Collision with terrain

Investigation summary

What happened

On 15 and 23 November 2025 respectively, the pilots of the Robinson Helicopter Company R22 helicopters, registered VH-8H8 and VH-HFQ, each experienced abnormal in-flight indications immediately ahead of a rapid decay in main rotor speed. 

Each pilot initiated autorotation and both aircraft subsequently landed hard. This resulted in significant damage to the helicopters, one of which was subsequently destroyed by post-impact fire after dry grass under the helicopter ignited. However, none of the occupants of either helicopter were seriously injured. Both occurrences were reported to the ATSB as suspected rotor drive belt (v-belt) failures.

What the ATSB found

The ATSB found that the occurrence involving VH-8H8 was consistent with drive belt failure. It was very likely that the forward belt became incorrectly engaged (misaligned) in the drive sheaves on startup, leading to rapid wear and failure, which then likely impacted and contributed to failure of the rear belt. The factors contributing to the belt misalignment were not determined.

The occurrence involving VH-HFQ was also likely to have been the result of failure of the drive belts. However, due to an absence of evidence the mechanism of failure was not determined.

Prior to the occurrences, both maintainers reported several instances of Robinson R22 drive belts requiring replacement at low hours due to stretching beyond allowable limits. While this appeared to be the case, any reasons for it were not determined, and the ATSB was unable to identify a broader issue.

Safety message

While the factors contributing to these occurrences were not fully determined, pilots should remain vigilant with pre-flight inspections, particularly around drive belt slack and alignment prior to startup. 

Pilots should be prepared to take appropriate precautionary or emergency actions per the pilot operating handbook in the event of abnormal clutch light indications, and/or unusual noise, vibrations or smells that may precede drive belt failure, or if one or both belts fail with limited warning. The instruction for pilots to ‘immediately lower collective to enter autorotation’ is of prime importance in low-inertia rotor systems, such as that in the R22. Main rotor RPM can rapidly decay, and any delay in initiating emergency actions could significantly affect the pilot’s ability to conduct an effective autorotation landing, particularly at low altitudes where there is limited rotor recovery time.

The ATSB continues to encourage aircraft operators and maintainers to report technical component or system issues through the Civil Aviation Safety Authority defect reporting service (DRS). Doing so will assist authorities in understanding the magnitude of any issues and to take action where appropriate. 

The investigation

The occurrences

Overview

In November 2025, the ATSB received 2 notifications of suspected rotor drive belt (v‑belt) failures involving Robinson Helicopter Company (RHC) R22 helicopters, registered VH-8H8 and VH-HFQ. Both resulted in hard landings, however none of the occupants were seriously injured. The helicopters had different operators and different maintainers.

VH-8H8, 15 November 2025

On the morning of 15 November 2025, the pilot of VH-8H8 was preparing for a flight around Argadargada Station, Northern Territory, to check on bores and stock. 

The pilot conducted the pre-flight checks, which included a physical assessment of the drive belt slack, per the R22 pilot operating handbook (see Pre-flight and startup checks). The pilot expressed a concern to the operator’s senior pilot that the belts may have been slightly loose. The senior pilot then also conducted a physical inspection of the belts and assessed that the belt tension was acceptable and consistent with their other helicopters. 

At approximately 0820, the helicopter took off with the pilot and a passenger on board. The pilot reported that the helicopter was operating normally. They noted that the clutch light flickered briefly during the flight, but nothing that they considered to be irregular or abnormal. 

Around 10 to 15 minutes after take-off, while the helicopter was in cruise flight at a height of around 300 ft, the pilot smelled burning rubber. About 2 seconds later, they heard a ‘bang’. The pilot’s attention was immediately drawn to a sharp increase in engine RPM, and was initially focused on that, before noticing that the main rotor RPM had decayed to about 90%. On recognising that, the pilot lowered the collective¹ to initiate autorotation,² during which the main rotor RPM began to recover. 

The pilot manoeuvred the helicopter from its initial downwind heading, back into the wind and towards an open space for landing. The helicopter impacted the ground with significant forward speed, and the skid on the pilot side dug into the ground, which caused the helicopter to roll over before coming to a stop (Figure 1). There was no post‑impact fire.

Figure 1: VH-8H8 accident site

The pilot shut down the engine before extracting themself and assisting the passenger from the wreckage. The pilot then radioed for assistance, before turning off the emergency locator beacon, which had activated during the accident. The pilot observed that the skids had spread significantly from the ground impact and that the passenger’s seat base had compressed. Additionally, the pilot noted that one drive belt had snapped and the other was separated into several pieces.

Subsequent examination of the helicopter by the operator showed additional evidence of in-flight drive belt failure, including an accumulation of black dust on the engine starter ring gear support (to which the lower drive sheave is connected), and rubber marks and impact damage to the oil cooler and feed lines adjacent to the belt drive (Figure 2).

Figure 2: VH-8H8 post-accident, viewed from underneath, showing oil cooler damage 

VH-HFQ, 23 November 2025

On 23 November 2025, at around 1030, the pilot and sole occupant of VH-HFQ departed on a point-to-point flight from Mount Surprise to Chillagoe Aerodrome, Queensland. Prior to departing, the pilot conducted a pre-flight inspection of the helicopter, including an inspection of the drive belts. No defects were observed. The pilot reported that it was a very hot day, at around 37°C.

Approximately 30 minutes into the flight, while the helicopter was cruising at around 
550 ft, the pilot heard a loud slapping noise, felt a significant vibration from the rear of the helicopter, and observed a rapid decay in main rotor RPM. The pilot lowered the collective to initiate autorotation and targeted a suitable landing site. The pilot did not recall hearing the low RPM horn.³

Just above tree height, about 30 to 40 feet above the ground, the pilot reported that they attempted to slow the helicopter and, because the engine was still running, momentarily applied collective to confirm the loss of drive. The helicopter dropped quickly and the pilot tried to cushion the landing. The landing caused the skids to spread horizontally and compress the base of the pilot’s seat. The helicopter remained upright.

The pilot was uninjured in the impact and was able to extract themself from the helicopter. As they did so, they noticed the remains of one of the drive belts hanging free of the drive train. The other drive belt was not observed. The pilot also observed that the fuel tanks appeared to be intact.

Shortly afterwards, a fire ignited in long, dry grass around the engine and exhaust. The fire subsequently destroyed the helicopter (Figure 3).

Figure 3: VH-HFQ post-accident

Context

Pilot information

The pilot of VH-8H8 had 1,488 hours total helicopter experience, including 1,132 hours on the R22. The pilot’s most recent biennial flight review was on 30 September 2025, which covered all emergency procedures, including multiple autorotations.

The pilot of VH-HFQ reported having accumulated approximately 9,000 hours total aeronautical experience over 20 years, and that they were up to date with their flight reviews. 

Helicopter information

The Robinson Helicopter Company (RHC) R22 is a lightweight, 2-seat, 2-blade helicopter, powered by a Lycoming 4-cylinder piston engine. 

VH-8H8 was an R22 Beta II, serial number 3293. It was manufactured in 2002 and first registered in Australia in 2023. The airframe had accumulated 2,943.8 hours total time in service.

VH-HFQ was an R22 Beta II, serial number 4279. It was manufactured in 2007 and first registered in Australia in 2008. The airframe had accumulated approximately 5,750 hours total time in service.

Rotor drive system

The R22 used a matched pair of banded, double-v, reinforced rubber drive belts (also known as v-belts) running on grooved aluminium sheaves (pulleys) to transmit power from the horizontally-mounted piston engine to the main and tail rotor clutch shaft (Figure 4 and Figure 5).

Figure 4: Diagram of the Robinson R22 rotor drive system

Figure 5: Typical mechanical arrangement of the R22 drive system (viewed from the rear with tailcone and cooling fan assembly removed) 

The lower sheave is bolted to the output flange of the engine crankshaft and is connected to the upper sheave by an electrically-driven clutch actuator. The upper sheave incorporates a free-wheeling clutch that allows the clutch shaft (and the rotors) to continue turning when the engine is not driving the system.

The engine is started with the clutch actuator retracted so that the drive belts are retained in their grooves, but with enough slack to allow the engine to start without the excessive load of driving the rotor system. After engine start the pilot selects the clutch switch to ENGAGE, which gradually raises the upper sheave to tension the drive belts to a pre-set load, at which point the actuator ceases driving. A clutch caution light, located in the cockpit directly in front of the pilot, illuminates when the clutch motor is operating. 

During normal operation the clutch switch is left in the engaged position until the helicopter is being prepared for shutdown on the ground. In operation, the drive belts become warm and can stretch slightly, lowering tension. When the belt tension reaches a lower threshold, the clutch motor automatically engages to restore the requisite tension. 

If one or both belts fails with the clutch engaged, the clutch motor should begin driving to achieve the requisite load, illuminating the clutch caution light until it stops. If only one belt fails, this could lead to the other belt failing due to over-tensioning. If both belts fail, the actuator will extend to the maximum (until the limit switch is activated).

Drive belt monitoring and maintenance

Pre-flight and startup checks

The RHC R22 pilot’s operating handbook (POH) included daily or pre-flight checks of the drive belt condition and slack with the clutch actuator retracted. The slack was tested by applying inward lateral force to one belt at a time, at a specific location (just above the fan scroll wheel on the right-hand side of the helicopter) to measure deflection relative to the other belt. A maximum deflection of 1.5 inches (4 cm) was specified. 

Additionally, the POH run-up checklist required pilots to verify that the rotor blades should begin turning within 5 seconds of clutch engagement on startup. A longer clutch engagement time could indicate excessively slack belts or a defective clutch actuator.

RHC safety notice SN-33, included in the POH, stressed the importance of pilots ensuring belts do not have excessive slack during engine start by completing the above checklist items. Measurements exceeding the prescribed limits increased the risk of the drive belts jumping out of the drive sheave grooves on clutch engagement after startup.

In addition to the above, the ATSB discussed with RHC other mechanisms for ensuring the belts were not excessively slack prior to startup. RHC offered that, as the drive belts were relatively accessible on an R22, it was possible for a pilot to attempt to physically dislodge the belts from their respective sheave grooves while the clutch was disengaged. The inability to do so would provide some indication that the belts were not excessively loose, although is not considered by RHC to be a replacement for the published test.

The clutch actuator could be adjusted to correct excessive belt slack on clutch retraction, with the POH noting that periodic adjustment by an aircraft maintenance engineer may be required as the belts wear in service. The actuator down‑limit stop screw on VH‑8H8 was adjusted to correct belt slack approximately one week (10 flight hours) after the previous 100‑hourly inspection.

Clutch caution light

Regarding illumination of the clutch caution light, the POH stated:

Clutch light may come on momentarily during run-up or during flight to re-tension belts as they warm-up and stretch slightly. If, however, the light flickers or comes on in flight and does not go out within 10 seconds, pull CLUTCH circuit breaker and land as soon as practical.⁴ Reduce power and land immediately if there are other indications of drive system failure⁵ (be prepared to enter autorotation). Have drive system inspected for a possible malfunction. 

Maintenance requirements

In addition to the daily inspections and actuator adjustment to correct excessive belt slack, the RHC R22 maintenance manual required periodic maintenance inspection of the drive belt system at 12‑month or 100‑operating‑hour intervals, whichever came first. 

The periodic maintenance included inspection of the physical condition of the drive belts. With the clutch engaged, the amount of drive belt stretch was assessed through a relative measurement of the clutch shaft angle. The belts were required to be replaced if the clutch shaft angle was outside of predefined limits. 

The condition and horizontal alignment of the drive sheaves needed to be assessed as part of the periodic inspection and also during the procedure for drive belt installation. The sheaves were required to be replaced if they displayed any corrosion, pitting, flaking, roughness, sharp ridges, wear through the anodised coating, or blistering of the optional metallised coating at the time of inspection. Otherwise, the clutch assembly, incorporating the upper sheave, was required to be replaced when it had accumulated 2,200 hours in service.

Maintenance history

VH-8H8

The helicopter’s drive belts were fitted on 4 September 2025 at the most recent 100‑hourly inspection (2,856.2 hours). The installed belt set was part number A190‑2 revision Z, lot number⁶ 2412130031. The reason for the belt replacement was not recorded.

The drive sheaves were not replaced with the belts. The maintainer reported that the intent was to replace the existing anodised aluminium upper sheave with the steel‑coated (metallised) type, as they had improved durability when exposed to dust and grit in harsh operating environments. However, the maintainer was unable to source a steel‑coated sheave at the time of the 100‑hourly inspection. The maintainer subsequently assessed that the condition of the existing upper sheave was acceptable for continued operation.

VH-HFQ

VH-HFQ had accumulated 5,720 hours total time in service at the time of the most recent maintenance. The helicopter maintenance release was destroyed in the accident, however the operator estimated that the helicopter had operated for approximately 30 hours since this time.

Maintenance records indicated the machine had recently had 2 A190‑2 revision Z belt sets replaced at low time, prior to the accident set. The reason recorded in each case was that the belts were ‘stretched to limits’ (Table 1).

Table 1: VH-HFQ drive belt maintenance history

Low-time belt replacements

Maintainer reports

The maintainers of the occurrence helicopters expressed a concern to the ATSB about a recent observed general increase in low-time belt replacements due to overstretching. This was identified through clutch shaft angle measurements exceeding limits during maintenance inspections. 

The maintainer of VH-8H8 advised that for a similar number of helicopters serviced each year, they had replaced 61 sets of drive belts in the 12 months prior to the occurrence. This compared to 50 in the year prior and 30 sets the year before that. In addition, the maintainer reported that they had received 10 sets of belts with the same lot number as the failed belts. From the helicopters with those sets fitted, 2 had been removed at the first 100‑hourly inspection due to the clutch shaft angle measurement exceeding the maintenance manual limit. 

The maintainer of VH-HFQ reported having installed 80 sets of belts in the 12 months prior to the accident, compared to 51 in the 12 months prior, and 32 belt sets in the year prior to that. There was also no significant change in the number of helicopters serviced. The maintainer advised that, along with the increase in belt replacements, they had observed variability in the texture of the new belts received, noting that some of the belts were comparatively softer and more rubbery when compared with others.

Defect reports

The ATSB reviewed the Civil Aviation Safety Authority (CASA) DRS (defect report service) reports from the previous 5 years (from January 2020). 

From January 2022 to April 2026 there were 16 instances of drive belt issues in RHC R22 and R44 helicopters in Australia. Of those, 15 related to R22 Beta helicopters, and included:

• 8 reports of drive belts stretched beyond limits. All of the occurrences were found during scheduled maintenance. All were reported in 2025 or 2026.
• 3 reports of delaminated or cracked belts, found during pre-flight inspections.
• 1 report of abnormal vibrations, attributed to lumps found on the drive belts.
• 3 reports of the drive belts failing in flight.

The 3 occurrences of the drive belts failing in flight were not investigated by the ATSB. Two of the reports included the following details:

• 23 January 2024: Pilot reported failed drive belt in flight. There was report of a loud bang followed by a vibration and illumination of the clutch light. After 6 seconds, pilot pulled the CB [clutch circuit breaker] and directed the aircraft into wind. A second loud bang followed (2 seconds after pulling the CB) at which point the pilot entered auto-rotation to the ground. Forward belt was found missing. Rear belt was still on both sheaves but running in the forward belt position.

• 18 August 2022: Pilot reported clutch light flickering more than normal followed by a burning rubber smell and a bang. Clutch light on continuously. Pilot landed aircraft and shut down. On inspection [they] noted that the front drive belt had departed the aircraft and the rear belt had jumped one pulley groove. 

There were no reports of stretched drive belts between November 2021 and May 2025. From May 2020 to November 2021, there were 20 reports of drive belt issues, 11 of which were for stretched belts and 2 for in-flight failures, and the remainder for defects found during routine inspections or maintenance. 

The ATSB contacted one of the major Australian distributors of RHC Helicopters and spare parts, who indicated that they were not aware of any recent increase in drive belt defects or concerns.

RHC reported a total of 7 drive belt warranty claims worldwide for 2025. RHC also advised that it had surveyed some local service centres in the United States, which reported that they were not experiencing any premature belt stretching. 

Component examination

VH-8H8

The ATSB did not attend the VH-8H8 accident site. The drive belt remains from the helicopter were examined at the ATSB technical facilities (Figure 6).

Figure 6: VH-8H8 drive belts as-recovered

The rear belt had a single tensile break through both vees in the same location and showed no abnormal wear or defect.

The forward belt was separated into multiple pieces. The front vee of the forward belt had entirely delaminated from the backing strap and was fractured at several places. The rear vee was still largely attached to the backing but was also separated in more than one location along the length. 

The largest piece of the forward belt had taken on a curve, indicating that the vees had been subjected to non-uniform stretching. Where still continuous, the centre of the backing strap (between the vees) had deformation consistent with running on the crest of a sheave groove. A cross‑section through the belt showed significant wear of the rear vee (Figure 7).

The abnormal, non-uniform wear and stretching was consistent with the belt running while misaligned, with the belt having pushed forward and one of the vees not running in the drive sheaves. RHC advised that in this configuration, the belts might last 10‍–‍20 minutes before failure. RHC also advised that the belts would have to be very loose for this to occur, particularly as the outer sheave groove is raised to reduce the likelihood of such an event.

Figure 7: VH-8H8 forward belt cross‑section (left) and new rev-Z belt (right)

VH-HFQ 

The ATSB did not attend the VH-HFQ accident site and no physical evidence was obtained from the destroyed helicopter.

Operational considerations

The R22 POH includes the following under ‘emergency procedures’: 

A power failure may be caused by either an engine or drive system failure and will usually be indicated by the low RPM horn. An engine failure may be indicated by a change in noise level, nose left yaw, an oil pressure light or decreasing engine RPM. A drive system failure may be indicated by an unusual noise or vibration, nose right or left yaw, or decreasing rotor RPM while engine speed is increasing. 

In the case of power failure, immediately lower the collective to enter autorotation. 

The pilot of VH-8H8 reported that their initial distraction by the sharp rise in engine RPM delayed, by a few seconds, their observation of main rotor RPM decay and action to lower the collective to enter autorotation. The pilot reflected that this event reinforced the need for them to instinctively and immediately enter autorotation at the first indication of a power failure.

When conducting autorotations, the POH cautions:

The R22 has a light, low-inertia rotor system. Most of the energy required for an autorotation is stored in the forward momentum of the aircraft, not in the rotor. Therefore, a well-timed cyclic flare is required and rotor RPM must be kept in the green until just before ground contact.

The main rotor will deplete its stored energy quickly once power is removed, which will lead to a rapid decay in rotor RPM. The POH lists the minimum R22 power off main rotor speed limit as 90% and, in the section on practice autorotations, cautions that ‘catastrophic rotor stall could occur if the rotor RPM ever drops below 80%, plus 1% per 1000 feet of altitude [above sea level].’

The ATSB enquired with RHC about operation of drive belts stretched to the limits of the clutch actuator. RHC advised that the actuator would stop driving after triggering the upper limit switch, which could result in under-tensioned belts that slip on the sheaves. In this case, the clutch light should illuminate and remain on, requiring pilots to land as soon as possible in accordance with the POH instructions. 

Injuries and damage

Spreading of the helicopter skids and compression of the seat base in each helicopter were features of the helicopter’s energy absorption design to reduce impact forces on the helicopter occupants during a hard landing or collision with terrain. In each occurrence, nothing was stored under the seat base. This ensured energy absorption functionality of the seat, minimising the risk of injury to the occupants. 

Related occurrences 

Hamilton Island, Queensland, 3 February 2021 (AO-2021-007)

While cruising at 1,500 ft, approximately 15 minutes into the flight, the pilot of an RHC R44 Clipper II, VH-SXC, smelled burning rubber and saw the clutch warning light flicker briefly. The pilot then heard what sounded like ‘a rubber band smacking against the cowling’, at which point the clutch warning light illuminated and remained on. The pilot identified a rise in engine RPM and a slow decline in main rotor RPM. The pilot pulled the clutch circuit breaker in response to the warning light and conducted a successful emergency landing with minimal damage to the helicopter and no injuries.

Of the 4 drive belts⁷ in the helicopter’s drive system, it was found that the forward 2 drive belts had dislodged and moved forward of the upper sheave. They then lodged against the sheave and clutch shaft, leading to damage to the drive belts and surrounding components. The other 2 drive belts remained intact but had shifted forward from their original sheave positions and were not effectively engaged within the grooves of the sheaves. Consequently, there was a loss of effective drive of the rotor system.

Outside of the occurrence event, the helicopter had experienced 2 instances of over‑stretched drive belts, which were replaced after 76.1 hours and 8.6 hours, respectively. The overstretching was attributed to a static belt‑stretching procedure that was introduced for new belts that were overly tight. RHC removed the belt‑stretching procedure in July 2021.

Julia Creek, Queensland, 9 May 2011 (AO-2011-060)

The pilot of an RHC R22 Beta II helicopter, VH-DSD, was conducting mustering operations and while the helicopter was operating in close proximity to the ground, drive to the rotor system was lost, resulting in a high rate of descent at the point of impact. The pilot was fatally injured. 

The ATSB found that both drive belts had failed prior to the collision with terrain. The rear drive belt was found severed and wrapped around the drive sheaves. Almost all of the forward belt was found in 2 adjacent locations about 60 m from the main wreckage. Black rubber marks, consistent with a flailing drive belt, were found on the sides and lower surface of the engine. The forward drive belts showed significant abnormal wear of the forward vee, indicating that the belt had rolled forward over the front edge of the drive sheave. The ATSB was unable to establish the factors that contributed to the dislodgement.

The final investigation report noted the necessity of flying at very low level when conducting helicopter mustering, but also the potential risk of doing so. The pilot would have had limited time to recognise the condition, respond accordingly, and for the autorotation to develop before attempting to land. As a result, the report stressed the importance of pilot proficiency in responding to emergency situations resulting from aircraft malfunction.

Safety analysis

Drive belt failures

The VH-8H8 pilot report of a burning rubber smell, followed shortly afterwards by the ‘bang’, the significant reduction in main rotor RPM and sudden increase in engine RPM, was all consistent with failure of the helicopter’s drive belts. The short (10 to 15 minute) duration of flight, rubber smell, and uneven belt wear, was consistent with the forward belt not being correctly seated in the drive sheave grooves. This belt misalignment most likely occurred during startup, as the flight duration was consistent with RHC’s experience of belt longevity when operated in this configuration. The abnormal wear indicated that the forward belt most likely failed first and, noting the very brief time interval between the 'bang' and the main rotor RPM decay, the forward belt probably interfered with the rear belt, which then fractured, resulting in the complete drive train disconnect.

The VH-HFQ pilot report similarly indicated a rapid decay in main rotor RPM, consistent with the drive belt separation subsequently observed by the pilot on the ground. However, the mechanism of failure in this case was not determined. The drive belts were not available to the investigation, and the recounted circumstances of the occurrence were slightly different. Specifically, the significantly longer (30-minute) flight time and the absence of any reported burning rubber smell preceding the event. This may be indicative of a different failure mechanism, although the presence of any rubber smell would be dependent on local conditions and not necessarily detected.

In each of the occurrences the helicopters had recently been inspected, the drive belts were relatively new, and pilots reported conducting the required pre-flight checks without observing any issues. It is worth noting that, although the pilot of VH-8H8 sought a second opinion on the belt tension, ultimately it was assessed as acceptable by 2 pilots and therefore unlikely to have been excessively slack. Otherwise, there were no obvious operational factors reported or identified that might have led to the drive belts becoming unseated from the sheaves or that would otherwise contribute to a belt failure.

Pilot responses

In both occurrences, the initial indications of drive train failure were reported as being almost coincident with the main rotor RPM decay. There was no prolonged or abnormal clutch light illumination, or any other timely indications preceding the failure, and therefore no opportunity to conduct any kind of power-on landing. 

As it was, both pilots had to assess the condition as an engine or drive system failure (noting the emergency procedure for both is the same), and immediately lower the collective to enter autorotation. Both pilots did this after observing the rapid main rotor RPM decay. The pilot of VH-8H8 later reflected on the few seconds delay in diagnosing the condition before lowering the collective and entering autorotation. In those few seconds the rotor speed decayed to the minimum allowable level, beyond which increased the risk of an adverse outcome, particularly at low level where time and altitude may be insufficient to recover low rotor RPM.

Aside from rotor RPM, there are a number of variables that can influence the success of an autorotation landing (including, airspeed, weight, density altitude, manoeuvring, and the timing and magnitude of pilot control inputs), and because of this, the specific factors that contributed to the hard landings in these events were not explored in detail. Nevertheless, these occurrences serve as a reminder that power loss events may occur with limited prior warning. They reinforce that pilots should be intimately familiar with the POH emergency procedures and be prepared to act immediately in the event of any abnormal in-flight indications.

Drive belt failure rates

Reports and records provided to the ATSB by both of the helicopter maintainers indicated a relatively recent increase in low-time drive belt replacements. The reported issues were similar to those captured in the CASA defect reporting scheme database around 2020–21 which was also reflected in the occurrence involving VH-SUX (AO‑2021‑007).

The occurrence belt sets, as well as the August low-time replacement on VH-HFQ and 2 other low-time replacements recorded by the maintainer of VH-8H8 were from the same lot number. This suggested the possibility that there was a manufacturing anomaly with a particular batch of belts that pre-disposed them to stretching. This would infer that the occurrence belts also had stretching issues, which was possible but could not be confirmed. There were also no reports to indicate that other belts, out of the 150 sets from the same lot number, had been replaced for a similar reason. 

Moreover, the increase in belt replacements had been occurring over the previous few years, which might suggest a more significant manufacturing anomaly than a single batch. Despite this, there was no evidence of a more widespread, corresponding increase in reporting of recent, similar belt failures or stretching at a greater rate than usual.

The ATSB considered the operational risk if there were a broader issue involving excessive drive belt stretching. If not carefully monitored, belt stretch could lead to excessive slack on startup, which would increase the risk of the belts jumping out of the sheave grooves. However, vigilance around the existing pre-flight checks and monitoring of the 5-second clutch engagement time should mitigate that risk. It is also noted that, due to the way the clutch system operates, gradual belt stretching by itself should not create a safety issue during flight without warning. 

The ATSB continues to encourage reporting of aircraft component failures or issues through the CASA DRS system to give a clearer indication of concerning defects or trends that may warrant further investigation.

Findings

From the evidence available, the following findings are made with respect to the rotor drive belt failures resulting in collisions with terrain, involving Robinson R22s, VH-8H8 and VH-HFQ, near Argadargada Aerodrome, Northern Territory, and Chillagoe Aerodrome, Queensland, on 15 and 23 November 2025. 

Contributing factors

• The forward drive belt on VH-8H8 probably became incorrectly engaged in the drive sheaves on startup, for reasons that could not be determined. This led to failure of the forward drive belt, which then likely impacted the rear drive belt and contributed to its failure. 
• The forward drive belt on VH-HFQ likely failed in-flight, for reasons that could not be determined.

Other findings

• Prior to the occurrences, there were several reported instances of Robinson R22 drive belts requiring replacement at low hours due to stretching beyond allowable limits. It was not able to be determined whether the subject occurrences were influenced by reported concerns.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of VH-8H8
• the pilot of VH-HFQ
• the station manager for VH-8H8 
• the maintenance organisation for VH-8H8
• the maintenance organisation for VH-HFQ
• Robinson Helicopter Company 

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:

• the pilot of VH-8H8
• the pilot of VH-HFQ
• the station manager for VH-8H8 
• the maintenance organisation for VH-8H8
• the maintenance organisation for VH-HFQ
• Robinson Helicopter Company
• the Civil Aviation Safety Authority 

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

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. ^    Collective is a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
2. ^    Autorotation is a condition of descending flight where, following engine failure or deliberate disengagement, the rotor blades are driven solely by aerodynamic forces resulting from rate of descent airflow through the rotor. The rate of descent is determined mainly by airspeed.
3. ^    An audio alert that sounds when the main rotor speed is below a certain level. In the Robinson R22, the threshold is 97% and is accompanied by the ‘LOW RPM’ caution light. The horn and light are muted when the collective is fully down.
4. ^    The Robinson R22 POH defines: Land as soon as practical as ‘landing site is at the pilot’s discretion, based on the nature of the problem and available landing areas.’ Whereas, Land immediately means ‘land on the nearest clear area where a normal landing can be performed.’
5. ^    Safety notice SN-28 in the POH notes these indications as the ‘smell of hot rubber, noise, or vibration.’
6. ^     When individual belts are received by RHC, they are tensioned in a simulated sheave system, measured and subsequently matched into a set (of 2 for a R22 and 4 for a R44). RHC advised that the lot number for drive belt sets is applied by RHC as part of this process. As such, the lot number does not directly relate to a manufacturing batch or date, although belts being matched into sets would likely be manufactured around the same time. Lot number 2412130031 comprised 150 belt sets.
7. ^    The Robinson R44 drive train has a matched set of 4 drive belts, as opposed to the set of 2 in the R22.

Investigation summary

What happened

At around 0655 local time on 7 November 2025, a Cessna 172N, registered VH-SCU and operated by Consolidated Pastoral Company (CPC), departed Newcastle Waters Airport, Northern Territory, on a training flight. On board the aircraft were the pilot and an instructor. The pilot was being trained to fly at low level, with the intention of obtaining a low-level operational rating. 

About one hour into the flight while flying at around 300 ft above the ground at an airspeed of 80 kts, and manoeuvring to follow a creek bed, the pilot initiated a steep turn to the right. During the turn, control of the aircraft was lost and it descended towards the ground. The instructor attempted to override the pilot’s control inputs but could not do so before the aircraft impacted terrain. The aircraft came to rest upright but was substantially damaged. The instructor received minor injuries, the pilot was uninjured.      

What the ATSB found

The ATSB found that while conducting a steep turn at low level, excessive aft control input was applied which almost certainly caused the aircraft to enter an aerodynamic stall. Subsequently, inappropriate recovery control inputs by the pilot limited the instructor’s ability to intervene before the aircraft collided with the ground.

The initial excessive control input was likely a combined result of the pilot being focused on maintaining a track over the ground feature and their inexperience in handling the aircraft during low-level flight. The subsequent application of an inappropriate stall recovery technique was likely caused by the pilot reverting to instinctive rather than learned behaviour under stress.   

The ATSB also found that the instructor's recovery control inputs likely prevented the aircraft from impacting terrain in a nose down attitude and reduced the severity of the collision. 

What has been done as a result

The flight training provider undertook a critical review of its training practices and risk mitigation measures. 

Safety message

This accident highlights the importance of understanding the relationship between the elevator control stick position and the aircraft’s angle of attack, to minimise the risk of an aerodynamic stall. The wing will stall when the control stick is moved beyond a fixed position, irrespective of airspeed and attitude. During steep turns at low airspeed, awareness of the stick position provides increased awareness of the aircraft’s performance relative to its limits. This is particularly important to consider when operating close to the ground, such as during take-off, landing, and when conducting low-level air work. Attention may become focused on positioning the aircraft relative to ground features rather than monitoring its aerodynamic performance, and the time available for recovery from an undesired state will be limited. 

The investigation

The occurrence

At around 0655 local time on 7 November 2025, a Cessna 172N, registered VH-SCU and operated by Consolidated Pastoral Company (CPC), departed Newcastle Waters Airport, Northern Territory, on a training flight. On board the aircraft were the pilot and an instructor. The pilot was being trained to fly at low level,¹ with the intention of obtaining a low-level operational rating and had completed 6 training flights with the instructor over the previous 3 days. The purpose of this flight was to consolidate the earlier training and prepare for the low-level rating flight test.

The aircraft was initially climbed to an altitude of approximately 2,000 ft above ground level (AGL), where the pilot demonstrated a sequence of flight manoeuvres. These included left and right turns at angles of bank up to 60° and minimum radius turns at angles of bank up to 45° (see the section titled Minimum radius turns). The pilot also demonstrated their ability to identify and recover from a stall during a minimum radius turn.

The pilot then proceeded to perform a pre-briefed low-level task, which simulated a typical airborne survey of station infrastructure. This task was flown at altitudes between 200 ft and 1,000 ft AGL and incorporated simulated contingencies such as system and engine failures. At the completion of this portion of the training flight, the aircraft was approximately 13 km south of Newcastle Waters Airport, just north of 9 Mile Yard (Figure 1).

The instructor then asked the pilot to return to the departure airport by following the Newcastle Waters Creek in a northerly direction, simulating a water course survey activity (Figure 1). The task commenced at an altitude of 300 ft and the pilot was reminded not to descend below the pre-briefed minimum altitude of 200 ft. At around 0750, a few minutes into the activity, the pilot observed that the creek bed ahead made a sharp turn to the right and they began to manoeuvre the aircraft to keep the ground feature directly below the aircraft. At the start of this manoeuvre, the aircraft was flying approximately 300 ft above the terrain at an airspeed of around 80 kt, with flaps retracted. 

Figure 1: Low-level flightpath over the Newcastle Waters Creek and the location of the collision with terrain  

Source: Google Earth, annotated by ATSB

The pilot rolled the aircraft right to a bank angle of around 45º. As the turn commenced, both the pilot and instructor noted that the aircraft’s nose was pitching down and the aircraft was beginning to descend. The instructor expected that the pilot would correct the pitch attitude by adding power, following the technique that had been taught and successfully demonstrated during the preceding training. 

In addition to the observed descent, the pilot also noted that the aircraft was not turning quickly enough to remain above the ground feature, and in response they rapidly applied more aft control column input to tighten the turn, recalling that they also added a ‘smidge’ more power, however the instructor advised no power was added. In response, the aircraft rolled further to the right and continued to descend. Immediately, the pilot attempted to level the aircraft’s wings and arrest its descent by applying left roll control input, however they maintained aft control input. They stated they did not hear the stall warning horn activate throughout the manoeuvre. 

The instructor could also not recall if they heard the stall warning, however they assessed that the aircraft was in an aerodynamic stall and attempted to intervene by making opposing corrective inputs through their own control column but they could not overcome the control forces being held by the pilot. They could not remember if they advised they were ‘taking over’ however, the pilot flying recalled that the instructor had announced that they were ‘taking over’ and they subsequently released the controls. The pilot advised that the aircraft was already below the tops of the trees before the instructor’s inputs could take effect. 

The instructor stated that they judged that the aircraft would now almost certainly impact the terrain, and that the rudder pedals and throttle were the only effective control inputs available. They applied full power and right rudder with the aim of raising the aircraft’s nose and inducing further right yaw. The instructor’s intent was to prevent the aircraft from impacting terrain nose first and therefore improve the likelihood of survivability. 

As the aircraft descended below the height of the treetops, its pitch attitude had almost levelled, its roll angle had reduced, and it was yawing to the right. The aircraft then impacted the trees, before coming to rest upright on its undercarriage, on relatively flat terrain. It had yawed during the impact sequence, such that it was facing back along its flightpath through the trees. The aircraft sustained extensive damage, particularly to its wings and tail section, with the latter being almost completely detached from the rear fuselage (Figure 2).

Figure 2: VH-SCU as it came to rest following impact with trees and terrain

Source: Supplied

Immediately after the aircraft came to rest, fuel began draining from a rupture in the right wing prompting the crew to exit the aircraft through the left door. During the impact, the instructor sustained minor injuries, while the pilot suffered no visible injuries but reported some neck pain. 

The pilot used a mobile telephone to report the occurrence to the operator, and a ground vehicle was dispatched, which arrived at the accident site at around 0835 and subsequently transported both crew members back to the Newcastle Waters station. Following an initial examination by medical staff, both crew were conveyed to a medical clinic for treatment. The instructor was later discharged, while the pilot was transported to a hospital in Alice Springs for further assessment and monitoring. The pilot was discharged from hospital the following day. 

Context

Flight crew

The pilot of VH-SCU held a Commercial Pilot Licence (Aeroplane) issued in 2024 and a class 1 aviation medical certificate. They had accumulated around 300 flight hours, mostly on single engine piston training aircraft, including the Cessna 172 and Diamond DA40. They had worked as a pilot on the station since October 2025.

The instructor held an Air Transport Pilot Licence (Aeroplane), a class 1 aviation medical, and a low-level rating, among other ratings and endorsements. They had accumulated a total of around 24,500 flying hours, with approximately 2,500 hours in the Cessna 172. They had flown 240 hours in the 90 days prior to the occurrence, with 25 of those in the Cessna 172. 

Aircraft

VH-SCU was a Cessna Aircraft Company 172N manufactured in the United States in 1977 and assigned serial number 17268700. It was equipped with a Textron Lycoming O‑320‑H2AD piston engine, fixed pitch propeller, and fixed tricycle undercarriage. Maintenance records indicated that the airframe had accumulated a total flying time of 15,995 hours prior to the accident flight and the engine had 927.6 hours since overhaul. The aircraft was being maintained under the Civil Aviation Safety Authority Schedule 5 and had flown 45 hours since its most recent maintenance event, which was a 100-hour inspection performed on 23 August 2025. 

The aircraft had no recording devices on board and nor was it required to.

Weather

No weather information was recorded for Newcastle Waters station, however the Bureau of Meteorology provided information for the nearest observation station at Daly Waters, approximately 123 km north. An observation issued at 0800 local time reported the temperature to be 29°, with a dew point of 21°, an atmospheric pressure of 1010 hectopascals, and a surface wind of between 8–10 kt from the north. This station did not provide a report of visibility or cloud cover.

Both flight crew provided consistent reports of the weather conditions at Newcastle Waters. They recalled a temperature of between 22–26°, winds of between 5–10 kt from the north-west, smooth air with no mechanical turbulence, and no cloud. There was light smoke haze but this did not significantly impair their visibility. The instructor estimated the density altitude² to be approximately 3,000 ft.  

Low-level training

The low-level flight training was being provided under the provisions of Part 141 of the Civil Aviation Safety Regulations (CASR). The instructor was qualified to deliver this training and had provided the same training to other pilots, employed at the station, on numerous occasions prior.

Part 61 of the CASR required an applicant for a low-level rating and aeroplane low-level endorsement to have, among other conditions: 

• undertaken at least 5 hours of dual flight training in an aeroplane while receiving training in low level operations

• pass a flight test defined in the Part 61 manual of standards.  

The Part 61 manual of standards prescribed a set of knowledge and flying competencies, which must be satisfactorily demonstrated during the low-level rating flight test. The specific activities and manoeuvres to be demonstrated during the flight test included:

• navigate at low-level

• conduct steep, max rate and min radius turns

• recover from approach to stalls – level and turning

• recover from unusual attitudes

• recover from wing drop at the stall

The training syllabus employed by the instructor planned for all airborne activities and manoeuvres to be taught over a period of 5 flying hours. The instructor reported that, in their experience, most students achieved competency within this period. 

At the time of the accident, the pilot flying had undertaken 10.1 hours of low-level training. Training records indicated that additional flying hours were required at the start of the course for the student to demonstrate competency in some manoeuvres, including maintaining altitude during steep turns, stall recognition and recovery. However, during a period of upper air work conducted earlier in the accident flight, the student had successfully demonstrated competency in all these manoeuvres. 

Aircraft stall behaviour

The angle of attack (AOA) is the angle at which the wing meets the relative airflow passing the aircraft. It is directly related to elevator position and therefore control stick position. The amount of lifting force produced by the wing increases with increasing AOA until a critical angle is reached. At the critical AOA (typically 16–18°), the wing aerodynamically stalls and lift production decreases abruptly. Recovering from a stall requires AOA be reduced below the critical angle by reducing aft control stick displacement. 

Should the critical AOA be approached during a turn, using aileron to level the wings increases the AOA of the inside wing and may cause it to stall prior to the outside wing. This can result in the angle of bank rapidly increasing rather than decreasing. Instead, it is recommended that rudder is used to level the wings when a stall is encountered. 

Minimum radius turns

A minimum radius turn achieves a change in aircraft direction over the smallest possible ground space. This technique is often used in low-flying operations where manoeuvring is made with respect to a ground feature and within confined terrain. Minimum radius turns are typically conducted at high angles of bank and lower airspeeds. Both conditions increase the AOA required to maintain level flight. The margin between required AOA and the critical (stalled) AOA is therefore reduced. 

Adding additional aft control stick displacement during a minimum radius turn can quickly result in the wing exceeding the critical AOA and entering a stalled condition. For this reason, pilots are often instructed to correct low attitude during minimum radius turns through application of power, rather than additional aft control stick input.

Related occurrences

There have been a number of recent ATSB investigations into fatal accidents that resulted from a loss of control while manoeuvring during low-level flight. 

ATSB investigation AO-2024-037

On 27 June 2024, the pilot of a Cessna 172N, registered VH-SQO, was mustering sheep at Mulgathing Station, South Australia. The aircraft was observed to dive to an estimated height of about 50 ft above the ground before climbing rapidly, turning to the left and then descending towards the ground. The ATSB found that, while mustering without the appropriate endorsement, the pilot lost control of the aircraft leading to an aerodynamic stall and spin from an altitude that was not recoverable.

ATSB investigation AO-2022-011

On 3 March 2022, the sole pilot of a Cessna U206G, registered VH-JVR, was conducting a low-level geophysical survey, about 120 km west of Norseman, Western Australia. At about 1430, the aircraft’s satellite tracking system stopped reporting its position. Wreckage was subsequently located 3.2 km west of the aircraft’s last recorded position. The ATSB found it was likely that, during a manoeuvre to intercept the next survey line, for undetermined reasons, control of the aircraft was lost at a height from which recovery was not possible. 

ATSB investigation AO-2021-016

On 13 April 2021, a Cessna R172K, registered VH-DLA, departed Canberra Airport, Australian Capital Territory, with a pilot and observer on board to conduct powerline survey work to the north of Sutton township, New South Wales. The aircraft was subsequently observed flying low above the trees before commencing a left turn that continued in to a steep descent and collision with terrain. The ATSB found that while manoeuvring to align the aircraft to inspect a powerline, the aircraft aerodynamically stalled and entered a spin at a height that was insufficient for recovery prior to the collision with terrain.

ATSB investigation AO-2021-052

On 4 December 2021, the pilot of an Air Tractor AT-400 aircraft, registered VH-ACQ, was conducting aerial spraying operations on a property 75 km west-south-west of Moree, New South Wales. During a right procedure turn, the aircraft was observed to climb then descend rapidly and collide with terrain. The ATSB found that the aircraft was too close to the start of the spray run during the turn, which probably resulted in the pilot tightening the turn. This almost certainly resulted in an aerodynamic stall at a height too low to recover before colliding with the terrain.

Safety analysis

The pilot and instructor were conducting a low-level navigation exercise, tracking along a ground feature at approximately 300 ft AGL and 80 kt. 

Accounts from both crew members indicated that while making a steep right turn to follow the ground feature, the aircraft’s nose dropped. Additionally, the pilot observed that the aircraft was not turning quickly enough to remain over the river. In response, they sharply increased their aft control stick input rather than increase the bank angle. This almost certainly placed the aircraft into an aerodynamically stalled condition rapidly increasing the rate of descent and further rolling to the right. 

The pilot did not follow the recommended method to address the nose drop at low level - application of power rather than increasing pitch, which they had demonstrated successfully earlier in the flight. The ATSB could not determine why the correct recovery technique was not applied. However, human factors research (Martin, Murray, Bates and Lee 2013) noted that when faced with a sudden unexpected aircraft condition, pilots may experience a rapid increase in stress and revert to instinctive behaviour over trained behaviour. 

After recognising that the pilot had applied inappropriate control inputs the instructor attempted to intervene. It is uncertain what verbal communication was made between the crew, but there was a period of confusion over who had control of the aircraft, and it is likely both crew members were making control inputs simultaneously resulting in the instructor being unable to override the control inputs of the pilot, delaying the effectiveness of the recovery actions. Due to the proximity to the ground, the aircraft descended into terrain before this confusion could be resolved. Despite this, the instructor’s inputs to the throttle and rudder likely prevented the aircraft from contacting the ground in a nose down attitude and reduced the severity of the impact.    

Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 172, VH-SCU, about 6 km south of Newcastle Waters, Northern Territory, on 7 November 2025. 

Contributing factor

• While training to follow a ground feature at low level, the pilot flying applied and held inappropriate control inputs, which led to an aerodynamic stall and limited the instructor’s ability to make corrective actions, resulting in the aircraft colliding with terrain.

Other finding

• The instructor's control inputs likely prevented the aircraft from impacting terrain in a nose down attitude and reduced the severity of the collision.

Safety actions

Safety action by flight training provider

The flight training provider undertook a critical review of its training practices and risk mitigation measures.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company
• Bureau of Meteorology.

References

Martin, Murray, Bates, and Lee (2015) Fear-potentiated startle: A review from an aviation perspective. The International Journal of Aviation Psychology, 25(2), pp.97-107.

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:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company
• Civil Aviation Safety Authority.

Submissions were received from:

• the pilot and instructor of the accident flight
• Consolidated Pastoral Company.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

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. ^    CASA defines low-level flight operation as any flying conducted below 500 ft above ground level (AGL), other than for the purpose of take-off or landing.
2. ^    Density altitude is the pressure altitude corrected for non-standard temperature. It is the altitude at which the aircraft ‘feels’ it is flying regardless of its actual height above sea level. 

Investigation summary

What happened

On the morning of 11 October 2025, a Piper PA-32R-300 Cherokee Lance, registered VH-JVA, commenced a take-off from runway 26 at Shellharbour Airport, New South Wales, for a private instrument flight rules flight to Bathurst Airport, with a pilot and 2 passengers on board.

After a ground roll of 410 m, the aircraft abruptly pitched up, yawed left and became airborne. The aircraft then climbed away from the runway in a nose high attitude while skidding and rolling left. It then followed a left-turning flight path and reached a maximum recorded altitude of about 50 ft above ground level (AGL) before it began descending. As the aircraft descended, it appeared to stall, the angle of bank increased, and the descent rate increased rapidly. The aircraft collided with terrain and came to rest at the threshold of the intersecting runway (runway 34). The pilot and passengers were fatally injured in the accident, and the aircraft was destroyed.

What the ATSB found

The ATSB found that during the take-off roll, the horizontal stabilator moved to a full, or near-full, nose up deflection and very likely remained in this position for the entire flight. The reason for the control deflection could not be determined.

The ATSB also found that at the time of the accident flight, required scheduled instrument and avionics maintenance inspections had not been completed. While not contributory to the accident, that reduced the assurance that these systems were functioning accurately.

What has been done as a result

In response, the aircraft maintainer advised that they had automated the tracking and alerting of aircraft maintenance requirements to ensure that all required items were completed.

Safety message

If not rapidly corrected, an uncommanded pitch up during take-off can lead to a stall and a loss of control. This is not a scenario typically included in training and a pilot confronted with this scenario faces an unexpected and challenging situation. If control cannot be quickly regained by pushing forward on the control column, engine power should be promptly reduced and control maintained as best as possible to attempt a landing.

Inspections of aircraft instruments and avionics are vital to ensure these systems operate correctly and present accurate and reliable information. While the overdue inspections did not contribute to the accident, pilots can be entirely reliant on these systems to ensure the safety of a flight. Therefore, both pilots and maintainers should ensure required inspections are completed prior to a flight.

Summary video

The investigation

The occurrence

On the morning of 11 October 2025, a Piper PA-32R-300 Cherokee Lance, registered VH-JVA, taxied for a private flight from Shellharbour Airport to Bathurst Airport, New South Wales. The flight was being operated under the instrument flight rules¹ with the pilot and 2 passengers on board.

At 0956 local time, as the aircraft approached runway 26, the pilot announced on the Shellharbour common traffic advisory frequency (CTAF) that the aircraft was entering the runway and lining up to depart. The pilot then taxied the aircraft onto the runway starter extension², lined up and conducted pre‑take‑off checks and engine run ups. While VH‑JVA was lined up, a Cessna Caravan taxiing behind VH‑JVA stopped at the holding point at the runway 26 threshold. The pilot of VH‑JVA invited the pilot of the Cessna to depart ahead of VH‑JVA and the Cessna took off shortly after.

About a minute after the Cessna departed, VH-JVA began a take-off from runway 26. Following a ground roll of about 410 m, VH-JVA abruptly pitched up and yawed left as it became airborne. The aircraft then climbed away from the runway in a nose high attitude while skidding³ and rolling left (Figure 1 and Figure 2).

Figure 1: Composite image of recorded security camera footage of the flight

Figure 2: Composite image of recorded security camera footage of later part of the flight

The angle of bank then appeared to stabilise briefly as the aircraft followed a left-turning flight path (Figure 3). As it turned to a heading of about 200° magnetic (M), it reached a maximum recorded altitude of about 50 ft above ground level (AGL) and then began descending. Three seconds after reaching 50 ft AGL, the aircraft appeared to stall, the angle of bank increased, and the descent rate began increasing rapidly. As the descent rate increased, engine power reduced before the aircraft collided with terrain. 

Figure 3: Flight overview

A post-impact fire commenced and the aircraft came to rest at the threshold of the intersecting runway (runway 34). The pilot and passengers were fatally injured in the accident, and the aircraft was destroyed.

Context

Pilot details

The pilot held a Private Pilot Licence (Aeroplane) and the required class rating and endorsements to operate the aircraft. The pilot also held a private instrument rating and Class 2 aviation medical certificate, which were both current at the time of the accident. 

The pilot’s logbook was reported to be in the aircraft during the accident flight. However, the cabin area of the aircraft was extensively fire damaged following the accident and the logbook could not be located.

At the pilot’s last aviation medical examination, the pilot had declared a total of 1,015 hours of aeronautical experience. Maintenance release entries showed that since that medical examination, the pilot had flown 27.1 hours in the aircraft. Of these, 4.6 hours were in the 90 days before the accident and none in the 30 days before the accident.

The ATSB found no indicators that the pilot was experiencing a level of fatigue known to adversely affect performance.

Medical details

A review of medical records and post‑mortem examinations of the pilot and passengers identified no pre‑existing conditions that were likely to adversely impact their actions or behaviours. Similarly, the toxicological examinations did not identify any substances, including carbon monoxide concentration, that could have impaired the pilot’s performance or adversely impacted the passengers’ actions or behaviours.

Aircraft details

General information

The Piper PA-32R-300 Cherokee Lance is a single-engine, low-wing, retractable-tricycle landing gear aircraft. The Lance is powered by a Lycoming IO-540 fuel-injected, horizontally-opposed piston engine driving a 3-blade, variable-pitch propeller. VH‑JVA (Figure 4), serial number 32R-7680030, was manufactured in the United States in 1975 and first registered in Australia in 1985. The maintenance release stated that the aircraft was approved for IFR, visual flight rules⁴ (VFR) night and VFR day operations.

Prior to the accident flight, the aircraft was last flown on 12 September 2025 and, at the completion of that flight, the aircraft had accumulated 3,915.5 hours total time in service. At the time of the accident, the engine had accumulated 2,043 hours in service since its last overhaul in 1991.

The aircraft was configured with 7 seats (all forward facing) and equipped with dual flight controls. The aircraft was not fitted with aileron trim and was equipped with a Century IIB autopilot, which incorporated a servo on the aileron control system only. In the event of a malfunction, the autopilot servo was designed to allow a pilot to manually override the system.

Figure 4: VH-JVA

Horizontal stabilator

The aircraft was fitted with a horizontal stabilator (Figure 5), sometimes referred to as an all-moving tail. A horizontal stabilator is a fully movable aircraft horizontal stabiliser in which the entire horizontal tail surface is responsive to control column inputs.

Figure 5: Horizontal stabilator

The stabilator was fitted with an anti-servo tab (Figure 6), a small, hinged surface set into the trailing edge of the stabilator. As the stabilator deflected from the trim position, the tab moved in the same direction, but further than the stabilator, to provide an opposing force.

Figure 6: Stabilator and anti-servo tab

Maintenance

The aircraft was maintained in accordance with the Civil Aviation Safety Authority (CASA) maintenance schedule, which required a periodic inspection every 100 hours or 12 months, whichever came first. The CASA maintenance schedule for periodic inspections is divided into airframe, engine, electrical, instruments and radio sections. For aircraft operating only under the visual flight rules (VFR), these inspections could be certified by an ‘airframe’ licenced aircraft maintenance engineer (LAME). For IFR approved aircraft, the radio section contained additional requirements that could only be certified by a suitably-endorsed avionics LAME.⁵

The logbook for VH-JVA indicated that a periodic inspection had been completed on 14 May 2025 at 3,898.2 hours in service. However, the logbook entry by the aircraft’s current maintainer (who was not an avionics LAME) did not specify which elements of the maintenance schedule had been completed. Logbook entries for previous periodic inspections conducted by other maintenance organisations specifically noted where the VFR-required inspections had been completed, with a separate entry certifying the completion of the IFR requirements.

The current aircraft maintainer advised that all logbook entries reflected inspections and maintenance completed as specified in work packages.⁶ The maintainer also advised that for several aircraft, including VH-JVA, the completed work package documents had been inadvertently disposed of, or destroyed by recent flooding of their premises. Therefore, the ATSB could not verify which elements of the VFR maintenance schedule had been completed by the maintainer under their airframe licence. The instrument and radio system inspections for IFR flight (required to be certified by an avionics LAME) were not completed during the May 2025 inspection or at any subsequent time before the accident flight.

Further to the periodic inspections, CASA Civil Aviation Order (CAO) 100.5 General requirements in respect of maintenance of Australian aircraft set out additional maintenance requirements for specific systems that were not covered in the maintenance schedule. The aircraft logbook recorded the following CAO 100.5 instrument and radio inspections as being last completed on the dates listed in Table 1.

Table 1: CAO 100.5 instrument and radio inspections

CAO 100.5 allowed for time extensions of up to 60 days for compliance with these inspections (to 16 June 2025, except for the airspeed indicator). However, there was no record of these CAO 100.5 maintenance inspections being completed before the accident flight in October 2025. 

The aircraft’s original maintenance release was not found in the fire-damaged wreckage, but the ATSB viewed the carbon copy of the current maintenance release that was retained by the maintainer. The current maintenance release, issued by the maintainer, was endorsed for IFR operations and was recorded as expiring on 14 May 2026, or 3,998.2 hours in service, whichever occurred sooner (Figure 7).

Part 1 of the maintenance release included a section where any maintenance required within the validity period could be recorded. Any flight outside of the conditions endorsed in the maintenance release was not permissible until the required item had been addressed and certified by a suitably qualified person. The ‘Maintenance required’ section of the current maintenance release noted that an ‘IFR annual’ was required before IFR flight. This ‘IFR annual’ (IFR-required periodic inspections) was not completed before the accident flight. Additionally, the ‘Maintenance required’ section of the release did not contain any entry relating to the CAO 100.5 inspections required to be completed by 16 June 2025.

Figure 7: Maintenance release carbon copy 

Aircraft loading and take-off performance

The pilot and a passenger were in the 2 front seats while the other passenger was seated in the left seat of the second row. Witness statements and fuel records indicated that the aircraft departed with full tanks.

The purpose of the flight was an overnight stay at Bathurst before returning to Shellharbour the following afternoon. No large or heavy items were identified in the aircraft during the examination of the wreckage and the ATSB estimated the aircraft to be within weight and balance limitations for the flight.

The pilot’s operating handbook (POH) indicated that for the conditions of the accident take-off, the ground roll for a maximum performance take-off could be expected to be between about 260 m (flaps 25) and 365 m (flaps 0).

Impact and wreckage information

Overview

The aircraft impacted the ground to the west of runway 34 while travelling in the 138° M direction (Figure 8). The left wing tip impacted the ground first with the aircraft at or near a 90° angle of bank and with a nose down attitude. The propeller and engine then impacted the ground about 12 m from the wing tip impact. The left wing separated from the aircraft and the main wreckage continued along the ground for a further 47 m before coming to rest on runway 34 near the runway threshold. The integral fuel tanks in both wings ruptured during the accident sequence, leading to a post-impact fire that destroyed most of the fuselage (Figure 9).

Figure 8: Accident site

Figure 9: Fuselage wreckage

All major aircraft components were accounted for at the accident site. The ATSB conducted an initial examination of the wreckage at the site before moving the wreckage to an airport hangar for further examination. This examination did not identify any pre‑existing faults with the aircraft, the primary flight controls or the associated trim systems.

The landing gear was extended, and the flaps were extended to the 10-degree setting at impact. The stabilator trim was set to slightly nose up and the rudder trim was neutral (both positions were in accordance with POH guidance for take-off). Damage to the pilot’s seat rails indicated that it was locked in an appropriate position for the flight. The left (inboard) pin of the passenger’s seat was found secured in the rearmost position while the right (outboard) pin was found not secured into a position. However, there was no damage to the passenger seat rails or outboard rail stop to indicate that this seat had slid rearward.⁷

An inspection of runway 26 and the wreckage examination found no evidence of an animal strike.

Engine and propeller examination

The damage to the propeller indicated that the engine was driving the propeller at the time of impact. The throttle, propeller and mixture controls were all found fully forward although movement of the controls during the accident sequence could not be ruled out.

In December 2025, the engine was disassembled and examined at a CASA-authorised maintenance facility under the supervision of the ATSB. The engine condition was consistent with the engine’s recorded time in service since overhaul. No internal or external damage was identified that may have prevented the engine from operating normally prior to the accident. No defects were identified in the induction system components or engine accessories that may have affected its pre-accident operation.

The propeller blades were all retained in the propeller hub. The blades and the spinner also exhibited signatures consistent with the propeller being driven by the engine at moderate power at the time of impact. Propeller ground scars and the tachometer needle position indicated that the engine was rotating at about 2,000 to 2,200 RPM at the time of the ground impact (Figure 10).

Figure 10: Tachometer from the aircraft (left) and an extract from the pilot’s operating handbook (right)

Recorded data

The ATSB obtained recorded automatic dependent surveillance‑broadcast (ADS-B) data for the accident flight. In addition, several security cameras captured the aircraft before and during the flight (Figure 11 and Figure 12)

Figure 11: The aircraft taxiing prior to take-off

Figure 12: Flight path and recorded data

A witness also captured 2 photographs of the aircraft while airborne (Figure 13 and Figure 14). From the security camera footage, photographs and ADS-B data, the ATSB was able to establish that:

• the primary flight controls were not locked
• during the initial take-off ground roll, the stabilator was in a neutral position
• the initial take-off ground roll appeared normal
• the recorded groundspeed at the time the aircraft became airborne was 61 kt
• the groundspeed increased to 64 kt as the aircraft commenced turning left and then remained between 60⁠–⁠61 kt as the aircraft turned through 180° M. As the turn continued and with an increasing tailwind component, the groundspeed increased to the recorded maximum of 70 kt immediately before impact
• in the second photograph (Figure 13), taken just before impact, the propeller was rotating at about 2,700 RPM
• there was no evidence of an animal strike
• all cabin and baggage compartment doors appeared to be correctly secured
• in the 2 photographs, the rudder was at a near-neutral position, the stabilator was at a full, or near-full, nose up deflection and the ailerons were partially deflected to the right
• in the first photograph (Figure 14), the stabilator trim anti-servo tab was deflected up (the tab is not visible in the second photograph)
• the security camera footage was not of sufficient resolution to determine control deflections during the flight.

Figure 13: Photographs of the aircraft during the accident flight

Figure 14: Enlargement of first photograph

A Garmin 750 navigation unit was recovered from the aircraft wreckage, but the installed software version did not record track logs.

Shellharbour Airport CTAF recordings captured no further broadcasts from the pilot of VH-JVA following those made prior to take-off.

Meteorological information

Shellharbour

The terminal area forecast valid for Shellharbour Airport at the time of the accident indicated winds of 10 kt from 260° M. Severe turbulence⁸ was also forecast below 5,000 ft above mean sea level (AMSL). From 1000, the winds were forecast to increase in strength to 15 kt, gusting to 25 kt. 

At 0959, as the aircraft departed runway 26, the Bureau of Meteorology automatic weather station at Shellharbour Airport recorded the temperature as 27°C and the wind as 12 kt from 278° M. There was no recorded cloud, and visibility was recorded as greater than 10 km.

The pilot of the preceding Cessna reported that during their departure, the winds were gusty with light windshear and moderate turbulence. This pilot also stated that this was common for Shellharbour Airport with strong westerly winds. The accident pilot and aircraft were based at Shellharbour Airport, and the pilot was reported to be familiar with mechanical turbulence associated with strong westerly winds at the airport.

En route and Bathurst

The flight plan indicated that the pilot intended to climb to 6,000 ft AMSL for the flight to Bathurst. The graphical area forecast valid for the flight to Bathurst included a visibility of greater than 10 km with scattered⁹ stratocumulus cloud between 4,000 ft AMSL and 8,000 ft AMSL. The terminal area forecast valid for the estimated time of arrival at Bathurst included winds of 12 kt from 260° M, with the ceiling, visibility and weather forecast to be OK (CAVOK).¹⁰ 

For the return flight planned for 1600 the following day, the terminal area forecast, valid for Bathurst Airport, included light showers of rain, winds of 10 kt from 250° M, scattered cloud at 3,435 ft (1,000 ft above the airport elevation) and visibility greater than 10 km. This forecast also included periods of up to 30 mins (INTER) with rain showers, wind of 20 kt gusting to 35 kt and a variable direction. These periods also forecast broken cloud at 3,235 ft (800 ft above airport elevation), scattered towering cumulus cloud at 5,435 ft (3,000 ft above aerodrome elevation) and 4 km visibility.

The graphical area forecast for this flight included a general visibility greater than 10 km but reducing to 7 km in scattered light rain showers and 3 km in isolated rain showers. Scattered cumulus cloud was forecast extending from 5,000 ft AMSL to above 10,000 ft AMSL. The scattered light showers were associated with scattered stratocumulus cloud between 4,000 ft AMSL and 8,000 ft AMSL and broken altocumulus/altostratus cloud from 8,000 ft AMSL to above 10,000 ft AMSL. The isolated rain showers were associated with isolated towering cumulus cloud from 6,000 ft AMSL to above 10,000 ft AMSL and broken stratocumulus and cumulus cloud from 2,000 ft AMSL to above 10,000 ft AMSL.

Safety analysis

Stabilator deflection

The aircraft started the take-off roll with the stabilator in a near-neutral position. However, during the take-off roll, the horizontal stabilator moved to a full, or near-full, nose up deflection.

The reason for the stabilator deflection could not be determined. The selected stabilator trim was correct and examination of the flight control and trim systems did not identify any pre-accident defects. Furthermore, neither control seat slid rearward, the aircraft was not equipped with an autopilot servo on the stabilator control and the observed stabilator anti-servo tab position during the flight indicated that the tab was operating correctly. In addition, the aircraft did not appear to be subjected to an external influence such as an animal strike or environmental effect. There was also no evidence to indicate that the stabilator deflection resulted from any intentional or inadvertent action or a medical episode of the pilot or passengers.

When the stabilator moved to the nose up deflection, the aircraft pitched abruptly nose up, yawed left and became airborne. The aircraft’s propeller rotated right (clockwise) when viewed from the cabin, generating a torque effect and a spiralling slipstream acting on the left side of the vertical stabiliser. These forces result in the aircraft yawing left with an associated rolling tendency. These left-turning tendencies are particularly apparent at high engine power settings and low air speeds, such as those experienced by the aircraft as it became airborne and are primarily corrected using right rudder input.

Photographs taken during the flight showed the rudder was maintained in a neutral position. The left yaw and roll and left turning flightpath likely occurred because of the aircraft’s left turning tendency not being corrected with rudder input. However, the right aileron input during the flight and the engine power reduction just before impact indicated attempts to correct the flightpath and reduce the severity of the impact.

The photographs and flight path indicate that the stabilator very likely remained in the nose up deflection for the entire flight. Late in the flight, as the aircraft began descending, it stalled, the angle of bank increased, and the descent rate increased rapidly before the aircraft collided with terrain. 

Overdue instrument and radio inspections

The aircraft logbook last recorded specific instrument system inspections required under Civil Aviation Order 100.5 as being completed on 17 April 2023 and, with the exception of the air speed indicator, these inspections needed to be completed again no later than 16 June 2025 (3 months before the accident).

On 14 May 2025, the maintenance release was issued with an expiry date or time of 14 May 2026, or 3,998.2 hours in service, whichever occurred sooner. This maintenance release included a statement in the ‘Maintenance required’ section noting that an ‘IFR annual’ inspection was required before an instrument flight rules (IFR) flight. However, the IFR annual instrument and radio system inspections were not completed before the accident flight that was conducted under the instrument flight rules. Additionally, the maintenance release did not state that certain CAO 100.5 inspections for visual flight rules flight were also due during the period of the maintenance release validity (16 June 2025). The aircraft logbook had no record of these inspections being completed prior to the accident flight. Therefore, the maintenance release should have ceased to be valid as of 16 June 2025.

The forecast weather conditions for the flight to Bathurst and particularly the return flight on the following day indicated a high likelihood of encountering cloud with associated reduced visibility. During these periods, the pilot would have been solely reliant on the aircraft’s instrument and radio systems to ensure the safe completion of the flight. The overdue inspections for these systems reduced assurance that the indications provided by these systems were accurate and therefore increased risk to the flights. 

While these inspections were not completed prior to the flight being conducted, they did not relate to the stabilator or its control systems. Therefore, the absence of these inspections did not contribute to the accident.

Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Piper PA-32R-300, VH-JVA, at Shellharbour Airport, New South Wales on 11 October 2025.

Contributing factors

• During the take-off roll, the horizontal stabilator moved to a full, or near-full, nose up deflection and very likely remained in this position for the entire flight.
• Following the significant stabilator movement the aircraft pitched abruptly nose up, yawed to the left and became airborne. The aircraft then followed a left turning flight path until it stalled and collided with terrain.

Other factors that increased risk

• At the time of the accident flight, required instrument and avionics maintenance inspections had not been completed, reducing the assurance that the indications provided by these systems were accurate.

Safety actions

Safety action by maintenance organisation

In response to the accident, the maintainer advised that they had automated the tracking of aircraft maintenance requirements to ensure that all required items were completed during maintenance events.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Civil Aviation Safety Authority
• Airservices Australia
• New South Wales Police
• New South Wales Health
• Shellharbour Airport
• Piper Aircraft
• the maintenance organisation for VH-JVA
• the aircraft co-owner
• witnesses
• security camera footage and photographs of the accident flight
• Bureau of Meteorology.

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
• United States National Transportation Safety Board
• Piper Aircraft
• the maintenance organisation for VH-JVA
• the aircraft co-owner.

A submission was received from:

• the maintenance organisation for VH-JVA

The submission was reviewed and, where considered appropriate, the text of the report was amended accordingly.

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. ^    Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.
2. ^    The runway starter extension is additional runway length available for take-off (not landing) before the runway threshold.
3. ^    A skidding turn is an uncoordinated turn where the fuselage of the aircraft is not aligned with the airflow. In a skid the tail of the aircraft follows a path that is outside of that followed by the nose.
4. ^    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 fly using external references and without relying on instrument indications.
5. ^    ‘Avionics’ LAME relates to where specialist knowledge, techniques and equipment is required by LAMEs for specified electrical, instrument and radio systems maintenance.
6. ^    Work packages are documents which define a set of maintenance tasks that are to be performed on an aircraft during an inspection. These contain notes of test results, certification for the completion of maintenance tasks and records of parts removed/installed.
7. ^    The seat rail stops limit the fore/aft seat movement, ensuring that the seat feet remain attached to the rails.
8. ^    Moderate turbulence is usually associated with small changes in airspeed and moderate changes to aircraft attitude and/or altitude, but the aircraft remains under positive control. Severe turbulence is associated with large changes in airspeed and abrupt changes to aircraft attitude and/or altitude; in severe turbulence the aircraft may be out of control for short periods.
9. ^    Scattered cloud indicates that cloud is covering between a quarter and a half of the sky. Broken cloud indicates that more than half to almost all the sky is covered, and ‘overcast’ indicates that all the sky is covered.
10. ^   CAVOK indicated that the following conditions were forecast simultaneously: visibility is 10 km or more, no cloud below the higher of 5,000 ft or the highest 25 nm minimum sector altitude, no cumulonimbus or towering cumulus cloud types, and no other weather of significance to aviation.

Investigation summary

What happened

On the evening of 9 October 2025, a Robinson R22 Beta II helicopter, registered VH‑LYD, was being operated by MDH Pty Ltd (MDH) 25 km south-south‑east of Kowanyama, Queensland. 

The helicopter left Rutland Plains at around 1845 to guide ground vehicles tackling a bushfire. At around 1920 the pilot told the ground crew that it was getting too dark and set off to return to Rutland Plains Station. 

Staff at the station lit the helipad for the arrival of the pilot. When the pilot did not return to the station, staff raised the alarm. 

The following morning, the helicopter wreckage was found. The helicopter had collided with terrain. The pilot of VH-LYD was fatally injured in the accident, and the helicopter was destroyed.

What the ATSB found

The ATSB found that the pilot operated the helicopter at night. The helicopter was not equipped, and the pilot was unqualified, for flight at night. However, it was normal for company R22 pilots to exceed the limits of last light. 

Instead of observing the legal limits, pilots chose their own limits, despite none of the company’s R22 pilots being qualified for night flight and none of its R22 helicopters being equipped for night flight. ATSB analysis of historical flight tracking data showed that on 39 occasions in the previous 6 months MDH pilots had flown beyond the legal minimums into night. Flying after last light was a tolerated and unmanaged risk on MDH properties.

In addition, the ATSB found that MDH did not require pilots to formally assess risk and did not provide tools or training to do so. This limited the ability of the company and its pilots to identify and understand operational hazards and their consequences.

What has been done as a result

MDH now requires its pilots to determine the official time of last light and has made it a clear responsibility of the pilot and the station manager to ensure aircraft are on the ground before last light. 

Additionally, pre-flight planning now includes consideration of fatigue, including rest and duty times, and consideration of risk assessment criteria.

MDH has also implemented a pilot mentoring scheme to assist, mentor and supervise MDH pilots during aerial mustering operations. This includes a pre-season low level risk assessment and standardised mustering workshop, the first of which took place in March 2026.

Safety message

This accident is the fourth fatal accident of this type in the last 5 years. Flying after last light without appropriate equipment and qualifications is an unsafe practice. The acceptance of this activity is leading pilots to fatal accidents.

The ATSB’s Avoidable Accidents No 7 - Visual flight at night accidents provides further discussion about these practices and how they have contributed to accidents. The requirement to operate under daylight conditions, and plan to land 10 minutes before last light, provides a reliable method for ensuring there are sufficient external visual references available to safely operate an aircraft. 

Pilots and the companies or landowners they work for, or contract to, must work together to avoid flight at night by unqualified, unequipped pilots. Development of risk management practices in any organisation should be an ongoing activity. It should develop an ability across all parties to document operational risks and codify learnings from operations.

The occurrence

On the evening of 9 October 2025, a Robinson R22 Beta II helicopter, registered VH‑LYD, was being operated by MDH Pty Ltd (MDH) at Rutland Plains, a cattle property in northern Queensland on the Gulf of Carpentaria (Figure 1). 

Figure 1: Area of operation

Source: Queensland Globe

The pilot started the day’s flying just after 0600, aerial mustering in an area about 40 km south‑west of another company‑owned property, Dunbar Station, Queensland. In the afternoon, the pilot travelled to Rutland Plains to collect a colleague and conduct aerial reconnaissance for another muster planned for the following day. After leaving their colleague, the pilot flew to a nearby location to collect parts for equipment needed for the planned muster at Rutland Plains. 

At around 1730, on the way to collect the parts, the pilot spotted a bushfire around 25 km south-south‑east of Rutland Plains station. The pilot advised crew at the station via radio and ground vehicles were dispatched to control the fire. Crew at the station recalled that after returning to Rutland Plains with the parts, the pilot flew to the fire to assist in guiding the ground vehicles through tracks and fences to the flame front. 

The pilot and helicopter were limited to daytime operations. The pilot departed Rutland Plains for the fire at around 1845. The time of last light (the beginning of nighttime) at Rutland Plains on 9 October was 1852. 

At around 1920, the pilot was providing airborne assistance to ground crew controlling the fire. Around that time the pilot announced over the radio that it was getting too dark, and the pilot needed to return to Rutland Plains. Hearing this, the crew at the station lit the helipad with the headlights of a vehicle to assist the pilot on their return. 

At around 1935, crew at the station checked to see if the pilot had landed. Discovering that the helicopter had not returned, they tried contacting the pilot by radio. When radio contact was unsuccessful, they escalated the non-arrival within the company and sought information from a satellite tracking system on board the helicopter to establish its location. Tracking had stopped at 1929 around 7.5 km south-south‑east of the station (Figure 2). 

Figure 2: Fire location and VH-LYD track

Source: Google Earth, BoM and SPOT Trace tracking data

Station crew conducted a ground search while company management contacted emergency services and the Joint Rescue Coordination Centre. A coordinated air search began just after midnight. 

The following morning, helicopter wreckage was found by a station crew member from Rutland Plains and a helicopter pilot from a neighbouring property. VH-LYD had collided with terrain around 1.5 km north of the last satellite tracking point. The pilot was fatally injured in the accident, and the helicopter was destroyed by impact forces.    

Context

Pilot information

The pilot held a valid Private Pilot Licence (Helicopter) (PPL(H)), which was issued in February 2023 and a mustering endorsement issued in April 2023. The pilot held a class 2 medical certificate which was valid to 31 August 2026.

The pilot commenced work in ground-based cattle operations with MDH Pty Ltd (MDH) in 2017 and transitioned to an aerial mustering role. The pilot had accumulated around 2,000 to 2,500 hours of flight time. 

In November 2024, the pilot attended a Robinson Helicopter Company safety course. On 16 January 2025 they underwent a biannual helicopter flight review. In March 2025 the pilot attended an MDH leadership conference. In June 2025 the pilot completed refresher training and check flights in mustering techniques. There was no record of the pilot being trained or qualified to operate under night visual flight rules (NVFR) [1]^,[2] (see Night flight regulatory requirements). 

It could not be determined if the pilot experienced a level of fatigue that would have impaired performance or decision‑making at the time of the accident (see Fatigue).

Helicopter information

VH-LYD was a Robinson Helicopter Company R22 Beta II helicopter, serial number 4471 (Figure 3). It was powered by a Textron Lycoming, O-360-J2A, 4-cylinder piston engine. VH-LYD was manufactured in the United States on 12 February 2010 and first registered in Australia on 19 May 2010. It was equipped and maintained to a day VFR standard. Its last 100-hourly maintenance was conducted on 24 September 2025. At the time of the accident VH-LYD had accumulated approximately 14,645 hours total time in service. 

Figure 3: Exemplar Robinson Helicopter Company R22

Note: This exemplar image has been digitally altered by the ATSB. Source: MDH Pty Ltd

The R22 had 2 seats, with the pilot flying from the right seat, and each seat was fitted with a seatbelt and inertia reel shoulder strap. VH-LYD did not have doors fitted at the time of the accident. 

Maintenance records and wreckage inspection both showed that VH-LYD was not equipped with instruments necessary for flight at night (see Night flight regulatory requirements). 

Recorded information

The helicopter was not fitted with a flight data recorder or a cockpit voice recorder, nor was it required to be. During the accident flight, data was transmitted from a SPOT Trace[3] satellite tracking unit fitted to the helicopter, which could be used by MDH personnel to track the location of the helicopter during flight. The unit provided 5-minute time-stamped updates on the helicopter’s location, speed and altitude. The recorded data captured the accident flight until shortly before the impact with terrain.

The SPOT Trace units were fitted to all MDH R22 helicopters, and the ATSB sourced the preceding 6 months of fleet data for analysis purposes. The data covered 596 days of helicopter operation across 4 helicopters (see Night flight data analysis).

Wreckage and impact information

The ATSB did not attend the accident site. The site was mapped, documented and assessed by a team from the forensic crash unit of the Queensland Police Service (QPS). QPS recovered the wreckage of VH-LYD to a secure location in Cairns, Queensland, where it was examined by 2 ATSB investigators. 

Site photographs and wreckage inspection indicate that VH-LYD was moving at high speed, around 90 degrees off track, at the time of the collision with terrain (Figure 4). The helicopter was significantly damaged by tree and ground impacts with the main rotor and transmission assembly separating from the helicopter. There were no pre-accident defects identified, and the engine was driving the main and tail rotor system at the time of the collision. The impact with terrain was not considered to be survivable.

Figure 4: VH-LYD accident site

Source: Queensland Globe, Queensland Police Service, annotated by the ATSB

Meteorological and environmental information

Weather 

A Bureau of Meteorology (BoM) aviation weather forecast for Kowanyama Airport (located around 20 km north‑west of Rutland Plains) for 9 October related the possibility of thunderstorms. Meteorological conditions recorded by the BoM weather station at Kowanyama Airport included distant lightning from around 1530, indicating that thunderstorms were reported within 30 NM (55 km) but not at the airport. Cloud developed through the day, with periods of scattered to broken cloud between 6,000 ft and 9,000 ft. No cloud was detected at Kowanyama Airport at the time of the accident.

No rainfall was detected throughout the day, and the wind had shifted from a variable easterly in the morning to a south-westerly wind of 6 kt from around 1730. Around that time the accident pilot reported to a colleague at Rutland Plains that dry storms^[4] were building in the area, and that there was smoke, indicating a bushfire. 

A witness who heard the departure of VH-LYD stated that on last light, shortly after the time the pilot departed Rutland Plains for the fire, cloud covered the area though there was still a visible horizon. 

Light 

The period between sunset[5] and the geometric centre of the Sun’s disk reaching 6° below the horizon is called civil twilight (Figure 5). The end of civil twilight is otherwise known as last light. For aviation purposes last light is the boundary between night and day. The period when the geometric centre of the Sun is between 6° and 12° below the horizon is called nautical twilight. After that time, it is ordinarily, for all practical purposes, dark. This is especially so in areas devoid of artificial lighting.

Figure 5: Limits of day and night relative to the position of the Sun

Source: Geoscience Australia, ATSB

The time of last light was readily available for any location in Australia from Airservices Australia’s national aeronautical information processing system (NAIPS). It could also be calculated using tables published in the aeronautical information package (AIP) at GEN Section 2.7 – First light and last light computations(Airservices Australia, 2024) or via Geoscience Australia’s calculator on its website.  

On 9 October 2025 at the location of the accident near Rutland Plains Station, Queensland, sunset was 1831, the end of civil twilight was 1852 and the end of nautical twilight was 1917. Celestial illumination would have been limited by cloud and there was no moonlight as a waning gibbous^[6] moon would not rise until 2045. 

Smoke

The 6 kt (10.8 km/h) south-westerly wind, though light, is likely to have kept smoke away from the pilot’s return track to Rutland Plains Station. Moreover, the pilot was unlikely to have approached the fire through smoke, and the pilot departed the fire on a reciprocal track.

Operational information

Operator overview

MDH Pty Ltd was one of Australia’s largest beef cattle operations. It was a family business that owned 14 properties covering 3.36 million hectares. MDH’s aircraft and pilots were spread over Queensland and managed from Brightlands Station just south of Cloncurry, Queensland. 

At the time of the accident MDH owned and operated 4 Robinson R22 helicopters, 1 Robinson R44 helicopter and 6 fixed wing aircraft. It had operated Robinson R22 helicopters since 1985. The chief pilot stated that at the time of the accident none of its R22 helicopters were equipped for night flight.

MDH had 4 helicopter pilots flying the R22s. Three of the pilots had Private Pilot Licences (Helicopter) and one had a Commercial Pilot’s Licence (Helicopter). All were endorsed for low‑level flight and mustering and none held a night visual flight rules rating.[7] 

The helicopters were being operated by paid employees, aerial mustering for commercial beef cattle operations. As the helicopters were company‑owned, and were being operated over private land, those operations were conducted as limited aerial work operations under Part 138 of Civil Aviation Safety Regulations (CASR), which do not require the issue of an aerial work certificate by CASA. Part 91 of the Civil Aviation Safety Regulations (CASR) (2025b) also applied unless a specific requirement of Part 138 disapplied it. This meant MDH had to comply with the requirements of CASR Part 138 with respect to pilot fatigue and risk management of operations.

Operator procedures and oversight

MDH did not have, and was not required to have, a CASR Part 138 aerial work certificate for the R22 operations. Therefore, it was not required to provide the Civil Aviation Safety Authority (CASA) with a complete operations manual covering all requirements of the regulations for its proposed operations.

Instead of an operations manual detailing how operations were to be conducted, MDH had limited manuals and procedures for helicopter operations. An induction handbook for pilots carried information on administration and basic instructions with respect to flight operations. A statement at the head of the document required pilots to observe all applicable laws and rotorcraft flight manual limitations.

Pilots stated that the document matched their operations, and that the expectation of pilots not breaching regulations was observed. MDH held pre-season[8] safety meetings with the pilots. The last was 21 March 2025 in Brightlands. The meetings would cover operational elements, as well as a review of the pilot induction material to refresh procedures.

MDH had a senior pilot who was positioned in the induction handbook as the chief pilot. They were to be contacted for aircraft and pilot issues. The chief pilot stated that oversight of the pilots was conducted, when possible, by the chief pilot or another senior manager, though they were most often not co-located with the pilots.

The chief pilot would roster pilots by date, helicopter and location and build in rest days. They would also ensure that pilots’ tasks remained solely associated with flying. Ordinarily pilots would start at first light, but it was left to the pilots as to when their duty would end. Days rostered were documented and retained by the company, but duty hours worked by pilots were not. 

The chief pilot acknowledged that there were occasions whereby pilots would have to use the helicopter for as long as possible and into twilight. They stated that they expected pilots to minimise their exposure to flight at night by landing near vehicles to get a lift home, or by staying at alternative accommodation. The chief pilot provided an example of setting this expectation to a pilot in mid-August 2025 after they exceeded last light by 35 minutes. 

They also stated that pilots would assess whether there was enough light to continue flight, and the decision was at the sole discretion of the pilot. MDH’s pilots concurred with this, and all stated that the pilot in command was solely responsible for the operation of the helicopter and had final say in all decisions related to the operation of their helicopter. 

There was one mention of daylight in the MDH induction handbook for pilots which concerned ferrying of aircraft. It stated:

A decision has to be made by the pilot if the daylight does not permit making the scheduled property in the afternoon to stay at a property and notify [management] that they did not make it.

Flight at night

Night flight AIP instructions and CASA guidance material

The CASA (2025f) Visual flight rules guide carried information on the regulations and requirements pertaining to night visual flight rules. It was a useful starting point for pilots and operators to ensure night flight was appropriately managed. In addition, advisory circular (AC) 61-05 Night VFR rating (CASA, 2022) was an important supporting document to the regulations and related notable hazards of night flight. 

Untrained (and therefore unauthorised) pilots were not allowed to conduct flight at night. AIP ENR Section 1.2 – Visual Flight Rules, paragraph 1 Flight Rules, sub paragraph 1.1 The Visual Flight Rules (VFR), sub sub paragraph 1.1.2 stated:

1.1.2 Unless the pilot in command is authorised under CASR Part 61 to conduct a flight under the IFR or at night under the VFR and the aircraft is appropriately equipped for flight at night or under the IFR, a VFR flight must not be conducted at night.

The appropriate equipment mentioned was listed in CASR Part 91 manual of standards (MOS) (CASA, 2021). This included specific equipment such as:

• equipment for displaying the rotorcraft’s attitude
• radio communications system equipment
• navigation systems equipment, such as an approved GNSS
• navigation and cockpit lighting.

Furthermore, there were rules about fuel reserves, alternate aerodromes, and calculating and flying above lowest safe altitudes. Additionally, AC 139.R-01 v3.1 (CASA, 2024a) carried guidelines for helipad dimensions and markings for night operations which were in excess of those required for operations by day.

AIP ENR Section 1.2 – Visual Flight Rules, paragraph 1 Flight Rules, sub paragraph 1.1 The Visual Flight Rules (VFR), sub sub paragraph 1.1.3 stated:

1.1.3 For pilots not authorised to fly at night, it is recommended that they plan to arrive at the later of the destination aerodrome or alternate aerodrome at least 10 minutes before last light (allowing for any required holding).

The AIP instructions and associated CASA guidance material clearly indicate that the regulations precluded an untrained or unequipped pilot from flying at night. Additionally. there was a clear intention that pilots aim to land at least 10 minutes before last light (10 minutes before end of civil twilight). 

Operator’s night flight practices

The ATSB interviewed 3 company R22 pilots and the chief pilot about practices related to night flight. 

MDH did not roster pilots to fly after last light. To do so was against regulations. However, pilots reported that the requirement to land before last light was not always observed. They stated that while they would not plan to land after last light, at times, operational needs led them to do so. 

On occasion, depending on the location and behaviour of the cattle, a muster could take longer than planned. In some locations where a holding yard was available, it was possible to re-plan and stop work without losing effort. Additionally, the option existed to land at the yards and return to the station in a vehicle rather than flying back to a station in fading light. However, that could delay the start of the following day’s muster and leave less time to manage overruns the next day.

In locations where cattle could not be held, ending the job before cattle were yarded up could lead to the loss of a day’s work. While there was no reported pressure on pilots to continue, pilots reported that they would do so rather than undo a day’s work. Exceeding last light was an accepted part of operations and pilots could make their own decisions about whether the light remaining was enough to finish the job and fly home. 

The actual time of last light and 10-minute buffer was not used in pilot assessments, and pilots did not use the time of last light to delineate between night and day. Instead, pilots would weigh environmental factors such as sunset, cloud and available horizon against their own tolerance for risk. The distinction became one between dark with a discernible horizon and fully dark.

From time-to-time emergencies, such as fires, could crop up and require input or oversight from a pilot in a helicopter. There was no expectation on the part of MDH that pilots would fly after last light, no matter the reason. At the same time, it was reported that in an environment where the pilots were most often unsupervised, no-one would prevent a pilot from doing so. Individual accountability in pilot decision‑making was reported to be the only determining factor.

Night flight data analysis

The SPOT Trace data for MDH’s 4 R22 helicopters for the 6 months preceding the accident was analysed by the ATSB to identify night flight practices. The data was pruned to remove any points that did not indicate flight, then differenced with the time of civil twilight for that location. Matches close to last light were further refined by measuring the distance to the next spot and calculating time available to destination.

The tracking data (Figure 6) showed that in the 6 months preceding the accident, the 4 company helicopters operated on 596 days. Of the 596 days of operation, company helicopters were flown after last light on 39 occasions, around 6.5% of days of operation across the 4 helicopters. The level of exceedance ranged from under a minute up to 1 hour 34 minutes, with the average exceedance being 17 minutes. Eight of the late flights, including the accident flight, extended beyond nautical twilight. 

Figure 6: Latest time flown after last light for 39 flights in company R22 helicopters

Source: SPOT Trace data

The largest exceedance of around 1 hour 34 minutes after last light took place in July 2025 in the vicinity of Mount Windsor Station, Queensland. While cloud cover is not known, the moon rose at 1404 and was approaching three quarters full at an altitude of 70° when the helicopter landed. 

Operational risk management

Risk management regulatory requirements

MDH, as a limited aerial work operator, was required to comply with CASR 138.370 which required risk assessment and mitigation. 

MDH had to ensure that, before beginning a task, a pilot had assessed the risk of an operation (Part 138 MOS 13.05). The pilot had to ensure that the operation could be conducted without unacceptable safety risk (Part 138 MOS 13.02). 

Part 138 MOS at 13.04 instructed pilots to take specific notice of:

(a) the operation and its particular characteristics;

(b) the location of the operation and its particular characteristics;

(c) the aircraft to be used in the operation, its particular characteristics, and its performance;

(d) the qualifications and experience of the crew members to be used in the operation;

(e) the hazards, external to the aircraft, that may be met in the course of the operation.

Advice on risk management was available to operators in AC 138-05 v3.0 Aerial work risk management (2025a). It stated:

For limited aerial work operations, a risk assessment and mitigation process must be undertaken by the pilot in command (PIC) before an operation is conducted… 

It is incumbent upon the operator … to ensure these procedures are carried out.

Annex A to AC 138-05 v3.0 was titled Sample risk assessment process - limited aerial work operator. It explained how to implement risk management to meet the requirements of the Part 138 Manual of Standards.

Operator’s risk management practices

MDH’s primary use of helicopters was aerial mustering. This activity was supported by training and operational documents. MDH provided training in aircraft knowledge, operational techniques and safety, which was suitable for conduct of its operations.

It had also outlined a pre-mustering assessment which pilots could use to discuss and manage mustering operations. The document contained some collected knowledge of hazards and prompts to identify powerlines and brief ground crew on safety around helicopters. However, it was essentially a task management document and did not address identification and management of risk. 

The flight planning section of the pilot induction handbook also prompted identification of threats with respect to reconnaissance of known local hazards such as powerlines and dead trees. While this applied to managing safety during a flight, it did not constitute risk management. Risk management was where a pilot and organisation could decide if an operation could be conducted within the organisation’s safety performance criteria (CASA, 2025d).   

The pilot induction handbook also contained a section called risk management which was a high-level outline of the pilots’ responsibilities with respect to weather, fatigue, mustering, aircraft handling, and sightseeing. It outlined some associated hazards but did not discuss risk management as an activity and no risk management plans were present. Specifically, there were no defined limits or organisational tolerance for risk. Additionally, there were no apparent tools or support for company pilots to formally identify and manage risks, to ensure that an operation could be conducted without unacceptable safety risk. This limited the guidance and support available to pilots undertaking novel or infrequently encountered activities such as fire spotting. 

Fatigue management

Fatigue management regulatory requirements

As a limited aerial work operator CASR 138.150 required MDH to have a system for managing crew fatigue that met the requirements of the Part 138 Manual of Standards. The Part 138 MOS at 6.02 required compliance with an element of Civil Aviation Order 48.1. That element at paragraph 16.1 of CAO 48.1 put the onus on a pilot to not carry out a task if at any point during that task, they were likely to be fatigued.

The requirement for MDH was then to ensure that pilots had knowledge and frameworks to understand and measure fatigue and to support pilot decision‑making around fatigue. 

While MDH was not required to comply with the rules for daylight aerial work operations from appendix 5A of CAO 48.1, it serves as useful guidance. CASA CAO 48.1 plain English guide (CASA, 2025c) stated:

• The maximum flight duty period (FDP) that can be assigned in 1 day is 14 hours.

• Following an FDP, you must be off duty for at least 10 hours.

• You cannot be assigned an FDP that starts 30 minutes before the start of morning civil twilight (MCT) or that ends later than the end of evening civil twilight (ECT).

• An FDP cannot be extended beyond the end of ECT, unless it is necessary to complete the duties associated with the last daylight flight.

The final provision was to allow a pilot to complete ground-based work after landing, not to continue flight. 

Further guidance was available to flight crew members (FCM) in Civil Aviation Advisory Publication (CAAP) 48-01 (CASA, 2024b). Advice on meeting that requirement warned:

3.1.1.3 Reduced alertness may impact judgement. To manage the potential for poorer judgment and decision making associated with a fatigued FCM, CASA recommends involving a non-fatigued individual along with multiple methods for measuring alertness to assist the FCM when assessing fitness to fly.

Operator’s fatigue management practices

The pilot induction handbook contained advice to pilots on fatigue and stated:

Fatigue, or tiredness, can often be an issue in mustering operations where early mornings and long days are involved. Fatigue can have a profound effect on the performance of the mustering crew. Due to the high level of concentration required by the PIC, fatigue can set in earlier for the PIC than for the other crew members.

The accident pilot’s flight and duty times for the 7 days leading up to the accident are captured in Table 1. 

Table 1: Pilot’s previous 7 days flight and duty

Source: Pilot’s roster and satellite tracking data from VH-LYD

In the 72 hours prior to the accident the pilot had flown 29.8 hours and completed an estimated 36.8 hours of duty. In the 2 days leading up to the accident the pilot had flown 21.6 hours and conducted an estimated duty of 27.8 hours. On both days the pilot’s duty exceeded daylight hours, with flight on 8 and 9 October being conducted at night. Additionally, the rest period between the duties was likely less than 10 hours. 

While the fatigue regulations of an aerial work certificate holder did not apply to MDH, by way of example, this was outside of the fatigue limits for aerial work under day visual flight rules documented in Appendix 5A of CAO 48.1. 

It was reported that the pilot’s accommodation was suitable for rest. Although the pilot had worked 2 long days leading up to the accident, the rest period earlier in the week potentially protected the pilot from an accumulation of fatigue. It is not possible to determine whether the pilot experienced a level of fatigue that would have impaired performance or decision‑making at the time of the accident.

Human factors

Fatigue

Fatigue can impact pilots in various ways. It can affect decision‑making, and CASA (2025e) states that fatigue at the end of a day, shift or flight, can lead people to persevere with a chosen course of action or ignore information which could contradict a decision to continue. Fatigue can diminish the ability of the eye to focus (Robson, 2008). It can also increase the risk of spatial disorientation, and lead to delayed response times as well as a range of pilot errors (ATSB, 2013). 

Spatial disorientation

For day VFR pilots, spatial orientation is being aware of how they are orientated and moving in space with reference to external objects such as the surface of the Earth (Young, 2003). Spatial disorientation is loss of that awareness, ordinarily due to a loss of visual information, leading to an inability to correctly interpret aircraft attitude, altitude or airspeed in relation to the Earth or other points of reference (ATSB, 2013).  

The mechanisms of spatial disorientation and dangers of flight at night, which by its very nature reduces available visual information, is discussed in detail in ATSB report Avoidable Accidents No.7 Visual flight at night accidents: what you can’t see can still hurt you (AR-2012-122) (ATSB, 2013). 

Young (2003) describes the sensory systems that support spatial orientation. They include:

• The visual system (sight) tells us where things are and what is present. It makes use of peripheral vision to detect self-motion relative to objects and the ground. The central vision can detect objects of known size and character to provide distance and closing information.
• The vestibular system (balance and orientation organs in the ears) is the primary system for sensing body motion relative to gravity and acceleration. It supports the muscle commands that keep our eyes and head stable and keep us upright relative to gravity.
• Proprioception (the sense of movement) helps to sense orientation and acceleration through pressure on the skin. It will also generate an accurate estimate of the current position of the body to plan movements and predict the outcome of future actions (Tuthill & Azim, 2018).

Sight provides around 80% of the information, and the balance organs and sense of movement, providing around 10% of the information each, are prone to illusions and misinterpretation. 

Poor visual cues are a feature of almost all spatial disorientation accidents. There are several well-known illusions that can affect pilots at night (ATSB, 2013): 

• Somatogravic, the brain cannot differentiate between acceleration and a pitch-up event. In the absence of visual cues, the pilot can easily confuse the two states. A pilot response to an incorrect sensation can increase the confusion.
• Somatogyral, the pilot’s vestibular system responds to angular acceleration. Without visual cues, this can lead to an incorrect understanding of an aircraft’s angle of bank in a turn or level flight. In the absence of external visual cues, successful orientation relies on the use of appropriate flight instruments.
• Autokinesis is the phenomenon of a single point of light (a star or light from a distant station) appearing to move randomly in the visual field.
• Blackhole approach involves an approach to land at night where there is nothing to see between the aircraft and the intended landing site. The absence of peripheral visual cues, especially below the aircraft, can lead pilots to perceive the aircraft is high and initiate an aggressive descent to correct their perceived approach path. The result can be landing short or impacting terrain.

The helicopter manufacturer also highlighted the dangers of disorientation specific to rotary wing operations. Safety notice SN-18 in the Robinson Helicopter Company Pilot’s Operating Handbook for the R22 stated:

Flying a helicopter in obscured visibility due to fog, snow, low ceiling, or even dark night can be fatal. Helicopters have less inherent stability and much faster roll and pitch rates than airplanes. Loss of the pilot’s outside visual references, even for a moment, can result in disorientation, wrong control inputs, and an uncontrolled crash.

Related events

Accidents involving flight at night in an unequipped Robinson R22 by pilots unqualified for night flight are frequently repeated in Australia. Common features related in the accident investigation reports in Table 2 are summarised below. 

Table 2: Investigations into similar events

All these events involved pilots who were not qualified to fly at night. In addition, in all but one accident (AO-2014-144), the helicopters were unequipped for night flight. There was a general acceptance by pilots involved in these accidents that being unqualified and unequipped was not an impediment to flying at night. 

One investigation report (AO-2014-144) noted that the pilot planned on landing with sufficient sunlight. In all other cases the flights were intentionally conducted after last light, or pilots did not discontinue the flight when presented with an opportunity to do so. In 2 accidents (AO-2023-058 and AO-2021-006), pilots departed locations with available accommodation into dark night conditions.

Many of the investigations related to hazards that would be easily detected or inconsequential in daytime but become difficult to detect and far more serious at night. Environmental conditions such as smoke (AO‑2023‑058) and cloud and rain (AO‑2022‑057, AO‑2021‑006, AO‑2016‑031, and AO‑2011‑051) were common features. Furthermore, in 3 of the accidents (AO‑2011‑087, AO‑2014‑144, and AO‑2016-031), lights inside the cabin from sources such as GPS, instrument lights and warning lights, were noted to interfere with vision outside of the helicopter by producing glare on the windscreen.

Several workarounds to support these activities were implemented by the pilots involved. These included turning off equipment to reduce glare (AO-2016-031 and AO-2014-144), flying at low level in an attempt to find ground references (AO-2023-061, AO-2021-006, and AO-2011-087), and lighting the helipad with vehicle headlights in anticipation of a late arrival (AO-2023-058).

All of the accidents took place while travelling between locations, as opposed to while conducting aerial work. All resulted in a high-speed collision with terrain or water and all but one of the accidents (AO-2011-051) resulted in fatal injuries.

Safety analysis

Flight at night

Witness statements and tracking data for VH-LYD on the night of the accident showed it was moving after last light and beyond nautical twilight. The last movement of VH-LYD was recorded at 1929, 37 minutes after last light (end of civil twilight at 1852) and 12 minutes after nautical twilight (1917) (Figure 7). Moonrise would not happen until 2045. The combination of cloud obscuring celestial light from stars, no artificial lighting on the ground, and no moonlight meant it was almost certainly very dark. This made the pilot susceptible to spatial disorientation and loss of control of the helicopter.

Figure 7: VH-LYD night flight

Source: SPOT Trace, ATSB

The pilot of VH-LYD did not have a night rating, and while there was evidence of the pilot previously operating at night, the pilot had not demonstrated competence or capability as part of a flight review or flight test. 

The wreckage inspection showed it was highly unlikely that any mechanical failure of the helicopter contributed to the accident. The inspection also showed that VH-LYD did not have equipment required for flight at night such as an artificial horizon. 

The extra risks inherent in visual flight at night are from reduced visual cues, and the consequent risk of spatial disorientation (ATSB, 2013). The accident site analysis showed that VH-LYD collided with a tree at high speed while travelling perpendicular to the direction required to reach Rutland Plains. While it is not possible to determine the exact nature of the disorientation affecting the pilot, being off track and too low at high speed indicated that the pilot was very likely disorientated and without visual references at the time of collision with terrain. 

Organisational acceptance

Risk management and decision‑making

The Civil Aviation Safety Regulations (CASR) Part 138 manual of standards explained that MDH Pty Ltd (MDH) had to ensure the pilot assessed that the operation could be conducted without unacceptable safety risk for the pilot and people on the ground in the context of the task. The accident occurred on the transit back from fire spotting and directing ground crew at night. 

There was no evidence of a risk assessment being conducted or of risk assessment tools or training being made available to the pilot. To align with the manual of standards, the assessment would have had to include the aircraft used in the operation and the qualifications of the pilot. MDH did not have trained pilots or suitably equipped helicopters available. Had a risk analysis been conducted, mitigating the risk of the operation involving an untrained pilot in an unequipped helicopter at night was not possible without cancelling the flight. 

Company pilots were making decisions about operations without input from the organisation, peers or risk management tools. The high level of pilot autonomy was reflected in interviews with the chief pilot, company pilots and employees. The consensus was that it was a pilot’s decision to fly and there was a position amongst pilots that it was not the place of others to tell a pilot to fly or not fly. 

While the pilots reported no pressure to fly after last light, they stated that they would fly beyond last light to complete a task and not lose a day’s work for a mustering team. Pressure on decision‑making can come from various sources without being overt. Bearman and Bremner (2016) wrote that:

• Situational pressure can lead people to pursue a particular goal.
• People internalise values of the organisation they work for and value decisions that benefit the organisation.
• Social pressure can influence decisions to optimise the impression we present to others.

Perhaps due to situational and social pressure, the pilot of VH-LYD elected to use the helicopter to support fire operations after last light, and that was accepted by the pilot’s colleagues. This was consistent with accepted practices within their working environment. 

Awareness of flight after last light

In MDH’s environment of animal management in remote areas, teams need to be flexible and be able to improvise solutions. Autonomy of crew is a large part of that. They also need to make best use of the resources available, and a helicopter is a valuable resource. Practices such as flying beyond last light, which is an unsafe practice, can develop to become normal operations. Especially if it provides positive outcomes without negative repercussions (CASA, 2017). 

Analysis of 6 months of tracking data for 4 company R22 helicopters showed that over a combined total of 596 days of operation, on 39 occasions pilots landed after last light.  There was evidence of exceedances in all company R22 helicopters. The average exceedance was just over 15 minutes. Combining the tracking data with pilot rosters showed that 3 of the accident pilot’s colleagues had flown after last light, reportedly for operational reasons.

The company was aware that the pilots were not trained nor equipped for flight at night and aware that last light was not always observed. The chief pilot stated that there were times that helicopters would be needed to be used as long as possible. Instead of observing the limits of last light, pilots would judge the available light by sight and operate to their own level of comfort. 

Relying on individual pilot decision‑making is reflective of the Part 91 flight operations, however, the context for these flights were primarily aerial mustering and related aerial work activities for commercial cattle farming.

While these were considered limited aerial work operations by the regulations, MDH had the ability to influence pilots and set an organisational tolerance for risk. By ignoring an actual time for last light, a distinct and easy to measure limit became ambiguous and inconsistent. The company limit was not that pilots should observe last light, rather that they should not push on into the dark. However, MDH did not provide oversight or definition of this and expected pilots to manage it themselves. 

Not preventing the activity normalised the deviation from a safe envelope of operations and indicated an acceptance of flight after last light. The only limit to the non-compliance became an individual pilot’s tolerance for risk. This meant the practice could easily extend to later times and different activities.

For the pilot of VH-LYD on 9 October 2025, flying at night to assist in firefighting was likely an easy step to take, especially in the absence of a formal consideration of risk. It is not possible to discern the factors that combined in the pilot’s decision‑making about the flight. Neither is it possible to separate that decision‑making from the general acceptance of flight after last light or the influence of the operating environment.

Within the operation, limited oversight and the absence of risk management, combined with an acceptance of flight after last light, created an increased and unmitigated risk of an accident at night by an untrained pilot in an unequipped company helicopter on MDH properties. 

Findings

From the evidence available, the following findings are made with respect to the collision with terrain at night involving Robinson R22 Beta II, VH-LYD, 25 km south-south-east of Kowanyama, Queensland, on 9 October 2025.

Contributing factors

• The pilot flew at night but was not qualified to fly at night and the helicopter was not equipped to be flown at night.
• It is very likely that the pilot became spatially disorientated, resulting in collision with terrain.
• Flying after last light by pilots without night ratings, in R22 helicopters not equipped for night flight, was a tolerated and unmanaged risk on MDH properties. This increased the risk of an accident in a company R22 at night. (Safety issue)

Other factors that increased risk

• MDH did not require its R22 pilots to formally assess risk and did not provide tools or training to do so. This limited the ability of the company and those pilots to identify and understand operational hazards and their consequences. (Safety issue)

Safety issues and actions

Accepted practice of exceeding last light

Safety issue number: AO-2025-063-SI-01

Safety issue description: Flying after last light by pilots without night ratings, in R22 helicopters not equipped for night flight, was a tolerated and unmanaged risk on MDH properties. This increased the risk of an accident in a company R22 at night.

Risk assessment not implemented

Safety issue number: AO-2025-063-SI-02

Safety issue description: MDH did not require its R22 pilots to formally assess risk and did not provide tools or training to do so. This reduced the ability of the company and those pilots to identify and understand operational hazards and their consequences.

Glossary

Sources and submissions

Sources of information

The sources of information during the investigation included:

• MDH Pty Ltd
• employees of MDH Pty Ltd
• accident witnesses
• Civil Aviation Safety Authority
• Queensland Police Service
• Robinson Helicopter Company
• maintenance organisation for VH-LDY
• Bureau of Meteorology
• recorded data from tracking units on company aircraft. 

References

Airservices Australia. (2024). AIP Australia Part 1- General. online: Airservices Australia Retrieved from www.airservicesaustralia.com/aip/aip.asp

ATSB. (2013). Avoidable Accidents No. 7 Visual flight at night accidents: What you can’t see can still hurt you. (AR-2012-122). Canberra, ACT

Bearman, C., & Bremner, P. (2016). Don't just do something, stand there! National Emergency Response, 29(4), 12-17. 

CASA. (2017, 15 May 2017). Safety in mind: Normalisation of deviance. Flight Safety. https://www.flightsafetyaustralia.com/2017/05/safety-in-mind-normalisation-of-deviance/

CASA. (2021). Part 91 (General Operating and Flight Rules) Manual of Standards 

2020. Canberra, ACT: Civil Aviation Safety Authority

CASA. (2022). AC 61-05 v1.1 Night VFR rating. Canberra: Civil Aviation Safety Authority

CASA. (2024a). AC 139.R-01 v3.1 Guidelines for Heliports - Design and Operation. Canberra: Civil Aviation Safety Authority

CASA. (2024b). Civil Aviation Advisory Publication (CAAP) 48-01 v3.3. Canberra: Civil Aviation Safety Authority

CASA. (2025a). AC 138-05 v3.0 Aerial work risk management (D25/124220). Canberra, ACT: Civil Aviation Safety Authority

CASA. (2025b). CASR Part 91, General operating and flight rules - Plain English Guie v5.1. Canberra, ACT: Civil Aviation Safety Authority

CASA. (2025c). Civil Aviation Order 48.1 Fatigue Management Plain English Guide. Civil Aviation Safety Authority 

CASA. (2025d). Safety behaviours: human factors for pilots 4th edition Resource booklet 8 Threat and error management. Civil Aviation Safety Authority. https://www.casa.gov.au/sites/default/files/2021-06/safety-behaviours-human-factor-for-pilots-8-threat-error-management.pdf

CASA. (2025e). Safety behaviours: human factors for pilots 4th edition Resource booklet 9 Human information processing. Civil Aviation Safety Authority. 

CASA. (2025f). Visual Flight Rules Guide (8.2 ed.). Civil Aviation Safety Authority. 

Flight Safety Foundation. (2025). Operational Risk Assessment. In Basic Aviation Risk Standard Aerial Mustering. Flight Safety Foundation. 

Liu, Y., Tian, J., Martin-Gomez, A., Arshad, Q., Armand, M., & Kheradmand, A. (2024). Autokinesis Reveals a Threshold for Perception of Visual Motion. Neuroscience, 543, 101-107. https://doi.org/10.1016/j.neuroscience.2024.02.001

Robson, D. (2008). Night Flight (2nd ed.). Aviation Theory Centre. 

Tuthill, J. C., & Azim, E. (2018). Proprioception. Current Biology, 28(5), R194-R203. https://doi.org/10.1016/j.cub.2018.01.064

Young, L. R. (2003). Spatial orientation. In P. S. Tsang, Vidulich, M.A. (Ed.), Principles and practice of aviation psychology (pp. 69-113). LEA Publishers. 

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:

• MDH Pty Ltd
• Cloncurry Air Maintenance
• Civil Aviation Safety Authority
• Bureau of Meterology
• Queensland Police Service

Submissions were received from: 

• MDH Pty Ltd
• Civil Aviation Safety Authority
• Bureau of Meterology.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

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.

Summary video

The occurrence

On 27 September 2025, the pilot and owner of a Pilatus PC-6/B2-H4 aircraft, registered VH-XAA and operated by Jump Aviation for SKYONE Moruya Heads parachuting organisation, was conducting parachute operations over Moruya Airport, New South Wales. After conducting 8 successful parachute drops, at 1348:58 local time, the pilot broadcast on the common traffic advisory frequency (CTAF)[1] that they were taxiing for runway 04[2] to conduct the next flight. On board were 8 parachutists and the pilot. The pilot was wearing the fitted 4-point restraint and an emergency parachute in accordance with company procedures.

At 1351:08, the pilot broadcast that the aircraft was airborne off runway 04, for an upwind departure and on climb to flight levels (FL)[3] for parachute operations. During the climb to the planned drop between FL 140 and 150, several parachutists reported feeling a bump and hearing the stall warning[4] activate momentarily, passing about 10,000 ft. 

At 1400:52, the pilot broadcast on the CTAF that they were 4 minutes to a parachute drop, then advised the same to Melbourne Centre air traffic control. Recorded data showed the ‘jump run’ tracked in a northerly direction about 2 km west of Moruya Airport runway 36, in a gradual descent between FL 150 and 140. The parachutists reported that the jump run was normal, and all the parachutists exited successfully. At 1406:15, the pilot broadcast that the parachutists had exited and the aircraft was on descent. 

Several witnesses on the ground observed the aircraft enter a steep nose-down dive, rotating left before pitching[5] up and rolling[6] right. Recorded data showed the aircraft initially descended from FL 140 at about 5,000 fpm, but approaching FL 120, the descent rate increased significantly. The last recorded automatic dependent surveillance‑broadcast (ADS-B) data position was at 1407:26 and 7,425 ft, descending at about 15,000 fpm (Figure 1). The aircraft subsequently impacted trees and terrain about 2 km north of Moruya Airport. The pilot sustained fatal injuries, and the aircraft was destroyed.

Figure 1: VH-XAA flight track and accident site

Source: Google Earth, annotated by the ATSB 

Context

Pilot

The pilot held a private pilot licence (aeroplane) with the last flight review conducted in August 2025, and a class 2 aviation medical certificate, valid until June 2027. The pilot held the appropriate ratings and endorsements for the flight. In addition, the pilot held aerobatics and spin endorsements and jump pilot authorisation. At the time of the accident, they had about 11,690 hours total aeronautical experience. In the previous 90 days, they had flown 135.2 hours, most of which were conducting parachuting operations in Cessna 206 and 208 aircraft. 

The pilot’s logbook recorded an endorsement for the Pilatus PC-6 (required by the then Civil Aviation Regulations) in 1998. The ATSB was unable to access some of the pilot’s logbooks to confirm how many hours they had logged flying the Pilatus PC-6 prior to purchasing VH‑XAA from New Zealand (NZ). Between 22 and 24 August 2025, the pilot and an instructor flew the aircraft from Auckland, NZ, to Dubbo, New South Wales, logging 19.5 hours of flight time. The pilot then recorded 2 hours operating the aircraft to Moruya on 12 September 2025. From 20 to 24 September 2025 inclusive, the pilot recorded 9.7 hours in the aircraft conducting parachute operations. At the start of the accident morning, the pilot had logged 31.2 hours in VH-XAA.

The pilot was an experienced parachutist and had been a member of the Australian Parachute Federation (APF)[7] since 1987. On 30 June 2025, the pilot reported having conducted 17,000 jumps. The pilot held numerous parachuting qualifications including senior instructor and a Certificate F, which was the highest certificate issued by the APF. The pilot was the senior pilot of Jump Aviation and the chief parachute instructor of the parachuting operator SKYONE Moruya Heads – a group member of the APF. 

Aircraft

General information

VH-XAA was a Pilatus Aircraft PC-6/B2-H4, short take-off and landing utility aeroplane with fixed landing gear (Figure 2). It was powered by a Pratt & Whitney Canada PT6A-27 turbine engine and a Hartzell Propellers HC-B3TN-3D 3-bladed propeller. The aircraft was not approved for aerobatic manoeuvres including spins. 

Figure 2: VH-XAA when operating in New Zealand as ZK-MCK

Source: Richard Currie, modified by the ATSB

It was manufactured in Switzerland in 1980 and issued serial number 809. The aircraft had been used for parachute operations in New Zealand (NZ) since 1982. As such, the passenger seats, copilot seat and copilot control stick had been removed. Additionally, a skydiving step and hand hold had been installed.  

A 7,000 hour/14-year ‘complete overhaul’ maintenance activity was performed in NZ and finalised on 14 August 2025. During the maintenance activity, the horizontal stabiliser electric trim actuator was removed and overhauled by the manufacturer in the United States. 

The aircraft was added to the Australian civil aircraft register on 15 August 2025, and a special flight permit[8] was issued to allow the aircraft to be flown from NZ to Australia. After the pilot ferried the aircraft to Australia, a certificate of airworthiness was issued for VH-XAA on 19 September 2025. At the time of the accident, VH-XAA had accrued 13,594.5 hours total time in service.

Doors

The aircraft had a door on each side of the cockpit for pilot and copilot access, which were fitted with a jettison system. Figure 3 shows the Pilatus PC-6 airplane flight manual[9] (AFM) procedure for emergency opening of the cockpit doors: 

Figure 3: Cockpit doors emergency opening checklist

Source: Pilatus PC-6 airplane flight manual

The aircraft cabin had a sliding door on the right side, which was used for parachutists to exit, and 2 hinged doors on the left side, which were fitted with an emergency jettison system. The sliding door had a mechanism to open it from inside the aircraft, but it could not be locked open. Parachutists reported that, on the day of the accident, the pilot had landed with the sliding door open on some flights and closed on others. Although it was not identified at the accident site, several parachutists reported that there was a fishing gaffer hook on a pole onboard the aircraft that the pilot used to close the sliding door in flight from the pilot’s seat. 

Key speeds

The AFM included the following key speeds:

• never exceed speed (V_NE)[10] 151 kt
• manoeuvring speed (V_A)[11] 119 kt
• maximum speed with the sliding door open 119 kt
• stalling speeds at a gross weight of 2,800 kg, power off and 0° angle of bank including:
  • 58 kt calibrated airspeed[12] (KCAS) with flap retracted
  • 52 KCAS with landing flap extended. 

Horizontal stabiliser electric trim system

The aircraft was fitted with a horizontal stabiliser electric trim system, designed to move the entire horizontal stabiliser to adjust the pitch trim of the aircraft and balance the aerodynamic forces to reduce the pilot control forces on the elevator. The system (Figure 4), consisted of:

• a dual motor (main and alternate motors) electrically‑operated linear trim actuator
• a 3-position spring-loaded trim switch, located on the control column grip
• a relay located on the firewall
• an interrupt system incorporating a guarded switch on the instrument panel shelf and an alternate trim control system with a 3-position spring-loaded trim switch (Figure 5)
• an electrically‑operated trim position indicator on the upper left side of the instrument panel.

Figure 4: Schematic of horizontal stabiliser trim system 

Source: Pilatus PC-6 Illustrated Parts Catalogue, modified and annotated by the ATSB

Figure 5: Instrument panel shelf horizontal stabiliser trim switches 

Source: Supplied and Pilatus PC-6 AFM, annotated by the ATSB

The AFM included the following procedure (Figure 6) in the event of a trim runaway:[13]

Figure 6: Horizontal stabiliser trim runaway emergency procedure

Source: Pilatus PC-6 airplane flight manual

The AFM included the following procedure (Figure 7) for jammed trim actuators:

Figure 7: Jammed horizontal stabiliser trim actuator emergency procedure

Source: Pilatus PC-6 airplane flight manual

The AFM also included the following procedure (Figure 8) for loss of elevator control:

Figure 8: Loss of elevator control emergency procedure

Source: Pilatus PC-6 airplane flight manual

Beta mode

The AFM described beta mode as ‘operation of the propeller used in flight to achieve fast deceleration and high rates of descent’. The AFM stated:

In the beta range, the propeller blades are set at a low positive pitch angle to provide a braking effect for steep controlled descents. When operating in the beta mode, the propeller pitch angle is controlled by power lever movement between the lift detent and the point where constant speed operation becomes effective. 

NOTE

BETA MODE is provided in descent at airspeeds below 100 KIAS [kt indicated airspeed] with the POWER lever near or at the detent. Only small movements of the POWER lever are necessary to change rate of descent or airspeed. Approaches in full BETA MODE (POWER lever at detent) are not permitted at airspeeds below 1.3 V_s.[14]

Meteorological information 

The Bureau of Meteorology aerodrome forecast for Moruya Airport, issued at 1109 on 27 September 2025 included wind from 090° at 5 kt, which was expected to change to 310° and become gusty between 1200 and 1300. The grid point wind and temperature chart showed the forecast winds:

• at 10,000 ft from 270° at 42 kt
• at FL 140 from 270° at 51 kt. 

The Bureau of Meteorology had also issued SIGMETs[15] for severe turbulence below 8,000 ft and mountain waves from 4,000 ft to FL 320 in an area that included Moruya Airport, between 1100 and 1500. 

The conditions recorded in the METAR[16] at Moruya Airport at 1400 included wind from 130° at 6 kt, visibility greater than 10 km, temperature 22°C, and QNH[17] 1,007 hPa. 

Recorded data

The ATSB conducted preliminary analysis of the aircraft’s 3-dimensional position information recorded in the ADS-B data for the 9 flights on 27 September 2025, the last of which was the accident flight. The positional data was interpolated between recorded positions and a trajectory analysis conducted to estimate other flight performance and handling parameters. The analysis was based on the forecast wind and an estimated aircraft weight of 1,587 kg (3,500 lb). For most of the flights, there was no recorded ADS‑B data below about 4,000 ft above mean sea level. 

A comparison of the following key parameters for the 9 flights was conducted for the descent following parachute drop from about FL 140: 

• altitude
• descent rate
• estimated calibrated airspeed
• estimated pitch and roll angles.  

For flights 1–5, 7 and 8, the values of these parameters were similar. In those 7 flights, the descent commenced at an airspeed of about 55–70 KCAS, with an initial nose-down pitch of about 30° and either a right or left roll of about 30° (on flight 4 the roll angle was possibly up to 50°). The maximum descent rate for these 7 flights was between about 5,500 and 8,000 fpm. 

On flight 6, the descent was initiated slightly slower, at about 54 KCAS, which increased within 10 seconds to about 145 KCAS, coincident with a maximum momentary descent rate of about 14,000 fpm, a steep (70°) pitch down in conjunction with a substantial roll right.

The descent on the accident flight (flight 9) was initiated at about 53 KCAS from 14,200 ft to a nose-down pitch of about 25°, with a 60° right roll. The aircraft briefly reduced pitch slightly before nosing vertically down (about 90°) in a left roll, reaching a maximum descent rate of over 20,000 fpm. The aircraft then pitched up to a shallow climb and into a roll of more than 120°. From the data it could not be confirmed whether this manoeuvre was conducted upright or inverted. Passing about 9,600 ft, the airspeed reduced to 125‍–‍130 KCAS before increasing again. The last recorded position, passing about 8,000 ft indicated the aircraft had accelerated to 173 KCAS, with a final descent rate above 15,000 fpm (Figure 9).

 Figure 9: Preliminary plot of key parameters from the accident flight descent

Due to the aircraft’s manoeuvring, the roll information may be inaccurate. Local time was UTC+10 hours. Source: ATSB

Site and wreckage

The wreckage site was about 2.5 km north (and slightly west) of the northern end of the Moruya Airport runway 36. ATSB examination showed that the right wing struck a tree on the eastern side of George Bass Drive and separated from the fuselage, before the aircraft collided with trees on the western side of the road and subsequently impacted terrain in a nose-down inverted attitude (Figure 10). The outer section of the right wing landed on the road but was moved clear by members of the public shortly after the accident. 

Figure 10: Overview of VH-XAA accident site

Source: ATSB

The examination identified: 

• there was fuel remaining and no post-impact fire occurred
• all major components of the aircraft were at the site, indicating there was no in-flight breakup
• the propeller had indications that the engine was producing power at impact
• there were no indications of any pre-impact mechanical anomalies that would have precluded normal engine operation
• the pilot’s 4-point restraint was undone, and the pilot was almost certainly not in the pilot seat at the time of impact
• the horizontal stabiliser trim actuator was found in the full nose-down position (Figure 11).

Figure 11: Horizontal stabiliser trim actuator showing trim position

Source: ATSB

Further investigation

To date, the ATSB has: 

• interviewed witnesses and involved parties
• obtained pilot and aircraft documentation
• analysed recorded data
• reviewed recorded audio transmissions
• assessed the accident site and examined the aircraft wreckage.

The investigation is continuing and will include further examination of:

• the horizontal stabiliser trim system
• recorded flight data
• aircraft configuration, maintenance and documentation
• operational procedures and documentation
• pilot training records
• survivability and opportunity for egress
• other similar occurrences. 

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. 

Acknowledgements

The ATSB would like to acknowledge the assistance of the NSW Police Force, Fire and Rescue NSW, and first responders.

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 2025 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]     Common traffic advisory frequency (CTAF): a designated frequency on which pilots make positional broadcasts when operating in the vicinity of a non-controlled aerodrome or within a broadcast area.

[2]     Moruya Airport had 2 sealed runways, 18/36 and 04/22. The runway number represents its magnetic heading. 

[3]     Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 140 equates to 14,000 ft.

[4]     A stall warning system provides the pilot with advance warning of an impending aerodynamic stall.

[5]     Pitching: the motion of an aircraft about its lateral (wingtip-to-wingtip) axis.

[6]     Rolling: the movement of an aircraft about its longitudinal axis.

[7]     The APF is the peak body for the administration and representation of Australian Sport Parachuting.

[8]     Special Flight Permit (SFP): issued to allow the operation of an aircraft that does not meet its airworthiness requirements but under certain circumstances, and for a particular intended purpose, the aircraft may still be capable of safe flight.

[9]     Airplane flight manual (AFM): a manual that is part of the certification basis of the aircraft, containing the operating limitations within which the aircraft is considered airworthy, and any other information required for the safe operation of the aircraft, including all amendments and supplements for that manual.

[10]    Never exceed speed (V_NE): the indicated airspeed which, if exceeded, may result in structural damage to the aircraft, normally represented by a red line on the airspeed indicator.

[11]    Manoeuvring speed (V_A): the maximum speed at which a pilot can make full or abrupt control movements without causing structural failure of the aircraft. 

[12]    Calibrated airspeed: indicated airspeed corrected for air speed indicator system errors.

[13]    Pitch trim runaway is an uncontrolled movement of the aircraft’s trim system causing uncommanded nose-up or nose‑down pitch.

[14]    Vs - Stall speed or minimum steady flight speed for which the aircraft is still controllable.

[15]    SIGMET: a concise description of the occurrence or expected occurrence, in an area over which area meteorological watch is maintained, of specified phenomena which may affect the safety of aircraft operations. 

[16]    METAR: a routine report of meteorological conditions at an aerodrome. METAR are normally issued on the hour and half hour.

[17]    QNH: the altimeter barometric pressure subscale setting used to indicate the height above mean seal level.

This preliminary report details factual information established in the investigation’s early evidence collection phase, and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003. 

The occurrence

On 3 October 2025, a Robinson R22 Beta helicopter, registered VH‑RDL and operated by Bankstown Helicopters,[1] was conducting a training flight at Bankstown Airport, New South Wales. On board the helicopter was a flight instructor, seated in the left seat, and a student pilot in the right seat. The flight instructor was the pilot in command (PIC), however, as it was a training flight, the student pilot was in the seat normally reserved for the PIC. 

The helicopter departed the main helicopter pad (Figure 1) at about 1328 local time. The plan for the flight was to conduct circuits[2] on runway 29. The student pilot stated to the ATSB that they had planned and prepared to conduct a lesson on practice forced landings. However, due to the weather, the instructor changed the lesson to circuits. Due to the windy conditions on the day, the instructor demonstrated the first circuit, with the student pilot following them on the flight controls.[3]

At about 1329, the instructor made a downwind position radio broadcast and was cleared by Bankstown Tower air traffic control for a ‘stop and go’ on the main pad. In interview with the ATSB, the student pilot recalled that, during the downwind leg of the circuit, the helicopter dropped suddenly and they noticed the revolutions per minute (RPM) reduce but could not recall if this was engine or rotor RPM (see section Helicopter information). The student also recalled hearing a whistling noise prior to the RPM reduction. Following the sudden drop and RPM reduction, the student recalled that the instructor kept their hands on the controls and continued to fly the aircraft while attempting an autorotation,[4] and they could not recall the instructor changing any switch positions.  

Dashcam video taken from a parked car captured the helicopter tracking along its flight path, before conducting a turn back into wind toward the airport. The video showed that the helicopter was flared[5] as it approached the ground, likely in an attempt to reduce the rate of descent. The helicopter impacted trees, before colliding with the rear of a car and the ground, coming to rest on its left side. The instructor was fatally injured, and the student was seriously injured. The helicopter was destroyed. 

Figure 1: Estimated flight path

Source: Airservices Australia, annotated by the ATSB

Context

Pilot information

The instructor held a Commercial Pilot (Aeroplane) Licence (CPL-A) issued July 1998, and a Commercial Pilot Licence (Helicopter) (CPL-H) issued July 2012. They also held a Grade 1 flight instructor rating for helicopter operations. 

The instructor began employment with the operator of VH-RDL in November 2024. Paperwork completed when joining indicated that the instructor had around 877 hours experience on fixed-wing aircraft, and 1,071 hours in helicopters. The instructor’s logbook indicated that, as of September 2025, they had a total helicopter flying experience of 1,131 hours, which included 993 hours as PIC. 

The instructor held a class 2 aviation medical certificate, which was current at the time of the accident. To exercise the privileges of a commercial pilot’s licence, pilots normally required a class 1 aviation medical. However, under Civil Aviation Safety Authority (CASA) General Exemption CASA EX28/23, commercial pilots with a class 2 medical certificate can fly commercial flights without passengers if the aircraft’s maximum take-off weight is less than 8,618 kg. This included flight training.[6] 

Video evidence showed the instructor was completing pre-flight duties in the office at approximately 0630. Their first flight of the day commenced at 0700 with a hover lesson. This was followed by another general handling instructional flight at 0830. All flights were conducted in VH­‑RDL.

The student pilot had approximately 33 hours of flight experience. They did not yet hold a pilot’s licence.

Helicopter information

VH-RDL was a 2-seat Robinson Helicopter Company R22 Beta, serial number 1498, powered by a 4-cylinder Lycoming O-320-B2C engine. The helicopter was manufactured in the United States in 1990 and placed on the Australian aircraft register on 16 April 2002. Bankstown Helicopters had been the registered operator of VH-RDL since 22 February 2024.

The helicopter had a combined engine and rotor RPM tachometer, which was positioned on the right side of the dashboard in front of the student pilot (Figure 2). The left side of the tachometer showed the engine RPM and the right side showed the rotor RPM. The position of the tachometer required the instructor to look across the dashboard to see the instrument.

Figure 2: VH-RDL engine and rotor RPM tachometer

Source: ATSB

Meteorological information

During taxi, the student pilot reported they had received information ‘golf’ from the automatic terminal information service (ATIS).[7] The information indicated that runway 29 was in use, mechanical turbulence was present on short final, the wind was 220° at 18 kt with a crosswind up to 20 kt, conditions were CAVOK,[8] the temperature was 24°C and QNH[9] 1014 hPa.

The ATSB obtained Bureau of Meteorology weather observations for Bankstown Airport taken at 1-minute intervals, which showed:

• at 1328, the wind was 278° T (true) and 265° M (magnetic) at 18.1 kt
• at 1329, the wind was 269° T (256° M) at 18.1 kt
• at 1330, the wind was 270° T (257° M) at 16.9 kt.

The operator’s alternate chief pilot, who was also instructing that day, had cancelled their flights as they assessed the weather to be challenging for their student’s experience level and the environmental conditions would have likely not resulted in useful learning for them.

Operational information

The operator advised the ATSB that their normal pre-landing checks in the Robinson R22 Beta, performed on the downwind leg of the circuit, included the following:

• warning/caution lights – out
• rpm (engine and rotor) – in the green
• temperatures and pressures – in the green
• fuel – sufficient for go around
• battery – charging
• carburettor heat – on
• hatches and harnesses – secure.

Wreckage information

The helicopter wreckage was contained within a relatively small accident site, with only minor wreckage spread and limited forward projection of debris. This indicated that the helicopter impacted the car and ground with a low forward speed. There was no post‑impact fire. The ATSB’s wreckage examination found that:

• there was sufficient fuel on board the helicopter to sustain continued engine operation
• damage identified in the main rotor system was consistent with low energy flight, as also indicated by the dashcam and the observed spread of the wreckage
• there was no evidence of pre-existing defects with the flight control system
• the pitot system was checked and considered to be serviceable prior to the collision with terrain
• inside the aircraft, the key switches were found in the following positions:
  • fuel selector – on
  • fuel mixture – rich
  • carburettor heat – on
  • master switch – off
  • magnetos – off

A witness to the accident confirmed that they had switched the master to the off position to secure the helicopter and make it safe. The ATSB was unable to establish how the magnetos came to be in the off position.

It was determined by the ATSB that the engine was intact, and all components were present. Examination of the engine by the ATSB on site identified an absence of physical damage expected of an engine that was operating (rotating) at the time of impact with terrain. The engine examination also found:

• Evidence of an exhaust gas leak between the exhaust riser mount flange/exhaust gasket surfaces of the no 4 cylinder. The leak was attributed to deformation of the flange that created space between the flange and the gasket (Figure 3). This leak was located directly above the carburettor heat intake scoop opening.
• Deposits of exhaust gas products were present on the no 2 and no 4 cylinder ignition leads that were routed beside the no 4 cylinder exhaust riser.

Figure 3: Exhaust leak found during the onsite inspection

Source: ATSB

Survivability information

First responders and witnesses stated that the instructor and student had their seatbelts on. Neither of them was wearing a helmet and nor were they required to. 

Further investigation

To date, the ATSB has:

• examined the wreckage and other information from the accident site
• obtained operator procedures
• conducted interviews with the student, witnesses and other involved parties
• reviewed the pilot records
• reviewed the helicopter maintenance records
• examined the dashcam video
• reviewed air traffic control communications.

The investigation is continuing and will include:

• an analysis of the audio signatures captured by the dashcam video
• further analysis of physical evidence including the exhaust system components retrieved from the accident site
• a review of the PIC’s experience performing autorotations in all helicopter types and specific to the Robinson R22 Beta
• a review of both the helicopter manufacturer and operator’s procedures for conducting autorotations.

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.

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 2025 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.