On 24 February 2009, at 1417 Eastern Standard Time, a Piper Aircraft PA28-180 Cherokee aircraft, registered VH-DAC, departed Normanton Airport, Qld on a visual flight rules private flight to Mount Isa with the pilot as the sole occupant. The aircraft did not arrive at Mount Isa as expected and was later found to have impacted terrain at a location adjacent to the planned track. The aircraft was seriously damaged, and the pilot was fatally injured. Examination of the wreckage did not indicate any pre-existing technical fault that may have contributed to the accident. The pilot was not qualified to fly in instrument meteorological conditions (IMC). He may have inadvertently entered IMC while attempting to avoid rain and cloud associated with a weather system that was moving over the intended route at the time.

On 11 February 2009 at about 1922 Eastern Standard Time, a Bombardier Inc DHC‑8‑315 commenced the take-off roll on runway 01 at Townsville Aerodrome for Cairns, Queensland. During the take-off, the pilot in command realised that the aircraft was aligned with the left runway edge. The aircraft was manoeuvred to the centre of the runway and the take-off rejected. It was later determined that the aircraft's left mainwheel had damaged a runway edge light. There were no injuries to the 34 passengers or five crew members and no damage to the aircraft.

The investigation found a number of factors that may have led to the pilot in command not aligning the aircraft on the runway centreline for the take-off. Those factors included misinterpreting the normal runway cues, time pressure to depart, the weather conditions at Townsville Aerodrome and the associated delays during the aircraft's arrival, landing and departure.

Following this occurrence, the operator amended their operational procedures to ensure aircraft were aligned on the centreline of the assigned runway. In addition, the Australian Transport Safety Bureau (ATSB) has released an Aviation Research and Analysis Report (AR-2009-033) that examined a number of domestic and international occurrences in which pilots commenced the take-off while aligned with the runway edge lighting. In that examination, eight common factors were identified that increased the risk of a misaligned takeoff or landing occurrence, including: the distraction or divided attention of the flight crew; a confusing runway layout; the presence of a displaced threshold or the conduct of an intersection departure; poor visibility or weather; air traffic control clearance(s) issued during runway entry; no runway centreline lighting; flight crew fatigue; and recessed runway edge lighting.

The ATSB has developed a Pilot Information Card that will alert pilots of the increased risk of a misaligned takeoff as a result of those factors, which will be distributed to relevant parts of the industry and will be available from the ATSB on request.

During the post-flight inspection of a Saab 340B passenger aircraft, the number two outboard main landing gear wheel was observed to have sustained noticeable damage. The flight crew reported that there was no prior indication of the failure, as the aircraft had handled normally during the landing and taxiing phase of the flight.

Subsequent examination found that the wheel inner rim had fractured away from the hub for approximately one-half of the total circumference. A circumferential fatigue crack had initiated at a location at the bead seat radius, and had propagated until a final ductile overload failure caused a section of the wheel rim to separate.

During the course of the investigation, it was found that the particular wheel design was being phased out due to recognised fatigue problems identified at the bead seat area.

Both the manufacturer and operator were aware of the increased fatigue susceptibility of the earlier wheel design and had established increased inspection regimes for those wheels remaining in service.

On 7 February 2009, five aircraft were engaged in circuit training and one aircraft was departing runway 03 left (03L) at Parafield Airport, SA. All of the aircraft in the circuit at the time were operated by a local flight school. The control tower was not open and Common Traffic Advisory Frequency - carriage and use of radio required, CTAF (R), procedures were in place.

At about 0736 Central Daylight-saving Time, a S.O.C.A.T.A.-Groupe Aerospatiale TB-10 (Tobago), registered VH-YTG, with an instructor and student on board, was on final approach for a practice short field landing. In the circuit behind the Tobago was a Grob - Burkhaart Flugzeugbau G-115 (Grob), registered VH-TGM, with an instructor and student on board. The Grob was on final approach for a practice flapless approach and landing. The Grob collided with the Tobago from behind, damaging the Tobago‟s rudder with the Grob‟s right wing. Both aircraft remained controllable and were landed on runway 03L and 03 right.

The investigation found that the pilots of the Grob experienced sun glare and background visual clutter on the base leg for runway 03L and were unable to sight the preceding Tobago. The pilots of the Grob did not discern some broadcasts from the Tobago pilots, significantly diminishing their situational awareness. The pilots of the Grob continued the approach without positively identifying the preceding aircraft in the circuit.

Soon after the accident, the aircraft operator's flight safety officer produced a comprehensive accident investigation report that captured the key aspects of the accident. Included in the report were a number of recommendations, which were implemented by the operator.

The investigation identified a safety issue regarding definition of the circuit traffic limit in CTAF(R) and a safety issue related to the positive identification of traffic before turning final.

On 2 February 2009, an Agusta Westland AW139 helicopter, registered VH-ESH, departed under the instrument flight rules from Mackay Aerodrome for Townsville Aerodrome, Queensland. The purpose of the flight was to return the helicopter to Townsville following the passage of a tropical cyclone.

Shortly after departure from Mackay, the crew were presented with an increasing number of alert messages indicating the failure of various helicopter systems. While the crew were focussed on assessing these messages, the autopilot altitude hold function disengaged, leading to a descent that was not detected by either the flight crew or air traffic services (ATS).

The helicopter descended undetected for over 6 minutes while flying towards an area of rising terrain, losing about 3,300 ft of altitude, before ATS observed the descent and alerted the crew.

The investigation determined that the helicopter sustained two independent technical problems; one associated with water and particulate ingress and a second related to the probable susceptibility of the air data system to in-flight turbulence. These failures resulted in multiple erroneous alert messages and uncommanded disengagement of the altitude hold function. The investigation also identified a number of safety factors relating to workload and task management by the crew and monitoring of the aircraft by ATS. That included the lack of an altitude deviation alert within the Australian Defence Air Traffic System (ADATS).

Following the occurrence, the helicopter manufacturer and operator, and the Civil Aviation Safety Authority (CASA) implemented a number of safety actions relating to the identified technical and operational safety issues. In addition, the manufacturer and operator of the helicopter, and CASA undertook proactive safety action in a number of cases for which no safety issues were identified.

A replacement common ATS system for ADATS and the civilian Australian Advanced Air Traffic System (TAAATS) has been announced by the Government that could be expected to include common alert functions, such as the existing cleared level adherence monitoring alert in TAAATS.

At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated, and the aircraft collided with terrain.

The pilot and passenger were seriously injured, and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

The pilot's decision not to obtain the relevant Bureau of Meteorology forecasts prevented a full understanding of the weather likely to affect the flight and what impact this might have on his flight planning, including alternate routes and fuel requirements. Similarly, the pilot's decision not to submit any form of formal flight notification, and to not replace the normally carried portable Emergency Locator Transmitter, adversely affected the prompt commencement of a search and rescue following the accident.

While not contributory to the accident, the investigation identified an error in the flight planning requirements in the Visual Flight Guide (VFG) for VFR flights away from a departure aerodrome. The Civil Aviation Safety Authority (CASA) has advised that the VFG has been withdrawn for amendment.

The investigation also identified that the optional nature of the navigational component of the Aeroplane Flight Review (AFR) meant that a pilot's navigation skills could remain un-assessed for an extended period. While this did not contribute to the accident, CASA has advised that the optional nature of the navigational component will be amended to being a recommended element of the AFR, and that guidance will be provided on its conduct.

On 22 Jan 2002, A Schweizer 333 helicopter, registered A2-HDB, crashed at Gaborone Airport in Botswana, killing the pilot, who was an Australian citizen. The Republic of Botswana Department of Civil Aviation (DCA) initiated an investigation into the accident.

The Australian Transport Safety Bureau (ATSB) was notified of the accident in 2005 and appointed an expert under the provisions of clause 5.27 of Annex 13 to the Convention on International Civil Aviation. To protect information supplied by the Botswana DCA to the ATSB and investigative work undertaken to assist the Botswana DCA, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003. A copy of a draft report was sent to the ATSB for review and comment in February 2008. The ATSB provided comments to the Botswana DCA on 20 February 2008.

The Botswana DCA is responsible for releasing a final investigation report regarding this accident. Once completed, a copy of the report can be requested from the Botswana DCA at the following address:

Department of Civil Aviation
PO Box 250
Gaborone
Republic of Botswana

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 21 April 2008 a European Airwings Springbok aircraft suffered a loss of engine power which led to a forced landing being carried out near Levroux, France. There were no injuries to the occupant and the aircraft was slightly damaged. The aircraft was fitted with an Australian manufactured Jabiru aero engine.

The Bureau d'Enquêtes et d'Analyses (BEA) of France is responsible for investigating this occurrence. The BEA requested assistance from the Australian Transport Safety Bureau (ATSB) in establishing a line of communication with the Australian engine manufacturer. The ATSB appointed an accredited representative in accordance with protocols established by the International Civil Aviation Organisation, (ICAO), Annex 13 regarding accident and incident investigation.

Contact was made with Jabiru and copies of correspondence were provided to the BEA. On 24 November 2008 the BEA advised that their investigation had been completed.

Accident reports published by the BEA may be found on the Bureau d'Enquêtes et d'Analyses (BEA) website.

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 5 November 2008 at about 1838 Eastern Standard Time1, the flight crew of a Saab Aircraft AB 340B, registered VH-UYI, identified an incipient stall while flying a holding pattern in icing conditions. The aircraft's stall warning system did not activate. The pilot in command disconnected the autopilot and recovered the aircraft from the stall. During the recovery manoeuvre, both engines exceeded their maximum continuous operating temperature for an extended period. The manufacturer's Aircraft Operating Manual stated that the Saab 340B stall warning system had an activation level designed for a clean wing only. The manufacturer has issued updated operating procedures for flight in icing conditions, designed to prevent ice build-up on the airframe.

On 26 December 2008, a Bombardier Inc DHC-8-315 (DHC8), registered VH-TQL, was conducting a regular public transport flight from Moree to Sydney Aerodrome, New South Wales. While on final approach, and after capturing the glideslope for the runway 34 Left (34L) instrument landing system approach, the autopilot commanded the aircraft to descend. This prompted the crew to make a number of configuration changes in an effort to continue the approach. Those changes destabilised the aircraft and diminished its performance, which lead to the activation of the aircraft's stickshaker. Shortly after, a missed approach was commenced by the flight crew.

In this occurrence, the crew continued the approach despite becoming aware of the unstable aircraft state. Positive action to avoid a stickshaker event could have been taken if the crew communicated to each other the inappropriate aircraft configuration as it progressed along the approach.

As a result of this occurrence, the operator has proactively implemented changes to its DHC-8 training syllabus, highlighted to its crews the destabilising effects of changes to an aircraft's configuration during an approach and emphasised to crews the importance of good communication in a multi-crew environment.