Jump to Content
Download final report
[ Download PDF: 1.31MB]
 
 
 

What happened

On 21 November 2016 at about 0730 Eastern Daylight‑saving Time, the pilot of an Air Tractor Inc. AT-802A, registered VH-NIA, was conducting aerial spraying activities from Trangie airfield near Narromine, New South Wales. The planned activities included spraying a small area of crop on a property about 30 km west of Narromine. The crop spraying was a continuation of the previous day’s activities that had been discontinued due to the weather becoming unsuitable for spraying conditions.

The property owner reported observing the aircraft arrive and that the pilot appeared to be experienced in the way he was manoeuvring the aircraft while spraying the crop. The property owner assumed that the pilot had completed spraying the crop as, after about 30 minutes, the aircraft departed in the direction of Trangie airfield.

At about 0810, witnesses briefly observed the aircraft to be in a nose-down attitude before impacting the ground, resulting in an intense fuel‑fed fire. The accident site was located about 5 km from the spray area. The pilot was fatally injured, and the aircraft was destroyed.

What the ATSB found

The ATSB found that the aircraft departed controlled flight, from which the pilot was unable to recover, leading to the collision with terrain. Based on the available evidence, it was not possible to determine the reasons for the loss of control.

The ATSB identified a number of observed incidents or potentially unsafe aircraft operations involving the accident pilot that were not reported to the operator’s chief pilot. This decreased the opportunity for the operator to identify and address risks that could affect the safety of operations.

What's been done as a result

The operator advised that meetings with staff have been beneficial in highlighting the importance of reporting incidents and accidents despite any concerns about an employee’s seniority or role in the company. Additionally, induction processes and documented safety reporting procedures have been reinforced.

Safety message

Operators must ensure that all personnel have an understanding of the importance of timely reporting of events that increase safety risk. A good safety reporting culture can assist operators with monitoring trends, identifying operational issues, and providing a timely response to reduce risk within the operating environment.

Air Tractor AT-802A, VH-NIA

Air tractor AT-802A, registered VH-NIA
Source:  Jayden Laing

Download final report
[ Download PDF: 1.31MB]
 
 
 

The occurrence

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
 
 

To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly.

 

Safety issue

AO-2016-157-SI-01 -  

Safety reporting culture and procedures

The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate action to minimise them.

Safety issue details
Issue number:AO-2016-157-SI-01
Who it affects:All owners and operators of aircraft
Status:Adequately addressed

 
General details
Date: 21 November 2016 Investigation status: Completed 
Time: 08:10 ESuT Investigation phase: Final Report: Dissemination 
Location   (show map):33 km W Narromine Investigation type: Occurrence Investigation 
State: New South Wales Occurrence type: Collision with terrain 
Release date: 13 March 2018 Occurrence class: Operational 
Report status: Final Occurrence category: Accident 
 Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Air Tractor Inc 
Aircraft model: AT-802A 
Aircraft registration: VH-NIA 
Serial number: 802A-0148 
Operator: Rebel Ag 
Type of operation: Aerial Work 
Sector: Turboprop 
Damage to aircraft: Destroyed 
Departure point:near Narromine, NSW
Destination:Trangie, NSW
 
 
 
Share this page Provide feedback on this investigation
Last update 13 March 2018