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Near collision involving an American Champion 8GCBC Scout and an Eagle 150B, 2 km north-west of Jandakot Airport, Western Australia, on 25 April 2024

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation. Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information in them is de-identified. 

What happened

On the afternoon of 25 April 2024, an Eagle 150B aircraft was approaching Jandakot Airport, Western Australia from the west on return from a recreational flight. The pilot of the Eagle 150B had checked the automatic terminal information service (ATIS) and was aware that the active runway for an approach from the west was runway 06 left (06L). Jandakot air traffic control cleared the Eagle 150B for a visual approach with instructions to join final for runway 06L and to follow preceding traffic, an American Champion 8GCBC Scout.

Upon sighting flashing white lights on early downwind, the pilot of the Eagle 150B mistakenly concluded that they were the rear lights on the aircraft they were to follow. Without identifying that turning towards this aircraft would put the Eagle 150B on downwind for runway 24 right, the pilot turned to follow the incorrect aircraft. This put the Eagle 150B on a reciprocal track with the American Champion Scout.

The air traffic controller was not initially able to visually locate the Eagle 150B due to environmental conditions but subsequently identified the aircraft on their tower situation air display. The controller issued the American Champion Scout a safety alert and avoiding instructions. When clear, the Eagle 150B was given instructions to rejoin the circuit. 

Safety message

This incident highlights the importance of following correct circuit procedures, complying with ATC instructions and using see and avoid procedures effectively, particularly in high traffic environments. Ensuring situational awareness, through familiarising with the aerodrome, reviewing procedures preflight and using ATIS information to anticipate the expected circuit pattern can help to ensure correct procedures are followed.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

Occurrence summary

Mode of transport Aviation
Occurrence ID AB-2024-009
Occurrence date 25/04/2024
Location 2 km north-west of Jandakot Airport
State Western Australia
Occurrence class Serious Incident
Aviation occurrence category Near collision
Highest injury level None
Brief release date 16/09/2024

Aircraft details

Manufacturer Eagle Aircraft Australia
Model 150B
Sector Piston
Operation type Part 91 General operating and flight rules
Departure point Jandakot Airport, WA
Destination Jandakot Airport, WA
Damage Nil

Aircraft details

Manufacturer American Champion Aircraft Corp
Model 8GCBC Scout
Sector Piston
Operation type Part 138 Aerial work operations
Departure point Jandakot Airport, WA
Destination Jandakot Airport, WA
Damage Nil

Flight controls involving a Eurocopter AS350 B3, 88 km south of Port Hedland, Western Australia, on 27 July 2024

What happened

On 27 July 2024, the pilot of a Eurocopter AS350 departed a mining airport in Western Australia. The helicopter flew about 10 NM to the east and landed at a pre-determined location to collect a team of surveyors. On landing, the pilot of the helicopter received a message from the surveyors who advised they required another hour at the site, the pilot then shut the helicopter down. Noting the strong and gusting wind conditions, they tied the main rotor blades down to prevent blade sailing or bouncing, they also noticed the tail rotor was “see-sawing” aggressively. The pilot then installed the tail rotor gust lock pin, which dampens the movement of the tail rotor when the aircraft is stationary and prevents any damage, and conducted their usual turnaround inspection of the helicopter.

Once the survey team had returned to the helicopter, the pilot untied the main rotor tie‑downs and stored them in the helicopter’s rear locker. From the rear locker the pilot conducted a pre-flight walk-around to the front of the aircraft, however did not inspect the tail rotor or remove the tail rotor gust lock pin. The pilot reported they had not previously installed the gust lock pin in the field and the deviation from their standard aircraft configuration contributed to the occurrence.

The pilot conducted normal pre-start and pre-departure checks, they noted an unusual, mild vibration from the main rotor and tail rotor which they presumed to be caused by the strong gusting wind from the 3 o’clock position. The pilot took off and immediately became aware that the pedals were jammed in a neutral position and determined the cause to be the tail rotor gust lock pin still being in place.

The pilot then briefed the passengers regarding the nature of the emergency and the plan to divert back to the original take-off airport. The pilot telephoned the airport reporting officer via the Bluetooth in their helmet to advise of the emergency. 

They then conducted the emergency procedure for jammed pedals and landed on the runway without incident. The pilot reported the landing was a gentle zero speed, no hover landing.

The helicopter was positioned on the runway preventing any further arrivals or departures until it could be removed. There was no operational impact to the airport whilst the helicopter was positioned on the runway.

The pilot advised the ATSB that there was no visual damage to the structure of the aircraft or to the tail rotor assembly. An engineering inspection confirmed no damage to the aircraft; however the gust lock pin was deformed in the horizontal axis. Due to this deformation, the manufacturer requested that the following parts be replaced:

  • tail rotor pitch change spider bearing
  • tail rotor control lever
  • all tail rotor control attaching hardware aft of the tail rotor control rod (long shaft) for pitch links, lever etc.

Safety action

The pilot’s awareness in determining the cause of the jammed pedals and their following actions to conduct a safe emergency landing at the airport, prevented the loss of control of the aircraft and potential injuries or fatalities to the occupants.

Safety message

This incident highlights the importance of a thorough pre-flight inspection, ensuring pilots follow a systematic procedure as per the aircrafts flight manual. If interrupted, it is best practice to start again from the beginning of the inspection to ensure nothing is missed.

As per the flight manual pilots should always check flight controls for free movement prior to engine start.

Further, anytime a pilot detects an unusual control feedback prior to take-off, it is recommended that pilots shut down the aircraft, complete a thorough inspection and contact the operators engineering provider to discuss the issue.

The operator reported that they have sought a customisation of the “remove before flight” tapes used on the tail rotor gust lock pin to increase their length and therefore visibility.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

Occurrence summary

Mode of transport Aviation
Occurrence ID AB-2024-035
Occurrence date 27/07/2024
Location 88 km south of Port Hedland
State Western Australia
Occurrence class Serious Incident
Aviation occurrence category Flight control systems
Highest injury level None
Brief release date 13/09/2024

Aircraft details

Manufacturer Eurocopter
Model AS350 B3
Sector Helicopter
Operation type Part 133 Air transport operations - rotorcraft
Damage Nil

DHC-1 Chipmunks may have incorrect rivets fitted

Safety Advisory Notice

To DHC-1 Chipmunk maintainers and owners

Crashworthiness of some DHC-1 Chipmunks may be compromised by incorrect specification rivets.

What happened

On the afternoon of 26 April 2024, the pilot of a DHC‑1 Chipmunk took off from Jandakot Airport, Western Australia. The engine cowling on the left side had not been fastened prior to take-off and began to open and close in flight. The aircraft turned to the left at low height near the end of the runway, with an increasing angle of bank, before descending and colliding with terrain. The pilot was transported to hospital and later succumbed to injuries.

What increased risk

The DHC-1 Chipmunk is a low-wing aircraft designed for military flight training. It has 2 seats that are arranged in tandem (one cockpit behind the other). The front cockpit shoulder harness is attached to the upper structure between the front and rear cockpits.

The ATSB found that on impact the upper structure between the front and rear cockpits, corresponding to the attach point for the front cockpit shoulder harness, was torn away from its mountings. Most noteworthy, all 12 rivets (6 per side) that attached the structure to the mountings had sheared (Figure 1).

Figure 1: Location of sheared rivets

Figure 1: Location of sheared rivets

Image source: ATSB, de Havilland Support Ltd, annotated by the ATSB.

The 2 mountings, called gussets, were installed as modification H.268. This modification was issued by Hawker Siddeley in 1966 to replace the original aluminium alloy gussets with high‑tensile steel. The modification required the forward row of rivets attaching the structure to the gussets to be part number SP85 mushroom head rivets, and the rear row to be part number AS2230 countersunk rivets (Figure 2).

Figure 2: Rivet detail

Figure 2: Rivet detail

Image source: ATSB, de Havilland Support Ltd, annotated by the ATSB.

Both part number SP85 and AS2230 rivets were required to be manufactured to British standard L.86, which was an aluminium alloy that included copper and magnesium (with international equivalences of Alloy Designation 2117, US specification AMS7222, and European specification ENAW-AlCu2.5Mg). The standard also specified that the rivets were to be anodised (a surface treatment) and coloured violet.

The sheared rivets were examined by the ATSB using metallurgical equipment and it was determined that:

  • The rear row of countersunk rivets appeared to be pure or near-pure aluminium and therefore the incorrect specification. Testing indicated a significant reduction in strength (estimated to be about one-third of the specification strength). 
  • The forward row of mushroom head rivets appeared to be an alloy consistent with L.86. The rivets were coated with a gold-coloured chromate conversion coating instead of violet anodising. ATSB testing indicated that the strength of the rivets met or exceeded literature values for L.86 alloy.

The ATSB has not determined when or where modification H.268 was embodied, or whether the rivets had been replaced since the modification.

The presence of the non-conforming rivets significantly reduced the integrity of the structure retaining the front cockpit restraint, and thereby compromised the crashworthiness of the aircraft. This non-conforming modification may be present in other Chipmunk aircraft, in which case it would likely affect survivability in an accident.

Crashworthiness design

One element of aircraft crashworthiness is the ability of a restraint system to restrain the occupant within the aircraft’s ‘living space’ throughout a crash. The use of upper torso restraints such as a shoulder harness can further prevent the occupant from striking the surrounding structure during an accident. All components forming part of the restraint system (including the structures to which they are attached) need to be to defined specifications.

Safety advisory notice

AO-2024-013-SAN-01: The ATSB advises DHC‑1 Chipmunk maintainers and owners to be aware that fitment of incorrect specification rivets where the upper structure between the front and rear cockpits attaches to the gussets on either side could significantly compromise the crashworthiness of the aircraft.

Those conducting work on aircraft must ensure modifications are carried out to the required specification, or during maintenance returned to that specification.

Read more about this ATSB investigation: Collision with terrain involving Oficinas Gerais de Material Aeronautico DHC-1 MK 22 Chipmunk, VH-POR, at Jandakot Airport, Western Australia, on 26 April 2024

Publication details

Investigation number AO-2024-013
Publication type Safety Advisory Notice
Publication mode Aviation
Publication date 11/09/2024

Saab 340 engine failure due to incorrectly seated coupling

Regional Express Saab 34 VH-RXE experienced an engine failure on the evening of 21 December 2022

The right engine of a Saab 340 flamed out shortly after the aircraft reached cruising altitude, after the engine’s hydro-mechanical unit driveshaft decoupled from the accessory gearbox due to an incorrectly seated coupling, leading to a fuel pump failure, an ATSB investigation report details.

The aircraft, with 2 flight crew, 1 cabin crew and 32 passengers on board, was operating a scheduled Regional Express service from Perth to Albany, WA, on the evening of 21 December 2022.

After climbing to 15,000 ft and establishing a direct track to Albany, the flight crew felt 2 bumps pass through the airframe, and felt the aircraft yaw.

Identifying that the right engine had failed, they conducted the associated checklists, secured the right engine, and returned to Perth where the aircraft landed without further incident.

“The ATSB’s investigation found that the right engine’s hydro-mechanical unit was incorrectly seated, resulting in a misalignment with the engine’s accessory gearbox, leading to significant wear and the eventual decoupling of the hydro‑mechanical unit’s drive shaft from the accessory gearbox,” ATSB Director Transport Safety Stuart Macleod explained.

“As a result, the fuel pump within the hydro-mechanical unit could not function, leading to the engine flameout.”

The engine, a GE Aerospace CT7, was removed from the aircraft for inspection at an authorised CT7 maintenance facility.

“While this inspection put the ATSB investigation on hold for an extended period, it did reveal that the V-band coupling securing the flanges of the hydro-mechanical unit to the accessory gearbox had wear on its inner surface from contact with the accessory gearbox flange,” Mr Macleod noted.

“Interference wear in this area was evidence of a misalignment and non-seating of the hydro‑mechanical unit onto the accessory gearbox.”

Maintenance records showed that the last recorded maintenance that required installation of the hydro-mechanical unit onto the accessory gearbox was during an engine workshop visit at a contractor maintenance facility in February 2018.

“This incident highlights that the incorrect alignment or seating of an aircraft or engine component may not be readily apparent after the installation of a V-band coupling or clamp,” Mr Macleod said. 

“As such it serves as a reminder to maintenance personnel installing V-band couplings to ensure the correct seating and alignment of flanges and the V-band coupling prior to the fitment and torquing of attaching hardware.”

Regional Express has since commenced a fleetwide inspection of its Saab aircraft to confirm the correct fitment of the V-band coupling, while GE Aerospace intends to share the learnings of this occurrence with its customers and maintenance facilities.

Read the final report: Engine failure involving Saab 340B, VH-RXE, 141 km south of Perth, Western Australia, on 21 December 2022

Chipmunk owners urged to ensure rivets are maintained to spec

Location of sheared rivets

The ATSB advises DHC-1 Chipmunk maintainers and owners that crashworthiness could be significantly compromised if incorrect specification rivets are used.

The safety advisory notice has been issued as part of the ATSB’s continuing investigation into a fatal accident involving a Chipmunk at Jandakot Airport, WA, on 26 April 2024. As detailed in a preliminary report in July, shortly after take-off the aircraft was observed turning to the left at a low height before colliding with the ground, fatally injuring the pilot.

During the ongoing investigation the ATSB has identified that non-specification rivets had been installed on the aircraft, attaching the upper structure between the front and rear cockpits to the fuselage. This structure provides the attach point for the front cockpit shoulder harness.

“Two sets of rivets – 12 in total – attaching the structure to the fuselage sheared during the accident,” Director Transport Safety Dr Stuart Godley said. 

“The ATSB found that the rear row of rivets in each set – that is, three of the six rivets on each side – were pure or near-pure aluminium.”

This meant the rivets did not meet the specification of the relevant modification.

“Testing indicated a significant reduction in strength, estimated to be about one-third of the specification strength,” Dr Godley said.

The rivets would have been originally replaced during the embodiment of modification H.268, issued in 1966 by the aircraft’s type certificate holder at the time, Hawker Siddeley, to replace alloy structure elements with steel.

The aircraft may have modified in the 1960s, however the ATSB has not determined precisely when, or if, the rivets had been replaced since the modification.

It is important to note that while the crashworthiness of the aircraft had been compromised by the presence of non-specification rivets, the ATSB has yet to establish whether it contributed to the outcome of this accident.

However, as there is the potential for other Chipmunks to have incorrect rivets installed in this location, the ATSB determined it was important to bring the issue to the wider attention of Chipmunk operators.

“The ATSB’s safety advisory notice highlights the importance of maintaining aircraft crashworthiness design elements, including its restraint system, to keep the occupant within an aircraft’s ‘living space’ during an accident sequence,” Dr Godley said.

“The use of upper torso restraints such as a shoulder harness can prevent the occupant from striking the surrounding structure during an accident. It is crucial that all components forming part of that restraint system and the structures to which they are attached are maintained to defined specifications.”

The notice therefore advises DHC-1 Chipmunk maintainers and owners to be aware that fitment of incorrect specification rivets where the upper structure between the front and rear cockpits attaches to the gussets on either side could significantly compromise the crashworthiness of the aircraft.

“Those conducting work on aircraft must ensure modifications are carried out to the required specification, or during maintenance returned to that specification,” Dr Godley concluded.

The investigation is continuing, and the ATSB will issue a final report, which will detail findings and analysis, at the conclusion of the investigation.

Read the Safety Advisory Notice: DHC-1 Chipmunks may have incorrect rivets fitted

Aircraft preparation event involving a Hawker Beechcraft Corporation B200, Gove, Northern Territory on 23 July 2024

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation. Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information in them is de-identified. 

What happened

On the night of 23 July 2024, a Hawker Beechcraft B200 was being prepared for an aeromedical flight between Gove Airport and Numbulwar Airport in the Northern Territory. Prior to departure, the pilot conducted a pre-flight inspection of the aircraft. A critical step in this process was to remove pitot covers from the pitot tubes[1] on both the front left and right side of the aircraft’s fuselage. These covers protect the pitot tube from contamination and are designed to slide on and off the tubes. 

The pitot covers used by the operator were made of tight-fitting rubber to prevent them falling off in the wind. These covers also had a small vent hole in the front which equalised pressure in the pitot system on the ground and facilitated their easy removal. A red streamer is also attached to these covers, which provides a visual reminder to pilots and ground crew that the covers have been fitted and need to be removed prior to departure.

The pilot advised that their usual habit was to tie the pitot cover streamer to the wheel chocks[2] to provide a visual reminder that the pitot covers were to be removed. However, the previous crew had only applied the pitot covers as the aircraft was due to depart later that night and had not set the wheel chocks. Therefore, when the pilot saw that the wheel chocks were not in place, they assumed that the pitot covers had been removed. The pilot advised that due to the shadows created by the floodlights in the hangar they did not notice the pitot cover nor the red streamer during their pre-flight inspection. 

The pilot commenced the take-off run and observed normal airspeed indications until the aircraft reached a speed of around 80 KIAS.[3] At that time, the airspeed indications stopped increasing even though the aircraft’s acceleration remained normal and there were no speed warnings in the cockpit. The pilot advised that they cross-checked the indicated airspeed between the primary flight displays (PFD) and the standby instruments, and observed no discrepancy between any of these systems. As a result, the pilot continued the take-off run and the aircraft rotated[4] successfully, albeit with an indicated airspeed lower than normal.

The aircraft climbed to the circuit altitude at Gove, but the pilot noted that the airspeed indicator only showed 100 KIAS even though the aircraft should have been accelerating to 160 KIAS. When the aircraft turned downwind at circuit height, the pilot observed a speed discrepancy in the right PFD and the standby instruments, both of which showed 180 KIAS. This aligned with the standard speed for that aircraft configuration and that stage of the flight. The pilot then watched the speed discrepancy reduce until the right PFD indicated the same speed as the left PFD. At this point, the pilot suspected that the covers had been left on the pitot tubes as they did not recall removing them before departure, and that the covers had now fallen off and speed indications had returned to normal.

The pilot therefore began comparing various data sources to verify the aircraft’s climb speed and performance. The pilot cross-checked the aircraft’s groundspeed[5] and true airspeed (KTAS)[6] on the multi‑function display (MFD), as well as with the aircraft’s air data computer and GPS indications. The pilot also compared the indicated altitude with the GPS altitude from OzRunways. As the aircraft parameters were consistent with normal flight conditions, the pilot elected to continue with the flight and landed without incident at Numbulwar.

After landing in Numbulwar, the pilot conducted a detailed visual inspection of both the pitot tubes and the aircraft in general. During this inspection, they found the remnants of the pitot covers still fitted to the tubes. As the pitot heat system had been turned on during flight, the covers on both tubes had partially melted, however the pilot noted no damage or debris in the actual pitot tubes. The aircraft had flown around 40 minutes and 250 km over remote, unlit terrain in this configuration. After conducting this inspection, the pilot determined it was safe to conduct the next sector to Darwin.

Similarities to previous incidents

The pitot tube issue on 23 July 2024 was not the first such incident involving this operator on this aircraft type. In May 2024, the ATSB reported on an occurrence where an aircraft departed from Darwin Airport with the pitot covers blocking the pitot tubes.[7] On that occasion, the pilot attempted to remove the pitot covers before departure but did not realise that the right-side streamer had detached from the right-side cover.

The pilot thought that the pitot covers had been removed entirely, and proceeded to take-off with the right pitot tube cover still in place. The pilot noticed an airspeed mismatch during rotation, and subsequently climbed to circuit height and returned to land. In both the May 2024 and July 2024 incidents, an airspeed discrepancy or mismatch did not become apparent until it was too late to reject the take-off.

Safety action

In response to this incident, the operator launched an internal investigation and undertook a series of safety actions to address the risks associated with blocked pitot tubes. 

To reduce the risk of pitot covers being missed during the pre-flight inspection, the operator has purchased high visibility pitot tube cover flags, with the wording ‘remove before flight’, to be used on all fixed-wing aircraft in the operator’s fleet. Processes are also being established around the ongoing inspection and maintenance of these flags to ensure they are free from contamination and that their visibility is not compromised in low-light situations.

To mitigate the risk of errant speed indications, the operator is also sourcing leather covers for the B200 fleet that do not have a small vent hole. This addressed the potential for the small vent hole in the existing covers to allow sufficient airflow into the pitot system to provide a symmetric, albeit incorrect, speed indication during the take‑off roll. The new leather covers would prevent the generation of any airspeed indications at all, which would indicate blocked pitot tubes significantly earlier in the take‑off run and increase the likelihood of a safe rejected take‑off.

To assist pilots with managing inflight pitot tube issues, the operator is looking to introduce training on partially-blocked pitot tubes. This training will include a startle/surprise element to ensure pilots can respond appropriately to pitot blockages and errant speed indications. This is intended to be a key safety focus item in their simulator-based recurrent training and proficiency checks, and will cover all flight crew within the next six months.

Safety message

This incident highlights the importance of conducting an airspeed check early in the take‑off run. This allows the take-off to be rejected as soon as a mismatch is detected. In circumstances where a rejected take-off is not possible, pilots should follow the standard climb-out procedure then seek to land as soon as practicable. Although the B200 stall warning system operates independently of the pitot system, unreliable speed indications can increase the risk of aerodynamic stall[8] and subsequent loss of control, and several accidents internationally have been attributed to blocked pitot tubes. 

This incident also illustrates the importance of maintaining a high level of attention and awareness when doing visual inspections of critical aircraft systems pre-flight, particularly at night. It is vital that the pitot tubes and static ports are fully uncovered and free from obvious obstructions, contamination, or damage prior to departure. Pilots should also remain cognisant of the risk that pitot covers may not be sufficiently conspicuous when installed on the aircraft, and follow standard procedures when fitting or removing these items. Targeted inspections of specific aircraft components, along with secondary means of accounting for ground-based protective equipment, can provide an extra layer of assurance that these items have been removed from the aircraft and are safely stowed prior to departure. 

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

[1]     Pitot tubes are part of the aircraft's pitot-static system and are used to compute the aircraft's indicated airspeed.

[2]     Aircraft wheel chocks are safety devices that prevent an aircraft from moving while it is parked. They are usually solid blocks of sturdy material and placed in front of and behind the wheels after the aircraft is parked.

[3]     KIAS: indicated airspeed expressed in knots, used by pilots as a reference for all aircraft manoeuvres.

[4]     Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.

[5]     Groundspeed: an aircraft’s horizontal speed relative to the ground.

[6]     KTAS: true airspeed expressed in knots, used by pilots for pre-departure flight planning and navigation purposes.

[7]     Flight preparation event involving Hawker Beechcraft Corporation B200, Darwin Airport, Northern Territory, on 8 May 2024 (AB-2024-025).

[8]     Aerodynamic stall: occurs when airflow separates from the wing’s upper surface and becomes turbulent. A stall occurs at high angles of attack, typically 16˚ to 18˚, and results in reduced lift.

Occurrence summary

Mode of transport Aviation
Occurrence ID AB-2024-034
Occurrence date 23/07/2024
Location Gove Airport
State Northern Territory
Occurrence class Incident
Aviation occurrence category Flight Preparation / Navigation
Highest injury level None
Brief release date 10/09/2024

Aircraft details

Manufacturer Hawker Beechcraft Corporation
Model B200
Sector Turboprop
Operation type Part 135 Air transport operations - smaller aeroplanes
Departure point Gove Airport, Northern Territory
Destination Numbulwar Airport, Northern Territory
Damage Nil

Brisbane River oil tanker breakaway and grounding

The breakaway and grounding of an oil tanker in the Brisbane River during a significant weather event in February 2022 illustrates the importance of clearly defined emergency and risk management arrangements, according to an ATSB investigation report.

On 27 February 2022, during a period of heavy, sustained rainfall and flooding in south-east Queensland, the 185 m Hong Kong-flagged oil products tanker CSC Friendship was berthed at the Ampol products wharf in the Port of Brisbane.

Currents in the Brisbane River increased until they exceeded the design mooring limits of both the ship and the berth, the ATSB investigation found.

“While weather conditions exceeded those initially forecast, the associated increased safety risk to shipping and the port was foreseeable,” ATSB marine investigation manager Captain Vik Chaudhri said.

“Numerous warnings from the Bureau of Meteorology provided sufficient information to identify and assess the increased likelihood of a breakaway, and the current in the river had exceeded the operational limits of the berth and the ship’s mooring arrangements more than 14 hours prior to the breakaway – yet the ship remained at the berth.”

The ship, loaded with about 32,000 tonnes of petroleum products, broke its mooring lines just prior to 11 pm.

Despite the deployment of the ship’s outboard anchor and the swift attendance of two tugs, the ship was swept across the channel, grounding 400 m downstream.

A port pilot boarded the vessel and, about six hours after the grounding, the ship was refloated.

However, during the recovery efforts, an attempt was made to retrieve the anchor, leading the ship to veer across the channel and ground again, close to Clara Rock, a charted hazard.

The anchor was then slipped and the ship was safely conducted downriver into Moreton Bay, where it anchored.

“Weather events can pose dynamic hazards to port infrastructure and ships, and their safe management requires clearly defined emergency and risk management arrangements,” Captain Chaudhri explained.

“These include accurately assessing all available information and erring on the side of safety where doubt exists – in particular considering the inherent uncertainty of weather forecasts.”

The ATSB’s investigation found Maritime Safety Queensland (MSQ), whose responsibilities include the management of an emergency in the Port of Brisbane, did not have structured or formalised risk or emergency management processes or procedures.

“Consequently, MSQ was unable to adequately assess and respond to the risk posed by the river conditions and current.”

MSQ has made significant changes to operations and systems in response to the incident and flood event, including policy and procedural updates and capital improvements.

It has also engaged with multiple investigations and analyses of the incident, engaged with multiple port stakeholders and facility owners, and established a distinct management role to lead a dedicated Maritime Emergency Management team.

However, while significant, the ATSB has assessed the safety action taken by MSQ has not fully addressed the identified safety issue concerning its risk management processes and procedures to manage any type of emergency.

“Subsequently, the ATSB has issued a safety recommendation to MSQ to further improve these processes and procedures,” Captain Chaudhri explained.

The final report also notes safety actions taken by the pilotage provider, Poseidon Sea Pilots, who the investigation identified did not have procedures to manage predictable risks associated with increased river flow or pilotage operations outside normal conditions.

In response, Poseidon Sea Pilots has taken various safety actions, including collaborating with MSQ on emergency evacuation procedures to respond to increased river flow.

Finally, the ATSB’s final report notes that Ampol had not considered the risk to the ship or the wharf due to increased river flow.

The wharf operator has subsequently conducted an incident investigation and analysis of mooring arrangements and limitations, and developed a document to specify wharf operational limits, and response actions for varying wind and river speeds.

“The extent of actions by all three of these key parties is encouraging,” Captain Chaudhri said.

“With these processes established, coordinated and timely decisions can be made when risks increase during future events like this one. Defined trigger points, priority lists, and escalation and contingency plans and procedures will help drive effective emergency responses.”

Read the final report: Breakaway and grounding of CSC Friendship, Port of Brisbane, Queensland, on 27 February 2022

FOI Disclosure 2024-25

Date of access (date decision released to applicant)

FOI reference number

Description of documents

Documents released

Access

26 June 2025FOI 24-25(18)

Regarding an accident on 7 January 2025 at Rottnest Island (investigation number AO-2025-001):

a complete copy of ATSB’s investigation file, comprising of, but not limited to; any investigation reports, file notes, photographs, witness statements, improvement notices and prosecution notices relating to the accident [non-restricted information only].

[excluding personal information of ATSB employees below SES level]

 Partial
26 June 2025FOI 24-25(17)

Regarding an accident on 7 January 2025 at Rottnest Island (investigation number AO-2025-001):

a complete copy of ATSB’s investigation file, comprising of, but not limited to; any investigation reports, file notes, photographs, witness statements, improvement notices and prosecution notices relating to the accident [non-restricted information only].

[excluding personal information of ATSB employees below SES level]

 Partial
23 June 2025FOI 24-25(16)

Regarding an accident on 7 January 2025 at Rottnest Island (investigation number AO-2025-001):

a complete copy of ATSB’s investigation file, comprising of, but not limited to; any investigation reports, file notes, photographs, witness statements, improvement notices and prosecution notices relating to the accident [non-restricted information only].

[excluding personal information of ATSB employees below SES level]

 Partial
3 June 2025FOI 24-25(14)

Access to occurrence data capturing the following related to air crew on-board medical events or incidents involving Regular Public Transport (RPT) operators for the years 2021 and 2022 only:

• date
• injury level
• summary of incident/event

 Partial
6 November 2024FOI 24-25(07)

1.Documents containing information about the number, classification levels, type of employment (e.g. full time, part time, fractional, casual) functions and position descriptions of Indigenous Liaison Officers or equivalent (e.g. First Nations Liaison Officer or Aboriginal and Torres Strait Islander Officer), if any, in your agency from 1 January 2014 until the present.

2.Documents containing information about the number of staff currently employed in your agency who identify as Aboriginal or Torres Strait Islander.

 Full
20 September 2024FOI 24-25(06)Regarding occurrence number 198602325, any information you have regarding the incident and any follow-up investigations. Partial
20 September 2024FOI 24-25(05)

Regarding investigation number MO-2022-005, copies of all non-restricted documents with respect to the following documents:

1. AMSA submissions with respect to the draft ATSB draft report.

2. All other submissions with respect to the check pilot framework.

3. All documents with respect to, related or considered in the analysis of the check pilot factor, later identified in the final Rosco Poplar investigation report.

 Partial
5 September 2024FOI 24-25(02)

Regarding investigation number AO-2024-001:

All non-restricted information including incident reports, statements, notices, fines, penalty notices, maintenance logs of aircraft, photographs and video footage between the period of 8 January 2024 and present [10 July 2024] relating to the incident on 8 January 2024 involving our client.

 Partial

Accredited Representative to the Transport Accident Investigation Commission investigation of engine issue on approach involving ATR 72, ZK-MVL, near Wellington Airport, New Zealand, on 1 September 2024

Summary

The Transport Accident Investigation Commission (TAIC) in New Zealand has commenced an investigation into an engine issue on approach involving a GIE Avions de Transport Régional ATR 72, ZK-MVL, near Wellington Airport, New Zealand on 1 September 2024.

During final approach, at about 300 feet, there was a low oil pressure caution, then an engine fault and engine fire warning for the aircraft’s left engine. The crew declared a mayday, landed safely and stopped on the runway. Airport emergency services attended promptly, and passengers and crew were evacuated on to the runway, with no serious injuries reported.

The TAIC has requested assistance and the appointment of an accredited representative from the ATSB. 

To facilitate this support and to provide the appropriate protections for the information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of the International Civil Aviation Organization Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

TAIC is responsible for the investigation and release of the final investigation report regarding this accident. Any enquiries regarding the investigation should be addressed to the TAIC via the contact details listed below:

Email: comms@taic.org.nz
Web: taic.org.nz(Opens in a new tab/window)

Last updated:

Occurrence summary

Investigation number AA-2024-009
Occurrence date 01/09/2024
Location Near Wellington Airport, New Zealand
State International
Investigation type Accredited Representative
Investigation status Active
Mode of transport Aviation

Preliminary report into Canberra flight below minimum safe altitude

Overview of MOMBI hold

A preliminary report from the ATSB’s on-going investigation into a flight below minimum altitude incident involving a Boeing 737 south of Canberra notes the operator involved has taken a number of proactive safety actions. 

On the evening of 13 June 2024, the Boeing 737-800 had departed Denpasar, Indonesia, operating Batik Air’s inaugural flight to Canberra, the report details. Forecast tailwinds resulted in an estimated arrival time just prior to 0600 on 14 June, which was earlier than planned, and before Canberra Tower and Canberra Approach air traffic control commenced services for the day. 

The crew elected to proceed, without delaying to wait for those air traffic services to become available, which meant arriving in Canberra using the Canberra Airport CTAF (common traffic advisory frequency – where pilots use radio calls to announce their positions and arrange separation from other aircraft). 

As the aircraft descended in darkness towards Canberra, the crew prepared to conduct the AVBEG 5A standard arrival route (or STAR – which uses satellite-based positioning waypoints to transition aircraft from en route flight to, in this case, an initial approach fix waypoint for Canberra Airport’s instrument landing system approach). 

“While the crew intended to fly the STAR, they did not request this from the air traffic controller managing the airspace,” ATSB Chief Commissioner Angus Mitchell said. 

Instead, the controller expected the crew to track along the clearance previously provided direct to Canberra Airport from the AVBEG waypoint, which is to the north-west of the airport and is also the first waypoint of the AVBEG 5A STAR. 

The crew proceeded with their planned standard arrival route, which meant the aircraft deviated from the cleared track direct to Canberra, and instead tracked to a series of waypoints to the south-west and south of the airport. 

The controller, unaware of the flight crew’s intentions, did not query the deviation, but did instruct them to maintain 10,000 ft to remain clear of a restricted area around the Deep Space Communications Complex at Tidbinbilla to the west of Canberra (this separation is built into the STAR).  

“After receiving this instruction, the flight crew became uncertain as to whether the aircraft would be operating within, or outside of, controlled airspace during the standard arrival route and approach,” Mr Mitchell explained. 

After levelling the aircraft at 10,000 ft, the crew subsequently requested ATC clearance to conduct the instrument landing system (ILS) approach to Canberra. The controller advised them that the Canberra tower was closed and that CTAF procedures applied for the airspace.  

A short time later, when tracking towards the airport from the south and having descended outside of controlled airspace, the flight crew identified they were above the desired flightpath, and the captain decided to conduct a holding pattern at the approach waypoint of MOMBI to reduce altitude. 

“During this holding pattern, the aircraft levelled out at 4,700 ft, but this meant it descended below minimum holding altitude of 5,600 ft, and at one point the aircraft passed 924 ft above terrain,” Mr Mitchell said. 

After rejoining the approach, the aircraft commenced descending again, following the runway 35 glidepath, and it landed without further incident. 

The report notes that while the aircraft was in the holding pattern, a controller in the Canberra Tower was preparing to commence the tower service for the day and they observed the aircraft below the minimum holding attitude. 

“The Tower controller made multiple attempts to contact the crew on the Canberra CTAF, but did not receive a response,” Mr Mitchell explained. 

At about the same time, the Canberra Approach controller commenced for the day – taking over the frequency the flight crew were listening to – and issued a safety alert that the aircraft was operating below the minimum safe altitude. 

The flight crew responded that they were visual with the runway and continued their approach. 

The ATSB’s continuing investigation will consider, among other elements, Batik Air’s procedures, training and route implementation processes, as well as air traffic control procedures and training. 

“A final report with analysis and findings will be released at the conclusion of the investigation, but we note the operator has already pro-actively taken safety actions,” Mr Mitchell concluded. 

“These include revising their Canberra Airport briefing documentation, issuing flight crew notices highlighting procedures for operating in non-controlled airspace, and rescheduling flights to Canberra to ensure they arrive during air traffic control operating hours.” 

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