In 2025 the ATSB adopted a new purpose statement, to “influence transport safety improvements for the greatest public benefit through independent no-blame investigations and fostering safety awareness”.

The updated statement highlights that our role is not just the independent investigation of transport accidents and incidents, it is also to use the reports and their safety messaging to influence safety changes across the aviation, rail and marine sectors.

But it also reflects the broader responsibilities of the ATSB in improving transport safety, such as by helping Australia’s neighbours develop their own best practice safety investigation bodies, providing investigator training for other safety agencies and organisations, administering the REPCON confidential reporting scheme, and publishing and maintaining a national aviation safety occurrence database.

In 2025, in line with our purpose, the ATSB published no fewer than 304 safety products, up from 202 in 2024 and almost double the 153 published in 2023.

Illustrating the breadth of the ATSB’s outputs, these comprised:

• 91 investigation final reports
• 34 other investigation reports, including preliminary and interim reports, safety studies and safety advisory notices
• 74 occurrence briefs
• 26 safety promotion videos, and
• 79 REPCON reports.

Significant among those 91 investigation final reports included, in the aviation sector, the systemic investigation of the midair collision of two sightseeing helicopters over the Gold Coast, which made 27 findings and identified 12 safety issues. 

Also concluded in 2025 was a systemic investigation into two international widebody airliners taking off over a closed section of runway at Melbourne Airport, which led to safety improvements being implemented or planned by Australia’s aviation regulator and air traffic management provider, the International Civil Aviation Organization and both airlines involved.

In the marine sector we released the final report from our investigation into the collision of a container ship with the Leeuwin sail training ship in Fremantle, with important lessons for marine pilots, and safety action taken by the port and marine pilot operator.

And in rail, our final report from the investigation of a washaway and derailment of a freight train at Traveston, near Gympie in Queensland, emphasised the importance of serviceable environmental monitoring equipment.

All of these significant investigations were supported by ATSB‑produced digital content in the form of educational videos that used graphics, animations and interviews with ATSB investigators to explain the nature of the occurrences, our findings, and broader safety lessons for industry. On social media platforms our videos can generate 10s, and even 100s of thousands of views. (The screenshot above is from an animation created to explain the Melbourne Airport runway investigation.)

In recent years we have invested heavily in producing digital content, as using footage, animations and graphics has proven to be very effective in sharing safety information in a time‑poor, information-rich world.

Occurrence briefs are another platform where the ATSB has increased investment to highlight safety messaging. Briefs are short reports into occurrences that may not justify investigation under the Transport Safety investigation Act, but still offer important safety lessons. Shared on our social media accounts, the 74 briefs published in 2025 (up from 27 in 2024 and 9 in 2023) generated a high level of engagement, increased awareness and discussion.

Also driving the year’s increased publication output was the ATSB’s renewed focus on preliminary and interim reports. For significant accidents and incidents the ATSB aims to publish a preliminary report within 8 weeks of the occurrence, while all investigations that extend beyond a year in length will now have an comprehensive investigation update, typically in the form of an interim report, published every 12 months.

That way industry and key stakeholders are kept updated and informed, and safety information is shared even before an investigation is completed and the ATSB’s findings are fully developed.

The critical role the ATSB plays in receiving and processing confidential reports, through our REPCON system, provides another platform to influence transport safety. REPCON is a voluntary and confidential reporting scheme where industry participants can raise transport safety concerns. After assessing those concerns and approaching involved parties for input and facilitating safety action, a summary REPCON report is published on our website for broader industry awareness.

Other ATSB publications in 2025 included 7 safety advisory notices, a safety study into passenger-carrying hot air ballooning, and 3 reports providing assistance to other Australian agencies conducting their own safety investigations. In addition, 7,636 aviation safety occurrences reported to the ATSB in 2025 were processed and added to our searchable online database.

Beyond Australia, the ATSB continues to engage with and support our equivalent transport safety agencies in the Asia Pacific. For example, long standing partnerships with our counterparts in Indonesia and Papua New Guinea in 2025 continued to see investigators from these nations undertake tertiary level investigator training under the ATSB’s partnership agreement with RMIT University (training that is also available to industry participants).

In addition, in 2025 the ATSB also delivered transport safety investigation training and specific investigation assistance to our colleagues in Tonga and Vanuatu – important capacity-building activities that were supported by funding from the Department of Foreign Affairs and Trade (DFAT).

More broadly our international responsibilities continued to extend to our participation in key United Nations transport agencies, the International Civil Aviation Organization (ICAO) and the International Maritime Organisation (IMO), where we play leading roles in shaping best practice transport safety investigation globally.

But that ability to influence transport safety investigation internationally is only because the ATSB has built and sustained a reputation for high quality, timely investigation reports and safety information products – a reputation that is critical to our ability to effectively influence safety action and foster safety awareness. 

A hot air balloon was operated on a passenger flight after its pilot conducted a field repair without fully understanding the manufacturer’s limits or requirements, an ATSB final report explains.

On 18 October 2025, a Kubíček BB142P hot air balloon was being cold inflated before an early morning sightseeing flight near Beaudesert, Queensland, when a change in wind direction pushed its partially inflated envelope across a field, striking two light posts.

After the crew recovered the balloon, the pilot identified a tear in one of the upper envelope panels above the balloon equator.

The pilot, who was also the maintainer of the aircraft, estimated the tear to be about 45 cm, and conducted a field repair using specialised adhesive tape.

During the subsequent flight with the pilot and 24 passengers on board, the repair degraded and a hole opened in the envelope, allowing air to escape from the balloon. The pilot was able to continue the flight and land at the planned destination without further incident.

“The initial damage occurred after an inflation and launch position was selected which did not provide sufficient clearance from nearby obstacles,” ATSB Director of Transport Safety Dr Stuart Godley explained.

“The resulting tear, which the pilot estimated as 45 cm, was far in exceedance of the 2.5 cm limit without overstitching defined by the manufacturer for this type of field repair. However the pilot did not fully understand the manufacturer’s guidance.”

Dr Godley said the pilot was likely also influenced by their perception of passengers’ expectations.

“After hot inflating the balloon and observing no immediate degradation of the repair, the pilot likely perceived the expectations of the 24 passengers, who had already arrived for the flight, as a strong motivator to continue,” he said.

“The weight of the perceived passenger expectation would likely have the pilot searching for solutions to allow the flight to proceed, rather than cancelling and rescheduling the flight to conduct required repairs.”

The pilot reported seeing the tape repair degrading during the flight, but assessed they did not need to land earlier than planned.

“When the repair degraded in flight, the pilot continued for the remaining 5-10 minutes of the planned flight, rather than landing immediately, despite the manufacturer’s flight manual instructions to land as soon as possible following in-flight envelope damage,” Dr Godley said.

A recent ATSB safety study provided balloon operators with guidance to reduce the risk of passenger injuries in commercial operations, with recommended risk controls including thorough passenger safety briefings, clear go/no-go decision criteria, and implementing a Safety Management System.

“This incident demonstrates how pilots and maintainers should be aware of external and internal commercial pressures to continue a flight without fully researching and conducting an appropriate repair, in the event of a damaged envelope,” Dr Godley added.

“These repairs must be conducted in accordance with the manufacturer’s instructions, as non-approved repairs can normalise unsafe practices over time, and represent a significant risk to those on board.”

Read the final report: Flight with damaged envelope involving Kubicek BB142P, VH RRP, near Beaudesert, Queensland, on 18 October 2025

Limited night-time hours on type and workload contributed to an autopilot mode selection error that resulted in an S-92 helicopter inadvertently descending below 200 ft above the water at night, triggering an EGPWS terrain warning, an ATSB investigation has found.

The investigation’s final report details that three pilots were onboard the PHI International Australia operated Sikorsky S-92A when it took off from Exmouth, WA just prior to last light on 1 February 2025.

The helicopter tracked towards the drilling rig Transocean Endurance, about 71 km to the north‑north-west, where each of the pilots was to conduct three take-offs and landings to maintain recency in case of an emergency night evacuation from an offshore rig.

The captain was the pilot flying for the outbound flight to the rig, with the copilot as pilot monitoring. The third pilot was seated in a passenger seat in the helicopter’s main cabin.

A short time after arriving in the vicinity of the Transocean Endurance, the helicopter continued descent below the intended pre-set circuit height, which was not recognised by the flight crew.

As it descended to 220 ft above the ocean, the helicopter’s enhanced ground proximity warning system (EGPWS) indicated a terrain caution alert, which was followed by a terrain warning about 4 seconds later, as the S-92 descended through 181 ft.

The crew responded and initiated a climb, stabilised, and debriefed the incident before continuing with the planned exercise.

The lowest recorded altitude of the helicopter during the incident was 152 ft.

The ATSB investigation final report notes that, when the helicopter arrived near the rig, the captain had set the radar altitude hold mode to the circuit height of 660 ft.

“The intent of this setting was for the helicopter to descend from its 1,500 ft cruise altitude to the circuit height, and then for it to automatically hold there,” ATSB Director of Transport Safety Dr Stuart Godley said.

“However, during the descent the captain inadvertently mis-selected the vertical speed mode while attempting to select the helicopter’s autopilot heading hold mode.

“This selection error, which was not recognised by either flight crew member, cancelled the original radar altitude hold order, and instead inadvertently commanded the helicopter to descend at a continuous 500 ft per minute.”

The ATSB found both the pilot flying and pilot monitoring at the time of the incident had limited experience on the S-92A at night, and were experiencing a higher than normal workload.

“The vast majority of the flight crew’s experience in the S-92A was from daytime passenger transfer flights, which involved flying first from Exmouth to Learmonth, to collect passengers before flying out to an offshore rig,” Dr Godley explained.

“The recency flight, which departed from Exmouth directly to the rig, was therefore shorter than usual, reducing the copilot’s time to complete the required cockpit administration and plan the approach, and resulting in the flight crew experiencing a higher than normal workload, at night.”

In the shorter flight time available, the pilots had been unable to accurately determine the take-off safety speed prior to their descent for landing. While in the circuit area the captain requested the copilot calculate it, increasing their workload and focusing them away from their monitoring duties.

At about the same time, the captain elected to activate the helicopter’s moveable searchlight, shifting their focus outside to adjust its position.

“This meant both flight crew members were preoccupied with additional tasks and therefore not monitoring the helicopter’s altitude as it descended towards the water,” Dr Godley said.

“In this case, the EGPWS performed its role, and alerted the flight crew to the undesired low altitude.”

In response to this occurrence, PHI International Australia made several procedural improvements, and adjusted its operational risk assessment for pilots with less than 500 hours on type, or for night flights where both pilots have less than 500 hours at night on type.

“This incident highlights the importance of disciplined and effective multi-crew cooperation, and is a reminder of the risks associated with divided attention in the cockpit.”

Dr Godley said the incident also highlights to S-92A operators of a potential hazard that exists with differing display versions of the automatic flight control system mode select panel.

“Due to the lighting of the panel, distinguishing between hard and soft keys is more difficult at night,” he explained.

“More recent versions of the mode select panel include a tactile white finger barrier installed between the rows of hard and soft keys, reducing – but not eliminating – the risk of a mode selection error.”

Read the final report: Ground proximity alerts involving Sikorsky S-92A, VH-IPE, 71 km north‑north-west of Exmouth Aerodrome, Western Australia, on 1 February 2025