Summary video

The occurrence

Background

On 13 July 2025, a Metro Trains Melbourne (MTM)[1] train was providing passenger services on the Mernda and Hurstbridge lines on the metropolitan network in Melbourne, Victoria (Figure 1). The train comprised 2 coupled X’Trapolis 3-car sets.

Figure 1: Mernda and Hurstbridge lines

Source: Digital Atlas of Australia, annotated by the Office of the Chief Investigator (OCI)

That evening, it was scheduled to undertake a final round trip from Flinders Street Station (Melbourne) to Mernda and return. For this round trip, there were 2 drivers in the driving cab, the rostered driver and a principal driver.[2] The principal driver was in control of the train for this round trip as they were seeking to maintain familiarity with driving this route. The outbound journey from Melbourne to Mernda was uneventful, and the train arrived at Mernda station at about 2131. 

The derailment

At about 2146, the train departed Mernda towards Melbourne as service TD1094, the final service of the evening before the line was to close for overnight maintenance. Initially the service proceeded as normal, stopping at all stations. At about 2225 the train departed Merri station and transited through a tight radius left curve before arriving at Rushall. It departed Rushall station at about 2227 travelling towards Clifton Hill (Figure 2).

Figure 2: Path of service TD1094 towards the High Street bridge

Overview of the incident area and the location of the High Street bridge. Source: Digital Atlas of Australia, annotated by OCI

After its departure from Rushall, the train initially accelerated to about 38 km/h. The driver then reduced the train’s speed in preparation for the right curve over the High Street bridge.[3] It was this driver’s normal practice to slow to about 30 km/h for this curve, which had a 40 km/h permitted speed. At about 2228 the train was proceeding through the curve at about 28 km/h when the leading wheelset of the first bogie of the 5th car derailed on the bridge (Figure 3). The left wheel of this wheelset had climbed over the left rail toward the outside of the right curve.

Figure 3: Location of derailment on the High Street bridge

Source: Nearmap, annotated by OCI

As a result of the leading wheelset moving to the left, the right wheel dropped to the inside of the right rail. The train continued to cross the bridge with the derailed wheelset impacting rail fixtures and sleepers. Witness marks on sleepers were consistent with the initial derailment being a single axle (Figure 4).

Figure 4: Marks made on sleepers by the derailed wheels 

Source: OCI

Initially the derailed wheels moved along the sleepers in close proximity to the rails. However, once off the bridge deck, the wheel path began to move further to the left until the front of the car-body and the first bogie struck a stanchion, part of an overhead wiring gantry. The impact of the front left corner of the bogie with the stanchion further rotated the bogie in an anticlockwise direction,[4] derailing its trailing axle toward the inside of the right curve and pushing the leading end of the 5th car back towards the alignment of the track.

The stanchion was substantially damaged by the impact (refer to photo at top of page) which caused the overhead wire that supplied electrical power to trains to move and lose tension. This resulted in electrical arcing between the overhead wire and the train, most probably the pantograph[5] mounted on top of the 5th car.[6]

The 2 drivers were not initially aware of the derailment. Instead, they were alerted to an issue when they heard the electrical arcing and observed the overhead wire moving in front of the train. The principal driver made a brake application, and the train was brought to a stop after travelling about 120 m in a derailed state. The train’s carriages remained connected, and the internal passenger compartment spaces were not damaged. There were no injuries to passengers or train crew.

Incident response and passenger evacuation

At 2229, after stopping the train, the principal driver made a radio call to the MTM train control centre (Metrol) informing them of a probable issue with the overhead power. In discussion, the principal driver and the Metrol train controller agreed that the principal driver would investigate further. The principal driver moved to the rear of the leading 3‑car set before alighting on the train’s left side. The other driver remained in the leading driving cab at the controls of the train.

An operator at MTM’s electrical systems control centre (Electrol) had also identified a potential electrical issue in the area at about the same time. Circuit breakers at sub‑stations supplying power to the Rushall station area had tripped. At about 2230, in response, field staff were tasked to patrol the area and look for a fault. Shortly after, the Metrol train controller notified Electrol of the train’s loss of power. Responding to the updated information, Electrol arranged for the overhead power response team to attend the incident.

Meanwhile, the principal driver proceeded back along the outside of the train and observed that that the leading bogie of the 5th car was derailed. They recalled that they attempted to call Metrol by mobile phone to inform them of the derailment, however the line was busy. They then called one of MTM’s rail incident commanders (RIC)[7] and informed them of the derailment.

While the principal driver was inspecting the train from its left side, the driver who remained in the driving cab looked down the right side of the train and observed the trailing axle of the leading bogie on the 5th car derailed to that side (Figure 5). They reported the derailment to Metrol by train radio at 2239.

Figure 5: View of derailment from the front of the train

Source: Supplied

The RIC arrived at the incident at about 2306 and the overhead power response team arrived at about 2310. At about 2317 the RIC reported their observations to Metrol including the substantial damage to the overhead power stanchion.

There were about 30 passengers on board the train at the time of the derailment.[8] Passengers were moved into the leading car of each 3‑car set (the 1st and 4th cars) to wait until it was safe to detrain. While they waited, passengers in the 4th car repeatedly forced open the mid‑car passenger doors. However, passengers remained on board and did not self-detrain.

At about 0128 following confirmation from the overhead power response team that the site had been made safe, the RIC reported to Metrol that it was safe to detrain passengers. Passengers were detrained through the driving cab doors of the 3rd and 4th cars with no reported injuries during the evacuation. 

Context

The train

Configuration

The train operating as TD1094 was a 6-car set made from 2 coupled X’Trapolis 3‑car sets.[9] The leading car‑set comprised cars 17M, 1309T and 18M and the trailing car‑set comprised cars 854M, 1627T and 853M (Figure 6).

Figure 6: Orientation of train for service TD1094

Source: MTM, modified and annotated by OCI

The motor (M) cars in each car-set incorporated a driving cab and traction motors. The trailer (T) cars were each fitted with a pantograph and associated power infrastructure that drew power from the overhead wire and distributed it to the traction motors on the motor cars. The trailer cars were not fitted with traction motors.

These car-sets had been operating together since 3 July 2025, including several services on the Mernda line up until 8 July. This train did not operate again on the Mernda line until 13 July, the day of the derailment. The derailment occurred on the fourth inbound Mernda to Melbourne trip the train had undertaken on the day.

Maintenance of derailed car-set

The most recent maintenance on the trailing 3‑car set 853M‑1627T‑854M[10] was completed on 6 June 2025. This maintenance included re‑profiling of all wheels on the 3 cars to the target (MP2) profile for the MTM passenger train fleet. At the time of the derailment, the wheels had travelled about 12,800 km since re‑profiling and measurements taken after the derailment showed that there had been little wear.

Inspection of the derailed car

Damage to the 5th car was consistent with the derailment sequence including impact damage to the leading left corner of the car‑body, bogie frame and suspension components (Figure 7). The impact with the stanchion also resulted in extreme rotation of the derailed bogie. This rotation damaged further suspension components and resulted in the rear left corner of the bogie frame impacting and piercing a battery box mounted to the underfloor of the car body. Rolling stock component testing and assessment is ongoing.

Figure 7: Impact damage to the car-body, bogie frame and suspension of the 5th car

Source: OCI

Power supply

The Melbourne metropolitan rail system is an electrified network. Trains were supplied 1500 V direct current (DC) by an overhead wire system. The power was distributed to the network in sections by sub‑stations that transformed a 22 kV alternating current (AC) electricity supply to 1500 V DC. The stanchion that was impacted during the derailment was part of a gantry that carried both the 1500 V DC overhead wire and 22 kV AC conductors, both of which were damaged during the impact.

Track

Layout

The distance from the departure end of the Rushall station platform to the start of the High Street bridge was about 220 m.[11] There were 2 parallel tracks on the bridge and the train was on the track normally used for trains travelling toward Melbourne.

Approaching the High Street bridge from Rushall, the track was tangent (straight) and uphill before transitioning to a right curve that continued over the bridge and toward Clifton Hill. Track geometry measurements taken in May 2025 (prior to the derailment) indicated the tightest radius in the right curve was about 258 m. There was also a vertical curve through the location with the bridge on a crest. Track geometry was measured following the derailment and assessment is ongoing.

Maintenance

Track maintenance on the High Street bridge was undertaken on the nights of 8 and 9 July 2025. The maintenance works included replacing 27 timber sleepers and ballast along a length of about 14 m at the Rushall end of the bridge. Additionally, both rails were replaced across the full span of the bridge (about 25 m).

Flange climb derailment

Post-derailment track inspection identified witness marks consistent with a left wheel climbing the left rail near the Rushall end of the bridge. The point of flange climb was about 1.9 m from the start of the bridge and the wheel dropped to left of the rail after travelling about 3.4 m along the top of the rail (Figure 8).

Figure 8: Distances of left wheel derailment from the Rushall end of the bridge

The derailment occurred on the High Street bridge. The approximate distances from the Rushall station end of the bridge are shown for key events. Source: OCI

The witness marks were consistent with the tip of the flange of the left leading wheel of the 5th car climbing onto the top of the rail from the inside (right) and running diagonally along the rail head before dropping to the left (Figure 9).

The presence of the wheel flange tip mark indicated that the initial derailment was by the action of flange climb. Flange climb occurs when lateral forces between the wheel and the rail exceed the capacity for vertical forces to restrain, either through excessive lateral force alone, or a combination of increased lateral force and reduced vertical force. The location of the derailment was in a tight radius curve. Therefore, the lateral force on the flange of the leading outside wheel was already high, as it was required to provide the force to turn through the curve.

Figure 9: Witness marks along the head of the left rail

The figure shows the flange climb mark made by the tip of wheel flange looking in the train’s direction of travel. The inset shows additional detail along the rail gauge corner. Source: OCI

Further investigation

To date, the following activities have been undertaken:

• Inspections of the incident site
• Inspections of rolling stock
• Examination of track geometry and rail profile
• Examination of train recorded data
• Examination of maintenance records
• Review of recorded communications between involved parties
• Interviews with involved parties.

The investigation is continuing and will include further review and analysis of:

• Factors potentially related to the flange climb derailment including:
  • Rolling stock wheel and suspension component condition
  • Track condition including geometry and maintenance practices
  • Wheel to rail contact conditions
• The emergency response to the derailment and overhead damage.

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, relevant parties will be immediately notified so appropriate and timely safety action can be taken. 

Rail safety investigations in Victoria  Rail safety investigations in Victoria are conducted by the Office of the Chief Investigator (OCI) in accordance with a collaboration agreement with the ATSB. OCI is the operational office of the Chief Investigator, Transport Safety, a statutory position established in the Transport Integration Act 2010 (Vic) to provide independent, no-blame investigation of transport safety matters in Victoria.  Under the collaboration agreement with the ATSB, OCI staff exercise powers and perform functions under the Transport Safety Investigation Act 2003 (Cth), and reports are approved for release under the TSI Act by the ATSB Commission. 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. Investigations under the TSI Act do not 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.  Under the TSI Act investigations endeavour 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.  TSI Act investigations are not 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. 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.

The occurrence

At 0832 local time on 7 February 2025, the 327 m bulk carrier FMG Nicola (image above) completed loading 237,088 t of iron ore at its berth in Port Hedland, Western Australia. The fully laden ship had a draught of 17.51 m forward and 17.69 m aft and was due to depart its berth in the afternoon (a high water of 5.56 m was predicted for 1634). 

At 1330, 2 harbour pilots, one of whom was under supervision, boarded the ship. The port authority’s marine services delivery manager (MSDM), who was also a harbour pilot, boarded to observe the departure. By 1348, the ship’s main engine and steering had been satisfactorily tested and the master-pilot information exchange was completed in readiness for departure. The pilot under supervision would conduct[1] the pilotage and 4 tugs were secured to assist (see the section titled Towage).

By 1412, all mooring lines had been cast off and the ship departed the berth (Figure 1). There was a 25-knot north‑north‑west wind with waves of up to 1.5 m on a 0.5 m swell in the area, including the port’s single shipping channel.

Figure 1: Overview of FMG Nicola's track through shipping channel

Source: Australian Hydrographic Office, data from Australian Maritime Safety Authority

At 1442, with the ship progressing along the channel as planned, the MSDM disembarked via pilot launch. At 1446, one of the tugs was let go and returned to base.

At about 1500, FMG Nicola was turned to port to follow the channel at a speed of about 7 knots. Of the 3 tugs assisting, FMG Mako was fast at the ship’s port shoulder,[2] FMG Dusky at the starboard shoulder and FMG Spinner through the centre lead aft. 

At 1514, as the ship approached beacons 32-33 (Figure 1), the pilot ordered a heading[3] of 334°. At about this time, FMG Mako’s master requested the pilot for its towline to be let go as there were choppy seas on the ship’s port side. The pilot concurred, and the towline was let go at 1515.

Soon after, at about 1516, FMG Nicola’s main engine suddenly shut down as it was passing beacons 32-33 (Figure 2). The ship’s speed was 8.3 knots and the pilot ordered the rudder midships. The pilot informed the tug masters that the ship had lost propulsion and directed them to help keep it in the channel. 

Figure 2: FMG Nicola track from about 1516 to 1552

Source: Australian Maritime Safety Authority, Marine Traffic, annotated by the ATSB

At 1518, the pilot notified Port Hedland vessel traffic service (VTS) of the emergency and requested additional tugs. The pilot gave helm orders and used the tugs to follow the channel. The ship’s speed had decreased to 7.4 knots and it was getting closer to the western side of the channel and with a slow rate of turn of about 4° per minute to port (Figure 3).

Figure 3: FMG Nicola speed and rate of turn at the time of the incident

Graph derived from Automatic Identification System data and should not be used for further analysis. Source: Australian Maritime Safety Authority, analysis by the ATSB

Meanwhile, the ship’s engineers identified that the engine had shut down as the ‘main bearing and thrust bearing lubricating oil pressure low’ non‑cancellable trip had activated. The engineers determined that it had activated due to faulty operation of the pressure switch. After confirming all engine systems were operating normally, the engine trip lockout system[4] was reset and, at 1523, the engine was restarted at dead slow ahead. 

At about 1525, FMG Nicola had passed beacons 30-31, and, with a rate of turn 7.5° per minute to port and speed of 4.3 knots, it closed on the eastern side of the channel. Soon after, the ship stopped turning and began moving along the side of the channel, which was aligned along a 318° (T) direction there.

The ship continued to move along the side of the channel (Figure 2). At 1534, the first of the additional tugs arrived and was tasked to push up on the ship’s starboard side. In the following 10 minutes, 3 more tugs arrived and assisted as required by the pilot. At 1540, the ship passed close to beacon 28 while moving along the side of the channel at a speed of 2.5 knots.

By 1550, the ship had been moved away from the channel side and its speed was increasing as the main engine speed had progressively been increased to full ahead. The tugs continued escorting the ship out the channel towards open water.

At about 1635, 3 tugs were released and a further 2 were released about 10 minutes later as the ship approached beacons C11-C12. The remaining 2 tugs were retained and escorted the ship until it passed beacons C1-C2 and to sea. 

By the time the ship passed beacons C1-C2, the ship’s crew had completed inspecting and testing the main engine systems and rectified the fault. They had also conducted an inspection, including sounding compartments, to confirm there was no ingress of water. 

Shortly after, at 1806, the pilots departed the ship by helicopter and the ship continued its passage to the next port, Dongjiakou, China.

During the passage, the crew inspected all ballast tanks on the starboard side and found no physical damage to the ship’s side or structure.

Context

FMG Nicola

General details

FMG Nicola was a Singapore-registered, capesize[5] bulk carrier built in 2016 by Jiangsu Yangzi Xinfu Shipbuilding, China. At the time of the incident, the ship was owned and operated by Fortescue Shipping Nicola, managed by Bernhard Schulte Shipmanagement (BSM), Hong Kong, and classed with Lloyd’s Register (LR).

At the time of the incident, FMG Nicola was crewed by 23 Sri Lankan and Indian nationals, including the master, all appropriately qualified for their positions on board.

The master had 26 years of seagoing experience, all on bulk carriers, with about 4 years in command. The master joined Bernhard Schulte Shipmanagement in 2015 and had completed several assignments on FMG Nicola since 2021. 

The chief engineer had about 18 years of seagoing experience, with about 9 years at that rank. The chief engineer joined Bernhard Schulte Shipmanagement in September 2024 and was assigned to work on FMG Nicola.

Main engine 

FMG Nicola’s propulsion was provided by a 6‑cylinder, MAN‑B&W 6G80ME‑C9.5 engine developing 18,240 kW. The main engine drove a single 4‑blade, fixed‑pitch propeller, providing a service speed of 14 knots.

Lubricating oil system

The main engine lubricating oil (LO) system was fitted with a hierarchy of oil pressure monitoring and alarm controls to limit inadvertent engine stoppage while preventing catastrophic engine damage. In addition to local, analogue indicators and pressure gauges, the LO pressure was monitored via a pressure transducer and pressure switches (Figure 4).

Signals from the sensors fed into the ship’s machinery alarm, monitoring and control system. This system provided real time, remote indication of the LO pressure. Software limits were incorporated to trigger alarms and other actions. Normal operating pressure for the system was about 250 kPa with software triggers set at:

• 210 kPa for standby pump start
• 200 kPa for low LO pressure alarm
• 180 kPa for main engine slow down alarm.

In addition to these triggers and alarms, the main engine LO system had a separate pressure switch set to activate at 160 kPa. This switch, independent of the oil pressure monitoring circuit, was for the main engine low LO pressure shutdown. This initiated rapid shutdown of the engine to prevent catastrophic damage due to complete loss of bearing lubricating oil. 

Figure 4: Main engine lubricating oil pressure sensing and switches

Source: Fortescue Metals Group

The normal, expected, sequence of loss of LO pressure indications would follow persistently falling oil pressure: standby pump start, low pressure alarm and main engine automatic slow down prior to main engine shutdown.

The machinery monitoring system allowed for (adjustable) time delays on activation of each of these triggers. At the time of the incident, the engine LO pressure shutdown delay was set to 0.1 s (following subsequent advice from the engine manufacturer that the delay could be increased up to 2 s, it was reset to 1.9 s).

Components of the main engine LO system were subject to regular maintenance through the ship’s planned maintenance system (PMS). The PMS records showed that the main engine pressure transmitter and pressure sensors had last been checked on 15 November 2024 (about 3 months before the incident).

Post‑incident action

The ship’s managers (BSM) conducted an investigation, which focused on the cause of the main engine shutdown. Other interested parties also conducted independent investigations, which included inspections by the engine manufacturer and an underwater (dive) survey. All investigations concluded that the root cause of the main engine shutdown was a faulty lubricating oil low pressure switch which triggered an engine emergency stop despite all system parameters being normal.

The separation between the LO shutdown system and the pressure monitoring system meant that when the shutdown switch activated, the monitoring system low LO pressure alarm was not triggered, and the pressure display did not show a fluctuation in pressure. 

Inspection and testing of the shutdown pressure switch showed it to activate at 185 kPa and to operate erratically. The switch was replaced with a new spare on board and the operating point set to 160 kPa. In addition, the planned maintenance system routines were amended to require calibration of main engine LO pressure switches monthly and replacement of the shutdown switch reduced to 2.5 years (from 5 years).

The ship’s hull inspections included an underwater survey. In summary, the survey report indicated that no evidence of hull or bilge keel damage was found and the hull paint was intact. Similarly, no damage to the propeller and rudder was reported.

All inspections, testing and corrective actions were conducted to the satisfaction of Lloyds Register, the ship’s Classification Society.

Port Hedland

General information

Port Hedland, situated in the Pilbara region of Western Australia, is the world’s largest bulk export port by tonnage, handling over 500 million tonnes of cargo annually. More than 95 per cent of this volume is iron ore, exported primarily by BHP,[6] Fortescue Metals Group (FMG) and Roy Hill Infrastructure, with the port serving as the companies’ main export hub for all Pilbara output. In addition to iron ore, the port also handles exports of salt, manganese, copper concentrates, lithium minerals and livestock.

At the time of the incident, the port’s infrastructure comprised 19 operational berths. Eight of these berths were owned and operated by BHP, with the remaining berths owned and operated by FMG (5 berths), Roy Hill (2 berths) and Pilbara Ports Authority[7] (4 berths). Shipping activity is significant, with more than 6,000 ship movements (inbound and outbound) each year.

Shipping channel

Access to the port was provided by a single 22‑mile[8] dredged channel, which allowed only one large ship to pass at a time. For most laden ships, particularly capesize ships, such as FMG Nicola, use of the channel was restricted by tidal conditions. The incident took place within the 10‑mile section of the channel closest to the port, an area prone to strong tidal flows and with particularly confined spaces, narrowing to a minimum width of 162 m and featuring steep batter slopes. The channel depth in this section was maintained at about 15 m, while adjacent waters were generally about 6 m deep.

The features of the channel described above make the risks associated with channel blockage high. A disabled ship can strand on a receding tide as well as blocking the passage of other ships. Depending on departure times, separation between ships and the location of an incident, up to 3 additional ships could be committed to, or within, the channel and exposed to this hazard at a given time. 

Pilbara Ports Authority

The port was managed by the Pilbara Ports Authority (PPA), which had overarching responsibility for safety and efficiency of port operations and the environment under state legislation. The PPA’s jurisdictional responsibilities were exercised through the Port Hedland harbour master.

The harbour master’s responsibilities included the coordination of vessel traffic services, ship scheduling, pilotage and maintenance of shipping channels, navigational aids and port infrastructure. The PPA issued third‑party contracts or licences for stevedoring, towage, some pilotage services and pilot transfers (helicopter and boat). 

Pilotage

Vessels 35 m or greater in length using the main shipping channel and navigating within port limits were required to use the services of a licenced harbour pilot. Pilotage services for the port were provided by PPA through directly employed pilots as well as by third‑party, contracted providers.

The pilots on board FMG Nicola at the time of the incident were employed by PPA. All PPA pilots had undertaken a competency‑based pilotage training program incorporating on‑water and simulator training and competency assessments.  

The supervising pilot had worked for PPA since 2023. They had over 25 years of experience in the maritime industry, including positions as a marine pilot in Brisbane, Queensland, as an LNG loading master and as Senior Advisor Seafarer Standards with AMSA.

The pilot under supervision joined PPA in 2024 after more than 15 years as a pilot in Ningbo‑Zhoushan, China. At the time of the incident, they held a level 3 authority to pilot in Port Hedland and were undertaking supervised pilotages to upgrade this licence to level 4.

Towage

The Port of Port Hedland - Port User Guidelines and Procedures documented the tug allocation requirements based on specified criteria. Laden outbound capsize ships required 4 tugs secured to the ship from the berth to Hunt Point, near the harbour entrance. The requirement for the transit from Hunt Point to beacons 31/30 was 3 tugs. 

Tugs in Port Hedland were operated under towage licences granted by the PPA to Pilbara Marine (a subsidiary of FMG) and BHP Towage Services (BHPTS). KOTUG operated tugs under the Pilbara Marine towage licence while Rivtow was contracted to operate the tugs under the BHPTS licence. 

The 4 tugs assigned to FMG Nicola on the day of the incident were ART85‑32W class advanced rotortugs, operated by KOTUG. Each tug had a bollard pull[9] of 85 tonnes and used a hybrid propulsion arrangement with 2 azimuth thrusters forward and a third azimuth thruster aft. 

The tugs which came to render assistance after FMG Nicola lost propulsion were operated by Rivtow and comprised of 2 ART80‑32 rotortugs and 2 RAstar85 azimuth stern drive (ASD) tugs.

Investigation into incident

Pilbara Ports Authority conducted an investigation into this incident, which focused on the loss of propulsion, the effectiveness of pilotage and towage procedures, and the response. The investigation recommended updating pilotage emergency response procedures to consider loss of ship propulsion resulting in loss of steerage and optimal positioning and use of tugs. Another recommendation was the additional training of pilots and tug masters, including on the hydrodynamic interaction between tugs and ships with low under keel clearance.

Incident reporting

The Navigation Act 2012 required owners and masters of all vessels involved in a marine incident in Australian waters report it to the Australian Maritime Safety Authority (AMSA).[10] The reporting involved a 2-step process by submitting an:

• incident alert form[11] as soon as ‘reasonably practicable’ (within 4 hours) after the incident either online or by email to the AMSA email address identified on the form.
• incident report form[12] with further details within 72 hours. 

Additionally, incidents were required to be reported to the ATSB in accordance with the governing legislation.[13] Under this legislation, responsible persons (that in summary, included the ship’s master, owner, operator, agent, the pilot, pilotage provider and VTS authority) were required to report an incident. Incident reports submitted to AMSA are forwarded to the ATSB, which allowed a responsible person to meet their TSI Act reporting obligations. 

Reporting of the incident

At 1642 on 7 February, a couple of hours after FMG Nicola’s propulsion loss, the ship’s local agent asked the master to submit the required incident reports, including the AMSA forms. Later that evening, the master emailed incident reports and supporting documents to the agent.

The following morning, 8 February, the agent forwarded the incident reports, including AMSA forms 18 and 19, and attachments to relevant parties, including AMSA’s local office in Port Hedland. The reports were forwarded to AMSA’s incident reporting email address on 10 February. The notifications submitted by FMG Nicola’s master regarding the loss of propulsion incident did not, at that time, reach the ATSB.

On 12 February, AMSA received an anonymous marine safety concern (AMSA form 355) of a ‘grounding event’ involving the ship that reportedly had occurred at 1412 on 8 February (the day after FMG Nicola’s departure). This report was forwarded to the ATSB and AMSA’s offices in Fremantle and Port Hedland. The Port Hedland office reported back that the ship’s agent and PPA had no record of a grounding event, but noted there had been a stoppage of the ship’s main engine during departure.

The ATSB immediately followed up AMSA for information about the anonymous report but no further information was reportedly available. Over the following weeks, the ATSB followed up with AMSA to check if further information, including AMSA incident report forms, had become available. The ATSB was advised no further information was available.

In July of 2025, the ATSB became aware of media reports about the grounding of FMG Nicola while departing Port Hedland on 7 February. The ATSB again followed up with AMSA and was advised that there was no information about such an incident, other than the form 355 previously provided.

The ATSB then contacted PPA, which confirmed an incident involving a loss of the ship’s propulsion had occurred. The port authority also provided copies of the incident reports and attachments that the master had submitted in February via the ship’s agent.

On 9 July 2025, after assessing the incident reports and other available information, the ATSB formally commenced an investigation into this incident and its reporting.

Further investigation

To date, the ATSB has collected evidence from relevant parties including:

• AMSA
• PPA
• FMG Nicola’s master
• FMG Nicola’s managers
• FMG Nicola’s local agent
• FMG International.[14]

The investigation is continuing and will include examination and analysis of the evidence received, including:

• event sequence
• corroborating data
• ship track and position
• response to the incident
• reporting of the incident to authorities.

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 appropriate and timely safety action can be taken.

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 7 July 2025, a Kavanagh Balloons G-450, registered VH-FGC, was conducting a morning scenic flight near Beaudesert, Queensland, carrying 20 passengers and the pilot.

Shortly after launch when climbing above a ridge, the pilot identified a change in the expected wind direction and the presence of fog. The pilot considered the safest option available was to proceed to an alternate landing site in reduced visibility. However, on approach to land, a low-level wind shift changed the balloon direction. The pilot elected to conduct a landing at a different landing site rather than continue flight over populous areas.

On landing, the balloon basket was carried forward with momentum, it skipped several times before it came to a stop. However, the balloon envelope made contact with a dead tree, resulting in minor damage to the envelope. No injuries were reported.

What the ATSB found

The ATSB found that the pilot reassessed operational and safety decisions as unexpected weather impacted the flight (wind direction and fog). Ultimately the pilot was unable to avoid contact with a dead tree in the final stages of landing in reduced visibility.

However, comprehensive passenger safety briefings meant that passengers adopted brace positions prior to landing which likely prevented injury.

Safety message

The formation, movement and depth of fog is difficult to predict with accuracy, which can lead to pilots inadvertently flying into reduced visibility. 

If contemplating ballooning operations in conditions conducive to fog development, even if it is not forecast, pilots are strongly encouraged to not only be aware of the possible formation of fog, but to plan for its likely effect on their flight. 

This accident highlights the importance of effective safety briefings and how passengers adopting the correct body position during landing substantially reduces the likelihood and severity of injury. The pre-flight briefing is critical in ensuring passenger preparation, particularly as opportunities to reinforce this information during flight may be limited. 

Pilots should use all available resources (such as passenger demonstrations and safety briefing cards) to ensure that each passenger understands the landing position and its importance.

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

The investigation

The occurrence

On 7 July 2025, a Kavanagh Balloons G-450, registered VH-FGC, operated by Hot Air Pty Ltd was conducting a morning scenic flight near Beaudesert, Queensland. 

The pilot conducted multiple weather assessments prior to the flight (see Pre-flight observations), and the balloon was set-up with the assistance of ground crew at The Overflow Estate (Figure 1).

At approximately 0623 local time, the balloon departed The Overflow Estate, at Wyaralong Dam in a north-easterly direction, carrying 20 passengers and one pilot. Based on their pre‑flight weather assessment, the pilot originally intended to land in a south-east landing site near Bromelton (Figure 1) and the ground crew had been instructed to make their way via car to assess the wind conditions near the intended landing site. However, after take‑off the balloon maintained a north-east flight path towards Woodhill and Cedar Grove.

Figure 1: Flight path overview

Source: Google Earth, annotated by the ATSB

About 13 minutes after launch, the balloon had passed over the dam when the pilot climbed the balloon over a ridge line. At about 500 ft above ground level (AGL), the pilot described encountering fog in the direction of travel (Figure 2). The pilot discounted nearby options for an early landing and considered that the safest option available, in the reduced visibility, was to select a new landing site clear of hazards in the north-east (Figure 3).

Figure 2: Fog visible after climbing a ridge at 0636

Source: Operator, annotated by the ATSB

Figure 3: Flight path details

Source: Google Earth, annotated by the ATSB

While en route to that preferred landing site, the fog thickened, before the pilot climbed the balloon above the fog (Figure 4).  

Figure 4: Fog conditions below the balloon at 0640

Note: Two other balloons from a separate (unidentified) operator were visible above the fog at this time. Source: Operator

At about 0703, while on approach to the preferred landing site (Figure 3), the balloon encountered a low-level wind change at about 200 ft, increasing in strength from 4–6 kt. The wind change tracked the balloon 90 degrees left, and made landing unfeasible due to a dam and trees. 

The wind shift was unexpected to the pilot as they described that surface conditions looked calm, with the fog not appearing to move. Due to ground crew traveling back from the first intended landing site, the pilot did not have information usually available via a surface wind assessment on the ground.

The pilot reconsidered the safest options available considering the reduced visibility and selected a different landing site further north, which was used infrequently by the operator, was closer to a populated area and isolated trees, but with no identified powerlines (Figure 3). The pilot burned[1] to lift the balloon over a wet area before descending towards the new landing site. 

On approach, the pilot burned again to lift the balloon over a boundary fence (Figure 5) before they commenced deflation to descend for landing and instructed the passengers to adopt their pre-briefed brace positions. While approximately 5 m from the ground, the pilot visually detected a dead tree (Figure 5). In response they rapidly deflated the balloon in an attempt to stop short of the tree. The pilot further reinforced the brace instruction to the passengers. At 0709, the balloon basket touched down, however was carried forward with the balloon’s resultant air mass momentum. The basket skipped 4 times before it stopped moving (Figure 5), however the balloon envelope inertia continued until the envelope contacted a dead tree (to the left of the basket), resulting in minor damage. 

Figure 5: Onboard video of the approach (left) and the final approach flight path (right)

Source: Operator and Google Earth, annotated by the ATSB 

The pilot and passengers were uninjured, and due to the delayed arrival of the ground crew, the pilot sought the help of 3 volunteer passengers to recover the envelope from the tree. There was no resultant damage to the basket, however envelope damage included 15 large tears due to contact with the dead tree.

Context

Personnel information

The pilot held a commercial pilot licence (balloon), with 1,253.2 hours total flying time, of which 1,174 hours were flown as pilot in command. In the previous 90 days, the pilot had flown 40.2 hours as pilot in command, including 7.2 hours on the G-450.

The pilot held a current CASA class 2 aviation medical certificate with no conditions.

The pilot reported starting work at 0430 on the day of the occurrence, having obtained about 6 hours of sleep the night before, and an additional 30‑minute nap the previous morning. They recalled feeling fully alert at the time of the occurrence. 

Aircraft information

VH-FGC was a Kavanagh Balloons G-450 manned free balloon, manufactured in 2017 by Kavanagh Balloons Australia Pty Ltd. The aircraft was certified in the manned free balloon category and operated with a valid certificate of airworthiness.

The G-450 balloon has an envelope capacity of 450,000 cubic feet and a maximum take‑off weight of 3,700 kg. At the time of the occurrence, the balloon envelope had accumulated a total time of 662.6 hours in service, while the basket had accumulated 1,614.1 hours. The basket was designed to carry a maximum of 24 passengers per basket (6 per passenger compartment).

The balloon was fuelled with 358 L of liquid petroleum gas propane at the start of the flight, with 135 L remaining at landing. 

Operator information

Hot Air Pty Ltd operates in the Scenic Rim area of South East Queensland and also the Atherton Tablelands in north Queensland. The organisation has agreements in place with landowners to access several launch and landing locations in a circular pattern near Beaudesert, referred to as the operator’s flying area. The locations include private and commercial properties. 

Recorded information

The balloon was equipped with the following equipment capable of recording:

• a GPS which records the flight track
• a ‘flight tablet’ which included an electronic Google Earth satellite map (Figure 6). The satellite map was overlaid with the operator’s flying map layer which was maintained/updated via an electronic register. The flying map included the following operational information:
  • launch and landing areas / property boundaries (dark blue)
  • sensitive zones (SZs), with restricted operation (red)
  • powerlines (yellow)
  • other relevant landowner information (white text).
• An onboard camera recording the front facing view of the flight.

Figure 6: Operator flying map showing the balloon flight path 

Note: Property names were blurred to maintain landowner privacy. Source: Operator, modified by the ATSB

The final landing site was designated an ‘emergency landings only’ area on the Operator flying map (Figure 6) in Woodhill. The operator occasionally used this site when necessary, but it was not used frequently. 

Meteorological information

Observations for surrounding area

The Beaudesert automatic weather station (AWS) provided the air temperature (°C), dew point temperature (°C), and relative humidity (%) along with other information and showed conditions conducive to fog formation (Table 1), that is: 

• temperature and dew point less than 1°C difference
• winds were calm
• high relative humidity (above 95%)
• no significant weather movement.

Table 1: Beaudesert AWS information for 7 July 2025

Forecast for surrounding area

A local graphical area forecast was valid for a six-hour period from 0300–0900 which indicated visibility of about 300 m with scattered fog.

At 0503, the Bureau of Meteorology (BoM) issued an updated aerodrome forecast (TAF)[2] for Amberley, which indicated fog and reduced visibility of 500 m up until 0700 at which time the conditions could be expected to improve. 

At 0607, the BoM issued a further update to the TAF, which forecast shallow fog with visibility of 8,000 m, and a 30% probability of fog reducing visibility to 800 m and scattered cloud at 200 ft, until 0900 that day. 

Satellite imagery

Satellite imagery was obtained from the BoM, valid as of 0500. The imagery depicted areas of fog or low cloud around, but clear of the original intended area of balloon operation (see Appendix A – satellite images).

Pre-flight observations

The pilot also reviewed several sources of weather information in the preceding hours prior to launch, as required by the operator’s exposition[3] (Version 1, 11 November 2024) and CASR Part 131[4] (Table 2).

Table 2: Pilot weather observations 

Based on the observations the pilot decided to depart from The Overflow Estate launch site (west of Beaudesert) with the plan to fly in a south-east direction back into their operational flying area (and towards Beaudesert). 

Regulatory requirements and guidance

Balloon pilots and operators must also comply with Part 131 of the Civil Aviation Safety Regulations (CASR), pre-flight weather assessment rules in section 12.02 of the Part 131 Manual of Standards (MOS).[5]

Balloon operations can occur in Class G airspace with at least 100 m visibility below 500 ft AGL when outside 10 NM from an aerodrome (such as in the case of Beaudesert). However, CASA highly recommends that pilots and operators exercise this significant reduction in the visibility requirements with caution and only if sufficient flight preparation has taken place. Further balloon guidance is available at Advisory Circular 131-02 v4.0.

Survivability

Pre-flight passenger safety briefing

One consideration in balloon accidents is the basket tipping during landing, which can increase the risk of injury. Tipping is more likely if a basket contacts, or lands on, a tree or fence. 

Passengers were provided with safety briefings and instructions prior to boarding as required by the operator’s exposition. These included:

• entry/exit to the basket
• remaining in the basket until instructed by crew
• securing and stowing personal items
• prohibited dangerous goods
• use of rope handles
• landing/brace positions (for normal/upright landing and emergency/hard landing).

The passengers included several foreign tourists from non-English speaking backgrounds. Verbal information was supported by physical demonstrations (of the required landing position) and graphical briefing cards with basic diagrams and translations in simplified Chinese, Japanese, Korean, and German. 

One passenger reported receiving pre-flight safety information via email at multiple points leading up to the flight, which was then supported by the safety demonstration on the day of the flight.

Related occurrences

A search of the ATSB occurrence database found that in the 10 years to July 2025 there were 37 balloon hard landings, ground strikes, or collisions with terrain in Australia, resulting in 17 injuries. Of these, 13 occurrences involved contact/collision with trees.

Further information on some of these occurrences can be found in Appendix B – Related occurrences.

Safety analysis

As is often required in balloon operations, the pilot was required to reassess operational and safety decisions at multiple points before and during the flight. 

This analysis will explore the assessment of weather, launch location, contingency options, and landings in reduced visibility.  

Fog encountered in flight

Fog was forecast for a wide area that included the operator’s flying area and the local conditions were conducive to fog. Satellite images support the pilot’s report by confirming that fog was likely not visible in the immediate flying area when the pilot travelled to the launch site before the flight. Based on their visibility assessment and pre-flight observations, the pilot determined it was safe to fly. 

However, after take-off and on climbing above the ridge line over the dam, the pilot identified fog in the direction of flight, and the balloon subsequently entered fog.

Approach to land

Once lined up and on approach to land at the preferred landing site, the balloon was affected by an unexpected low-level wind shift and tracked about 90 degrees to the left. 

Subsequently, the pilot considered other landing locations and associated risks, and selected an emergency landing site, used infrequently by the operator.

Reduced visibility

Once committed to landing in the final landing area in significantly reduced visibility, the pilot visually detected a tree through the fog in front of the balloon. In an attempt to take avoiding action, they rapidly deflated the envelope to land the balloon, however due to inertia, the balloon envelope made contact with the tree and was damaged. 

Comprehensive safety briefings

The passengers were provided with comprehensive safety information leading up to, and before the flight. The ground crew and pilot also ensured understanding of the brace positions prior to launch.

As a result of the proper brace position, effective briefing and re-enforced communication during landing, no injuries were sustained.

Findings

From the evidence available, the following findings are made with respect to the controlled flight into terrain involving Kavanagh Balloons G-450, registration VH-FGC, 12 km north‑north-west of Beaudesert, Queensland, on 7 July 2025. 

Contributing factors

• After clearing a ridge line, fog was encountered in the direction of the flight path.
• During the approach to land in low visibility, an unexpected low-level wind shift diverted the balloon away from the preferred clear landing area, and required the pilot to select an alternate unplanned landing site in the final stages of landing.
• Due to reduced visibility, the pilot was unable to see hazardous obstacles in the final landing area and therefore unable to take timely avoiding action.

Other findings

• Comprehensive passenger safety briefings meant passengers adopted brace positions prior to landing which likely prevented injury.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of the accident flight
• the chief pilot of the operator
• Civil Aviation Safety Authority
• Bureau of Meteorology
• accident witnesses
• video footage of the accident flight and other photographs and videos taken on the day of the accident
• recorded data from the GPS unit on the aircraft.

References

CASA (Civil Aviation Safety Authority), (2025), Part 131 Aircraft – Operations, Advisory Circular AC 131-02v4.0, CASA

CASA (Civil Aviation Safety Authority), (2025), CASR Part 131 – Guide for balloons and hot air airships, v1.2, CASA

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

Submissions were received from:

• 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 A – satellite images

High resolution visible satellite imagery

Satellite imagery was obtained from the Bureau of Meteorology and was valid at 0500 (Figure A1) showing fog/low cloud as light blue areas.

Figure A1: High resolution visible satellite imagery from 0500

Note: This imagery was not available to the pilot at the time of the event. Source: The Bureau of Meteorology, annotated by the ATSB

Appendix B – Related occurrences

Hard landing involving balloon, VH-EUA, near Yarra Glen, 8 February 2018 (AO-2018-016)

On 8 February 2018, a Kavanagh B-350 hot-air balloon, registration VH-EUA, departed Glenburn, Victoria, for a scenic charter flight with a pilot and 15 passengers on board. About 45 minutes into the flight, over the Yarra Valley, the balloon experienced a sudden wind change with associated turbulence. The pilot decided to land immediately rather than continue over rising and heavily vegetated terrain. The resulting landing was hard and fast and 11 passengers were injured, with 4 of them receiving serious injuries. 

Collision with terrain involving Kavanagh E-240 Balloon, VH-LUD, near Yamanto, Queensland, on 8 October 2021 (AO-2021-042)

On 8 October 2021, a Kavanagh Balloons E-240 balloon, registered VH-LUD and operated by Floating Images Aust. Pty Ltd was conducting a morning scenic flight about 45 km south‑west of Brisbane, Queensland. On board were a pilot and 9 passengers. About 55 minutes into the flight, the pilot commenced a descent to locate a suitable landing area. During the descent, the balloon entered an area of localised fog where visibility reduced to 10 m.

The pilot continued the descent into the fog until a tree was observed in the path of the balloon. The pilot attempted to avoid the tree by initiating a climb, but the balloon collided with, and came to rest on the side of, the tree, damaging the lower part of the balloon envelope. The pilot subsequently climbed the balloon off the tree and above the fog. The flight continued to an uneventful landing in a nearby paddock that was clear of fog. There were no injuries.

Controlled flight into terrain involving Kavanagh Balloons G-525, VH-HVW, Pokolbin, New South Wales, on 30 March (AO-2018-027)

At about 0710 Eastern Daylight-saving time on 30 March 2018, a Kavanagh Balloons G‑525 balloon, registered VH-HVW (HVW) and operated by The International Balloon Flight Company (Australia), launched from a site near Pokolbin, New South Wales, for a planned 1-hour scenic flight. HVW was one of three balloons launched by the company from the same site. After climbing through fog to about 2,000 ft and realising how far the fog layer extended, the pilot of HVW, along with the other 2 pilots, decided to abort the flight and descend for a landing at the nearest suitable site. On approach to land in low‑visibility conditions, HVW collided with trees, which caused the basket to rotate 180 degrees. It then landed heavily, resulting in injuries to 16 of the 24 passengers, 3 of them serious. The pilot was uninjured and 74 of the balloon’s panels required patching or repair. 

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 25 June 2025, the flight crew of a Jetstar Airways Airbus A321-251, VH-OYF, were conducting a scheduled passenger transport flight, JQ38, from Denpasar International Airport, Bali, Indonesia, to Sydney, New South Wales. The first officer was the pilot flying and the captain was the pilot monitoring.

During the landing at Sydney Airport, the aircraft floated for a prolonged period along the runway, was subject to a right crosswind and drifted left of the runway centreline. The captain responded by commanding a go-round which the first officer executed. 

The crew proceeded to continue with the published missed approach procedure and subsequently landed without further incident. 

What the ATSB found

The ATSB found that after the first officer initiated the flare manoeuvre, their control inputs resulted in a lateral deviation from the runway centreline when the aircraft floated for a prolonged period in crosswind conditions. 

After the captain commanded a go-around, they inadvertently manipulated their sidestick control, which resulted in a brief period where simultaneous control inputs occurred. The crew were alerted by a ‘dual input’ generated voice message and the captain took control. There was a moment of preoccupation which resulted in the first stage of flap being retracted out of sequence, however, there were no associated flight envelope exceedances or negative effects on aircraft performance. 

Safety message

Sound go-around decision-making is an effective defence against the hazards associated with low-level manoeuvring during the landing phase of flight, such as lateral runway excursions. If adequate safety margins cannot be maintained during an approach and landing, the correct and expected response is to go around.

Being go-around minded improves crew readiness and supports timely, coordinated actions during a period of high workload. This should involve crew members reviewing potential go‑around scenarios, procedures and responses prior to conducting an approach. 

When flight crews are faced with the unexpected need to execute a go-around even at the final stages of landing, effective crew resource management, with clear communication between flight crew, is essential. This promotes effective teamwork when responding to disruptions and increased workload under stress, ensuring that the aircraft remains on a safe flight path and is correctly configured for the relevant phase of flight.

The investigation

The occurrence

On the evening of 25 June 2025, a Jetstar Airways Pty Limited Airbus A321-251 registered VH‑OYF was operating on a schedule passenger transport Jetstar flight, JQ38, from Denpasar International Airport, Bali, Indonesia, to Sydney, New South Wales. The flight was scheduled to arrive at Sydney Airport the following morning at 0630 AEST.[1] The operating crew included the captain, first officer, 6 cabin crew and 234 passengers. For the flight to Sydney, the first officer was the pilot flying (PF) and the captain was the pilot monitoring (PM).[2]   

After departing Denpasar, the aircraft climbed to flight level (FL) 330[3] and later descended to FL310 after reaching Australian airspace due to turbulence en route. Due to the turbulence en route, the captain elected not to take any controlled rest on the nearly 6‑hour flight, while the first officer stated they would not usually take controlled rest in flight. 

Prior to descent, the flight crew briefed for the arrival at Sydney, recalling that the turbulent conditions and the crosswind for the approach and landing were the main considerations. 

At 0554, the flight crew commenced their descent to the west-south-west of Sydney Airport and was cleared for the approach for runway 16R[4] which was conducted in day visual meteorological conditions[5] using the autopilot. The flight crew recalled there was a 30 kt crosswind down to about 500 ft above mean sea level (AMSL) and the approach up to that point was ‘pretty normal.’ Air traffic control (ATC) advised the crew to expect an 8 kt right crosswind for landing and the first officer chose to land in the flap 3 configuration,[6] which was consistent with guidance for landing in ‘rough’ conditions. (The first officer was procedurally restricted to a maximum crosswind landing component of 20 kt).

The aircraft reached 500 ft at 0621:14 and the captain called ‘stable’ (see Stabilised approach criteria). The first officer disengaged the autopilot 5 seconds later as the aircraft approached 400 ft and recalled encountering turbulence which placed the aircraft ‘a little higher’ on the approach. At 0621:45 at 90 ft, the first officer pitched forward, which they observed resulted in a 900 ft per minute rate of descent. 

At 0621:51, the first officer initiated the flare at 50 ft and reduced the thrust levers to idle at around the final approach speed (VAPP)[7] of 150 kt, which included a wind correction of 5 kt. At this point the first officer recalled they ‘over flared’. The captain also observed that the first officer applied the flare technique that was consistent with the technique for landing in the flap full configuration. The aircraft subsequently floated for a prolonged period along the runway after the first officer’s flare manoeuvre.

During the prolonged float, the aircraft was subjected to the crosswind conditions for a greater length of time. After observing the centreline deviation, the captain commanded a go-around approximately 600 m past the runway threshold, just prior to touchdown. The captain recalled they were ‘startled by the need to go around’ as the approach seemed ‘benign’ aside from the crosswind. They also reported a sudden stress response at this time as they had to rapidly transition from landing to commencing the go-around.

In response to the captain’s command, the first officer set take-off/go-around thrust at 0621:59 (Figure 1), which initiated the published missed approach procedure for the 16R GBAS landing system (GLS)[8] approach in the aircraft flight management system. The first officer also referenced their primary flight display (PFD) to command a target pitch attitude of 15° nose up.   

At this point, the captain recalled they instinctively applied control inputs via their sidestick while the aircraft was just above the runway, and the crew were alerted to this by the aircraft’s ‘dual input’ voice message (see Sidestick priority logic). 

The captain then engaged their sidestick pushbutton, and the first officer recalled hearing the ‘priority left’ voice message and the captain announce, ‘I have control.’ The captain subsequently took control of the thrust levers and the first officer relinquished control and became PM after the aircraft achieved a positive rate of climb. It was the role of the PM to retract the flap ‘one step’ at this point (see Go-around procedure). 

Figure 1: Overview of go-around 

Source: Google Earth, annotated by the ATSB

The captain announced the active flight modes on their PFD, which prompted the first officer to call ‘positive climb.’ The captain subsequently instructed the first officer to retract the landing gear, which was accomplished 42 ft above the runway at 0622:20. 

At this time, the captain looked up to the flight control unit located on the cockpit glareshield to engage the autopilot. After this was actioned, they looked back to their PFD and was ‘startled’ when they noticed that the aircraft suddenly banked right and responded by disengaging the autopilot at 0622:22. They subsequently realised that the aircraft flight director was providing commands for the published missed approach procedure and subsequently re-engaged the autopilot at 0622:29. 

The captain then requested flap 1, but the first officer noticed they were still configured with Flap 3 and retracted the flap by one step and announced, ‘flap 2.’ This occurred at 0622:32 when the airspeed reached 174 kt, which was below the maximum flap 3 speed of 195 kt.

They continued to follow the missed approach procedure, and the first officer advised ATC they were going around. The crew were given instructions to track for a right downwind for runway 16R at 4,000 ft. The captain recalled conducting a welfare check on the first officer, briefed the cabin manager via the interphone and made an announcement to the passengers through the public address system. 

The captain elected to remain as PF for the remainder of the flight, with the first officer acting as PM. The crew then conducted a second GLS approach for runway 16R, landing at 0638 without further incident.

Context

Flight crew information

The captain held an Air Transport Pilot Licence (Aeroplane), class 1 aviation medical certificate, and had accrued 5,921 hours total flying time, 1,480 of which were in the Airbus A320 and A321 aircraft types.

The first officer held a Commercial Pilot Licence (Aeroplane), class 1 aviation medical certificate, and had 2,212 hours total flying time, 551 of which were on the Airbus A320 and A321 aircraft types.

Fatigue

The captain reported that they felt 'moderately tired' during the go-around, likely due to the back-of-the clock[9] flight, which departed Denpasar at 0057 local time in Sydney. They also stated there was limited opportunity for controlled rest during the flight and their nap prior to the flight was disrupted due to noise at the hotel. The first officer reported feeling 'ok, somewhat fresh.’  

The flight crew also reported they had an adequate rest opportunity the evening prior to the flight and obtained around 6 hours sleep in the previous 24 hours and around 13‍–‍14 ‍hours in the previous 48 hours. Their sleep during the rest opportunity was reported to be good quality and the conditions at the hotel where they spent the night were suitable and therefore conducive to obtaining restful sleep. Biomathematical modelling[10] of the flight crew’s roster for the 2 weeks leading up to the flight indicated a low likelihood of fatigue.

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

Aircraft information

General

The Airbus A321-251NX is a modern, fly-by-wire aircraft, powered by 2 CFM International LEAP-1A32 turbofan engines and had seating for 232 passengers in a single-class layout. 

All the flight controls are electronically actuated with the pilots using sidesticks to fly the aircraft in pitch and roll during manual flight. The 2 sidestick controllers are not coupled mechanically, and they send separate sets of signals to the flight control computers. 

Sidestick priority logic

Jetstar Airways A320-A321 Flight crew operating manual (FCOM) contains the following description of the aircraft sidestick priority logic: 

At all times, only one flight crewmember should fly the aircraft. However, if both flight crewmembers use their sidesticks simultaneously, their orders are algebraically added.

The flight control laws limit the combined order to the equivalent of the full deflection of one sidestick.

In this case the two green SIDE STICK PRIORITY lights on the glareshield come on and "DUAL INPUT" voice message is activated.

 A flight crewmember can deactivate the other sidestick and take full control, by pressing and keeping pressed the sidestick pb (Figure 2).

A “PRIORITY LEFT” or “PRIORITY RIGHT” audio voice message is given each time priority is taken.

Figure 2: Airbus A320/A321 captain's side sidestick and sidestick pushbutton

Source: Operator, annotated by the ATSB

Post-flight maintenance

The operator reported that there were no corrective maintenance actions that were required to be carried out in relation to the occurrence. The aircraft subsequently operated a scheduled passenger service the following day.

Meteorological information

The pre‑flight briefing package provided to the flight crew from the operator’s flight dispatcher included the aerodrome forecast[11] for Sydney Airport. The forecasted weather conditions for the scheduled time of arrival 0630 local time on 26 June indicated:

• wind direction of 240° at 15 kt with gusts up to 25 kt
• CAVOK[12]
• moderate turbulence[13] below 5,000 ft.

One-minute weather data for Sydney Airport from the Bureau of Meteorology indicated a wind direction of 255° at 17 kt with gusts up 20 kt at the time of the occurrence.

Airport information

Runway 16R at Sydney Airport is oriented on a magnetic heading of 155° and has a declared length of 3,962 metres with a width of 45 metres. A precision approach path indicator system is installed and set to 3° with a threshold crossing height of 64 ft. 

For daytime operations, the runway centreline, aiming point and touchdown zone markings provide visual references to assist pilots with approach and landing (Figure 3).

Figure 3: Sydney Airport runway 16R markings

Source: Google Earth, annotated by the ATSB

Recorded information

The aircraft’s quick access recorder data which captured the incident approach indicated that, as the aircraft descended below 1,000 ft, it maintained an appropriate speed and flightpath with no sustained exceedances of the stable approach criteria throughout the approach. 

At 0621:59, the recorded data captured the captain’s control inputs commencing concurrently with the initiation of the go-around, while the first officer was actively manipulating their sidestick control. Simultaneous control inputs lasted for a duration of 6 seconds (Figure 4), while the aircraft’s pitch attitude remained below the aircraft’s pitch limit of 11.5° until the aircraft had climbed through about 50 ft. 

The recorded data further indicated that the wind direction and speed varied following the flare manoeuvre, however the crosswind component remained well below the first officer’s operational limitation. The wind direction and speed was 315° at 13 kt with a crosswind component of 5 kt when the go-around was initiated.

Figure 4: Graphical representation of the recorded quick access data

Source: Quick access recorder from VH-OYF, annotated by the ATSB

Following the initiation of the go-around, the landing gear was retracted at 06:22:20 and 12 seconds later, the flap was retracted to the flap 2 configuration[14] at 174 kt.

Operational information

Stabilised approach criteria 

Jetstar Airways A320-A321 Flight crew operating manual (FCOM) defined a stabilised approach criteria as being established on the correct lateral and vertical flight path by 1,000 ft height above airport (HAA), configured for landing, and within the stated tolerances with the required checklists completed by 500 ft HAA. The FCOM also stated that if these criteria could not be met, or if the approach became unstable below 1,000 ft HAA, a missed approach was required. 

The crew reported the approach was stabilised against these criteria, which was consistent with the available recorded data.

Touchdown zone 

The FCOM provided the following operational information regarding the touchdown zone: 

The touchdown zone commences at 300 m (1000 ft) beyond the threshold and will not normally extend further than 600 m (2000 ft) beyond the threshold.

It is a requirement that the touchdown is planned to occur within the touchdown zone. Should it become apparent that the aircraft will touch down further than 600 m (2,000 ft) beyond the threshold, and the PIC believes that the landing is safe to continue, the PF must apply maximum reverse thrust and sufficient braking to ensure the aircraft stops within the landing distance available. If the PIC decides that a go-around is required, they will without delay, call “Go-Around”. In all cases this must be completed before the PF initiates reverse thrust.

The captain stated that runway 16R in Sydney was long enough to stop the aircraft on the runway if they had continued with the landing during the occurrence. This would have involved requesting maximum reverse and manual braking as necessary after the aircraft touched down. 

The FCOM did not specifically reference runway centreline tracking during a visual approach, however the captain stated that it was their personal expectation that a deviation from the runway centreline would lead them to calling for a go-around. 

Transfer of control  

The operator described procedures for transfer of control within the FCOM as follows:

The pilot relinquishing control of the aircraft shall say “You have control”. The pilot assuming control shall ensure that they have clear and unobstructed access to the flight controls and, when ready, say “I have control”. Only then is the pilot relinquishing control permitted to remove their hands and feet from the flight controls.

In critical phases of flight the PIC must be alert and positioned such that they can assume immediate control of the aircraft.

Following the occurrence, the captain stated the preferable method to conduct a go‑around at low level would have been to announce ‘I have control’ and initiate the go‑around themselves. They stated that their primary consideration when conducting a go‑around at low level was to avoid the risk of tail strike. 

Go-around procedure 

The FCOM defined the go-around procedure for the A320/A321, which specified the task sequence, memory-based crew actions and applicable guidance relating to techniques and navigation (Figure 5).

Figure 5: Jetstar Airway A320/A321 go‑around procedure below acceleration altitude

Source: Operator, annotated by the ATSB

Following the occurrence, the captain stated that although they could have taken over and landed, they believed that going around was considered the safest option. The first officer also stated, at about that time, that they were in the mindset of preparing to initiate a go-around themselves. 

Related occurrences

The following ATSB investigation highlights the importance of pilots maintaining their readiness for a go-around on every approach as it is typically a period of high workload requiring effective crew coordination. 

ATSB Investigation

On the morning of 18 May 2018, an Airbus A320 aircraft, registered VH-VQK, was being operated on a regular public transport flight by Jetstar Airways. The flight departed from Sydney for Ballina/Byron Gateway Airport, New South Wales.

The flight crew conducted a go-around on the first approach at Ballina because the aircraft’s flight path did not meet the operator’s stabilised approach criteria. On the second approach, at about 700 ft radio altitude, a master warning was triggered because the landing gear had not been selected DOWN. The flight crew conducted a second go‑around and landed without further incident on the third approach.

The flight crew did not follow the operator’s standard procedures during the first go‑around and subsequent visual circuit at 1,500 ft. In particular, the flaps remained at flaps 3 rather than flaps 1 during the visual circuit. This created a series of distractions leading to a non‑standard aircraft configuration for a visual circuit. Limited use of available aircraft automation added to the flight crew’s workload.

Safety analysis

During the approach to Sydney airport, with the first officer acting as the pilot flying (PF), the flight crew reported experiencing a crosswind of up to 30 kt until descending through about 500 ft above mean sea level. The crew were advised by air traffic control to expect a right crosswind component of 8 kt for landing, which was within the first officer’s operational crosswind limit of 20 kt. The captain confirmed the approach was ‘stable’ at 500 ft and the first officer continued the approach as PF.

At 50 ft, the first officer initiated the flare manoeuvre prior to landing. They recalled they ‘over flared,’ and the aircraft subsequently floated for an extended period along the runway. During this time, the first officer’s control inputs did not counteract the effect of the crosswind, and the aircraft drifted left of the centreline. After observing the lateral deviation from the centreline, the captain commanded the first officer to conduct a go‑around. 

This occurred just prior to the aircraft touching down when the flight crew would normally be focused on landing. The flight crew did not expect a go-around at the time and had to rapidly shift their focus to conducting the missed approach procedure. The captain recalled being ‘startled’ by the unexpected need to discontinue the landing, however they were more likely experiencing ‘surprise.’ Surprise is a cognitive-emotional response to something unexpected, which results from a mismatch between one’s mental expectations and perceptions (Rivera, Talone, Boesser, Jentsch, & Yeh, 2014). But their decision was consistent with the expectation that an approach be discontinued if the aircraft departed from the correct lateral flight path.

The unexpected change from landing to conducting a go-around close to the ground also resulted in the captain experiencing a sudden stress response at this time. When experiencing acute stress, people can respond quickly to a situation, but without conscious decision‑making (Wickens, Helton, Hollands, & Banbury, 2022). After the go‑around was commanded, there was a rapid increase in pitch attitude, engine thrust and airspeed, and in response the captain instinctively and inadvertently manipulated their sidestick while the first officer was flying, resulting in a dual-input alert. 

The captain reported they only realised they had manipulated their sidestick when they heard the dual input alert. Their primary consideration during the go-around was to avoid an excessive rotation rate to avoid a tail strike, which did not occur. Additionally, operator procedures directed captains to be alert and be positioned to ‘assume immediate control of the aircraft’ during critical phases of flight. 

Following the dual input alert, the captain took full control by engaging their sidestick push‑button and announced ‘I have control’, and the first officer assumed the role of pilot monitoring. A consequence of the control handover during the initial stages of the go‑around was the momentary interruption of sequential crew actions during the go‑around procedures. Interruptions typically disrupt the chain of procedure execution so abruptly that pilots turn immediately to the source of the interruption without noting the point where the procedure was suspended (Loukopoulos, Dismukes, & Barshi, 2009). 

Additionally, there was a further disruption (rapid task switching) associated with the first officer and captain exchanging pilot flying and pilot monitoring roles. As a result, some of the procedural items were completed out of sequence (flap 3 retraction occurred after gear retraction). 

Pilots are highly vulnerable to errors of omission when they must attend to multiple tasks. If one task becomes demanding, their attention is absorbed by these tasks demands and they can forget to switch their attention to other tasks (Loukopoulos, Dismukes, & Barshi, 2009). Although the flap retraction occurred out of sequence during the go-around, there were no associated flight envelope exceedances or negative effects on aircraft performance.  

Findings

From the evidence available, the following findings are made with respect to the control issues during landing and go-around involving Airbus A321, VH-OYF, at Sydney Airport, New South Wales, on 26 June 2025.

Contributing factors

• During the landing after crossing the threshold, the first officer’s control inputs resulted in a lateral deviation from the runway centreline during a prolonged float.
• After calling for a go-around, the captain inadvertently manipulated their sidestick while the first officer was the pilot flying, which resulted in a simultaneous control input and the go-around procedure being completed out of sequence.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Jetstar Airways Pty Limited
• Bureau of Meteorology
• the flight crew
• recorded data from the quick access recorder from VH-OYF.

References

Loukopoulos, L., Dismukes, R., & Barshi, I. (2009). The perils of multitasking. AeroSafety World, 4(8), 18-23.

Rivera, J., Talone, A., Boesser, C., Jentsch, F., & Yeh, M. (2014). Startle and surprise on the flight deck: Similarities, differences, and prevalence. In Proceedings of the human factors and ergonomics society annual meeting (Vol. 58, No. 1, pp. 1047-1051). Sage CA: Los Angeles, CA: SAGE Publications.

Wickens, C. D., Helton, W. S., Hollands, J. G., & Banbury, S. (2022). Engineering psychology and human performance, 5th edn. Routledge, doi: 10.4324/9781003177616.

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:

• Civil Aviation Safety Authority
• the flight crew
• Jetstar Airways Pty Limited
• Bureau of Meteorology.

Submissions were received from:

• the flight crew
• Jetstar Airways Pty Limited.

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.