A Diamond DA40 exceeded airspeed, bank angle and pitch limits after an instructor attempted to demonstrate a wingover, a manoeuvre they had not been trained in, an ATSB investigation has found.

The Flight Training Adelaide instructor and student pilot had taken off from Wellcamp Airport, near Toowoomba in southern Queensland on 12 February 2025, for a navigation training flight that also included stall and upset recovery training, the investigation report details.

About 90 minutes into the flight, when at an altitude of about 6,300 ft near Jimna, the instructor pilot took control and, acting on impulse and without briefing the student, attempted a wingover.

During the manoeuvre, the bank angle quickly exceeded the aircraft’s 60° bank angle limitation before continuing beyond inverted and the aircraft’s pitch became steeply nose down.

“The instructor responded to the nose down attitude by reducing power to idle, but then prioritised minimising G load during the recovery from the dive,” ATSB Director Transport Safety Stuart Macleod said.

“While this kept G load well below the airframe maximum, by not increasing pitch more positively, the pilot allowed the aircraft’s speed to increase rapidly, exceeding the airframe limit.”

Flight data showed the aircraft reached a maximum indicated airspeed of 198 kt, above the aircraft’s 178 kt V_NE ‘never exceed’ speed.

Over approximately 36 seconds from initiation of the manoeuvre to recovery, the aircraft descended over 2,000 ft to an altitude of 4,159 ft above mean sea level, about 2,600 ft above ground level.

“Wingovers are permitted in the DA40, but it was a manoeuvre the instructor had not been trained to perform,” Mr Macleod said.

“As such, this incident underlines to pilots the importance of not attempting unfamiliar manoeuvres without the appropriate training, so as to reduce the likelihood of mishandling and to be prepared to respond appropriately if things do not go as planned.”

After landing, while the instructor was aware the aircraft had exceeded its maximum airframe speed and they confirmed the aircraft had no further bookings for the rest of the day, they did not mark the aircraft as unavailable or endorse its maintenance release at that time.

After subsequently recognising the incident needed to be reported, the instructor marked the aircraft as unserviceable early the following morning.

“In this case an inspection determined that the aircraft was not damaged from the overspeed, but it is important that all exceeded limitations are entered onto the maintenance release and reported quickly to ensure other pilots are not exposed to the risk of operating a damaged aircraft,” Mr Macleod concluded.

Read the final report: Airframe overspeed involving Diamond DA40, VH-EQF, 63 km east of Kingaroy Airport, Queensland, on 12 February 2025

A midair collision overhead Caboolture airfield highlights the risks of aircraft using multiple runways at non-towered aerodromes, an ATSB investigation report details.

On the morning of 28 July 2023 a Piper Pawnee being used by the local glider club as a tug aircraft was returning to land from the south-west on Caboolture’s runway 06, while a Jabiru J430 with a pilot and passenger on board was preparing to depart to the east from the intersecting runway 11.

“Caboolture has two intersecting runways and is a non-controlled aerodrome where pilots rely on making radio calls and visual scans to maintain separation from other aircraft – a principle known as ‘alerted see-and-avoid’,” explained ATSB Chief Commissioner Angus Mitchell.

Just prior to the Pawnee touching down, a Cessna 172 being taxied by a solo student pilot, who was unaware of an aircraft on approach, crossed runway 06. 

In response, the Pawnee pilot initiated a go-around, a routine procedure when an aircraft encounters an issue on approach and landing.

“The Pawnee pilot applied power and initiated a climb, maintaining the runway heading as they made a go-around radio call,” Mr Mitchell said.

“At the same time, the Jabiru lifted off from runway 11.”

The two aircraft converged, and shortly before impact the Jabiru commenced a left turn, likely in an attempt to avoid the Pawnee.

However, they collided above runway 06, just beyond the runway intersection, at a height of about 130 feet.

The collision separated the Jabiru’s right wing-tip and aileron, and it pitched downward and rolled to the right before impacting the ground, fatally injuring both on board and destroying the aircraft.

The Pawnee remained flyable despite damage to its left wing and landed safely with no injuries to the pilot.

“While in the circuit, the Pawnee pilot had made positional radio calls, and a call stating their intention to land and hold short of the runway intersection, but did not hear an entering runway or rolling call from the Jabiru,” Mr Mitchell said.

“Based on the Jabiru pilot's apparent unawareness of the Pawnee until just before the collision, and most witnesses not recalling hearing any calls from the Jabiru throughout the event, it is likely that the Jabiru pilot could not transmit or hear radio calls.

“Because of this, and a stand of trees between the intersecting runways that blocked visibility between them, neither pilot was aware of the other aircraft.”

While both the Jabiru and Pawnee pilots were familiar with the aerodrome and its line-of-sight limitations, the ATSB found that the aerodrome operator did not effectively manage or inform pilots of the risk of trees and buildings preventing pilots from seeing other aircraft on intersecting runways and approach paths.

“The local gliding club regularly chose to operate on runway 06 when winds and traffic were light, including during periods when other traffic was generally using the intersecting runway.” 

Since the accident, the aerodrome operator has prohibited simultaneous runway operations, and has mandated take-off radio calls.

“The investigation also found that the regulatory guidance pilots relied on when using non‑controlled aerodromes like Caboolture was not clear in defining what was considered an ‘active runway’, leaving room for different interpretations,” Mr Mitchell noted.

Further, this guidance did not provide practical advice to pilots using a secondary runway, and in some situations, it was contrary to existing regulations.

Following the ATSB investigation, CASA is removing all references to the term 'active runway' to better align guidance with the regulations and avoid confusion, and will also expand the guidance to assist industry understanding of this issue.

“This tragic accident highlights that relying on alerted see-and-avoid principles for separation at non controlled aerodromes is not infallible,” Mr Mitchell concluded.

“Pilots can help mitigate this by establishing two-way communication with other traffic, being mindful of the potential for radio communications to be missed or misinterpreted, and never to assume a runway is safe to use simply because no other aircraft are visible.”

Read the final report: Midair collision involving Jabiru J430, VH-EDJ, and Piper PA-25-235, VH-SPA, Caboolture Airfield, Queensland, on 28 July 2023

A Dash 8 airliner began its take-off roll while its flight crew was unaware of another aircraft about to depart from a cross runway, highlighting limitations with the use of Dash 8 radio systems for ground‑based traffic communication at non-controlled airports.

The ATSB has released a final report from its investigation into the 29 September 2023 incident, in which a QantasLink Dash 8 taxied to the threshold of runway 09 at Mildura Airport, in Victoria, for a passenger flight to Melbourne.

At about the same time, a four-seat Lancair light aircraft was taxiing to the threshold of the intersecting runway 36 for an intended take‑off.

Both aircraft had made taxiing, entering, and backtracking calls on the Mildura common traffic advisory frequency, but neither was aware of the other until the Lancair broadcast a rolling (take‑off) call after the Dash 8 had made a rolling call and had begun its take‑off.

The Dash 8 had already passed the take‑off decision point when its crew heard the Lancair’s rolling call, and in response the Dash 8 first officer immediately responded with ‘aircraft rolling 36, hold’.

Believing that the Dash 8 crew’s call may not have been heard by the Lancair, the pilot of a third aircraft relayed to the Lancair that there was another aircraft rolling on runway 09. Having not yet begun to roll, the Lancair pilot acknowledged and aborted their take‑off. The Lancair remained at the threshold about 730 m from the runway intersection as the Dash 8, taking off on runway 09, crossed runway 36.

“The ATSB’s investigation sought to determine why the pilots of both aircraft had not heard radio calls from the other aircraft,” ATSB Chief Commissioner Angus Mitchell explained.

“One call was partially over‑transmitted, and the Dash 8 crew was actively arranging separation with other aircraft in the air at the time of their departure. But more significantly the investigation identified limitations in the strength and readability of the Dash 8’s VHF radios on the ground.”

The investigation established that there was reduced radio reception and transmission strength towards the rear of the Dash 8 when on the ground, affecting radio call readability to and from other ground‑based airfield users.

Additionally, the ATSB found that ground‑based transmission and reception on the aircraft’s VHF COM 2, which has an antenna on the aircraft’s underbelly, had reduced strength and clarity. Dash 8 series aircraft have two VHF radio systems: VHF COM 1, which has its antenna on the roof, and VHF COM 2.

“The ATSB conducted rigorous testing at Mildura, in conjunction with the Australian Communications and Media Authority, Mildura Airport, and QantasLink, which provided a Dash 8 for testing,” Mr Mitchell said.

“This allowed investigators to conclude that ground‑based transmissions on VHF COM 2 had reduced strength and clarity.”

As per procedures, QantasLink Dash 8 flight crews used VHF COM 2 for ground calls at non‑controlled aerodromes such as Mildura.

“This likely led to the Lancair having difficulty receiving and understanding radio transmissions from the Dash 8, and the Dash 8 not receiving other transmissions,” Mr Mitchell said. 

The investigation also established that De Havilland Aircraft of Canada Limited – the type certificate holder for the Dash 8 – had not published guidance to operators on transmission and reception limitations of VHF COM 2 radios for ground‑based communications.

De Havilland Aircraft of Canada Limited has subsequently issued two flight operations service letters to all Dash 8 operators relating to the transmission and reception performance limitations of VHF COM 2 radios for ground‑based communications.

The ATSB is also releasing a safety advisory notice to Dash 8 operators to highlight this issue.

“We’re asking all Dash 8 operators and crews to consider the use of VHF COM 1 radios, which uses the roof antenna, for ground‑based communication while operating at non‑controlled aerodromes, to improve radio transmission and reception with other nearby stations,” Mr Mitchell said.

At Mildura Airport, aircraft are not directly visible to each other on the thresholds of runways 09, 27 and 36 due to topography and buildings. The ATSB found that, although not a factor on this occasion, the lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take‑off.

In response to this incident, and a related earlier incident in 2023 investigated by the ATSB, Mildura Airport now requires that radio calls be made by pilots commencing take‑off at Mildura.

QantasLink now requires crews to use VHF COM 1 radio for ground‑based departure communications at Mildura, improving ground‑to‑ground radio communication, mitigating collision risks presented by the cross‑runway layout and communication difficulties between runways.

“The ATSB welcomes changes made to the radio procedures at Mildura, but also notes that other aerodromes in the country may be subject to similar interference issues and consideration of expanding the Mildura Dash 8 operational procedures may be warranted,” Mr Mitchell concluded.

Read the final report: Aircraft separation issue during take-off involving Lancair, VH-VKP, and De Havilland Aircraft of Canada Limited DHC-8-315, VH-TQZ, Mildura Airport, Victoria, on 29 September 2023

Read the Safety Advisory Notice: Dash 8 reduced ground-based communications quality on VHF COM 2