when they reached Kennedy Developmental Road, the cloud ceiling height had reduced. The pilot estimated they had more than 10 km visibility and a ‘good horizon’ with a crosswind from the east of about 15–18 kt.

After following the road north for about 3.5 minutes the pilot recalled that a ‘white-out’ appeared ahead and, shortly after, they entered instrument meteorological conditions (IMC).

Recorded data

The pilot used a flight planning application on an iPad for en route flight planning, navigation and to obtain weather information.

The software provider was an approved source of electronic aeronautical charts, however the application could not be used as a primary means of GPS‑based navigation as the iPad GPS did not meet certification for aviation use. Additionally, there were limitations to the recorded data as altitude information had a resolution of 100 ft, and filtering applied to smooth the data can affect the accuracy of small sections of data.

The aircraft height was about 560 ft AGL when the aircraft began to track north along Kennedy Developmental Road which the pilot followed for about 3.5 minutes. At 0934 the aircraft began to deviate away from the road after an increase in altitude of about 500 ft, however due to the rising terrain was about 250 ft AGL (Figure 8).

Figure 8: VH-TSS height above terrain

Source: ATSB, data provided by OzRunways and Google Earth

After tracking away from Kennedy Developmental Road, the aircraft turned to the west about 100° in 30 seconds. The turn radius then tightened conducting a 360° left orbit in 65 seconds, during this time the aircraft recorded altitude fluctuated between about 0 ft and 700 ft AGL.

The aircraft then maintained a westerly heading while commencing a climb from about 200 ft AGL with a reducing ground speed to 54 kt over a 20 second period.

The data then recorded the aircraft conducting a left turn through about 70° with a reduction in altitude to the terrain height, in about 5 seconds. The aircraft then commenced a further climb to 1,000 ft AGL before stabilising its altitude over the following 4 minutes in a southerly direction.

At 0941 the aircraft commenced about one and a half descending left turns through about 470° and descended from 1,300 ft AGL to about 300 ft AGL. The flight track then followed a dirt track before tracking east to again intercept Kennedy Developmental Road.

The flight track remained in close proximity to Kennedy Developmental Road, tracking south, passing within 0.7 NM of Greenvale ALA at 1017. The pilot continued to track at about 1,000 ft AGL and followed main roads until it landed at Charters Towers Airport at 1114. 

Operational information

Visual meteorological conditions

Visual meteorological conditions (VMC) are expressed in terms of in-flight visibility and distance from cloud (horizontal and vertical) and are prescribed in the Civil Aviation Safety Regulations (CASR) Part 91 (General Operating and Flight Rules) Manual of Standards 2020: 2.07 VMC criteria. For aircraft in class G[8] airspace (Figure 9) the following requirements apply at a height below whichever is the higher of 3,000 ft AMSL or 1,000 ft AGL:

 - a minimum of 5,000 m visibility

 - maintain flight clear of cloud

 - aircraft must be operated in sight of ground or water

Figure 9: Visual meteorological conditions criteria below 10,000 ft as illustrated in the CASA Visual Flight Rules Guide

Source: Civil Aviation Safety Authority

Minimum height rules

CASR Part 91.267 (2) stated that for flight over non-populous areas: 

The pilot in command of an aircraft for a flight contravenes this subregulation if, during the flight:

 - the aircraft is flown below 500 ft above the highest feature or obstacle within a horizontal radius of 300 m of the point on the ground or water immediately below the aircraft 

 - is not taking off or landing or conducting a missed approach

 - is not carrying passengers and conducting practice forced landings with permission from the landowner.

The Civil Aviation Act,1998 section 30 also stated: 

 (1) In any proceedings for an offence against this Act or the regulations, it is a defence if the act or omission charged is established to have been due to extreme weather conditions or other unavoidable cause.

 (2) Any defence established under subsection (1) need only be established on the balance of probabilities.

Flight planning

The pilot submitted an online flight plan at 0544 that morning to Airservices Australia via the NAIPS[9] application and received notification that the plan had been accepted.

The flight was planned to depart from a private ALA at 0630, climb to 4,500 ft AMSL and to track direct to Charters Towers, before descending and tracking direct for Atherton at 2,500 ft AMSL. Flight plan distance was about 425 NM. 

Terrain heights on a direct track between Charters Towers and Atherton indicated terrain elevation consistently over 2,500 ft AMSL with areas above 4,000 ft AMSL.

The pilot reported that they had originally planned to fly on 17 June, however after reviewing the encroaching forecast weather conditions, planned the flight a day earlier.

CASR Part 91 (General Operating and Flight Rules) Manual of Standards 2020: 7.02 Forecasts for flight planning, described that a pilot in command must before commencing flight below 10,000 ft, study:

• the authorised weather forecasts and authorised weather reports for the route being flown, departure aerodrome, planned destination, planned alternate aerodrome and any other reasonably available weather information that is relevant to the intended operation
• the authorised weather forecast must include a wind and temperature forecast as well as either, a GAF, GAMET area forecast or a flight forecast
• should the forecasts and reports be studied more than 1 hour before commencing the flight, the pilot in command must obtain, and review, an update to that information before the flight begins.

The pilot reported that they obtained the weather forecast for Mareeba the evening prior to their flight and again on the morning of their departure. They stated that they were aware of a frontal system that was due in the area later that day or evening. However, they had not obtained a GAF before their departure.

Alternative aircraft landing area 

On regaining visual reference with the ground after the collision with terrain, the pilot continued the flight for about 155 NM, and about 1.5 hours flying time. During the flight, the aircraft passed within a nautical mile of another suitable ALA as it returned to Charters Towers. 

The pilot stated they were aware of other aerodromes in the vicinity as they tracked towards Charters Towers and that although they were aware that the aircraft had sustained damaged during the collision, they were unaware of the extent and assessed that the aircraft was flying to an acceptable standard to continue the flight to Charters Towers Airport.

Other suitable airports or ALA in the area of the incident site included: 

• Greenvale ALA 38 NM south (within 1 NM of return track)
• Einasleigh Airport 36 NM west
• Valley of Lagoons ALA 50 NM south-east
• Georgetown Airport 68 NM west.

Human factors

Spatial disorientation

The ATSB publication Avoidable Accidents No. 4: Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions(AR-2011-050) discusses the physiological limitations of the human body when trying to sense its orientation in space. 

In conditions where visual cues are poor or absent, such as in poor weather, up to 80 per cent of the normal orientation information is missing. Humans are then forced to rely on the remaining 20 per cent, which is split equally between the vestibular system and the somatic system. Both of these senses are prone to powerful illusions and misinterpretation in the absence of visual references, which can quickly become overpowering. 

Pilots can rapidly become spatially disoriented when they cannot see the horizon. The brain receives conflicting or ambiguous information from the sensory systems, resulting in a state of confusion that can rapidly lead to incorrect control inputs and resultant loss of aircraft control. 

As described in ATSB report AR-2011-050 statistics show non-instrument rated pilots may not be able to recover at all. Research has shown the pilots not proficient in maintaining control of an aircraft with sole reference to the flight instruments will typically become spatially disoriented and lose control of the aircraft within 1 to 3 minutes after visual cues are lost. 

ATSB report AR-2011-050 was updated in 2019 and identified that in the 10 years prior, there were 101 visual flight rules (VFR) into IMC occurrences in Australian airspace reported to the ATSB. Of these, 9 were accidents resulting in 21 fatalities. This details an almost 10% chance of a VFR into IMC encounter ending in a fatal accident. 

The ATSB Aviation Occurrence Database indicated that in the 10 years since 2015, there have been 108 VFR into IMC occurrences reported to the ATSB. Of these, 14 resulted in accidents with 23 fatalities. The dangers of spatial disorientation following a loss of visual cues remains one of the most significant causes of concern in aviation safety.

Decision‑making

The pilot explained they had not previously flown in poor conditions and had previously turned back when conditions were not suitable on many occasions. 

Flight under the VFR requires minimum conditions of visibility and distance from cloud (see Visual meteorological conditions). Variation from the expected weather conditions en route may prevent a pilot from reaching their destination under visual conditions. 

Flight into IMC can occur in any phase of flight. However, a 2005 ATSB research publication – General Aviation Pilot Behaviours in the Face of Adverse Weather (B2005/0127) – concluded that the chances of a VFR into IMC encounter increased as the flight progressed, with the maximum chance occurring during the final 20 per cent of the planned flight. It stated: 

This pattern suggests an increasing tendency on the part of pilots to ‘press on’ as they near their goal. To turn back or divert when the destination seemed ever closer became progressively more difficult.

Research conducted by (Orasanu and others, 1998) titled Errors in Aviation Decision Making contained the following:

Ambiguous cues and organisational and social factors may not in themselves be sufficient to cause decision errors. However, when the decision maker's cognitive limits are stressed, these factors may induce errors in certain contexts. Errors may be mediated by underestimation of the risk inherent in a situation, overconfidence in one's ability to cope with the situation, or failure to evaluate the consequences of planned actions.

Similar occurrences

ATSB investigation

VFR into IMC, loss of control and collision with terrain involving SOCATA-Groupe Aerospatiale TB-20, VH-JTY

On the morning of 28 October 2023, a SOCATA-Groupe Aerospatiale TB-20, registered, VH‑JTY, departed Montpelier aircraft landing area, Queensland, for a visual flight rules private flight to Palmyra aircraft landing area, Queensland. The flight was to be just over one hour duration and the pilot and their passenger were familiar with the route. 

Around 30 NM from the destination, shortly after commencing descent for the intended landing, the aircraft began a steep descending turn to the left towards mountainous terrain. During this descent, the aircraft exceeded the airframe’s designed maximum airspeed before pitching up and passing over the top of Bull Mountain. The aircraft then entered a second steep descending turn, this time to the right, before the recorded flight path data ceased. The aircraft collided with terrain, the aircraft was destroyed and both occupants received fatal injuries.

The ATSB found that, after encountering cloud en route, the pilot elected to continue along the intended flight path through cloud instead of diverting around or remaining on top of it. Shortly after, it is very likely the pilot entered weather conditions not suitable for visual navigation, leading to spatial disorientation and a descent into mountainous terrain.

ATSB investigation

VFR into IMC and in-flight break-up involving Van's Aircraft RV-7A, VH-XWI 90 km south of Charters Towers, Queensland, on 23 April 2021

On 23 April 2021, a Van’s Aircraft RV-7A, registered VH-XWI, was being operated on a private flight under the visual flight rules (VFR) from Winton to Bowen, Queensland. During the flight, the pilot most likely entered IMC and lost control of the aircraft several times. This led to the airspeed limitations for the aircraft being exceeded and the aircraft sustained an in-flight break-up. The pilot was fatally injured, and the aircraft was destroyed.

VFR into IMC resources 

The 2011 ATSB publication, Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions (AR-2011-050), updated in 2019, includes a selection of weather‑related general aviation accidents and incidents that show weather alone is never the only factor affecting pilot decisions that result in inadvertent IMC encounters. The documented investigations consistently highlight that conducting thorough pre-flight planning is the best defence against flying into deteriorating weather. 

CASA also released a collection of resources related to this type of occurrence on its website titled Weather and forecasting. 

For more information on VFR into IMC occurrences, recognising inadvertent entry into IMC, and what to do to recover, refer to the following publications: 

• United Kingdom Civil Aviation Authority: Safety sense booklet VFR flight into IMC
• United States Aircraft Owners and Pilots Association: Encountering IMC.

Safety analysis

Pre-flight planning

The flight was planned to track from the departure aircraft landing area (ALA) direct to Charters Towers and then Atherton, a distance of about 425 NM. The flight north of Charters Towers was flight planned at 2,500 ft above mean sea level (AMSL), however terrain elevations on the planned route north of Charters Towers were consistently higher than 2,500 ft AMSL.

The pilot had obtained a weather forecast for Mareeba Airport (close to their intended destination), which indicated a cloud height of 2,000 ft above the airport elevation (1,564 ft), conditions that the pilot considered suitable for visual flight rules (VFR) flight.

An updated available graphical area forecast (GAF), issued about 4 hours prior to departure, indicated cloud heights were forecast to be about 2,000 ft AMSL at the time the aircraft had planned to be flying over areas of high terrain.

While the pilot was aware of encroaching weather and accelerated their planned flight to a day earlier to avoid the weather, the pilot’s pre-flight planning in respect to planned altitude north of Charters Towers and the weather conditions at the time of the flight was inadequate. Without the required aviation forecast, or appreciation of weather conditions en route, the pilot departed for their destination without the knowledge of expected cloud en route that was lower than terrain elevation and would likely have prevented visual flight.

Continued flight at low level

After assessing in flight that conditions were unsuitable for continued flight direct to Atherton due to the low cloud height, the pilot planned for an alternate airport of Mareeba, visually tracking west to avoid higher terrain.

About 35 minutes after the diversion, the pilot intercepted and began to track north following Kennedy Developmental Road towards rising terrain. 

The pilot described having visibility of greater than 10 km and a good horizon while tracking north following the road. As the terrain elevation increased about 900 ft during the few minutes of northerly flight along the road, the pilot was unable to maintain the minimum terrain clearance of 500 ft above ground level or the minimum 5 km visibility before entering instrument meteorological conditions (IMC).

The pilot stated that they had turned back several times on previous flights due to marginal weather conditions. The pilot and passenger were travelling on a private flight, it was unlikely that there was time pressure to arrive at the intended destination.

Consistent with other occurrences of visual flight rules (VFR) into IMC, the aircraft entered IMC conditions within the last 20% of the flight after continuing flight below the minimum required altitude. Although the pilot recalled initially having good visibility, they continued flight towards the destination below a safe altitude, this indicated a desire to ‘press on’ to the destination and increased the risk of unintended entry into IMC and collision with terrain.

Spatial disorientation

The pilot described being surprised how quickly they entered a ‘white-out’ that appeared in front of the aircraft. Likely as a result of attempting to avoid entering the cloud and losing visual reference, they instinctively reduced power and commenced a left turn. During the turn the aircraft entered cloud and the pilot described becoming ‘totally disorientated’ shortly thereafter. 

Data showed that the aircraft altitude began to fluctuate with several changes of up to 500 ft vertically in about a 60-second period. While in cloud the aircraft came close to impacting terrain on more than one occasion.

The instability of the flight path with numerous rates of climb and descent are commonly observed in spatial disorientation occurrences where pilots perceive a departure from stable flight and attempt to correct the unusual flight sensations without visual reference. 

Unable to reference the aircraft’s visual position or orientation to terrain after entering cloud, the pilot conducted a steep left turn and then engaged the autopilot with the intent to stabilise the aircraft. 

Autopilot engagement and aircraft stall

The engagement of the autopilot levelled the aircraft’s wings and held a constant heading. However, the aircraft became established in a climb due to the aircraft attitude when the autopilot was engaged, capturing a high rate of climb.

The pilot used the heading bug on the horizontal situation indicator to reverse their track 180° to try to fly out of cloud.

The aircraft airspeed was likely less than the recorded ground speed of 54 kt due to a tailwind and therefore most likely below the aircraft’s published stall speed.

The pilot’s decision to engage the autopilot stabilised the aircraft’s heading, however without adequate power, the autopilot maintained the captured rate of climb while the airspeed reduced. As the aircraft commenced the pilot‑commanded left turn, the increased angle of bank and slow speed likely resulted in the aircraft stalling and entering a rapid descent at low level. The pilot’s immediate reaction to the red terrain display instigated them applying stall recovery techniques that very likely prevented a more serious collision with terrain.

Flight past a suitable landing area with a damaged aircraft

The pilot was aware the aircraft had sustained damage during the collision with terrain, reporting that the aircraft required additional right rudder trim to maintain balanced flight due to the damage.

Once the pilot became visual with the ground and tracked to the south, rather than conduct a precautionary landing or divert to a nearby aerodrome, they maintained a track following major roads towards Charters Towers for an additional 1.5 hours.

Following the collision with terrain the pilot likely became focused on the recovery of the damaged aircraft from the remote area. During the return flight south to Charters Towers, the pilot flew within 1 NM of the Greenvale aircraft landing area (ALA) about 41 minutes after the tree collision, and there were 3 other potential landing areas that were closer than Charters Towers. Instead, the pilot continued flight in the damaged aircraft to Charters Towers, a familiar airport with a longer runway.

With known damage and the performance characteristics of the aircraft adversely affected, the pilot’s decision to continue the flight to Charters Towers (past a suitable ALA) rather than seek the nearest suitable landing area that provided an opportunity to properly assess the damage, placed additional risk on the occupants’ safety.

Use of aircraft instruments for navigation

Following the impact with the tree, the pilot flew the damaged aircraft using basic flight instruments until they became visual again above the cloud layer. 

Although the pilot had not recently practised instrument flight, their knowledge gained during their initial flight training, their familiarity with the aircraft systems and their use of the navigation instruments assisted to stabilise and manoeuvre the aircraft out of IMC conditions to regain visual reference and were then able to determine a track south away from cloud.

Findings

From the evidence available, the following findings are made with respect to the VFR into IMC and collision with trees involving Cessna 182T, VH‑TSS, 57 km south-east of Mount Surprise, Queensland, on 16 June 2025.

Contributing factors

• During pre-flight planning, the pilot obtained weather for the destination, however, did not obtain weather for the flight planned track.
• Although the pilot could not maintain 500 ft terrain clearance due to the low cloud base, they continued flight towards the destination rather than divert to a known area of higher terrain clearance.
• The visual flight rules pilot entered instrument meteorological conditions at low level and reduced power when they became disorientated. This resulted in an unintentional turn and near collision with terrain.
• While disorientated in IMC, the pilot initiated a climbing turn and engaged the autopilot at reduced power, resulting in the aircraft being unable to maintain airspeed and likely entering a stall and rapidly lost height. During the recovery, the aircraft impacted with trees but continued to fly.

Other factors that increased risk

• While aware of damage and controllability issues, the pilot did not land at the closest suitable aerodrome and continued for 1.5 hours to a larger airport.

Other findings

• The pilot was able to use the aircraft’s instruments to stabilise the damaged aircraft and navigate out of instrument meteorological conditions

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot
• Civil Aviation Safety Authority
• Bureau of Meteorology
• Ozrunways.

References

Australian Transport Safety Bureau. (2005). General Aviation Pilot Behaviours in the Face of Adverse Weather. Aviation Research Investigation Report B2005/0127.

Australian Transport Safety Bureau. (2011). Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions.

Orasanu, J. L.-A. (1998). Errors in Aviation Decision Making: Bad Decision or Bad Luck.

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
• Civil Aviation Safety Authority
• the manufacturer
• Bureau of Meteorology.

Submissions were received from the:

• pilot
• Civil Aviation Safety Authority
• Bureau of Meteorology.

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

Appendices

Appendix – Graphical area forecasts

Graphical area forecast issued 2013, 15 June

Source: Bureau of Meteorology

Graphical area forecast issued 0224, 16 June 

Source: Bureau of Meteorology

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 2025 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.

On 16 July 2025, a Defence ARH Tiger helicopter experienced a hard landing at Timber Creek, Northern Territory.

The Australian Transport Safety Bureau (ATSB) is providing technical assistance to the ongoing Defence Flight Safety Bureau (DFSB) investigation.

To facilitate this support and to provide the appropriate protections for the information, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003.

Investigation summary

What happened

On the morning of 21 July 2025, a Virgin Australia Airlines Boeing 737-800, registered VH-YFY, was being operated on a scheduled air transport passenger flight from Sydney, New South Wales, to Hobart, Tasmania. About 10 minutes prior to landing in Hobart, one cabin crew member was checking the cabin was secure for landing when they identified smoke and flames coming from the top of an overhead locker. When the overhead locker was opened, a passenger’s backpack was found to be on fire. The cabin crew doused the flames with a fire extinguisher, and with the assistance of some passengers, poured water on the bag until no smoke was emitted. The aircraft landed without further incident. 

After landing, aviation rescue firefighters retrieved a burnt power bank from inside the backpack. 

What the ATSB found

The ATSB found that the lithium-ion battery in a power bank experienced a thermal runaway, resulting in a fire in the overhead locker inside a passenger’s bag. Due to the timing of the fire, when the aircraft was already close to landing, the cabin crew had limited time to complete the lithium battery firefighting procedure. 

It was also identified that, while the cabin crew attempted to use the protective breathing equipment provided by the operator, difficulties during its fitment meant that they did not find it effective in this incident. 

What has been done as a result

Following this incident, Virgin Australia Airlines reviewed its policy regarding the carriage of power banks and spare batteries. As of 1 December 2025, guidance provided to passengers stated:

• Power banks, spare and loose batteries must be carried as carry-on baggage only and must be protected against damage.
• Each battery and power bank must be individually protected to prevent short circuiting by placing it in the original retail packaging, in a separate plastic bag, a separate protective pouch or insulating the terminals by applying tape over the exposed terminals.
• Only bring batteries and power banks that are clearly labelled and made by reputable manufacturers. Unlabelled, damaged, leaking, subject to product recall, and counterfeit batteries or power banks must not be brought on board the aircraft.
• Batteries and power banks must be stowed in the seat pocket, under the seat in front, or be kept on you/in your hands. Do not store them in the overhead lockers.
• Power banks must not be used to charge other devices on board the aircraft. Even when not in use, remove all cables/USB cables connected to power banks and batteries.
• Power banks and batteries must not be recharged using the aircraft’s power supply. 

Virgin Australia Airlines also stated that batteries that were damaged, swollen, leaking, recalled, showing signs of defects, or had been repaired or modified, could not be carried in either checked or carry-on baggage. 

Safety message

Passengers often travel with multiple devices that contain lithium batteries, including laptop computers, mobile phones, headphones, and power banks. To reduce the risk associated with lithium battery fires, passengers should ensure their devices are packed safely, easily accessible in the cabin and are not carried on board an aircraft if they show signs of damage or deterioration.

The thermal runaway of a lithium battery can be difficult to manage, particularly when the aircraft is airborne. In-flight fires pose a significant risk to the safety of an aircraft if not managed quickly and appropriately. An operator’s procedure to manage battery fires is designed to limit the risk and reduce the likelihood of re-ignition of the battery until the aircraft can land. However, it requires the batteries to be out of a bag and accessible to be easily completed.

Passengers are encouraged to review their airline’s website, and check the Civil Aviation Safety Authority ‘Pack Right’ website to confirm that equipment they are planning to take on board an aircraft is permitted and packed safely.

Summary video

The investigation

The occurrence

On the morning of 21 July 2025, a Virgin Australia Airlines Boeing 737-800 aircraft, registered VH-YFY, was being operated on a scheduled air transport passenger flight from Sydney, New South Wales, to Hobart, Tasmania. There were 2 flight crew, 4 cabin crew (comprised of a cabin manager under training (‘1L’), a cabin crew trainer (‘1R’), and 2 cabin crew (‘2L’ and ‘2R’) and 149 passengers on board. The first officer was pilot flying and the captain was the pilot monitoring.[1]

At about 0901 local time, as the aircraft descended through 10,000 ft with the seatbelt sign illuminated, the cabin crew began their final checks on the cabin prior to landing at Hobart. While near the front of the cabin, the 1R heard a sound that they described in their interview with the ATSB as a popping and hissing sound. On looking, they saw white smoke, then flames, emanating from the overhead locker above row 7DEF (Figure 1). They immediately instructed the passengers seated in both sides of rows 6,7 and 8 to move away from the area and into other seating in the aircraft. The 1R then retrieved a fire extinguisher, the portable breathing equipment (PBE), and water from the forward galley.

The 1L made a call from the front galley to the other cabin crew for assistance. The 2 rear cabin crew brought more water and another fire extinguisher forward. The 1R and 2R attempted to don the PBE around the same time, however, one was unable to stretch the neck ring sufficiently to don the PBE, and the other, after donning the PBE felt it restricted their ability to see and communicate effectively so decided to remove it. 

Figure 1: Aircraft seat plan showing the location of the overhead locker where flames and smoke were observed

Source: Virgin Australia Airlines, modified by the ATSB

When the overhead locker was opened, flames and smoke were observed emanating from a backpack. Although they could not see what was causing the fire, from their training, the cabin crew suspected it was from a portable electronic device overheating. The 1L discharged a fire extinguisher into the locker until the flames were extinguished. The 1L and 1R then poured water over the bag, with the assistance of the 2R and passengers. To reduce the risk of re‑ignition, a second fire extinguisher was discharged into the locker. The cabin crew instructed passengers to keep their heads down and cover their nose and mouth to avoid inhaling smoke. They also asked the passengers who was the owner of the bag but did not receive a response at the time.

While the other cabin crew managed the fire, the 2L called the flight deck. The captain recalled in interview that, prior to the call, they detected a smoky odour in the flight deck, which they thought was ozone. The 2L advised the captain there was a fire in an overhead locker, which was extinguished, but there was still smoke, and the 1L was dousing the bag with water. They also stated that there were still passengers standing. On ending the call, the captain asked the 2L to ensure everyone was seated for landing. 

Following receipt of this information, at 0905:17, just prior to descending through 5,100 ft, the captain made a ‘PAN PAN’[2] call to the Hobart approach air traffic control to advise of a possible fire in the cabin, and that they would require assistance on landing. The captain also asked to speak to the tower controller earlier to request clearances. The approach controller coordinated to get the tower controller on frequency. 

The captain decided to take control of the aircraft for landing due to the emergency. At 0906:00, the aircraft was cleared to land on runway 30 by the tower controller. At this time, the first officer also asked to cancel the approach they had been previously cleared for and to instead conduct a visual approach. This change was permitted. At 0906:28, air traffic control contacted the aviation rescue and firefighting service at Hobart Airport, which deployed in preparation for the aircraft landing.

The 2L then retrieved gloves and the portable electronic device fire containment bag and took it to the other cabin crew, intending for the burnt device to be placed in the bag, and the bag stored in the rear lavatory, as per procedure. The backpack was too large to fit in the fire containment bag and there was difficulty in locating the device inside the backpack. Given the short amount of time remaining before landing, the decision was made by the 1R to keep the device inside the backpack in the overhead locker above row 7. It was identified by the cabin crew that the rounded shape of the overhead locker retained the water that had been poured on the backpack, which kept the bag soaked, and would help reduce the risk of re‑ignition during landing. The cabin crew planned to keep the overhead locker open, with the 1R seated in seat 7C adjacent to the locker to monitor the device during landing, with water to use if necessary. The cabin crew also directed the passengers standing to be seated immediately, even if it required 4 passengers to be in a row.

As recalled by the captain in interview with the ATSB, the first officer contacted the 1L just prior to the aircraft turning onto the final approach. This was likely just prior to 0909, with the aircraft between 1,500 ft and 1,000 ft. The 1L confirmed the fire was out, and the passengers were seated, but that the cabin crew were still standing. They assured the first officer the cabin crew would be seated for landing. 

The 1L, 2L and 2R secured the final items for landing and seated themselves in their designated seats, except for 1L who sat in 1R’s seat to maintain better visibility of the cabin. On their way to their seat at the front, the 1L checked the overhead lockers around row 7 for heat or any developing hot spots. Once all the cabin crew were seated, the 1L signalled to the flight crew the cabin was secure. The 1L made a final announcement to passengers to ensure their seatbelts were fastened, to remain seated for landing and follow instructions of crew following the landing.

Flight data provided by Virgin Australia showed that the aircraft touched down at Hobart at 0910:29 (Figure 2). 

Figure 2: Flight path with key events

Source: Google Earth, annotated by the ATSB

The captain stopped the aircraft on the taxiway and exited the flight deck to speak to 1L and observed the cabin to determine whether an evacuation was required. As the fire appeared to be contained, the captain taxied the aircraft to the parking bay. At 0919, the aviation rescue and firefighting personnel boarded the aircraft and removed the backpack from the overhead locker. They confirmed the origin of the fire was a lithium power bank, stored in one of the backpack’s front pockets (Figure 3). 

Figure 3: Backpack containing the power bank 

Source: Airservices Australia

The passengers were cleared to disembark normally at 0927. After disembarkation, one cabin crew member (2L) was treated by paramedics. It was unknown if this was due to the effects of smoke as they had been unwell throughout the flight prior to the fire commencing. No other crew or passengers reported to the operator about seeking medical attention from the effects of the smoke. The fire caused minor damage to the overhead locker above row 7/8 DEF (see section Aircraft damage). 

Context

Cabin crew information

The flight comprised of 4 cabin crew, 2 located at the front set of aircraft doors (called ‘1L’ and ‘1R’) and 2 at the rear of the aircraft (called ‘2L’ and ‘2R’). Each cabin crew member had designated roles on the flight, based on which door they were operating. On this flight, the 1L position was filled by a trainee cabin manager who had previous experience in this role working for other airlines, but was completing their first flight as a cabin manager under training for this operator. The 1L was supervised by a cabin crew trainer in the 1R position.

Each of the cabin crew had between 1 and 17 years of experience as cabin crew. They had all completed their annual emergency procedures training between November 2024 and June 2025. This training included both theoretical information and a practical review of the lithium battery firefighting procedure. All cabin crew reported having completed simulated scenarios where the fire occurred either during cruise or on the ground, where there was plenty of time to complete the firefighting procedure, and store the damaged battery appropriately. None of the cabin crew had completed a simulated scenario involving a time‑pressured situation.  

Aircraft cabin information

VH-YFY was a Boeing 737-800 aircraft, with a single aisle in the cabin and seating for 182 passengers. In economy, where this fire occurred, there were 3 seats on either side of the aisle. 

The cabin on this aircraft was fitted with the Boeing 737 sky interior design. In this design, the overhead lockers lowered from the ceiling, creating a contained basket for the bags to sit in. In comparison, the doors in other locker designs would open upwards. 

Lithium batteries

Overview

There are 2 primary types of lithium batteries – lithium metal and lithium-ion. Lithium metal batteries cannot be recharged and are designed to be disposed of once their initial charge has been used, whereas lithium-ion batteries are rechargeable. Compared to lithium metal, lithium-ion batteries store a high amount of energy and are commonly found in many portable electronic devices (PEDs) such as smartphones, tablets, cameras, laptops, and power banks. 

Guidance on the safe carriage of lithium-ion batteries on board aircraft

Lithium batteries are classified by the United Nations as dangerous goods. As such, the International Civil Aviation Organization’s Technical Instructions for the Safe Transport of Dangerous Goods by Air (2025-2026 Edition) stated that lithium batteries, including power banks must be carried as carry-on baggage only.

The Civil Aviation Safety Authority stated that spare batteries and power banks should be packed in carry-on baggage only, so that trained aircrew can manage any issues quickly and safely. Their Pack right website provided safety tips when travelling with lithium batteries:

These simple steps help keep you and your fellow passengers safe:

• choose reputable suppliers when buying devices and spare batteries

• follow airline and manufacturer rules for carrying and charging lithium batteries

• keep spare batteries with you in the cabin and protect them from damage

• stop using or charging batteries that show signs of damage, overheating, or swelling

To prevent short circuits, protect spare battery terminals by:

• keeping them in original packaging

• covering terminals with tape

• placing each battery in a separate plastic bag or case.

At the time of the incident, the operator’s policy permitted power banks to be carried in the cabin only, but they could be stored inside a bag and there were no restrictions on their use on board. Advice on the carriage of power banks and other electronic devices was provided to passengers on the operator’s website and during check-in. 

Thermal runaway

Thermal runaway is a rapid and uncontrolled increase in temperature and occurs when the internal cell(s) of a lithium battery become damaged for reasons including:

• internal short circuits
• breakage from dropping or crushing
• exposure to excessive heat
• failure of the battery cell due to manufacturing defects.

The operator’s Aircrew Emergency Manual stated that crew should be alert not just for signs of smoke or fire in the cabin but also to the smell of overheating electronic devices. 

The smell of overheating may be the first sign of an impending lithium battery/PED fire. PEDs approaching a thermal runaway start initially displaying hissing, crackling sounds, as well as bubbling or blistering casings.

Once a lithium battery cell thermal runaway starts, it quickly leads to the failure of adjacent cells in a chain reaction that can produce fire, which is especially difficult to extinguish. A fire caused by lithium batteries can produce a fire burning with a temperature as high as 1,000^°C, explosions releasing toxic gases and flammable electrolytes as well as shrapnel from damaged PED casings. The manual also stated that in some cases, the explosive force of the venting gasses could be significant enough to cause spikes in cabin pressure.

Managing lithium battery fires

The operator’s Aircrew Emergency Manual stated a general risk about onboard fires was that:

Any fire, no matter how small, may rapidly become out of control if not combatted quickly. Research has shown that if left uncontained, a smoke-filled cabin can be consumed by fire in as little as 6-10 minutes. The first priority shall always be to put the fire out.

In order to manage the risk, the manual outlined 3 important principles of firefighting:

• Immediately locate the source of fire, smoke or fumes. Specific to lithium battery fires, all smoke or fire events occurring in baggage within an overhead locker should be assumed to be a PED/lithium battery fire until the source is positively confirmed.
• Aggressively attack and extinguish the fire using all available resources, which can include able bodied persons.
• Communicate to other crew and the flight crew, as soon as possible, specifying the location and source of fire.

Furthermore, the manual also guided crew that: 

It is important to protect yourself from the effects of smoke and fumes while attempting to flight a fire. In some circumstances it may be safe and thus more important to attack a fire first than fitting of PBE [portable breathing equipment]. PBE should be worn by at least one person when a team is formed to flight a fire and anytime by the primary firefighter when they are in smoke, a confined space of affected by fumes.

In regard to managing a lithium battery fire, the manual stated:

The primary method for stopping a lithium battery from thermal runaway or overheating is to cool it down by pouring water or other non-flammable liquid on the battery or device. This should be done once any flames have been extinguished and continued until the device is cooled and there is no evidence of smoke, heat, crackling or hissing sounds usually associated with an overheating lithium battery. This could take as long as 10–15 minutes. 

Another recommendation in the emergency procedures manual was a suggestion not to open any baggage if there was smoke or flames emanating from it, unless it was required to get a fire extinguisher and liquid onto an identified battery. Once the device was cooled, it could then be placed in a fire containment bag or other suitable container.

Aircraft firefighting equipment

Overview

The operator fitted the Boeing 737 aircraft with firefighting equipment. In addition to this designated equipment, the cabin crew were taught to use other equipment available on board as required, such as drinks used in the cabin service as well as wet blankets and pillows to smother a fire.

Fire extinguishers

The aircraft had 4 bromochlorodifluoromethane (BCF)/halon fire extinguishers. These fire extinguishers are designed to be used on all types of fires by discharging a colourless, odourless, non-corrosive, liquified gas. This gas is not cooling, meaning that further steps are required in fighting a lithium battery fire.

Fire protection gloves

Fire protection gloves were designed to protect the wearer’s hands when fighting fires, including lithium battery incidents. The emergency procedures also suggested that crew should use gloves whenever fighting fires, including using oven gloves if the fire protection gloves were not available.

The L2 retrieved the fire protection gloves from the galley with the intention to move the power bank once the fire was suppressed, but the gloves were not used during the firefighting process.

Portable breathing equipment

Portable breathing equipment (PBE), commonly referred to as a smoke hood, was provided for each cabin crew member on board. The PBE supplied was designed to protect the wearer from fumes and smoke by forming a secure seal using an elastic neoprene neck ring (Figure 4). An oxygen generator on the nape provided oxygen to the wearer. 

Figure 4: Exemplar PBE, showing how to open the neck ring (left) and when donned (right)

Source: Virgin Australia Airlines, modified by the ATSB

Operator procedures recommend PBE should be used by at least one person involved in firefighting, or when one person was fighting a fire in an enclosed environment. Although, consideration was given that the first person to a fire might need to immediately attend to the fire while others gathered and donned the PBE. 

The 2 cabin crew who attempted to use the PBE stated that the equipment provided in training was much easier to don as the neck ring was stretched from repeated usage.

In October 2025, the Airbus Safety First magazine contained an article about PBE, reviewing a case study where 7 cabin crew had difficulties using the PBE provided. The analysis indicated that, similar to this incident, despite having regular training in the use of PBE, the cabin crew found it difficult to use the PBE in a real emergency. The article recommended that ‘dummy’ PBE used in training may not represent the equipment found on board.

Fire containment bags

There were 2 sizes of fire containment bags carried on the operator’s Boeing 737 aircraft. The smaller sized bag, designed to fit an iPad, was carried in the flight deck in the event of a thermal runaway involving one of the flight crew’s electronic flight bags.

A larger bag, designed to fit a device the size of a laptop, was carried in the aircraft cabin (Figure 5). The purpose of this bag was to place the device in after it was cooled post‑fire, so that it could be stored in a water filled container in a secure place.

Figure 5: Fire containment bag

Source: Virgin Australia Airlines

Damage to the power bank

The power bank was inspected by the aviation rescue firefighters after being removed from the aircraft. 

The power bank had a rated output of 37 watt hours and had both USB‑A and USB‑C charging ports. It was not charging a device when the fire started, but there was a cable plugged into the USB‑A charging port. When orientated with the manufacturer’s label facing up, most of the damage was observed along the top and right side of the power bank. The damaged right end contained the USB-C charging port. External observations suggest that the power bank contained 2 internal cells, of which only 1 was affected by the thermal runaway by the time the fire was extinguished (Figure 6). The power bank was not protected from short circuits as it did not appear to have the terminals covered and was not separated from other items in the bag by being placed in a protective pouch or the original packaging. The backpack was reported by the operator to be substantially damaged by the fire.

The owner of the power bank advised the operator that it was purchased in 2024 and:

• it had no pre-existing damage
• was fully charged the day prior to the incident, and there were no previous issues during charging or use
• it was not dropped, exposed to moisture or heat prior to the incident. 

Figure 6: Power bank showing damage from the back (left) and side view (right)

Source: Airservices Australia (left) and Virgin Australia Airlines (right)

Aircraft damage

An inspection of the aircraft found fire damage in the panels above and behind the overhead locker above row 7 and 8 DEF. The passenger service unit containing the reading lights, call bell and information signals under this locker also sustained fire and water damage. The overhead locker needed to be replaced post-fire (Figure 7). 

Figure 7: Overhead locker above row 7DEF where the smoke and flames were observed (left) and area behind the overhead locker showing fire damage (right)

Source: Airservices Australia (left) and Virgin Australia Airlines (right)

Related occurrences

Australian data

This incident was the first reported power bank-related in-flight fire either in Australia or on an Australian‑registered aircraft. A review of the ATSB’s occurrence database identified 3 previous incidents where smoke was reported emanating from a power bank in the aircraft’s cabin, but no fire occurred:

• OA2025-01608: On 20 January 2025, a Boeing 737 aircraft was being operated on a flight from Brisbane, Queensland, to Melbourne, Victoria. During cruise, a power bank overheated in the cabin, and smoke was observed emanating from the attached charging cable. The power bank and cable were placed in a container and stowed in the rear lavatory for the remainder of the flight.
• OA2019-04325: On 28 May 2019, an Airbus A330 aircraft was being operated on a flight from Melbourne, Victoria, to Hong Kong. During cruise, smoke was detected emanating from a passenger's power bank.
• OA2019-02629: On 15 April 2019, an Airbus A330 aircraft was being operated on a flight from Hong Kong to Melbourne, Victoria. During passenger disembarkation, smoke was observed emanating from a passenger's power bank. The crew doused the power bank in water.

ATSB records showed that, in the past 10 years, there were 4 in-flight fires resulting from mobile phones, 3 of which occurred after the mobile phone was crushed in the seat mechanism, damaging the lithium battery contained inside. The reason for the fourth fire was unknown.

International incidents

While this was the first reported incident in Australia, there have been a number of significant fires resulting from power banks, including: 

• In January 2025, an Air Busan A321 aircraft was preparing for flight at Busan, South Korea. Prior to taxi, a power bank fire started in an overhead locker. The fire spread, resulting in an evacuation. The aircraft was destroyed.
• In March 2025, a Hong Kong Airlines A320 aircraft diverted after a power bank experienced a thermal runaway. The fire was extinguished.
• In October 2025, an Air China A321 aircraft had to divert after a battery caught fire in an overhead locker. 

The United States Federal Aviation Administration recorded 8 in‑flight fire incidents involving power banks occurring in the past 10 years. 

Safety analysis

Power bank thermal runaway

For unknown reasons, one of the cells in a lithium-ion power bank stored in an overhead locker failed during the descent into Hobart. In this case, there was no reported pre‑existing damage, or any other identified problems with this power bank prior to flight. However, the power bank was stored with a cable in it and the ports uncovered, both factors which can increase the risk of a fault.

Inspection of the power bank post-flight, combined with the cabin crew reports of sounds they were trained to expect in the event of a lithium battery fire, suggested that the fire was characteristic of a thermal runaway. As the temperature of the power bank continued to increase, smoke, followed by flames resulted.

Completion of firefighting procedures

As described in the operator’s procedures, fires on board aircraft can spread quickly. As the aircraft was already on descent when the smoke was initially observed, there was limited time for the cabin crew to manage the power bank fire by completing all the procedures they were trained to do in response to an in-flight fire. In addition, they had the responsibility to ensure the cabin was secure for landing. 

In less than 8 minutes, the cabin crew worked together to identify a fire, gather the required equipment, and aggressively fight the fire to a point where the fire appeared suppressed. In addition, they communicated the problem with the flight crew and managed moving passengers to alternative seating. 

While the cabin crew had received emergency procedures training, they had never trained for a lithium battery fire in a compressed time. They completed as many of the procedures as they were able to in the available time, but by the time the fire was considered controlled, there was only around 90 seconds for the cabin crew to clear up the cabin and be seated for landing. Besides the logistics and risk that would result from handling the power bank to remove it from the backpack and place it in a fire containment bag, there was no time available. 

The cabin crew identified an alternate solution to moving the burnt power bank. While the overhead locker held the water poured on the backpack, there was no assurance that the power bank was going to remain fully submerged for landing, in accordance with the operator’s procedures, or isolated from other lithium battery devices. Although there was no consequence as a result of the power bank remaining in the overhead locker, there was an increased risk of cabin occupant injury and aircraft damage if the power bank re‑ignited due to further exposure to fire and smoke. 

Protective breathing equipment

Protective breathing equipment (PBE) was available for cabin crew to use if deemed necessary in preparation to fight a fire, and all crew were trained in their use. Two of the cabin crew attempted to use the PBE, but did not find it effective due to fitment and communication/visibility issues. As the cabin crew were unable to use the PBE, they had no protection from the smoke and were placed at an increased risk of smoke inhalation. While these cabin crew did not experience any residual effects from the smoke, any protective equipment provided should be efficient to don and wear continuously while managing an emergency situation.

Findings

From the evidence available, the following findings are made with respect to the in-flight fire involving Boeing 737, VH-YFY, 56 km north‑north‑east of Hobart Airport, Tasmania, on 21 July 2025. 

Contributing factors

• During the descent, a passenger's lithium-ion power bank, located in the overhead locker, overheated due to thermal runaway and began to emit flames and smoke.

Other factors that increased risk

• Due to the timing of the fire starting on descent, the cabin crew had limited time to complete the procedure for managing a lithium battery fire.
• The cabin crew attempted to use the protective breathing equipment provided by the operator but did not find it effective when managing the lithium battery fire.

Safety actions

Safety action by Virgin Australia Airlines

Virgin Australia Airlines advised it has reviewed its policy regarding the carriage of power banks in the cabin. As of 1 December 2025, guidance provided to passengers stated:

• Power banks, spare and loose batteries must be carried as carry-on baggage only and must be protected against damage.
• Each battery and power bank must be individually protected to prevent short circuiting by placing it in the original retail packaging, in a separate plastic bag, a separate protective pouch or insulating the terminals by applying tape over the exposed terminals.
• Only bring batteries and power banks that are clearly labelled and made by reputable manufacturers. Unlabelled, damaged, leaking, subject to product recall, and counterfeit batteries or power banks must not be brought on board the aircraft.
• Batteries and power banks must be stowed in the seat pocket, under the seat in front, or be kept on you/in your hands. Do not store them in the overhead lockers.
• Power banks must not be used to charge other devices on board the aircraft. Even when not in use, remove all cables/USB cables connected to power banks and batteries.
• Power banks and batteries must not be recharged using the aircraft’s power supply. 

Virgin Australia Airlines also stated that batteries that are damaged, swollen, leaking, recalled, showing signs of defects, or have been repaired or modified, cannot be carried in either checked or carry-on baggage. 

It has updated the cabin crew’s pre-flight announcement and website to inform passengers of the revised policy.

Virgin Australian Airlines has also acknowledged that, while it made changes to its policy, there are challenges in monitoring passengers’ compliance with these measures. It also stated that greater awareness about the risks of travelling with lithium batteries should be delivered by all airlines and airports.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the cabin crew
• the captain
• Virgin Australia Airlines
• Airservices Australia
• Civil Aviation Safety Authority.

References

Airbus. (2025). Focus on protective breathing equipment. https://safetyfirst.airbus.com/focus-on-protective-breathing-equipment/   

Civil Aviation Safety Authority. (n.d.). Lithium batteries. Retrieved 25 July 2025, from https://www.casa.gov.au/packright/lithium-batteries

International Civil Aviation Organization (2025). Technical instructions for the safe transport of dangerous good by air 2025-2026. https://www.icao.int/Dangerous-Goods/Technical-Instructions 

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 cabin crew
• the flight crew
• Virgin Australia Airlines
• Airservices Australia
• Civil Aviation Safety Authority.

Submissions were received from:

• Virgin Australia Airlines
• 2 cabin crew members
• 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 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 2025   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

On the morning of 14 July 2025, a Bell 206L-3 helicopter, registered VH-JMM, was being operated on multiple passenger charter flights around the Arnhem region in the Northern Territory. On board was a pilot and one passenger. 

During the fourth leg of the day at approximately 1338, while looking down and to the left out of the helicopter, the pilot heard a loud bang. The pilot saw a large bird laying between the 2 occupants, and what appeared to be serious injuries to the passenger’s upper body. The pilot reached over to the passenger to check for a pulse but was unable to feel one. Noting the passenger required immediate attention, they decided it would be better for the passenger to receive medical attention at Lake Evella Aerodrome where a police station was next to the airport.

Police, a local nurse and doctor attended to the passenger, however the passenger had succumbed to injuries. The helicopter sustained minor damage. 

What the ATSB found

While cruising at about 900 ft AMSL, the helicopter struck a white bellied sea eagle which passed through the windshield and impacted the passenger.

The pilot had limited opportunity to detect the bird as they were looking down and to the left of the helicopter’s trajectory, reducing the pilot’s ability to see the bird and change the helicopter’s flight path in time, and likely rendering the collision unavoidable under the circumstances.

The passenger was not wearing a helmet at the time, nor was there an aviation regulatory requirement for them to do so. In this case, the location of the bird strike on the passenger was such that wearing a helmet probably would not have reduced the level of injury.

Safety message

Birdstrike is an almost unavoidable and relatively common hazard for all aviation operations. While these strikes typically result in minor or no damage to an aircraft and no injuries to occupants, this is the third fatal birdstrike accident in Australia in recent years.

Pilots are reminded that maintaining effective lookout will assist in maintaining better situational awareness in flight, and also assist in providing better outcomes to see‑and‑avoid not only birds, but other airspace users. 

Additionally, pilots should maintain situational awareness, especially when flying over waterways or wetlands. It is relatively common for large birds, such as eagles, hawks, and gulls, to attack helicopters and drones, often perceiving them as threats or territorial intruders. These birds may display aggressive behaviour during nesting or breeding seasons, diving at or striking the aircraft in an attempt to drive it away. Helicopter operators should consider whether available occupant protections, such as the wearing of flight helmets and the fitment of impact-resistant aircraft windshields, are appropriate for their operations.

The investigation

The occurrence

On the morning of 14 July 2025, a Bell 206L-3 helicopter, registered VH‑JMM, was being operated by Nautilus Aviation on multiple air transport (passenger charter) flights around the Arnhem region in the Northern Territory. On board was a pilot and a passenger. 

At approximately 0928 local time the helicopter departed Gove Airport for Donydji. The pilot reported that from Donydjii, they flew to ‘Nyquist tower’[1] and then on to Mirrnatja before departing for Burrum, which would be the last stop of the day before returning to Gove (Figure 1).

Figure 1: Flight path overview

Source: Google Earth, annotated by the ATSB

The flight departed for Burrum at 1313 (Figure 2) and the pilot established a cruise altitude of about 900 ft above ground level. The pilot recalled having a conversation with the passenger about a waterway which they were flying near, and was familiar to the passenger. The pilot recalled slightly deviating off track to view the waterway. At approximately 1338, while looking down to the left out of the aircraft, the pilot recalled hearing a loud bang. 

The pilot saw a large bird laying between the 2 occupants, and what appeared to be serious injuries to the passenger’s upper body. The pilot reached over to the passenger to check for a pulse, but was unable to feel one. Noting the passenger required immediate attention, the pilot deliberated whether to land nearby and attempt resuscitation, and initially began to descend. However, considering the logistical issues with getting medical attention in a remote location, they decided it would be better for the passenger to receive medical attention at Lake Evella Aerodrome where a police station was next to the airport. 

Figure 2: Accident flight overview

Source: Google Earth, annotated by the ATSB

The pilot landed the helicopter at Lake Evella Aerodrome at approximately 1346. They stated they attempted to call emergency services on 000, however the call did not connect. They decided not to attempt the call a second time and ran to the police station for assistance instead. 

Police, a local nurse and doctor attended to the passenger, however the passenger had succumbed to injuries. The aircraft sustained minor damage (see Helicopter damage). 

Context

Pilot information

The pilot held a valid Class 1 Aviation Medical Certificate and a Commercial Pilot Licence (Helicopter). The pilot had accumulated 2,553 hours of aeronautical experience, of which 1,319 hours was on the Bell 206L.

The pilot had been with the operator since September 2024 and had regularly flown these routes to remote communities as part of their employment. 

Passenger information

The passenger was a frequent passenger on the routes operated on the day and had travelled by helicopter regularly to remote communities as part of their employment since 1995.

The pilot reported to having flown this passenger to remote communities on multiple occasions. Familiar with the aviation environment, the pilot reported the passenger would assist with monitoring for birds during flights, as they were aware they presented a hazard in flight. 

The post-mortem examination report indicated the passenger was hit between the lower jaw and the upper chest, sustaining fatal injuries to the neck, chin, lower jaw and the right side of the chest. 

Helicopter information

General

VH-JMM was a Bell Helicopter Company B206L‑3 Long Ranger, S/N 51400, manufactured in Canada in 1990. It was first registered in Australia in June 2017. The aircraft was registered to the operator in January 2024.

VH-JMM was a helicopter with two‑bladed main rotor and tail rotor systems, powered by a single Rolls-Royce 250‑C30P gas turbine engine.

At the time of the accident, the helicopter had completed 13,250 hours in service and had a current maintenance release.

Helicopter damage

The helicopter sustained damage to the passenger side windshield. There was no other reported damage to the aircraft (Figure 3).

Figure 3: Helicopter damage

Source: Northern Territory Police Force, annotated by the ATSB

Helicopter windshields

VH-JMM was fitted with standard acrylic windshields, which were not rated for impact resistance.

In 2016 Bell Helicopter Company introduced polycarbonate windshields, through a supplemental type certificate (STC) for the Bell 206 series, including the 206L. These were available as an additional option for current owners, offering higher impact resistance compared to traditional acrylic, reducing the risk of breaches from birdstrikes or other impacts. These were rated to United States regulatory requirements of a 2.2 lb (1 kg) bird traveling at V_NE (the helicopter’s never-exceed speed).[2]

Despite having a higher impact resistance than acrylic, polycarbonate windshields are more sensitive to scratches, and reportedly susceptible to clouding or hazing due to ultraviolet light exposure, resulting in loss of optical clarity and necessitating more frequent replacements.

Weather information

The terminal aerodrome forecast for the accident region forecasted clear conditions for the flight with scattered cloud above 3,500 ft and visibility greater than 10 km.

At 1530, the weather station at Elcho Island Airport, 48 km north of the accident location, recorded the wind as 4 kt from 110° magnetic. There was scattered cloud at 1,000 ft, visibility was greater than 10 km and the temperature was 23°C.

The pilot reported that the weather varied depending on where they were flying, however it was mostly clear with some areas of cloud. They reported the clouds were above their cruise height. 

Recorded data

The aircraft was fitted with a Spidertracks flight tracking unit and the pilot used OzRunways electronic flight bag software; both recorded flight data. Flight data indicated that the aircraft was cruising at 900 ft above ground level at a groundspeed of 94 kt at the approximate time the bird was struck. The data showed an initial deceleration to 86 kt groundspeed and a decrease in altitude of 50 ft, followed by a secondary decrease in altitude of approximately 150 ft (likely associated with the pilot’s consideration of whether to land). The track showed that the helicopter then climbed to 800 ft and increased groundspeed to about 70 kt (Figure 4).

Figure 4: Recorded flight track

Source: Google Earth, annotated by the ATSB

Bird information

Recovered biological specimens of the bird, including wing feathers and residue from the carcass, were found both inside the helicopter and on the passenger. Through images of the bird, the ATSB determined the species to be a white‑bellied sea eagle. 

The white-bellied sea eagle (Haliaeetus leucogaster) (Figure 5) is a large raptor commonly found in coastal regions of Australia, recognised for its distinctive white head, belly, and tail contrasted by dark greyish‑brown wings and back. Adults measure approximately 66‍–‍85 cm in length, with a wingspan of 1.8‍–‍2.2 m (Debus, 2017). Adult males typically weigh between 1.8‍–‍3 kg, while females average 2.5‍–‍4.5 kg (Marchant & Higgins, 1993). The weight and sex of the bird in this accident was unknown. 

Figure 5: Some of the bird remains retrieved from the helicopter

Source: Northern Territory Police Force

These eagles are often observed soaring over coastlines, estuaries, or inland waterways, preying on fish, seabirds, or carrion, and can reach heights of up to 1,000 m (about 3,300 ft) (Ferguson‑Lees & Christie, 2001). Their activity increases during the June to January period in Australia, which is their breeding season (Debus, 2017). 

It is relatively common for large birds, such as eagles, hawks, and gulls, to attack helicopters and drones, often perceiving them as threats or territorial intruders. These birds may display aggressive behaviour during nesting or breeding seasons, diving at or striking the aircraft in an attempt to drive it away (Washburn & others, 2015). 

Limitations of see-and-avoid

The human visual system is inherently limited in detecting small objects such as birds at distances. Hobbs (1991) notes that effective visual scanning requires systematic eye movements across the visual field, yet pilots often employ unsystematic techniques, resulting in unsearched areas. Furthermore, the cognitive process of identifying a threat, assessing its collision risk, deciding on evasive action, and executing control inputs requires time that is often unavailable in low‑altitude, high‑speed scenarios.

Birds present unique challenges to the see‑and‑avoid principle due to their relatively small size, unpredictable flight paths, and speed difference compared with aircraft. Unlike aircraft, birds cannot be tracked electronically, meaning pilots must rely solely on visual identification.

Survivability

Restraints

The helicopter was fitted with 4‑point harnesses in the front seats. The pilot reported both they and the passenger had been fastened into the seats by the aircraft’s 4‑point harnesses. 

Helmets

The pilot reported wearing a flight helmet[3] and reported wearing a helmet whenever possible, noting that helmets had saved lives in the past. The pilot recalled previously having a discussion with the passenger about helmets and the benefits of them. 

The passenger was not wearing a helmet at the time, nor was there an aviation regulatory requirement for them to do so. Nautilus Aviation stated that there was no requirement for passengers to wear a helmet and the decision on their use rested with the passengers themselves or their employers.

Telstra helicopter charters

The passenger was on board the aircraft as part of their work for Telstra, a telecommunications company. Telstra reported that its employees took about 630 helicopter charters on average per year, a mix of passenger charter (transit) and aerial work.

The employer had an operational framework for chartering aircraft that addressed many risks typically associated with helicopter flights, outlining expectations for the aircraft operator. These included the requirement for the aircraft operator to perform a risk assessment ‘prior to the first flight of any new operation by the Charter operator.’ 

Telstra did not have prescribed or recommended personal protective equipment for employees travelling or working on helicopters. Telstra advised that it relied on the licenced and accredited aviation providers that it engages to advise on safety of flight aspects including the use of personal protective equipment (PPE).

Related occurrences

Global data

Birdstrikes are a recognised hazard in aviation and there are mitigators in place at certified airports, however, there are challenges when operating outside of these areas. 

A review of Australian and internation data was conducted using the Avisure serious accident database. Between 1912 and 2024, birdstrikes have resulted in 763[4] reported aviation occurrences worldwide that involved serious or fatal injuries, of which 204 were fatal. Among these fatal cases, 18 involved rotary‑wing aircraft such as helicopters. These 18 accidents comprised 13 civil and 5 military rotary‑wing aircraft (Figure 6).

Figure 6: Global birdstrike data resulting in fatalities

Data does not include this occurrence (AO-2025-039). Source: Avisure

United States data

In the United States, a total of 13,667 bird strike occurrences were reported to the Federal Aviation Administration (FAA) in operations involving aircraft (fixed-wing and rotary-wing) under 5,700 kg maximum take‑off weight from 2014 to 2024. Of these, 60 occurrences resulted in non-fatal injuries, and 11 were fatal. 

A subset of 334 occurrences involved birds striking and damaging the aircraft windshield, with 48 of these occurrences (14.4%) resulting in serious injuries and 6 (1.8%) leading to fatal injuries. 

Of the total, 3,001 occurrences involved rotary-wing aircraft, which equated to a birdstrike every 285,390 flight hours (Table 1). These included 201 recorded windshield strikes, that resulted in 28 (13.9%) serious injuries and 2 (1.0%) fatalities. 

Table 1: Reported helicopter birdstrikes comparison 2014–2024

In comparison to the most frequently struck aircraft component, the wings, with 1,171 occurrences, only 6 (0.5%) resulted in injuries including 1 with fatal injuries (0.09%), indicating that the proportion of serious and fatal outcomes from windshield strikes is unexpectedly high relative to other aircraft parts. 

Australian data

Birdstrikes in Australia

Between 2014–2024 the ATSB aviation wildlife dashboard indicated there were 17,060 reported birdstrikes reported to the ATSB across all aircraft types (including fixed‑ and rotary-wing). There were 412 reported birdstrikes during helicopter operations (Table 2), which equated to a birdstrike every 39,690 flight hours. The data did not include what component was struck unless the component was damaged, so it was not possible to determine the proportion of windshields struck that were penetrated or damaged. Of the 412 reported birdstrikes to helicopters, 17 had damage to the windshield.

Table 2: Reported helicopter birdstrikes within Australia 2014–2024

ATSB records indicate there were 2 fatal accidents in civil aircraft in Australia due to birdstrike. Additionally, there was 1 serious accident involving a bird entering through the windshield. These investigations are described in the following subsections.

Birdstrike involving Glasair Sportsman GS‑2, N666GM, near Bathurst, New South Wales, on 24 December 2015 (

)

During take-off the aircraft collided with a wedge‑tailed eagle (Aquila audax), penetrating the windscreen and causing significant damage to the propeller and engine, while also striking the pilot, who sustained serious facial injuries and was temporarily unable to see. The pilot, who was wearing a headset and spectacles (both dislodged and damaged during the impact), managed to land safely. 

Birdstrike and in-flight break-up involving a Bell 206L‑1, VH‑ZMF, near Maroota, New South Wales, on 9 July 2022 (AO‑2022‑034)

Shortly after departing from a private helipad, the helicopter was struck by a wedge‑tailed eagle (Aquila audax) just below the front left windscreen. The pilot, likely startled by the birdstrike and distracted by sun glare and a required radio frequency change, made abrupt control inputs that caused the main rotor to sever the tail boom, resulting in an in‑flight breakup and collision with terrain. The pilot, who was the sole occupant, was fatally injured.

Birdstrike and collision with terrain involving Air Tractor AT‑502B, VH‑KDR, 32 km east‑north‑east of Chinchilla Airport, Queensland, on 19 September 2022 (AO‑2022‑043)

During low-level aerial spraying at about 8 feet above ground, the aircraft was struck by a large Australian bustard (Ardeotis australis), which shattered the right windshield. The bird entered the cockpit, likely impairing the pilot’s ability to control the aircraft. The aircraft continued for approximately 310 m before colliding with terrain, resulting in the pilot being fatally injured and destruction of the aircraft.

Safety analysis

Birdstrike

Images from the accident site showed that the aircraft collided with a white‑bellied sea eagle (Haliaeetus leucogaster). The pilot had limited opportunity to detect the bird as they were looking down and to the left of the helicopter’s trajectory, so it was probably in their peripheral vision where detection of small objects is very limited. Even if they had been looking ahead at the time, they may not have been able to see the bird in time to avoid it due to the inherent limitations of the see-and-avoid principle. The closure rate to the soaring bird would have been around 94 kt and the difference in speed between them would have also made the relative trajectory almost direct. These factors further reduced the pilot’s ability to see the bird and change the helicopter’s flight path in time, likely rendering the collision unavoidable under the circumstances.

Considerations for aircraft operators and employers

Windshield impact resistance

The analysis of bird strike data highlights the significant safety risks posed to windshields. In windshield impacts in the United States, 14.4% caused serious injuries and 1.8% caused fatalities. Australia’s occurrences included 3 fatal and 3 serious injuries. Comparison of the United States and Australian data indicated that there was a higher chance of both birdstrike and the strike resulting in windshield damage per flight hour in Australia.  

There is an elevated risk for helicopter operations due to low‑altitude operations and often less robust windshield designs. This is because if a bird penetrates the windshield, it can directly impact occupants, causing injury or incapacitation of flight crew, which may lead to loss of aircraft control or further operational hazards. While advancements in windshield design, such as laminated materials and reinforced structures, have mitigated many impacts, the data highlights vulnerabilities in extreme cases. 

Manufacturers like Robinson and Bell have both released birdstrike‑rated windshields that provide higher impact resistance and significantly decrease the likelihood of objects breaching the windshield upon impact. However, these windshields have been rated to withstand a 1 kg bird strike at the aircraft’s never‑exceed speed, and the occurrence scenario involving a 3 kg bird colliding with the helicopter would likely exceed the windshield’s design limits. Nevertheless, and noting there are some disadvantages of impact‑resistant windshields, operators are encouraged to consider installing impact‑resistant windshields if operating in areas with a high probability of birdstrike.

Helmets

Helicopter pilots often wear helmets as a safety measure due to their frequent exposure to the dynamic conditions of rotary‑wing flight, where turbulence, rapid manoeuvres, and potential accidents pose risks of head injury. In contrast, passengers often do not wear helmets, as the risk is lower for occasional travellers, particularly considering the other safety measures associated with commercial passenger transport operations.

Passengers who travel frequently in helicopters fall between these 2 extremes. They are naturally exposed to a higher risk (over the occasional passenger) simply due to the increased number of flights. While the pilot reported being a helmet advocate and had previously discussed the potential benefits with the passenger, the decision whether to wear a helmet was ultimately left to the passenger’s discretion.

Helmets provide an additional layer of protection against birdstrikes, particularly in aviation scenarios like the Glasair Sportsman GS‑2 incident (AO‑2016‑001). A helmet, often equipped with a sturdy visor, can shield the face and head from small‑object impacts, reducing the risk of injury from a shattered windshield. Additionally, a helmet, especially one designed for aviation, is engineered to absorb and disperse kinetic energy from impacts with larger objects such as a bird potentially mitigating the severity of injuries like those sustained by the pilot of the Glasair, who was not wearing a helmet and suffered serious facial injuries. The helmet’s hard outer shell and padded inner liner work together to reduce the force transmitted to the skull, significantly lowering the risk of traumatic brain injuries, concussions, or skull fractures.

A helmet would not have prevented the passenger’s injuries in this case due to the impact location. Nevertheless, wearing a helmet as standard practice would provide some protection against a range of other potential hazards.

Pilot response

The pilot maintained control of the aircraft despite the sudden disruption and potential aerodynamic effects of the compromised windscreen. They promptly identified the nearest suitable landing site with access to medical facilities and executed a controlled descent and landing. 

The pilot’s effective response and adherence to emergency procedures ensured the injured passenger was positioned for immediate medical response, highlighting sound decision‑making under extreme circumstances. 

Findings

From the evidence available, the following findings are made with respect to the birdstrike involving Bell 206L‑3, VH‑JMM, 16 km west-north-west of Lake Evella Aerodrome, Northern Territory, on 14 July 2025.

Contributing factors

• While cruising at about 900 ft above mean sea level, the helicopter struck a white‑bellied sea eagle, which passed through the windscreen and impacted the passenger.

Other factors

• Despite the injuries to the passenger and the damage to the aircraft, the pilot demonstrated composure and maintained control of the aircraft, enabling a calm and controlled return to a location where medical assistance could be provided.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot
• Nautilus Aviation
• Northern Territory Police Service
• recorded data from the Spidertracks unit on the helicopter
• OzRunways.

References

Australian Transport Safety Bureau (2002). The Hazard Posed to Aircraft by Birds. Canberra: ATSB.

Debus, S. J. S. (2017). Australasian Eagles and Eagle-like Birds. CSIRO Publishing.

Ferguson-Lees, J., & Christie, D. A. (2001). Raptors of the World. Christopher Helm.

Hobbs, A. (1991). Limitations of the See-and-Avoid Principle. Canberra: ATSB. 

Marchant, S., & Higgins, P. J. (Eds.). (1993). Handbook of Australian, New Zealand and Antarctic Birds: Volume 2 - Raptors to Lapwings. Oxford University Press.

Washburn, B. E., Begier, M. J., & Wright, S. E. (2015). Wildlife strikes to civil helicopters in the United States, 1990–2011. Wildlife Society Bulletin, 39(1), 115‑120.

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
• Nautilus Aviation
• Telstra
• Civil Aviation Safety Authority
• Northern Territory Police Force
• TSB Canada.

Submissions were received from:

• Nautilus Aviation
• Telstra

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. Terminology 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 2025   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.