GNR = General notification roster – available for after hours phone duty
On rare occasions and to meet operational requirements such as a major accident, the need for a particular skill or specialist knowledge, or concurrent accidents, non-rostered transport safety investigators may be contacted in- or out-of-hours and asked if they are able to deploy at short notice.
All investigators on the deployment roster are provided with a Go-kit for deployment purposes. The Go-kit typically contains a uniform and Personal Protective Equipment (PPE) used during deployments.
The ATSB is investigating a runway incursion and near collision involving a Cessna 402C, registered VH-HMG, and a safety vehicle, at Jandakot Airport, Western Australia, on 3 March 2026.
During take-off for an air transport operation flight with 4 passengers on board, the sole pilot of the Cessna 402 observed a safety vehicle enter the runway in front of the aircraft. The aircraft was above the maximum speed for a rejected take-off and took off above the vehicle in close proximity.
The ATSB has commenced the examination and analysis of the initial evidence collected. To date, the ATSB investigation has included:
interviewing witnesses and involved parties
retrieving and reviewing recorded data
collection of other relevant information
A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Occurrence summary
Investigation number
AO-2026-064
Occurrence date
03/03/2026
Occurrence time and timezone
07:07 Western Australia Standard Time
Location
Jandakot Airport
State
Western Australia
Report status
Pending
Anticipated completion
Q3 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Examination and analysis
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Near collision, Runway incursion
Occurrence class
Serious Incident
Highest injury level
None
Aircraft details
Manufacturer
Cessna Aircraft Company
Model
402C
Registration
VH-HMG
Serial number
402C1002
Aircraft operator
Paul Lyons Aviation Pty Ltd
Sector
Piston
Operation type
Part 135 Air transport operations - smaller aeroplanes
Activity
Commercial air transport-Non-scheduled-Passenger transport charters
Despite continued concerted efforts to prevent collisions at level crossings by local, state and federal governments in conjunction with the rail industry, the ATSB continues to investigate similar occurrences.
The following investigations highlight some key learnings for both road users and rail infrastructure managers to help reduce collisions at level crossings.
A truck driver who failed to stop before a passive level crossing collision in southern Queensland was probably influenced by expectation bias, having likely never seen a train at the crossing in the past.
On 23 May 2024, a prime mover hauling a skid steer was about 50 metres north of Gooray Road level crossing, near Goondiwindi, when the truck driver saw a train approaching from the west. Assessing they could not stop in time, the truck driver accelerated, but the truck was unable to clear the crossing before the train collided with the truck’s trailer.
The truck driver and two train drivers were seriously injured in the collision, which also destroyed the train’s two locomotives and 12 grain hoppers, and the truck’s prime mover and low-load trailer.
Due to the infrequency of trains on that corridor, it is likely the truck driver had not seen a train at that crossing in the past. This created an expectation bias which probably reduced the effectiveness of the truck driver’s scan while approaching the crossing. Nonetheless, the signage instructed the driver to stop at the crossing, and the driver did not comply with this requirement.
This accident demonstrates the limitations of passive controls at level crossings, where the onus is on road users to follow these controls – making them particularly vulnerable to unintentional driver error, or intentional driver decisions.
Passive controls are common at level crossings where road and rail traffic volumes are low, and it is unlikely most road users will encounter a train at such a crossing. As road users become familiar with a level crossing where they have not previously encountered trains, they can unconsciously form an expectation that no trains will be present every time they approach that crossing.
It is therefore crucial that road users remain cognisant of the potential presence of trains at every level crossing, and are mindful of the consequences of a collision such as this one.
Lessons learnt
Passive controls cannot physically prevent vehicles from entering a crossing, and the onus is on road users to follow these controls. This makes passive level crossings particularly vulnerable to driver error (unintentional) or driver decisions (intentional), which can place road users at imminent risk of collision with rail traffic.
This incident also highlights, for truck drivers, the importance of completing preparatory checks and rectifying any problems which may be observed prior to moving their vehicle, as there is a significant risk of harm and damage when driving vehicles with mechanical issues.
A motorist was fatally injured in a collision with a passenger train at the Kianawah Road level crossing, near Lindum Station in Wynnum West, Queensland after they passed through a gap between the end of the lowered boom barrier and a median island.
On the afternoon of 26 February 2021, a Queensland Rail suburban express passenger train was approaching the Kianawah Road level crossing in the Brisbane suburb of Wynnum West, Queensland. The boom barriers were in the lowered position and other protection devices (flashing lights) were active at the level crossing.
At the same time, after stopping to give way to opposing road traffic at the intersection, immediately adjacent to the level crossing, a motor vehicle turned towards the crossing. It then continued through the level crossing, bypassing the lowered boom barrier, colliding with the train. The motor vehicle was destroyed, and the sole occupant was fatally injured. The only 2 occupants of the train, the driver and guard, were not injured.
Our investigation found that there was a 3.1 m gap between the end of the boom barrier and the median island, which meant that the barrier only partially blocked road traffic that approached the level crossing from Lindum Road. In this instance, it was very likely that the driver of the motor vehicle followed the turn line markings on the road surface, which directed them past the end of the lowered boom barrier onto the level crossing and into the path of the approaching train. Safety concerns raised by local road users and work undertaken by the Government also indicated that the road-rail interface at the Kianawah Road level crossing was complex and visually noisy from a road user’s perspective.
Queensland Rail had not been managing risk at level crossings in accordance with the requirements of its level crossing safety standard. In particular, the standard stated that public and pedestrian level crossings were to be assessed every 5 years or sooner. However, the Kianawah Road level crossing had not been assessed for 19 years. Some other level crossings with high instances of incidents and accidents had also not been assessed for 20 years.
It was also identified that, between 2016 and 2021, Queensland Rail had just one person qualified to assess all their public, pedestrian, private, maintenance, and construction level crossings, which numbered in the thousands. Of the 1,138 public level crossings that required assessment within the 5-year timeframe, just 52 were completed.
Further, Queensland Rail and the Brisbane City Council did not have a formal road-rail interface agreement in place at the time of the accident, although negotiations were ongoing. This was a missed opportunity to collectively identify any unique risks associated with the level crossing and manage and maintain those risks through an agreed process.
Following the accident at the Kianawah Road level crossing, Queensland Rail and the Brisbane City Council have formalised an interface agreement encompassing all level crossings where they have a shared responsibility. In addition, Queensland Rail:
Has installed a new boom barrier at the level crossing, compliant with the Australian Standard (1742.7), that fully protects road users when approaching the active crossing from Lindum Road. In addition, rectified a safety issue where the boom barrier did not fully comply with the requirements of the Australian Standard at 29 other level crossings within its jurisdiction.
Assessed the Kianawah Road level crossing in accordance with the Australian Level Crossing Assessment Model (ALCAM) to establish a current assessment risk score rating.
Has trained 4 internal staff to undertake ALCAM assessments and introduced a procurement process to engage a contract firm to update outstanding regional ALCAM assessments over the next 5 years.
Lessons learnt
Level crossings are a complex environment and are well known for their high-risk consequences. While the ultimate preference is to avoid or remove level crossings, this is often very costly and not a practical solution. Therefore, it is important that road authorities and rail infrastructure managers collectively manage these risks. To achieve this, they should enter into an interface agreement as soon as possible to identify and manage hazards and risks at the road and rail interface, so far as is reasonably practicable.
Sighting from road vehicles can be severely restricted at passively protected level crossings with an acute angle road-to-track interface.
On 13 July 2016, a Warrnambool-bound V/Line passenger train collided with a semi-trailer at the Phalps Road passive level crossing at Larpent, near Colac, Victoria.
When the truck initially stopped at the crossing, the train was more than 300 metres away. The truck commenced moving towards the track when the train was between 220 and 260 m from the crossing. Unaware of the train approaching beyond their line of sight, the truck driver entered the level crossing and heard the train’s horn shortly before the locomotive struck the truck’s semi-trailer.
After impact, the train’s locomotive and all passenger cars derailed. The locomotive driver, train conductor, 18 passengers and the truck driver were injured. There were no fatalities.
The investigation, conducted by Victoria's Chief Investigator, Transport Safety, on behalf of the ATSB, found the driver was unable to detect the approaching train on the left due to the restricted view from the level crossing’s acute road-to-rail angle and the composition of the truck’s passenger-side window.
The ability of a truck driver to see along a railway track to their left can be affected by in-cab obstructions. The Australian Design Standard for passively controlled level crossings accounts for this possibility by requiring a viewing angle of no more 110 degrees for a driver looking to their left from the straight-ahead direction. If this viewing angel is exceeded, passive level crossing controls should not be used.
The investigation found that for a vehicle stopped at the northern side of the Phalps Road level crossing, the viewing angle to achieve the required sighting distance was 116 degrees. The Phalps Road level crossing was subsequently upgraded to active protection controls in August 2016.
Lessons learnt
Rail infrastructure and road managers should ensure that risk assessment processes take account available risk controls for hazards stemming from poor sighting at acute-angle level crossings and actively pursue their implementation.
Road users should be particularly cautious at passively-controlled acute-angle level crossings where their vision to the left may be affected by the road vehicle cabin design.
Conclusion
Each year, people continue to lose their lives or are injured at Australia's level crossings causing significant social and economic impacts on individuals, communities and businesses.
Record investment in rail and road infrastructure, combined with growing passenger traffic and freight demand, is continuing to increase interactions at level crossings.
Our investigations have identified there is a higher rate of collisions at passive level crossing, with a large proportion of these collisions involving heavy vehicles.
Passive controls cannot physically prevent vehicles from entering a crossing, and the onus is on road users to follow these controls. This makes passive level crossings particularly vulnerable to driver error (unintentional) or driver decisions (intentional), which can place road users at imminent risk of collision with rail traffic.
Ensuring the safety of rail travel is integral to growth in patronage, economic contribution, innovation, and sustained investment. There is a significant public benefit in avoiding rail accidents and incidents (occurrences). The ATSB aims to prevent future occurrences by ensuring lessons are learned and safety improvements are made through independent, evidence-based, no-blame investigations, providing assurance that systems are operating safely through growth and change.
What are no-blame investigations?
We do not investigate for the purpose of taking administrative, regulatory, or criminal action.
The Transport Safety Investigation Act 2003 (TSI Act) guards against the inappropriate use of evidence gathered in ATSB investigations in legal proceedings. This gives those directly involved in an occurrence greater confidence that they can provide open disclosure in the interests of safety.
Depending on the circumstances, ONRSR, the police, work health and safety regulators, and coroners may also investigate. The investigation remit of the ATSB, OTSI and OCI is distinct from these organisations. For example, ONRSR undertakes compliance investigations and may employ enforcement mechanisms. In contrast, we investigate and report on systemic safety issues involving risk controls in the rail transport operator, standards, and regulatory frameworks. Safety action taken in response reduces the risk of future occurrences.
Resourcing
ATSB rail safety investigations rely on a combination of funding and resourcing from the Commonwealth and State governments. In addition to the collaboration arrangement we have in New South Wales and Victoria, the Queensland Government provides funding for ATSB investigations in their State. Other States and Territories have not opted into similar arrangements. We are working with governments to provide future certainty around resourcing for a national capability.
Deciding to investigate
The ATSB receives approximately 160 notifications of investigable occurrences each year. Investigation resources are prioritised to investigate occurrences likely to have the greatest public safety benefit through lessons learned.
The ATSB considers:
the availability, including extant tasking, of ATSB rail resources
whether the track is part of the interstate network
if the track is off the interstate network, whether the relevant State or Territory provides funding
whether OTSI or OCI will commit existing resources under the Commonwealth TSI Act
the prioritisation given to mainline passenger operations and then freight and other commercial operations
the severity of the occurrence and anticipated safety outcomes of the investigation.
The severity of the outcome, such as deaths, injuries and damage, does not necessarily indicate the extent of the anticipated safety outcomes. It is important that the ATSB considers near miss occurrences for investigation. The factors that led to the near miss might reveal safety issues that, left unaddressed, could lead to a catastrophic accident in the future.
The criteria above is important for decision-making as the ATSB is currently only able to commence a limited number of investigations annually with its available resourcing.
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The Australian Transport Safety Bureau has published a preliminary report from its ongoing investigation of last month’s accident involving a Cessna 210 off Murray Mouth, South Australia.
The preliminary report, which presents evidence gathered so far in the ATSB’s investigation but does not include analysis or findings, notes the accident occurred on the afternoon of 6 February 2026, approximately 13 minutes after take-off from Goolwa Airport.
“The purpose of the flight was for a commercial licensed pilot, seated in the front left seat, to accumulate Cessna 210 flying experience, under the supervision of a flight instructor,” said ATSB Chief Commissioner Angus Mitchell.
The instructor, who was head of training and checking for the aircraft operator, was seated in the front right seat.
Seated behind them in the second row left seat was a third occupant, a passenger who held a recreational pilot licence.
“A witness on the west side of Murray Mouth saw the aircraft in a steep descent and filmed the aircraft for a few seconds before it collided with water,” ATSB Chief Commissioner Angus Mitchell said.
“The footage shows the aircraft in a left turn spin in a steep nose down and left-wing low attitude, with the landing gear retracted.
“Several witnesses reported the engine sounded like it was running until the collision.”
The 3 occupants were fatally injured and the aircraft was destroyed.
The preliminary report details that to date, investigation activities have included analysis of the video footage, as well as a review of air traffic control radar data, which showed the aircraft’s altitude had reached 3,375 ft and its groundspeed had reduced to 74 kt, before the descent started.
As the investigation progresses, an onboard GPS unit will be examined and data from electronic flight bag apps will be analysed, while an elevator control cable turnbuckle was recovered from the aircraft wreckage for further examination in the ATSB’s Canberra facilities.
A final report will be released at the conclusion of the investigation once the available evidence has been analysed and findings are developed and established.
“However, should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify affected parties so they can take safety action,” Mr Mitchell concluded.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation. Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information in them is de-identified.
What happened
On 9 December 2025, an Ayres Thrush S2R-T34was being used to conduct agricultural spraying, which involved multiple circuits and landings to pick up and disperse approximately 40 loads.
During landing, before picking up the final load for the day, the pilot observed a vehicle approaching the landing strip towards the loading area. The pilot applied additional braking to avoid a possible collision with the vehicle and the aircraft subsequently veered towards a drainage channel adjacent to the landing strip.
While the pilot monitored the approaching vehicle, the aircraft continued towards the end of the landing strip and the drainage channel. The pilot subsequently attempted to correct the aircraft to remain on the strip however there was insufficient distance and time, and the aircraft entered the channel. There were no injuries to the pilot, and the aircraft was substantially damaged.
Figure 1: Aircraft damage
Source: operator, edited by the ATSB
Safety message
In this occurrence the distraction of the vehicle approaching the landing strip diverted the pilot’s attention from monitoring the landing roll, resulting in a loss of situational awareness.
This type of distraction is more likely to impact performance due to the cognitive demands of one spatial visual scanning task (i.e. monitoring landing roll) being interrupted by another spatial task (i.e. a vehicle moving towards the aircraft’s projected path), particularly during a critical phase of flight where there is very little time to assess the situation.
Concurrent task management depends on the pilot’s ability to effectively prioritise tasks and appropriately time share tasks by rapid switching, whereby attention quickly shifts between tasks. This is essential when the pilot is dealing with multiple tasks, which are all critical to flight safety.
The ability to appropriately prioritise and use rapid switching may be affected by workload and fatigue, which can be a factor during operations involving large numbers of short, similar flights in quick succession. Effective use of rapid switching can also be improved through experience as well as specific task management training.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
The ATSB is investigating a tail rotor failure and subsequent collision with terrain involving a Robinson R22 Beta, registered VH-UBY, about 56 km west of Coonamble Airport, New South Wales, on 6 February 2026.
During aerial mustering operations approximately 100 ft above the ground, the pilot and sole occupant of the helicopter experienced an RPM spike followed by a yaw and a loss in rudder effectiveness. Unable to counteract the yaw, the pilot attempted to land the helicopter, which spun several times during the descent.
Upon contact with the ground, the helicopter rolled onto its side, resulting in substantial damage. The pilot experienced serious injuries, but was able to exit the helicopter without assistance. There was no fire.
The evidence collection phase of the investigation will involve examining tail rotor components, interviewing the pilot and any witnesses, examination of maintenance records, retrieving and reviewing recorded data, and the collection of other relevant information.
A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Occurrence summary
Investigation number
AO-2026-063
Occurrence date
06/02/2026
Occurrence time and timezone
10:15 Australian Eastern Daylight Time
Location
About 56 km west of Coonamble Airport
State
New South Wales
Report status
Pending
Anticipated completion
Q3 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Evidence collection
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Abnormal engine indications, Collision with terrain, Propeller/rotor malfunction
Occurrence class
Accident
Highest injury level
Serious
Aircraft details
Manufacturer
Robinson Helicopter Co
Model
R22 Beta
Registration
VH-UBY
Serial number
4733
Aircraft operator
Dustdevil Helicopters Pty Ltd
Sector
Helicopter
Operation type
Part 138 Aerial work operations
Activity
General aviation / Recreational-Aerial work-Agricultural mustering
The ATSB is investigating a runway event involving a Beechcraft B200C King Air, registered VH‑FDI, at Brisbane West Wellcamp Airport, Queensland, on 24 February 2026.
During take-off for an aeromedical flight with 2 medical crew on board, the sole pilot misaligned the aircraft on the runway and struck a runway light. The pilot rejected the take-off and the aircraft sustained minor damage.
The ATSB has completed the evidence collection and analysis phases of the investigation and is drafting the final report.
The final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
Last updated:
Occurrence summary
Investigation number
AO-2026-062
Occurrence date
24/02/2026
Occurrence time and timezone
00:03 Eastern Australia Standard Time
Location
Brisbane West Wellcamp Airport
State
Queensland
Report status
Pending
Anticipated completion
Q3 2026
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation phase
Final report: Drafting
Investigation status
Active
Mode of transport
Aviation
Aviation occurrence category
Ground strike, Rejected take-off
Occurrence class
Incident
Highest injury level
None
Aircraft details
Manufacturer
Hawker Beechcraft Corporation
Model
B200C
Registration
VH-FDI
Serial number
BL-162
Aircraft operator
Royal Flying Doctor Service of Australia (Queensland Section) Limited
Sector
Turboprop
Operation type
Part 135 Air transport operations - smaller aeroplanes
Activity
Commercial air transport-Non-scheduled-Medical transport
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation. Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information in them is de-identified.
What happened
On 21 November 2025 at approximately 1135 Central Standard Time, the pilot of a Piper PA‑32R was conducting a private flight from Numbulwar Aerodrome to Tindal Aerodrome, Northern Territory. During cruise the aircraft engine experienced a sudden loss of performance and subsequently failed at 2,500 ft above mean sea level.
The pilot undertook immediate engine failure actions and attempted multiple restarts but was unable to restore power. The pilot conducted a forced power-off landing in a clear area north of Bamyili, Northern Territory.
During the landing the aircraft impacted trees and uneven ground surfaces, resulting in substantial structural damage including a detached left wing tip and landing gear, a hole in the right wing and bent propellor blades. The pilot was able to self-evacuate and did not sustain any injuries.
Figure 1: Aircraft accident site
Source: Operator
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
