Collision with terrain

Summary video

The occurrence

On 19 March 2026, a Cessna 441 Conquest aircraft, registered VH-LBZ and operated by Skippers Aviation, was being utilised for a non-scheduled passenger air transport flight from Broome Airport to Mungalalu‑Truscott aerodrome, Western Australia. The flight was being operated by 2 pilots – a pilot in command under supervision¹ (pilot flying), seated in the left seat and a training captain in the right seat. There were 5 passengers on board.  

The aircraft had a permissible unserviceability, under the minimum equipment list (MEL)² applied for the right engine fuel control computer. The MEL deferred defect log stipulated that both engines be operated in manual mode for take-off, using a specific procedure. The training captain, in consultation with the pilot flying, requested that they be assigned VH‑LBZ for training purposes, to cover the manual mode procedure. In preparation, the pilot flying reviewed the manual mode procedure both the night before and on the morning of the flight. This was in addition to having talked through and observed the training captain perform the procedure about 2 weeks prior. 

The pilot flying arrived at the airport at about 0900 local time, about 40 minutes prior to the scheduled sign-on time, to prepare for the flight and to participate in a briefing with the training captain. The briefing was reported to be normal except that it included the procedure to operate the aircraft’s engines in manual mode, with the pilots referencing the flight manual. 

The flight was scheduled to depart at 1030. Both pilots prepared the aircraft for departure and at about 1035 all 5 passengers had checked in and were escorted to the aircraft. The passengers received a safety briefing from the training captain at the aircraft. 

The aircraft start was as per the manual mode procedure and, at 1058, Broome tower air traffic control (ATC) provided a clearance and the aircraft taxi was commenced. During the taxi to the runway holding point, the pilots completed their take-off brief, where they again discussed differences related to operating in manual mode. This included an earlier decision speed³ of 105 kt, setting an engine torque limit of 1,500 ft-lbs per side and that manual fuel enrichment using the START buttons may be required during the take‑off roll.

At about 1115, after waiting for traffic, VH-LBZ was cleared for take-off. The aircraft was lined up on runway 10 and the pilot flying moved the power levers up for a normal take‑off. The pilot flying noted that the engine torque increased to about 650 ft-lbs per side, below the target of 1,500 ft-lbs. In response, the pilot flying pressed the START buttons as per the procedure, alternating between left and right to enrich with fuel, reaching 1,450 ft-lbs engine torque before rotation.⁴

After take-off, both pilots recalled that, just after they had completed the after-take-off checks and at about 500 ft above mean sea level, with the autopilot engaged, the pilot flying verbalised their intention to enrich again as the torque was at 1,450 ft-lbs, and they wanted to increase it to 1,500 ft‑lbs. The pilot flying pressed what they believed to be the left and right START buttons (without looking at the panel). 

At about 1117, immediately following the enrichment, the pilot flying recalled a change in engine sound, feeling the aircraft yaw slightly and an absence of thrust. The training captain also reported an immediate sound change and seeing the engine torque reduce asked the pilot flying if they had pressed the STOP buttons. The pilot flying was unsure, however, immediately lowered the nose to maintain airspeed.

The training captain called for an ‘air start’ and instructed the pilot flying to press the START buttons again. The training captain pulled the power levers back to where they believed the air start zone was, however, with limited time available to restart the engines, they decided to conduct a forced landing. At 1117:12, a MAYDAY⁵ call was made, and the pilot flying handed over control to the training captain. Broome tower ATC activated the crash alarm at 1117:18. 

The decision was made by the training captain to land in the mangroves, relatively straight ahead of the aircraft track. The landing gear was extended as instructed by the training captain, and the pilot flying called for the flaps down, which the training captain actioned. The passengers were instructed to brace for impact. 

The training captain conducted a controlled descent and moved the condition levers to shut-off just before the aircraft impacted terrain at 1117:54, at a ground speed of 76 kt (141 km/h) (Figure 1). As a result of the impact, one passenger was seriously injured and the 2 pilots and 4 passengers received minor injuries. The aircraft was substantially damaged. 

Figure 1: Flight track and location of accident site

Source: ATSB

The aircraft emergency locator transmitter activated on impact and the training captain attempted to contact Broome tower ATC via radio, however, was unsure if the radio was working, as they did not receive a response.

Broome tower ATC attempted to contact the aircraft operator to confirm the number of people on board, and if there were any dangerous goods, but was unable to do so. This information was instead obtained through contact with the training captain on their mobile phone. 

The occupants commenced exiting the aircraft and the training captain was the last to egress, taking the fire extinguisher. The pilot flying applied first aid to the seriously injured passenger.  

A search and rescue helicopter was dispatched at about 1141, arriving on site at 1210. Western Australia police arrived at about 1213. The seriously injured passenger was airlifted from the accident site and transported to hospital by ambulance. The flight crew and remaining passengers were assisted by police and the Department of Fire and Emergency Services to walk from the accident site and were met by ambulances. 

Context

Personnel information

Pilot in command under supervision 

The pilot in command under supervision held a Commercial Pilot Licence (Aeroplane), issued in 2018 and with class ratings for multi- and single-engine aeroplanes. They had accumulated 1,256.8 total flight hours, with 56.6 hours on the Cessna 441 aircraft type. The pilot held a current instrument rating, with their last proficiency check completed in January 2026, and a current class 1 aviation medical certificate (valid until April 2026) with no conditions. The pilot reported being well rested and fit to fly.

Training captain 

The training captain held a Commercial Pilot Licence (Aeroplane) issued in 2022 and with class ratings for multi- and single-engine aeroplanes. They had accumulated 1,764.7 total flight hours, with 1,080.9 hours on the Cessna aircraft 441 type. They held a current instrument flight rating, with their last proficiency check completed in November 2025, and a current class 1 aviation medical certificate (valid until November 2026) with no conditions. The training captain reported being well rested and fit to fly.

In addition to their position as training captain, they also held the roles of Broome senior base pilot and the Cessna 441 fleet manager for the operator. 

Aircraft information

General

The Cessna 441 Conquest is a pressurised, low‑wing aircraft, with seating for up to 2 pilots and 10 passengers. However, the Skippers Aviation operations manual limited the number of passengers that could be carried to 9. 

VH-LBZ was powered by 2 Honeywell International Inc TPE331-10N-531S turboprop engines, fitted with Hartzell HC-B3TN-5 propellers. Both pilot seats were equipped with flight controls, however, single‑pilot line operations were flown from the left seat. The right pilot seat would normally only be occupied by a second pilot for training and checking, although for this flight the operator’s client had stipulated via policy that 2 crew would be carried. 

The accident aircraft, serial number 4410038, was manufactured in the United States by the Cessna Aircraft Company in 1978 and registered in Australia as VH-LBZ in July 1984. At the time of take-off, the aircraft had a total time-in-service of 29,267.9 flight hours. The aircraft was operating under a Civil Aviation Safety Authority supplemental type certificate that, with specific maintenance requirements, permitted operators to continue operating the Cessna 441 past its service life of 22,500 flight hours to 40,000 flight hours.  

Aircraft maintenance 

The aircraft was maintained in accordance with the Skippers Aviation Cessna 441 maintenance program, which incorporated the requirements of the life extension program, permitted by the supplemental type certificate. 

The aircraft had a deferred defect log⁶ entry dated 16 March 2026, which showed that the right engine fuel control computer was unserviceable. A yellow sticker was affixed to the right fuel control computer switch located on the left vertical panel inside the aircraft to identify the unserviceability (see START and STOP buttons). This was a permissible unserviceability in accordance with the aircraft’s MEL. As this was a category C defect,⁷ the aircraft was permitted to operate for a maximum of 10 days, with one or both fuel computers unserviceable, provided certain limitations were adhered to. Those limitations were:

• manual mode (see Engine fuel control system) procedures in the airplane flight manual were followed 
• manual mode performance charts in the airplane flight manual were used
• propeller reversing was not to be used for the engine operating in manual mode
• propeller synchrophasing⁸ was inoperative. 

The airplane flight manual procedures recommended that, where one fuel computer was inoperative, both engines were to be in manual mode for take-off. The operator’s deferred defect log included the MEL requirements and added that both engines were to be in manual mode for take-off and landing. Further, the operator required that the abovementioned specific MEL requirements be covered in line training for take-off and landing. 

Engine fuel control system

Normal mode operation

Each engine was equipped with an electronic fuel control system (normal mode operation), which included an electronic fuel computer for regulating fuel flow and engine speed. The system automatic functions included:

• automatic engine starting
• fuel enrichment and optimum fuel scheduling
• calculating a single red line exhaust gas temperature to assist the pilot with managing engine power
• limiting engine torque and temperatures to prevent exceedance
• the engine revolutions per minute (RPM) automatically changed with the condition lever selection⁹
• electronic underspeed governing of the propeller.¹⁰

 Manual mode operation

The electronic fuel control system was also fitted with a manual backup system (manual mode operation), which was to be used when the electronic fuel computer became inoperative for any reason. When operating in manual mode, among other reductions in certain system functions: 

• fuel enrichment required for take-off and engine acceleration was achieved by pressing the engine START button
• the engine starting functions were to be performed manually by the pilot 
• the condition lever did not control the engine speed
• the propeller synchroniser was inoperative 
• engine torque and temperature were to be monitored and manually adjusted by the pilot to prevent engine damage as the limiting functioning was inoperative  
• engine response to power lever advances was slower 
• aircraft performance was changed
• propeller reversing was not permitted.

START and STOP buttons

The aircraft was fitted with START (black) and STOP (red) buttons for the left (L) and right (R) engines. Slightly recessed, the buttons were located in proximity on a horizontal switches panel to left of the left pilot seat (Figure 2). The START button was pressed momentarily to initiate the start sequence, in normal and manual modes. 

When the STOP buttons were pressed, this activated the electrical fuel shutoff valve initiating an immediate cessation of fuel flow. When using the STOP buttons for a normal shutdown, the airplane flight manual advised that the buttons were to be pressed and held for 5 seconds to allow for any remaining fuel in the system to be purged. 

Figure 2: Location of START and STOP buttons and electronic fuel control switches

Source: ATSB

Use of the START button for fuel enrichment

The fuel enrichment valve, part of the fuel control assembly,¹¹ permitted fuel enrichment during engine start, primarily to accelerate the engine smoothly to operating speed. The electronic fuel computer controlled the fuel enrichment for acceleration while simultaneously ensuring that the exhaust gas temperature remained within limits. In manual mode, the pilot provided fuel enrichment by pressing and holding the START button, after fuel flow had been established. The procedure for manual mode starting included the START button could be pushed ‘as required for fuel enrichments to assist engine acceleration to 85% RPM’. The pilot must monitor exhaust gas temperature to remain within limitations.

The airplane flight manual further stated that the START button could be used as required to aid engine acceleration to 100% RPM, with brakes applied prior to the commencement of the take-off roll. However, it did not mention the use of the START button for enrichment during any other phases of flight. 

Meteorological information  

The aerodrome forecast for Broome Airport, valid from 1000 on 19 March 2026, indicated the wind was 100° at 14 kt, and CAVOK¹² conditions. The forecast temperature was 34°C. 

Wreckage and impact information

The forced landing area was in mangrove swampland about 3.6 km east of Broome Airport, in-line with the aircraft’s approximate take-off track. The flight path angle was about 9° nose down and the distance between the initial contact with mangrove trees and the wreckage was about 30 m (Figure 3).

Figure 3: Overhead view of aircraft accident site

Source: ATSB

The ATSB’s onsite examination identified that:

• The aircraft was relatively intact with the landing gear down and the flaps partially extended. The aircraft rapidly decelerated once the landing gear had contacted the muddy terrain.
• There was fuel in the left and right wing tanks and clean fuel in the left and right engine‑driven fuel pump filter bowls.
• Examination of the left and right engine turbines viewed through the exit ducts did not show any observable damage.
• Damage to the left and right propeller showed back bending and limited rotational abrasion damage, which indicated the engines were not driving the propellers at the time of the impact (Figure 4).

Figure 4: Aircraft wreckage showing propeller back bend

Source: ATSB

Recorded information 

The ATSB recovered 3 Garmin electronic recording devices from the aircraft:

• G600 TXi flight display
• GI 275 attitude indicator
• GTN 650Xi GPS, navigation, communications and multifunction display.

While there were no parameters on the devices recovered that directly pertained to the engines, the GI 275 recorded the system voltage (aircraft power). The data retrieved from this unit showed a drop in the system voltage beginning at 1116:59, from 27.7 volts direct current (VDC) to 26.8 VDC within 1 second, then slowly decreased to 24.5 VDC over the next 17 seconds. The base system voltage was nominally 24 VDC, however, would be about 28 VDC when the generators¹³ were on. Therefore, a drop in voltage was consistent with the generator speed reducing as the engines shut down. In addition, there was also a rapid decrease in longitudinal acceleration at the same time. 

The data retrieved also indicated that, at 1116:59, the aircraft (Figure 5):

• was at an altitude of 490 ft above mean sea level
• had an indicated airspeed of 141 kt (261 km/h)
• was climbing at 1,225 ft/min 
• had about 9° nose-up attitude and 4° left roll
• was on a heading of about 107°.

At 1117:54, the impact occurred at an indicated airspeed of about 82 kt (152 km/h) and a ground speed of 76 kt (141 km/h) coming to a stop by 1117:58. 

Figure 5: Location of aircraft engine shutdown

Orange section is with power available, blue section is following the engine shutdown.Source: ATSB

Survival aspects

The liveable space within the aircraft cabin was maintained, and the exits were tested by the ATSB and found to function correctly. However, there was significant disruption to the cabin interior including displaced equipment, deployed oxygen masks and the complete detachment of 2 passenger seats from their seat tracks, with some of the floor structure lifting. An additional seat had partially detached and the seat behind the right pilot was significantly distorted, with a backward bend of almost 45° (Figure 6).

Figure 6: Aircraft cabin immediately after the accident

Source: Pilot of VH-LBZ

In addition, a passenger seated on the right side of the second row of passenger seats reported that their seatbelt failed during the impact, throwing them forward into the back of the seat ahead before coming to rest between the 2 pilots. This passenger received serious injuries. Figure 7 shows the location of the full and partially failed seats, and where the seriously injured passenger was seated. All other passengers and the pilots received minor injuries.  

Figure 7: Location of seat failures and seriously injured passenger

Source: ATSB

Related occurrence

A previous ATSB investigation (200601053) involving a Cessna 441 Conquest, VH-LBA, 40 km north-west of Callion, Western Australia, on 27 February 2006, found that the pilot in command inadvertently shut down the left engine in-flight by pressing the STOP button. The investigation noted that:

…Prior to the event, the flight crew were discussing the use of the Start Button Guard Plate which was in place over the engine START buttons. In the course of explaining to the second pilot the use of the Start Button Guard Plate, the PIC inadvertently depressed the left engine STOP button...

Safety action

The Civil Aviation Safety Authority (CASA) issued a safety alert to Skippers Aviation Pty Ltd to prevent the use of Cessna 441 Conquest aircraft that have an MEL applied that requires the use of manual mode. The safety alert advised:  

Skippers must not dispatch a flight where an MEL involving the use of manual mode is in force in any C441 Conquest operated by them until CASA has approved amendments to the Exposition and the Training and Checking manual that detail the use of manual mode and Skippers has conducted the appropriate training and checking of the flight crew assigned to the flight.

Skippers Aviation Pty Ltd advised that it has taken the following safety action, which addressed the safety alert issued by CASA and included additional actions:

• Immediate grounding of the Cessna 441 Conquest fleet. 
• Issuance of a companywide ‘Memorandum to All Staff – The use of MEL 76-00-01 Fuel computers is Prohibited’. 
• Completion of a risk review of Cessna 441 Conquest operations which encompassed procedures, training, maintenance, workload, safety and staffing. The review determined that, while the operator considered all controls were compliant, multiple challenges existed and a decision was made to cease all Cessna 441 Conquest revenue operations permanently. 
• A cost benefit analysis was completed, and Broome operations were considered no longer feasible. 
• A review of companywide procedures and training is in progress, including all procedures related to the management of MELs.

Further investigation

To date, the ATSB has:

• examined the wreckage and accident site
• examined recorded data from the Garmin G600 TXi, GI 275 and GTN 650 devices
• interviewed the pilots and passengers
• collected radio communication, aircraft traffic surveillance data, and navigational application data
• collected aircraft, pilot, crew and operator documentation.

The investigation is continuing and will include further review and examination of:

• operational procedures and training 
• aircraft maintenance and MEL practices
• crashworthiness and survivability aspects 
• aircraft design features (including the START/STOP buttons).

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken. 

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is reducing the severity of injuries in accidents involving small aircraft.

Acknowledgements

The ATSB would like to thank the Department of Biodiversity, Conservation and Attractions for its assistance in facilitating access to the aircraft accident site. 

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. About ATSB reports ATSB investigation reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines. Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2026  Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

1. ^     In-command under supervision allows a pilot to perform all duties and functions as a pilot in command under the supervision of a pilot in command appointed for that purpose.
2. ^     Minimum equipment list (MEL) is a list that provides for the operation of aircraft, subject to specified conditions, with particular equipment inoperative. 
3. ^    An engine failure below the decision speed should result in a rejected take off; above this speed the take-off should be continued.
4. ^    Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.

5. ^     MAYDAY is an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.

    

6. ^    The deferred defect log identified the system affected, date and aircraft hours when logged, any limitations and deferral expiry date, a copy of which was in the flight log available to the pilots.

7. ^     Minimum equipment lists and repair categories are explained in Civil Aviation Advisory Publication (CAAP) 37-01 v5.1.

    

8. ^    Propeller synchronising and synchrophasing provide a means to match the RPM of both engines and establish a blade phase relationship between the left and right propellers to reduce vibration and cabin noise.
9. ^    The condition lever controlled engine speed (RPM) and fuel flow while the power lever adjusted the engine torque and propeller speed.
10. ^   The electronic underspeed governor is primarily to control fuel flow to maintain engine RPM during ground operations. It differs in operation to the propeller governor that directs oil to, or from, the propeller to maintain selected propeller/engine RPM.
11. ^   The fuel control assembly regulates fuel flow to the engine and contains a mechanical fuel shutoff valve and an electrical fuel shutoff valve.
12. ^    Ceiling and visibility okay (CAVOK): visibility, cloud and present weather are better than prescribed conditions. For an aerodrome weather report, those conditions are visibility 10 km or more, no significant cloud below 5,000 ft, no cumulonimbus cloud and no other significant weather.
13. ^   A combination starter-generator was mounted on each engine. The units operated as a starter during ground starts and were the aircraft’s primary power source.

Investigation summary

What happened

At 0834 Australian Eastern Standard Time on 13 March 2026, a Robinson R44 II helicopter, registered VH-TCF, departed from Gold Coast, Queensland, for a private flight to Mudgee, New South Wales (NSW), with an intermediate stop at Armidale, NSW, to refuel. 

The pilot’s iPhone crash alarm activated, 72 minutes after the aircraft departed, and the wreckage was located the following day in dense bushland, 46 km north-east of Tenterfield, NSW. The pilot sustained fatal injuries and the helicopter was destroyed. 

What the ATSB found

The ATSB found that it was very likely the pilot entered weather conditions unsuitable for visual flight, resulting in a loss of control and subsequent collision with terrain.

Safety message

The ATSB encourages all pilots, no matter what their experience levels, to develop the knowledge and skills required to avoid unintentional operations in instrument meteorological conditions (IMC). This includes having alternate plans in case of unexpected changes in weather, and making timely decisions to land, turn back, divert or hold in an area of clear weather. The use of a ‘personal minimums’ checklist can also be a strong mitigator against the risk of flying into bad weather. 

The Vertical Aviation Safety Team, formally known as the International Helicopter Safety Team, has published several fact sheets about inadvertent IMC (IIMC) that are available from their website. Their fact sheet, Inadvertent entry into instrument meteorological conditions (IIMC), acknowledges that these encounters are the ‘most demanding, disorienting, and dangerous conditions a pilot can experience’ and result in the highest percentage of fatal injuries from helicopter accidents. 

The fact sheet explained the immediate actions required by pilots in IIMC stating that: 

A pilot’s immediate actions after encountering inadvertent IMC will determine the outcome of the entire event. Pilots who possess a plan of action prior to encountering it are more likely to experience a successful outcome (staying alive) than those who are less trained and proficient in the recognition and recovery procedures. 

In addition, their fact sheet stated that: 

Comprehensive training on IIMC is necessary for all rotorcraft helicopter training. This training should include, but not limited to:

• Determination of enroute weather

• Avoidance of inadvertent flight into instrument meteorological conditions

• In-flight weather abort procedures

• Recovery from inadvertent flight into instrument meteorological conditions. 

The ATSB booklet Accidents involving visual flight rules pilots in instrument meteorological conditions (AR-2011-050) provides guidance on avoiding flight into adverse weather. Further information specific to helicopter pilots is also available on the ATSB website.

The investigation

The occurrence

On 13 March 2026, the pilot and sole occupant of a Robinson R44 II helicopter, registered VH-TCF, planned to conduct a private flight under the visual flight rules (VFR),¹ from Gold Coast, Queensland, to Mudgee, New South Wales (NSW), with an intermediate stop at Armidale, NSW, to refuel (Figure 1).

Figure 1: Map showing accident site and key locations

The pilot was intending to travel over 3 days, to join a helicopter safari in southern Victoria with the intention of flying around Tasmania. A relative of the pilot reported that the pilot was ‘very excited about the trip’. They further advised that the pilot had been monitoring the weather in the days leading up to the departure and was expecting clear conditions for the flight. 

At about 0834 Australian Eastern Standard Time (AEST),² the helicopter departed from a private helipad, around 35 km from the Gold Coast Airport. 

NSW Police advised that an automated emergency message associated with activation of the pilot’s iPhone crash alarm³ was received at 1046 Australian Eastern Daylight saving Time (AEDT),⁴ 72 minutes after the aircraft departed. In response, a formal search was commenced by NSW Police. 

The wreckage was located at 1113 AEDT on 14 March 2026, in dense bushland, 46 km north-east of Tenterfield, NSW. The pilot sustained fatal injuries and the helicopter was destroyed. 

Context

Pilot information 

Flight experience 

The pilot held a Private Pilot Licence (Helicopter) and a single‑engine helicopter class rating. The pilot did not hold an instrument rating and had not logged any instrument flight time. As of 7 March 2026, the pilot’s logbook showed they had accrued about 1,262 hours total flight time, 84 of which were accrued on an R22. The remaining hours were obtained operating R44 helicopters, with all but 11.5 in VH-TCF. The pilot completed their last flight review on 21 September 2025. The instructor who conducted the review reported that it included ground theory training followed by a 1‑hour flight, and a second 1-hour flight the following day, consistent with entries in the pilot’s logbook. The instructor reported discussing interpretation of a weather forecast with the pilot, but did not require, or observe the pilot demonstrate, planning a flight based on the weather forecast. The instructor described the pilot as a ‘confident and comfortable’ pilot. 

Medical information 

At the time of the accident, the pilot was 77 years old. Their class 2 aviation medical certificate application was completed by a designated aviation medical examiner on 5 September 2025 and was valid to 5 September 2026. The certificate had the following limitations:

Must use [continuous positive airway pressure] CPAP in sleep period prior to exercising privileges of medical certificate.

Reading correction to be available whilst exercising the privileges of this licence. 

Records obtained from the CPAP provider showed that the pilot was regularly using the CPAP machine as required. 

The ATSB reviewed the pilot’s CASA aviation medical history since 2017. While the pilot had multiple conditions that increased the risk of medical incapacitation, these had been disclosed to CASA and were assessed as being adequately controlled. 

The pilot was reported to have slept normally the night before the accident and had eaten breakfast before departing. There was no evidence to indicate the pilot was unwell, nor experiencing a level of fatigue known to affect performance. 

The post-mortem did not identify any evidence of incapacitation, however, toxicology results were not available at the time of report writing.  

Aircraft information

General information 

The Robinson R44 II is a 4-seat helicopter, powered by a single Textron Lycoming IO‑540‑AE1A5 piston engine, driving a 2‑blade semi-rigid main rotor system and 2‑blade tail rotor system. VH-TCF, serial number 11912, was manufactured in the United States in 2007 and first registered in Australia in October 2007.

The helicopter was being maintained in accordance with the Robinson Helicopter R44 maintenance manual, the Lycoming IO-540 operator’s manual, supplemental type certificates and engineering orders. Its last periodic inspection was conducted on 13 February 2026 at 2,103.4 hours. Prior to the commencement of the accident flight, VH-TCF had accumulated 2,104.7 hours total time in service. It was equipped and maintained to a day visual flight rules standard, with the maintenance release reflecting this limitation.

The helicopter was equipped with lap sash seat belts and was being operated with the doors fitted. 

Rotor system 

The Robinson R44 main rotor hub assembly is a semi-rigid rotor head, otherwise known as a teetering rotor head (Figure 2). Bolts secure the blades to the hub at the coning hinges. During stopping and starting of the main rotor, when RPM is low, blade tusks rest against droop stops, restricting teetering and preventing the blades from drooping. As the main rotor RPM increases, the blades straighten and become rigid due to rotational forces, and the tusks shift off the droop stops. During normal flight, the rotor is free to teeter and flap around its designed flight axis via the teeter hinge, while polyurethane teeter stops limit the degree of teetering. 

Under certain flight conditions, semi-rigid rotor systems are susceptible to extreme teetering where the blades teeter beyond their normal operational range, resulting in what is commonly known as ‘mast bumping’ (see the following section titled Mast bumping).

Figure 2: Robinson main rotor hub assembly

Mast bumping

Mast bumping is the common term used to describe contact of the main rotor shaft, by the inboard main rotor spindle (Figure 3).

Mast bumping severity can generally be identified by extensive damage to, including destruction of, the teeter stops and varying degrees of damage to the main rotor shaft from direct impact. 

Extreme teetering can also result in the pitch change links exceeding their maximum displacement and often results in failure of one or both pitch links, typically at the upper rod end thread. Failure of a pitch link will allow uncontrolled rotation of the blade about its pitch axis and at this point, control of the helicopter is no longer possible. As documented in many investigation reports worldwide, scenarios involving mast bumping have been attributed to inappropriate flight control inputs that permit the development of, and/or inappropriate response to, low g⁵ flight conditions.

Figure 3: Extreme mast bump

Site and wreckage information 

Accident site

The accident site was located about 46 km north-east of Tenterfield Airport in a densely vegetated area. It was situated on the southern side of a steep slope, at an elevation of about 900 m (2,950 ft). 

The wreckage trail was approximately 12 m long in a westerly direction (Figure 4). It consisted of an initial impact point, followed by a trail of debris down the slope leading to the fuselage, engine and main rotor, much of which were consumed by a post-impact fire. Damage was evident on 2 trees located near the initial impact point, indicating the helicopter had struck these trees in a near vertical descent. 

Figure 4: Accident site

The aft section of the tailcone assembly, including the tail rotor and stabilisers, had separated from the fuselage and was located approximately 20 m from the fuselage across the slope through dense vegetation (Figure 4). A large, soft shell travel bag was located in the tree canopy (Figure 4), around 12 m upslope from the initial impact with the trees. Various other items from within the helicopter, such as a headset, were located between the bag and the initial impact site, indicating they had been liberated from the helicopter above the tree line, prior to the initial impact point. 

The main instrument panel was located a further 10 m down the slope away from the fuselage.

Wreckage examination

Disruption to the helicopter and post-impact fire damage precluded a detailed examination of a significant proportion of the helicopter. This included testing of electrical and fuel system components and the determination of engine controls and instrument panel switch selections. 

The intensity of the post-impact fire was indicative of a considerable amount of fuel on board the helicopter. A fuel jerry can, which had been filled at the helicopter’s departure location, was found on site. The contents were consistent with avgas, and testing showed no presence of water in the fuel.  

Main rotor assembly

Examination of the main rotor components identified:

• the main rotor hub was secure to the main rotor shaft, which was secure to the main rotor transmission
• both main rotor blade tips were located within the accident site
• one teeter stop had fractured in the centre due to severe impact forces from the spindle, with the upper half liberated 
• the other teeter stop was not present (Figure 5)
• both teeter stop stainless steel mounts exhibited distortion from spindle impact (Figure 5)
• impact damage to the main rotor shaft at both teeter stop locations (Figure 5).

Figure 5: Example of damage to teeter stop and main rotor shaft on one side

• both main rotor pitch change links had fractured in overstress, at the upper rod end thread (Figure 6) 
• one pitch horn had detached, with the fracture surface consistent with overstress (Figure 6)
• the other pitch horn was secured to the spindle and exhibited damage consistent with contact with the main rotor hub (Figure 6).

Figure 6: Main rotor hub

Tailcone separation

The aft section of the tailcone was located around 20 m to the right of the wreckage trail with limited damage to the structure. Signature marks where it had separated from the tail boom, the lack of structural damage and its location, were consistent with the tailcone likely separating above the trees during the accident sequence, rather than it being a precursor to the accident.

Other systems

Where flight control tubes had been destroyed by impact or fire, the integrity of the control system was limited to confirming the connection at their respective attachment points and for the presence of securing hardware. In that context, no defects were identified. Further, fracture surfaces of rod ends, and other flight control components were consistent with overstress failure.

The examination also identified the following:

• all major components were identified at the site
• damage to the cooling fan was indicative of the engine rotating at the time of impact 
• damage to, and location of, the instrument panel (Figure 4) was consistent with a high energy liberation event, possibly from a main rotor strike.  

Recorded data 

Although the pilot was reportedly using the OzRunways⁶ electronic flight bag software, which provided a map overlaying the helicopter’s GPS location to aid in navigation, no track data was transmitted to the service provider. There were no other recording devices on board the helicopter. 

VH-TCF was identified on WebTrak⁷ around Gold Coast Airport. It showed the helicopter tracking roughly south-west at about 3,000 ft, before crossing the NSW border at 0854 AEST. This service then stopped recording the helicopter’s position.

Airservices’s secondary radar further detected unidentified aircraft returns in the vicinity of the accident site, however, these could not be confirmed as VH-TCF. 

Weather information 

Forecasts 

The Bureau of Meteorology (BoM) terminal area forecast (TAF)⁸ issued at 0612 AEST on 13 March 2026 and valid from 0700 AEST for the Gold Coast Airport included:

• visibility greater than 10 km with scattered cloud at 1,000 ft and broken⁹ cloud at 1,600 ft 
• from 0800 AEST, light showers of rain and broken cloud at 2,000 ft
• a TEMPO¹⁰ between 0700–0900 AEST visibility greater than 10 km with broken cloud at 1,000 ft
• a TEMPO between 0900–1800 AEST included visibility of 3,000 m, showers of rain and broken cloud at 1,000 ft and few towering cumulous at 2,000 ft 
• an INTER¹¹ between 1800 AEST on 13 March and 0400 on 14 March included visibility of 4000 m, showers of rain and broken cloud cover at 1,200 ft

The BoM graphical area forecast (GAF),¹² issued at 0809 AEST on 13 March 2026 for the area encompassing the flight path south of Gold Coast to the accident site (Figure 7) included:

• visibility greater than 10 km with broken stratus with bases at 1,500 ft and tops at 2,000 ft and broken stratocumulus with bases at 2,000 ft and tops to 9,000 ft
• visibility 4,000 m in isolated¹³ showers of rain with broken stratus with bases at 1,000 ft and tops at 2,000 ft, and broken cumulus/stratocumulus with bases at 2,000 ft and tops to 9,000 ft
• visibility 3,000 m in isolated drizzle with broken stratus with bases at 800 ft and tops at 2,000 ft, and overcast stratocumulus with bases at 2,000 ft and tops to 9,000 ft 
• in a small coastal area just south of Gold Coast, isolated thunderstorms and rain were forecast, reducing visibility to 2,000 m with associated cumulonimbus with bases at 2,000 ft and tops above 10,000 ft, broken stratus with bases at 500 ft and tops at 2,000 ft, and broken cumulus/stratocumulus with bases at 2,000 ft and tops above 10,000 ft. 

Figure 7: Geographical area forecast

The previous GAF issued at 0226 on the morning of 13 March reflected essentially the same expected weather conditions without the forecast small area of thunderstorms. An AIRMET¹⁴ valid from 0624 to 1024, was also issued for isolated thunderstorms in that area. 

The aerodrome forecast (TAF) for the pilot’s first intended stop at Armidale Airport, NSW, issued at 0422 EDT and valid 0600–1900 on 13 March included:

• wind from 080° at 8 kt
• visibility greater than 10 km
• cloud broken at 400 ft (TAF cloud heights are above aerodrome elevation). 

During the period 0900–1100:

• wind from 100° at 12 kt
• visibility greater than 10 km 
• light showers of rain 
• scattered cloud at 3,000 ft 
• temperature 16°C at 0600 and 19°C at 0900
• QNH 1,016 hPa at 0600 and 1,019 hPa at 0900. 

Weather observations

The Gold Coast aerodrome observations (METAR)¹⁵ at 0830 AEST on the accident morning were:

• wind from 170° at 9 kt
• visibility greater than 10 km
• few cloud at 1,500 ft (cloud heights above aerodrome elevation)
• scattered cloud at 2,000 ft
• broken cloud at 2,500 ft 
• temperature 27°C and dew point 24°C
• QNH 1,013 hPa

Distant lightning strikes were reported at 0800 and 0930.

Satellite imagery

High resolution visible satellite imagery showed extensive cloud extending inland to the NSW/Queensland border, including at the accident site (Figure 8).

Figure 8: Satellite cloud imagery at 1040 AEST (6 minutes before the accident) 

Source: Satellite image processed by the Bureau of Meteorology from the geostationary meteorological satellite Himawari-9, operated by the Japan Meteorological Agency, annotated by the ATSB

Witness reports

Several witnesses located near the accident site (Figure 9) reported very low cloud and drizzle on the morning of the accident. They stated that they observed a helicopter flying very low, ‘before lunchtime’ on the day. All witnesses reported that it was unusual to see a helicopter in the area, but this one was particularly unusual due to its low altitude. 

In addition, one witness stated that the helicopter seemed to be stuck below cloud and remarked to their partner that it ‘looks like it’s trying to find a way out’. Another witness recalled waving at the helicopter and stated that it passed them twice before heading west. 

Figure 9: Witness locations

Source: Google Earth, annotated by the ATSB 

Operational information 

Visual meteorological conditions

For flights under the VFR, the Civil Aviation Safety Regulations (CASR) Part 91 Manual of Standards (MOS) specified criteria for visual meteorological conditions (VMC)¹⁶ in terms of visibility and distance from cloud. The criteria for all aircraft operating in Class G (non‑controlled) airspace were:

At or below whichever is the higher of 3,000 ft AMSL and 1,000 ft above ground level (AGL):

• visibility 5,000 m
• clear of cloud
• aircraft must be operated in sight of ground or water.

For helicopters (rotorcraft) operating below 700 ft over land in non‑controlled airspace (and not within 10 NM of an aerodrome with an instrument approach procedure), the criteria were:

• flight visibility 800 m
• clear of cloud
• by day
• at a speed that allows the pilot to see obstructions or other traffic in sufficient time to avoid a collision, and
• if not more than 10 NM from an aerodrome with an IAP — in a way that ensures the flight maintains a separation of at least 500 ft vertically from any aircraft that is: less than 10 NM from the aerodrome; and conducting an IFR operation.

Flight planning requirements 

Under section 7.02 Forecasts for flight planning, the MOS required that pilots study the appropriate authorised weather forecasts and reports. This included:

• the route to be flown
• the departure aerodrome, the planned destination aerodrome and any planned alternate aerodrome
• any other reasonably available weather information that is relevant to the intended operation.

The pilot did not submit a flight plan and was not required to submit one for a private VFR flight in Class G airspace. 

National aeronautical information processing system (NAIPS) records showed that weather information was accessed by the pilot’s account at 0740 and 0745 on 13 March 2026. The pilot had requested a location briefing for the Gold Coast aerodrome. In making this selection, a pilot may also select the graphical area forecast, however, the data did not record if this was requested, therefore the ATSB could not verify if the pilot had viewed this forecast. 

The pilot did not request a location briefing for their first destination at Armidale. Although they requested a location briefing for Tenterfield, the Bureau of Meteorology did not issue aerodrome forecasts for Tenterfield Airport. 

Spatial disorientation 

Spatial disorientation occurs when a pilot does not correctly sense their aircraft’s attitude, airspeed, or altitude in relation to the earth’s surface. It is often described simply as the inability to determine ‘which way is up’, although the effects can often be more subtle than implied by that description. 

Spatial disorientation occurs when the brain receives conflicting or ambiguous information from the sensory systems. It is likely to happen in conditions in which visual cues are poor or absent, such as in adverse weather or at night. It presents a danger to pilots, as the resulting confusion can often lead to incorrect control inputs and resultant loss of aircraft control. The flight control sensitivity and relative instability of helicopters compared to aeroplanes increases the risk of such a control loss.

VFR into IMC occurrences 

Between 2015 and 2025 there were 116 VFR into instrument meteorological conditions (IMC)¹⁷ occurrences in Australian airspace reported to the ATSB. Of these, 13 were fatal accidents resulting in 24 fatalities. Based on these figures, approximately 1 in every 9 reported VFR into IMC occurrences results in a fatality. 

For non-instrument rated pilots, entering IMC can quickly become fatal. Research has shown that pilots not proficient in instrument-only flight will typically become spatially disoriented and lose control of the aircraft within 1–3 minutes after visual cues are lost.

CASA’s flight safety article ‘Every which way but loose’ stated that:

the inherent instability of a helicopter means that even an [instrument flight rules] IFR-rated pilot who is proficient and enters cloud in a helicopter not designed for instrument flight will have difficulty maintaining control. Without the normal strong visual cues of a horizon, the pilot will quickly experience dynamic instability and be fighting the aircraft to maintain a stable altitude and airspeed. 

Safety analysis

Prior to the flight, the pilot obtained a meteorological location briefing for the Gold Coast, which may have included a graphical area forecast. Although it was reported the pilot expected clear conditions for the flight to Armidale, there were several layers of cloud at Gold Coast Airport forecast at the time the pilot obtained the briefing, and at the time of departure. Further, the area forecast showed that there were likely to be extensive areas of low cloud, with low visibility along the flight path. This did not preclude the pilot from commencing the flight, but it did indicate a high likelihood of encountering conditions unsuitable for flight under the visual flight rules that would require a diversion or landing.

The available tracking data showed that the helicopter initially tracked south-west at around 3,000 ft, towards the NSW border. However, as the electronic flight bag software was not set to transmit the flight data, there was no further flight data available. 

The graphical area forecast and satellite imagery was consistent with witness statements that there was thick cloud and precipitation in the area at the time of the accident. As such, it was very likely that the helicopter entered an area where there was low cloud and/or low visibility in precipitation.  

While the ATSB could not rule out that the pilot applied a large control input due to avoiding a bird or terrain, it is very likely that without instrument training or an appropriately equipped aircraft, when they encountered low visibility conditions, they became spatially disorientated and applied inappropriate control inputs. 

Consistent with this, the wreckage examination identified signatures of the main rotor assembly being subject to excessive teeter and mast bumping that resulted in both pitch links failing. Following this, the main rotor blades were free to rotate through various pitch angles, and the helicopter was no longer controllable. 

The location of the bag and other items from inside the cabin at the accident site was indicative of main rotor contact with the cabin while airborne. In addition, the vertical path through the tree canopy was consistent with a complete loss of control prior to the collision with terrain. 

While the evidence showed that the engine was operating when the accident occurred, a transient condition such as a partial or complete power loss could not be ruled out, although such an event should not have resulted in a loss of control. Further, there was no evidence to indicate that the pilot became incapacitated prior to the accident sequence due to a pre-existing medical condition.

Findings

From the evidence available, the following findings are made with respect to VFR into IMC and collision with terrain involving Robinson R44 II, VH-TCF, 46 km north-east of Tenterfield, New South Wales, on 13 March 2026. 

Contributing factors

• It was very likely that the pilot entered conditions unsuitable for visual flight, resulting in a loss of control and subsequent collision with terrain.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• a relative of the pilot 
• Civil Aviation Safety Authority
• New South Wales Police Force
• maintenance organisation for VH-TCF
• accident witnesses
• recorded data from Airservices Australia (WebTraks) 
• Bureau of Meteorology.

References

Civil Aviation Safety Authority (2026), Visual flight rules guide, p.207

Civil Aviation Safety Regulations (2025), Part 91 Manual of Standards

Reinhardt, B. (2020), Every which way but loose, Flight Safety Australia, Civil Aviation Safety Authority

United States Helicopter Safety Team (2023), Training Fact Sheet – Inadvertent Entry into Instrument Meteorological Conditions (IIMC)

Submissions

Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report. 

A draft of this report was provided to the following directly involved parties:

• Civil Aviation Safety Authority
• Robinson Helicopter Company
• The United States National Transportation Safety Board.

A submission was received from the Civil Aviation Safety Authority. The submission was reviewed and, where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations The objective of an ATSB safety investigation is to improve transport safety through: identifying safety issues for action by organisations with the responsibility for managing that safety risk influencing safety action through engaging with stakeholders, communicating findings, and fostering awareness of safety issues and concerns.  In accordance with the TSI Act, the ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action, and cannot apportion blame, assist in determining liability, or, as a general rule, assist in court proceedings.  About ATSB reports ATSB safety investigation reports are developed in accordance with ATSB procedures and guidelines, and with regard to applicable international standards and instruments. Reports must include factual material of sufficient weight to support the investigation’s analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. An explanation of terminology used in ATSB investigation reports is available here.   Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2026 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The  CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

1. ^    Visual flight rules (VFR): a set of regulations that permit a pilot to operate an aircraft only in weather conditions generally clear enough to allow the pilot to see where the aircraft is going.
2. ^    Australian Eastern Standard Time (AEST): Coordinated Universal Time (UTC) + 10 hours
3. ^    Apple iPhone Crash Detection is designed to detect severe car crashes — such as front-impact, side-impact and rear-end collisions, and rollovers. If the Apple device has satellite, mobile or Wi-Fi connection, it will automatically call emergency services after a 30-second countdown if the alert is not manually dismissed.
4. ^    Australian Eastern Daylight saving Time (AEDT): Coordinated Universal Time (UTC) + 11 hours
5. ^    g: an abbreviation for acceleration forces acting on a body with reference to earth’s gravity at sea level. 1 g = 9.8 m/s². 

6. ^    OzRunways is an electronic flight bag application that provides navigation, weather, area briefings and other flight 

   information. It provides the option for live flight tracking by transmitting the device’s position and altitude.

7. ^     WebTrak uses information from air traffic control secondary surveillance radars to display aircraft movements.
8. ^    A TAF is a statement of meteorological conditions expected for a specified period within a radius of 8 km of the aerodrome reference point.
9. ^    Cloud cover: in aviation, cloud cover is reported using words that denote the extent of the cover – ‘few’ indicates that up to a quarter of the sky is covered, ‘scattered’ indicates that cloud is covering between a quarter and a half of the sky, ‘broken’ indicates that more than half to almost all the sky is covered, and ‘overcast’ indicates that all the sky is covered.
10. ^   TEMPO:  used to indicate significant temporary variations from the prevailing conditions previously given in the forecast. TEMPO is used for periods of 30 minutes or more but less than 60 minutes.
11. ^   INTER: used to indicate significant intermittent variations from the prevailing conditions previously given in the forecast. INTER is used for periods of less than 30 minutes.
12. ^   In a graphical area forecast (GAF), all cloud heights are above mean sea level (AMSL).
13. ^   Weather coverage is given as isolated if it consists of individual features which affect, or are forecast to affect, an area with a maximum spatial coverage of up to 50%.
14. ^   AIRMET provides information of certain meteorological phenomena that are not contained in the current area forecast.
15. ^   METAR: Meteorological aerodrome report.
16. ^   Visual Meteorological Conditions (VMC): an aviation flight category in which visual flight rules (VFR) flight is permitted – that is, conditions in which pilots have sufficient visibility to fly the aircraft while maintaining visual separation from terrain and other aircraft.
17. ^   Instrument meteorological conditions (IMC): weather conditions that require pilots to fly primarily by reference to instruments, and therefore under instrument flight rules (IFR), rather than by outside visual reference. Typically, this means flying in cloud or limited visibility.