Collision with terrain

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 28 March 2025, at about 1710 local time, the Sky Aces formation aerobatics team, which consisted of 4 Pitts type aircraft operated by Paul Bennet Airshows, became airborne to perform a display at the Australian International Airshow, Avalon Airport, Victoria. The 4 aircraft began their planned routine and flew several aerobatic manoeuvres in 2 and 4 ship[1] configurations. 

At about 1715, the pilot of VH-PVX departed the formation, as planned, and began a solo routine while the formation of the 3 remaining aircraft relocated to the south for their next manoeuvre. At about 1717, while conducting their solo routine, the pilot began a ‘triple avalanche’ manoeuvre[2] and entered the aircraft into a loop (example shown in Figure 1, 2 days prior using a smoke system). At the top of the loop and from an inverted position, the pilot performed 3 snap rolls[3] with one wing aerodynamically stalled.[4] The snap rolls were completed and the aircraft returned to stable flight while still inverted. It then entered the back half of the loop, however, the aircraft’s descent rate was unable to be arrested before it collided with terrain. The pilot was seriously injured.

Figure 1: A successful triple avalanche manoeuvre performed by the pilot in VH‑PVX 2 days prior to the accident 

Note: This is a still image extracted from a video recording of the validation flight (refer to section titled Flight validation). Source: AMDA Foundation, annotated by the ATSB

Context

Pilot information

The pilot held a valid commercial pilot licence (aeroplane) and class 2 aviation medical certificate. They successfully completed a private instrument rating in August 2023, which satisfied the requirements of a flight review for single-engine aircraft. Additionally, they had the required flight activity and aircraft design feature endorsements to conduct a formation aerobatic display in the Pitts S1-11X aircraft without a minimum altitude limitation. Their formation aerobatics flight activity endorsement was issued in July 2015. 

The pilot’s logbook, which was completed up to 17 March 2025, showed a total flying experience of 2,248.6 hours. It recorded multiple aerobatic preparation flights in VH-PVX and evidence of participation in other airshows. The pilot had also conducted practice flights for the Avalon airshow between 17 March 2025 and the accident flight.

Aircraft information

The aircraft was a single-seat aerobatic Pitts S1-11X amateur-built biplane, modified from the Pitts S1-11B and constructed in Germany in 2010 by Wulf (Wolf) Aircraft. It was powered by a Ly-Con AEIO-540-EXP experimental engine and fitted with a 3-bladed, MTV-6 constant-speed propeller of laminated wood construction. The aircraft was a combination of fabric-covered wood and metal, and composite fibre structure and designed for unlimited aerobatics up to +/-10 G. 

The aircraft was first registered in Australia in 2015 and issued with a special certificate of airworthiness in the experimental category.[5] It had been operated by Paul Bennet Airshows since that time. The aircraft was to be maintained as per Civil Aviation Safety Authority Schedule 5 and required a periodic inspection every 100 hours or 12 months, whichever came first. The most recent periodic inspection was conducted by an authorised maintenance organisation on 28 February 2025. At the time of the accident the aircraft had accumulated 303 hours total time-in-service, about 5 hours since the previous periodic inspection. There were no defects listed on the aircraft maintenance release.[6]

Meteorological information  

The Bureau of Meteorology provided automated weather observations taken at 1-minute intervals at Avalon Airport during the aerobatic display. Between 1710­ and 1717, the highest recorded windspeed was 5 kt with gusts up to 6 kt. The temperature was 30°C, visibility greater than 10 km, and the atmospheric pressure ranged 1015­–1014 hPa for the period. 

Wreckage and impact information 

The aircraft collided with terrain on a grassed area west of runway 18/36,[7] in an area of the airport designated as the pyrotechnics box[8] (Figure 2) where multiple pyrotechnics were live and were planned to be used in the show. Additionally, there were many boxes of fuel positioned in the pyrotechnic box that were planned to be ignited during the ‘wall of fire’ display later that evening. 

Figure 2: Accident site location

Source: Google Earth, annotated by the ATSB

A ground scar, approximately 95 m long, was on a south-south-west heading (Figure 3). The aircraft came to rest upright and oriented toward north, almost opposite the direction of the impact sequence and debris trail. The initial impact point occurred several metres from the fuel boxes within the pyrotechnics array. 

While the ATSB conducted a preliminary examination of the accident site, due to access restrictions for the operational airport and airshow, the aircraft wreckage was relocated to a secure facility for detailed examination.

Figure 3: Accident site overview showing the location of the initial impact mark, pyrotechnics array, and the wreckage of VH-PVX

Source: No 1 Security Forces Squadron, annotated by the ATSB

The aircraft sustained substantial damage from the impact with terrain (Figure 4). Examination of the wreckage at a secure facility identified:

• no evidence of pre-impact defects with the flight control system or fuselage structure to the extent that could be determined
• the uppermost section of the canopy was fractured and parts of the airframe had departed the main structure
• the engine had separated from the airframe
• the propeller blades had fragmented, however, the propeller hub remained attached to the engine
• the front landing gear was distorted
• the upper and lower wings had separated, and the lower fuselage section had sustained compression damage
• the rigid outlet lines from the fuel tanks were fractured resulting in post-accident leakage of fuel.

Figure 4: Aircraft wreckage at the accident site

Source: ATSB

Aerobatic manoeuvre

Practice flights

A review of training videos showed that previous triple avalanche manoeuvres performed by the pilot in VH-PVX were started at approximately 200 ft above ground level (AGL)[9] and an airspeed of 165 kt. The recordings showed the aircraft would reach an altitude of approximately 800 ft prior to entering the snap rolls. The aircraft would climb during the rolls to about 1,100 ft before beginning the back half of the loop. After the accident, the pilot reported that their normal minimum altitude for commencing the snap rolls was 1,000 ft. 

Accident flight

The ATSB recovered a GoPro video camera from within the cockpit of the aircraft that was forward facing and operating during the accident flight. Flight instruments including the altimeter and airspeed gauges were visible in the recording. The recording identified that the pilot set the altimeter to 0 ft (runway reference height) prior to take-off, in accordance with their standard practice when conducting aerobatic manoeuvres.[10] 

During entry to the triple avalanche, the indicated airspeed was approximately 165 kt and the altitude was 100 ft. Just before the aircraft reached its peak altitude, the altimeter was showing 700–800 ft (Figure 5). After this point, the altimeter was blocked from the camera’s view by the pilot’s body position just prior to the collision with terrain.

Figure 5: Still image from the accident flight recording showing the altimeter just prior to the first snap roll during the triple avalanche manoeuvre 

Source: ATSB

Figure 6 provides a representation of the triple avalanche manoeuvre, showing the loop with the 3 snap rolls (indicated by inverted triangles) and the approximate position where the image shown in Figure 5 was taken. 

Figure 6: Triple avalanche profile and the approximate position in the manoeuvre where the still image from Figure 5 (above) was taken

Source: ATSB

Flight validation

The event organiser required that participants in the airshow successfully complete a flight validation prior to the public display. On 26 March 2025, the formation group satisfied the flight validation requirement, which included the pilot completing the accident manoeuvre in VH-PVX. The event organiser validation report had not noted any concerns about the routine or ability of those involved to successfully perform it on the day of the show.

Emergency response                         

Due to the location of the accident, the pyrotechnicians were nearby and therefore were first to arrive at the aircraft wreckage and assist the pilot. The pyrotechnicians reported that the pilot was wearing a 5-point safety harness, and the cockpit canopy remained closed. They also reported difficulties opening the canopy as there was not an obvious mechanism or external signage on the aircraft to assist them. The first responders reported smelling fuel and observing it leaking from the aircraft, however, there was no post-impact fire.

The Aviation Rescue Fire Fighting (ARFF) service was notified of the accident at 1718 and arrived onsite at 1721. The ARFF provided 3 tenders, 2 responding from the main southern base and one from the northern temporary base. They reported their response times were increased as, while the pyrotechnicians were busy providing first aid to the pilot, they were unable to be safely guided by the technicians through the pyrotechnics area. Additionally, the northern ARFF response vehicle had to deviate around a passenger-carrying jet aircraft on the northern taxiway. ARFF responders took control of the scene and continued providing first aid to the pilot until an ambulance arrived at 1731. The pilot was subsequently transported to hospital by helicopter. 

Further investigation

To date, the ATSB has:

• examined the accident site and aircraft wreckage
• interviewed the pilot, operator, and first responders
• reviewed the meteorological conditions during the display routine
• reviewed accident and training video recordings.

The investigation is continuing and will include review of:

• components recovered from the aircraft
• the aircraft maintenance records
• video recordings of the accident flight
• the emergency response plan and actions of the responsible organisations
• preparation for the display
• survivability factors.

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.

Preliminary report released 28 May 2025

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

Overview

On the morning of 21 March 2025, a pilot was conducting 2 ferry flights of Cessna 150 aircraft that were operated by Norwest Air Work. The first flight, from Shark Bay Airport to Geraldton Airport, Western Australia, involved a Cessna 150M, registered VH‑TDZ. Once at Geraldton Airport, the pilot was to swap aircraft at the maintenance hangar and fly back to Shark Bay Airport in VH‑WWU, the operator’s other Cessna 150M which had been released from maintenance on 18 March 2025. 

The pilot was the sole occupant on board both flights. The operator’s senior base pilot was holding SARTIME[1] for both flights. 

On the ground at Geraldton Airport

Closed-circuit television (CCTV) showed that the pilot landed VH‑TDZ at 0914:20 local time and taxied the aircraft to the maintenance organisation’s parking bay. At 0922, the pilot texted the senior base pilot informing them of their arrival in Geraldton. 

Between 0925 and 0931, the pilot manoeuvred VH‑WWU out of the parking bay and moved VH‑TDZ into it. Once completed, the pilot walked to the maintenance hangar (Figure 1). Witnesses at the airport reported that the pilot appeared unwell and had mentioned having had severe gastroenteritis in the preceding days. Witnesses did not report any apparent speech or physical impairment.

At 0945:15, the pilot left the maintenance hangar, walked to VH‑WWU and conducted a pre‑flight inspection. The aircraft had been refuelled on the morning by the airport refueller. Approximately 2 minutes later the pilot started the engine and taxied the aircraft to the centre apron. 

Figure 1: Aircraft changeover

Source: Geraldton Airport, annotated by the ATSB

Geraldton to Shark Bay

At 0955:16, the pilot reported on the local CTAF[2] that they were lining up and rolling on runway 08. The aircraft lifted off the runway 40 seconds later. At 0957:08 the pilot reported they had departed the runway and were tracking out to the north climbing to 2,500 ft through 600 ft. This was the last recorded call from VH‑WWU on the CTAF. Shark Bay is about 340 km north‑west from Geraldton.

Directly after take‑off, the pilot texted the senior base pilot with the expected arrival time at Shark Bay, which was 1230.

At 1008:52, the pilot took a photo of the aircraft oil temperature gauges. Eight minutes later the pilot sent the photo to a staff member at the maintenance organisation with accompanying text stating ‘WWU flies beautiful, smooth, and tight. Oil temp a little high for a cool day so we might have to look at fitting those coolers back onto WWU. I’d hate to see the rings[3] suffer.’ The maintainer responded via text at 1018, and the message was recorded as delivered (indicating that the pilot’s phone was still functional at that time). The oil temperature shown in the photo was towards the upper end of the normal range but below the 240°F maximum oil temperature limit.

At 1116:43, a call was placed to police by a member of the public stating they had come across aircraft wreckage by the side of a road as they were driving past (Figure 2). The accident was 84 km north‑west of Geraldton Airport, and about 0.5 km right of the direct track. The member of the public stated that although they had been nearby, they had not seen or heard the aircraft or the impact.

Figure 2: Original final position of VH‑WWU at the accident site[4]

Source: Western Australia Police Force

The aircraft was destroyed, and the pilot was fatally injured.

Context

Pilot information

The pilot held a commercial pilot licence (helicopter and aeroplane), with both single and multi‑engine class ratings for aeroplanes and a single engine class rating for helicopters. They held low‑level operational ratings for sling, aerial mustering helicopter and aerial musting aeroplane operations. In addition, the pilot held flight instructor ratings for low‑level flight tests in both aeroplanes and helicopters.

The pilot completed single engine aircraft and low‑level flight reviews on 12 February 2024.

The pilot held a valid class 1 aviation medical certificate which was approved in October 2024. This specified a requirement for the pilot to wear distance vision correction and a headset while flying. It also required reading vision correction to be available. 

The pilot logbooks were not available at the time of publication. 

Aircraft information

The Cessna 150M is a high‑wing, all metal, 2‑place, unpressurised aircraft with a fixed landing gear. VH‑WWU was manufactured in 1976 and was first registered in Australia on 5 May 1986. It had a single, Continental O‑200‑A reciprocating piston engine driving a fixed-pitch propeller. The aircraft was not equipped with an autopilot.

A periodic and other scheduled inspections were carried out between 6‍–‍18 March 2025. The periodic inspection identified minor defects that were subsequently rectified. The aircraft’s engine reportedly had excessive oil consumption, and to address the issue all 4 engine cylinders were removed, honed[5] and refitted along with new piston rings. Additionally, the engine ignition harness was replaced due to it being in poor condition. The engine was tested by carrying out a ground run 3 days before the accident and found to be functioning correctly. At the completion of maintenance, the aircraft had accrued a total time in service of 14,208 hours.

Site and wreckage

The wreckage was located about 20 m south of an east‑west road. The Western Australia Police Force and emergency services attended the site on the day of the accident.

The ATSB commenced the accident site examination on the following day, 22 March. The wreckage trail extended in a north‑easterly direction, about 23 m from the initial impact point to where the main wreckage, including the wings, empennage, engine and propeller had come to rest (Figure 3). There was no fire, and fuel could be smelt in the area. 

Figure 3: Overview of VH‑WWU accident site

Source: ATSB

Ground impact marks and damage to the airframe indicated that the aircraft impacted the terrain in a left wing‑low, steep nose‑down attitude at high speed (Figure 3). All major aircraft components were accounted for at the accident site. The disruption to the airframe from the impact limited the extent to which the aircraft could be examined. Of the components that could be examined, no pre‑impact defects were identified. Bending and damage to the propeller was consistent with the engine running at the time of impact.

A damaged Garmin 296 GPS receiver was recovered from the accident site. There were no available radar or ADS‑B recordings of the flight.

Meteorological information

The graphical area forecast for the accident region forecasted clear conditions for the flight with no forecast cloud and visibility greater than 10 km.

At 1030, the Bureau of Meteorology (BoM) automatic weather station at Geraldton Airport, 85 km south of the accident location, recorded the wind as 5 kt from 121° magnetic. There was no recorded cloud, visibility was greater than 10 km and the temperature was 34°C.

Further investigation

To date, the ATSB has:

• examined the wreckage and accident site
• recovered the GPS for further examination
• conducted interviews with witnesses and the maintenance organisation
• collected aircraft, pilot and operator documentation
• collected CCTV and CTAF recordings.

The investigation is continuing and will include:

• review and examination of any recovered GPS data
• collection and review of additional pilot medical information
• examination of the aircraft maintenance history.

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. Terminology 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.

Investigation summary

What happened

On 26 February 2025, a Robinson Helicopter Company R22, with an instructor and a student on board, departed Archerfield Airport, Queensland, to conduct advanced emergency training at Pannikin Island in Moreton Bay, Queensland. 

After practising emergency procedures and low-level flying, the student pilot performed several low-level torque turns, a manoeuvre not originally included in the lesson plan. During the final turn, the helicopter entered a low nose attitude and descended rapidly. The instructor attempted to recover, but due to the low height, was unsuccessful. The helicopter impacted the ground and skidded for some distance before rolling and coming to rest on its left side. The instructor sustained serious injuries and the student sustained minor injuries. The helicopter was destroyed.

What the ATSB found

Low‑level torque turns that were not part of the lesson plan, nor a requirement for commercial licence training, were conducted by a student pilot without a formal pre-flight briefing or guidelines. As the manoeuvre fell outside of the syllabus the ad hoc nature of its inclusion and conduct at the end of the lesson relied on an inflight briefing by the instructor to prepare the student for the exercise. Beginning the low-level torque turn exercise at 50 ft AGL rather than starting higher and working down as the student’s capability improved increased operational risk. Due to the low-level conduct of the exercise, this reduced the available safety margin and placed reliance on the instructor as the only risk control to recover from any unexpected mishandling of the sequence. 

Although the instructor immediately identified that the helicopter was descending rapidly, and took the controls, their actions were unable to recover the helicopter before colliding with terrain. Environmental conditions may have further reduced the safety margin and complicated the low-level recovery.

The operator had no formal process for monitoring the return of training flights. This would likely delay any search and rescue response and reduce post-impact survivability of the helicopter occupants in the event of life-threatening injuries.

What has been done as a result

The operator reported that SARTIME procedures for the flying school have been revised.

Safety message

Ensuring and maintaining sufficient height for recovery is vital in a training environment when a student has limited experience to manage unexpected aircraft or helicopter behaviour. 

All aspects of the lesson should be clearly briefed before flight including planned sequence, risks and hazards to ensure an understanding between instructor and student.

Instructors must rely on conservative in-flight decision‑making to manage risk during flight training operations and to anticipate and be ready to intervene quickly, especially during low-level, or elevated risk manoeuvres.

The investigation

The occurrence

On 26 February 2025, an instructor and a pilot under instruction (student) were conducting an advanced emergency training exercise in a Robinson Helicopter Company R22 (R22), registered VH-8BW, operated by Utility Helicopters, leased from Heliflite. The training commenced from the operator’s company base at Archerfield Airport, Queensland.

At about 0700, the student conducted a daily inspection of the helicopter under the supervision of the instructor. The intended training flight formed part of the requirements for a commercial helicopter pilot licence and the lesson plan intended to cover advanced emergency procedures. 

At about 0730 the helicopter, with the student flying, departed Archerfield Airport to the south‑east for a designated training area located in Moreton Bay. After reaching the uninhabited Pannikin Island training area, the emergency training commenced with autorotation[1] and tail rotor failure practise. After about 45 minutes, the student then commenced low-level flying practise, completing several clockwise laps around the island. These were completed between 50–100 ft above ground level (AGL) and at a speed of between 60–70 kt. 

Toward the end of the lesson, the instructor recalled that the student requested to practise some agricultural flying operations, which included torque turns.[2] These manoeuvres were not on the lesson plan for the flight, or part of the commercial flight training syllabus, and there had been no plan to conduct them until this point. The instructor demonstrated the manoeuvre before the student took control and successfully completed 4 torque turns. The instructor reported these were conducted at a height of about 50 ft AGL. 

The instructor stated that the low-level turns were conducted across the island roughly in an east–west direction. The exercise was conducted across the prevailing wind direction to avoid a downwind component on each low-level manoeuvre. Torque turns were performed on the eastern side of the island and procedural turns on the western side, with about 4 turns completed at each location. These were executed at a height of about 50 ft AGL. 

As the lesson neared completion, they elected to do one more torque turn before returning to base. The instructor recalled noticing the wind had increased a little and had started gusting but stated that these were not considered abnormal conditions and that both he and the student had flown in these conditions before.

The instructor described that at the top of the last torque turn, they were at a height of 100–150 ft AGL when they began to descend to build airspeed and return to level flight. During the recovery, the instructor noticed that the nose of the helicopter was pointing slightly down toward the ground at a height of about 20 ft. The instructor recalled that they were about to correct the student when a sudden gust of wind increased the rate of descent. Aware of the ground proximity,the instructor immediately took over the controls and recalled moving the cyclic[3] aft to arrest the rate of descent. The instructor reported the helicopter shuddering, shaking, and experiencing a jolt in the collective but was unable to prevent the helicopter impacting the ground. 

Both occupants recalled that everything happened quickly prior to ground contact and that the estimated speed at impact was about 60–70 kt. The instructor recalled that the helicopter impacted hard in a flared nose high attitude and that the stinger[4] contacted the ground first. The helicopter slid along the ground on its skids for about 40–50 m between mangrove bushes before the left skid dug into the muddy ground and dynamically rolled over.[5] The helicopter came to a stop on its left side after numerous rotations and was destroyed (Figure 1). The instructor recalled that the student remained in the helicopter momentarily after impact and then managed to exit and appeared to have had less injuries than themselves so was able to follow instructions to shut down the machine. 

Figure 1: Accident site

Source: Student

The student turned off the battery master and assisted the instructor to exit the helicopter. The instructor was unsure if any staff would be in the office and recalled asking the student to use their mobile phone to call for help. They stated that calling the office would not be as effective as calling their partner, as they were aware that several of the staff were away on business. The company was contacted and another helicopter from the base at Archerfield Airport was then dispatched to collect both occupants. About 25 minutes later they were rescued by a colleague who arrived in another helicopter. 

Emergency services were contacted, and an ambulance met the retrieval helicopter on arrival back at Archerfield Airport. Post-accident medical assessment determined that the instructor had sustained serious injuries and the student only minor injuries, both were taken to hospital for treatment.

Context

Aircraft information 

The Robinson R22 is a 2-seat, 2-bladed, single-engine, light utility helicopter manufactured by Robinson Helicopter Company in the United States. It has a maximum all up weight of 622 kg. The R22 is powered by a Lycoming O-360 4-cylinder piston engine that is derated to 131 horsepower for take-off and 124 horsepower for cruise at 2,652 RPM. The R22 is mostly used for private operations, rotary wing flight training and agricultural operations. 

The instructor reported that there were no mechanical issues identified with the helicopter during the daily inspection and pre-flight that would have precluded normal operation.

Flight controls 

The helicopter was fitted with conventional light helicopter flight controls, such as dual cyclic controls for each seat, and a centre‑mounted collective.[6] The engine throttle is connected to collective inputs through a mechanical linkage; when the collective is raised, the throttle is opened and when lowered, the throttle is closed.

Pilot information

Instructor 

The instructor held a commercial pilot licence (CPL-H) helicopter and had been an instructor with the operator for 3 years and 3 months. They began as a grade 3 instructor and progressed to a grade 1 instructor during their employment, logging about 2,800 flying hours. The instructor’s last proficiency check was 29 November 2024. The instructor obtained a low-level rating in 2021 and their low-level flight review for the R22 was valid until 13 November 2025. The instructor held a current Class 1 medical certificate.

Student pilot 

The student pilot had been conducting training with the operator for about 3.5 years. Initially training for a private pilot licence (PPL-H) helicopter, they had not finalised the required ground theory or conducted a flight test. Although they did not hold a PPL-H, they continued training to obtain the required flight hours for a CPL-H. 

Nearing completion of the commercial flight training, the student scheduled their lessons to coincide with their work commitments and they were not regular, but rather when time permitted. Their last lesson before the accident was conducted on 29 January 2025, about 4 weeks prior. They had previously completed advanced emergency training and the intention was to use the lesson as a refresher for CPL-H competency elements. The student reported they wanted to consolidate their low-level flying skills with a goal of working in the agricultural sector. 

At the time of the accident the student had accrued 89 hours of pilot training with the operator. The student reported that about two thirds of all the lessons had been taken with the instructor involved in the accident and the remainder with head of operations (HOO) and one other instructor. 

Meteorological information

Minute-by-minute wind data from the Bureau of Meteorology around the time of the accident indicated generally moderate winds with some directional variability.

Brisbane Airport observations recorded winds at 126°–143° with wind speeds of 9–13 kt, gusting to 18 kt. Similarly, Gold Coast Airport recorded winds at 150°– 208° with wind speeds of 9–14 kt, gusting to 18 kt. The accident site which was located between these two reporting stations (Figure 2) was likely subject to similar wind conditions.

Figure 2: Map showing location of weather stations and Pannikin Island

Source: Google Earth, annotated by the ATSB

The instructor stated that they checked the weather conditions before departing, and that the wind direction indicated a south‑easterly wind at about 15 kt. On arrival at Pannikin Island, they recalled that the surface wind was observed to be more southerly in direction and felt slightly stronger than 15 kt. 

Downdraught 

Downdraught is a vertical atmospheric condition where a current of air sinks rapidly, leading to sudden changes in conditions at ground level and can produce strong surface winds. Downdraughts can pose a significant threat to rotary aircraft, particularly while manuevering at low level. The most common causes of downdraught experienced by helicopter pilots are due to irregular terrain when combined with strong surface winds, mechanical turbulence,[7] temperature inversions or thermal convection movements. 

Accident site and wreckage

The operator conducted training over Pannikin Island, a designated training area to the south-east of Archerfield Airport. The island is one of several uninhabited islands located in southern Moreton Bay, about 56 km south-east of Brisbane (Figure 3).

The instructor recalled that the Pannikin Island training area extended from sea level to 3,500 ft. The vegetation on the island is mainly mangrove shrubland, with no buildings or power lines in the vicinity, and for this reason was used for low-level training.

Figure 3: Google Earth image of location of Pannikin Island, Queensland

Source: Google Earth, annotated by the ATSB

The initial ground contact of the helicopter indicated a high‑speed, upright skid contact before further loss of directional control and impact (Figure 4). The student and instructor reported that the speed on touchdown of the helicopter was about 70 kt and was consistent with the skid mark length.

Figure 4: Photograph of impact site

Source: Student

After further impacting mangrove trees, the tail rotor assembly, including tail rotor, gearbox vertical and horizontal stabiliser, separated from the cabin and was reported as being located about 15 m north of the wreckage (Figure 5) and was largely intact. 

Figure 5: Photograph of main and tail rotor wreckage at accident site

Source: Student

Post-accident aircraft examination

The operator’s chief engineer carried out an inspection of the helicopter at the accident site before the wreckage was removed. The engineer reported that their examination found no evidence of mechanical issues that could have led to the accident. 

Recorded data

There was no onboard data recording on the helicopter to determine the flight control inputs and their effect on the helicopter during the accident. 

Recorded radar data was available of the helicopter in the training area, however due to the low-level nature of the operation, this was intermittent.

Helicopter exercises and operator’s procedures 

Helicopter pilots are taught a range of manoeuvres as part of their training and licensing requirements. These are typically categorised as either normal, advanced or emergency procedures and are detailed by the Civil Aviation Safety Authority (CASA) for different licence levels and ratings.

In addition to the standard syllabus for advanced emergencies (e.g. autorotation, tail rotor failure), advanced procedures that are not required for the CPL-H may be introduced by flight instructors to extend a student’s capability and confidence. The approved Civil Aviation Safety Regulation (CASR) Part 141 operator exposition did not include torque turns as a requirement to obtain a CPL-H.

Pre-flight briefing

Briefings prior to a flying lesson are an essential part of flight preparation and represent an opportunity to gather, mentally prepare and organise the structure of the upcoming training flight. It is also an opportunity to assess the potential risks and hazards that might arise during normal and emergency operations. Discussion on the procedures to be used in the case of unexpected events disrupting the planned flight operations are also covered, and this prepares and sets student expectations for the lesson.

While pre-flight briefings were normally conducted before each lesson covering the intended lesson sequences, on this occasion the instructor considered a detailed briefing was unnecessary due to the student’s previous experience. Before departure, the instructor and student recalled a brief discussion focused primarily on the weather, but this did not include a formal briefing covering the planned exercises and potential risks. 

The intent of the lesson was to consolidate the student’s prior training and both pilots recalled that the session was to refresh and consolidate advanced emergency procedures. 

Low-level operations 

A low-level operation is defined by regulation 61.010 of CASR as flight at a height lower than 500 ft AGL, other than when taking off or landing, and is not permitted unless the circumstances outlined in sub regulation 91.267(3) of CASR apply to the flight and the pilot is authorised under Part 61 to conduct the operation. Low‑level operations can introduce increased risk for all pilots as the proximity to terrain and reduced margin for recovery intensify the consequences of any deviation from the expected performance. There is also an increased susceptibility to adverse environmental conditions for students with less experience.

Torque turns 

A torque turn is an advanced manoeuvre to quickly complete a 180° change in direction of flight (Figure 6). The manoeuvre begins with a pitch upwards to reduce forward airspeed followed by an application of power to increase altitude. As airspeed decreases, aerodynamic stability is reduced and the increased torque induces yaw.[8] This yaw is used to initiate the turn which continues until the helicopter is facing the opposite direction. Once the turn is complete, the pilot regains airspeed, eases out of the dive and resumes level flight in the new direction. 

Figure 6: Helicopter torque turn flight sequence

Source: ATSB

The student reported that their request to conduct the torque turn training was driven by their desire to seek employment in the agricultural domain (aerial application and dispensing operations) after obtaining their commercial licence. They recalled completing several turns successfully before the accident turn. 

However, in response to the draft report, CASA stated that torque turns are not common and are actually avoided in rotorcraft aerial application and dispensing operations, in favour of accurately flown and coordinated procedure turns (see below).

No official height for conducting torque turns in training is provided by CASA, however general guidance provided for starting more advanced or complex manoeuvres is to begin at higher altitudes and reduce once competence is gained.

Procedure turns

A procedure turn is a standard course reversal manoeuvre used to change the helicopter’s direction. ICAO defines the manoeuvre as a turn made away from a designated track followed by a turn in the opposite direction to permit the aircraft to intercept and proceed along the reciprocal of the designated track. Procedure turns may be designated as being made either in level flight or while descending, according to the circumstances of each individual approach procedure. To commence the turn the aircraft would turn off track, maintain airspeed, conduct the turn and turn onto the reverse of the original course. They are sometimes referred to as ‘P turns’ as the flight track looks like a ‘P’ from above.

The Part 61 Manual of Standards competency standards for unit AA2 – Helicopter aerial application operation, specifically requires procedure turns in element AA2.6 – Manipulate helicopter at low level:

(a) manoeuvres helicopter at all speeds below 500 ft AGL, up to and not beyond the limits of the flight-manoeuvring envelope, without exceeding the operating limitations of the helicopter; 

(b) conducts coordinated, smooth procedure (P) turns with varying power settings.

Operator low-level training

In line with the CASA requirements, the operator’s exposition stated that procedure turns were required for advanced low-level training and detailed amongst other manoeuvres that the height range for the conduct of these was between 200 ft and 5 ft AGL. However, no specific minimum height was declared for procedure turns.

There was no reference for torque turns in the operator’s exposition.

Search and rescue

Search and rescue time (SARTIME) is the time nominated by a pilot for the initiation of search and rescue action. Any person deemed to be a responsible person can hold SARTIME for a pilot’s safe arrival. 

There was no regulatory requirement for the operator’s local training flights under CASR Part 91 for a SARTIME, however the absence of a formal flight following process during flight training may have implications for the operator’s duty of care during the operation.

The operator’s head of operations (HOO) reported that a range of tracking systems were used across the operator’s fleet, including satellite trackers and transponders. These devices allowed staff to monitor the location of helicopters during flight and, if a helicopter did not return within an expected time, its position could be quickly determined. A television screen located in the operator’s office displayed tracking data, however, no personnel were specifically assigned to monitor return times or to observe the radar feed.

Many of the flight training lessons were conducted from the operator’s base at Archerfield Airport, where staff could maintain direct visual oversight of helicopter movements. However, as the accident flight was early in the morning, there was only one other instructor conducting flight training and the office staff were not yet on duty.

Some helicopters in the fleet were fitted with electronic locator transmitters and others with personal locator beacons. Under CASR regulations these are mandated for flights greater than 50 NM from the departure aerodrome. The accident helicopter was fitted with a manually‑activated personal locator beacon, however the instructor reported that they were dazed immediately after the accident and did not prioritise the activation.

Safety analysis

Introduction

An instructor and a student were conducting advanced emergency training in a Robinson Helicopter Company R22 (R22) helicopter, registered VH-8BW, at Pannikin Island in Moreton Bay, Queensland. Near completion of the commercial helicopter pilot lesson, the instructor and student agreed to conduct torque turns, an advanced helicopter handling manoeuvre that was outside of the training syllabus. After conducting several torque turns, the helicopter entered an increased low nose attitude during recovery at low altitude which resulted in a collision with terrain and dynamic rollover. 

This analysis will consider decision‑making of the instructor and student and the instructor’s recovery as factors in the accident. 

Decision-making

Instructing is a complex task and flight instructors must balance the benefit to the student’s learning and experience with safe margins of operation in a dynamic and sometimes rapidly changing environment. 

The decision to conduct torque turns was only discussed between the instructor and the student during the flight.

Instructors consider several factors such as student performance, recent progress and training objectives when making in‑flight decisions to alter or vary the training flight plan. While instructors can adapt lessons to suit the student’s progress, deviations from planned activities should be underpinned by clear safety considerations, briefings and effective risk management. 

Effective instructional decision-making balances educational value with operational risk. The instructor assessed the student to be capable of performing the manoeuvres based on their recent progress and performance during the lesson and having completed many previous training hours together. However, this assessment was done during the training flight, limiting the time available for the instructor to fully consider the benefits and risks (including height to conduct the training – see below).   

The benefits of conducting a pre-flight brief of the lesson, especially where training operations are conducted in emergencies is well-established. Such a briefing reaffirms standard operating procedures, promotes predictable behaviour, and sets expectations (Sumwalt and others, 2010). 

The torque turns were not part of the syllabus and were not necessary for the lesson. However, if the decision to conduct them had been agreed before flight, this would have allowed for a full ground briefing to establish the torque turn procedures, discuss the conduct of the manoeuvre and ensure a common understanding of how the practise turns would be conducted. 

Manoeuvre height

Torque turns were outside of the advanced emergency lesson for the operator’s commercial pilot training syllabus and consequently no procedure was identified in the training materials for conducting them during training. The absence of a defined procedure places the reliance on the instructor to become the risk control. In this case there was an increase in risk as the manoeuvre was conducted at a height that reduced the available safety margin and limited the opportunity for recovery when the helicopter entered an undesired state. By contrast, if the manoeuvre had been initiated at a higher altitude, the increased height would have provided more time for the student and instructor to identify, intervene and recover from the undesired aircraft state. Increased altitude when practising a high-risk manoeuvre with a student would allow time for corrective control inputs from the instructor to avoid collision with terrain. 

Beginning the low-level torque turn exercise at 50 ft AGL, rather than starting higher and working down as the student’s capability improved, increased operational risk.

Instructor recovery

During the torque turn, the helicopter exited the manoeuvre in a lower than expected nose attitude. Instructor intervention is a critical control in flight training and is often the final opportunity to regain control of the helicopter. Although the instructor took over control as soon as they recognised the rapid descent rate, the low height on exiting the torque turn limited the time available to arrest the descent before ground contact occurred. Environmental conditions may have further reduced the safety margin and complicated the low-level recovery.

Due to the high speed of the helicopter and approaching vegetation, the instructor likely attempted to slow the helicopter using rear cyclic (as would be normal practice when airborne), however, after skid contact with the ground in an upright attitude, this likely resulted in the main rotor disk flexing and making contact with the tail boom. This resulted in the severing of the tail boom by the main rotor blades, loss of torque control and the front left skid digging into soft soil, leading to a dynamic rollover. 

SARTIME 

The operator had no formal process for monitoring the return of training flights. While many operations were conducted within line-of-sight or in close proximity to the operator’s base, this informal system provided limited assurance that an overdue returning training flight outside of the airport vicinity would be identified. In this case, had the crew been more seriously injured or rendered unconcious, the lack of formal SARTIME and flight following would likely have delayed the initiation of search and rescue efforts and substantially reduced survivability. 

Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Robinson R22 Beta, VH-8BW, 29 km north of Southport Aerodrome, Queensland, on 26 February 2025.

Contributing factors

• While conducting commercial training consolidation for low‑level and emergency procedures, the instructor and student agreed to conduct torque turns, which were outside the lesson plan and training syllabus.
• Without a procedure, the instructor conducted the exercise at an inappropriate low height, which increased risk and did not allow for a margin of error.
• During the torque turn exercise the helicopter exited the turn in a lower than expected attitude. The instructor assumed control but was unable to prevent a collision with terrain.

Other findings

• The operator had no formal process for monitoring the return of training flights. This would delay search and rescue response and reduces post-impact survivability of aircraft occupants in the event of life-threatening injuries.

Safety actions

Safety action addressing SARTIME

The operator has implemented a SARTIME procedure using an application for shared messaging between instructors and staff. For each flight, the instructor records the helicopter registration, flight details and estimated time of arrival back at base. Any delays are communicated through the group and landings are confirmed upon arrival at base or the intended destination. The procedure is documented on the pre-flight board.

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• instructor of the accident flight
• student pilot
• operator CEO and HOO
• Civil Aviation Safety Authority
• Bureau of Meteorology.

References

Sumwalt, R. L. Lemos, K. A., & McKendrick, R. (2019). The accident investigator’s perspective. In Crew resource management (pp. 489-513). Academic Press.

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:

• instructor of the accident flight
• student pilot
• operator CEO and HOO
• Civil Aviation Safety Authority.

Submissions were received from:

• instructor of the accident flight
• operator CEO and HOO
• 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 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.

The ATSB is investigating a loss of control event involving a Bell 412EP, registered VH-VJF, 57 km north-east of Strahan Aerodrome, Tasmania, on 10 March 2025.

The helicopter was being operated by Coulson Aviation for firefighting operations using a sling‑loaded water bucket. While hovering to load the bucket from a river, the helicopter unexpectedly sank about 50 ft. In an attempt to recover, the pilot initiated forward flight but was unable to jettison the load before the longline became taut, causing a sudden stop and an abrupt tail-down motion. This resulted in the external hook and longline making contact with the lower fuselage.

The pilot flew back to the base at Zeehan where inspection identified damage to the helicopter’s fuselage, control tubes for both the engines and the tail rotor. Damage was also identified to the bucket and longline.  

To date, the ATSB investigation has included:

• interviewing involved parties
• retrieving recorded data
• the collection of other relevant information
• reviewed recorded aircraft information
• reviewed the forecast and observed weather conditions
• reviewed maintenance documentation for VH-VJF
• analysed recorded helicopter information
• reviewed pilot training delivered by Coulson Aviation.

An interim report, which detailed factual information established during the course of the investigation, was released on 17 March 2026 (see separate tab).

The continuing investigation will include:

• review of Coulson Aviation’s risk controls for bucketing operations in the Bell 412
• review of Coulson Aviation’s operational and reporting procedures
• review of Tasmanian Fire Service operational and reporting procedures.

In the course of the investigation, the ATSB has identified potential limitations in risk controls that are considered likely to have contributed to the occurrence. Examination of these factors represent a significant increase in the scope of this investigation, and it has been upgraded from Short to Defined as a result (the ATSB's different levels of investigation are detailed here).

The ATSB has completed the evidence collection and analysis phases of the investigation and is drafting the final report.

The 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 that appropriate safety action can be taken.

Investigation summary

What happened

On the morning of 25 February 2025, an Agusta A109E helicopter was conducting a marine pilot transfer operation on the inbound bulk carrier Star Coral at Blossom Bank pilot boarding ground, about 200 km north‑east of Mackay, Queensland.

At 0901 local time, during take‑off from the ship with 2 pilots on board, the helicopter developed severe vibrations. The pilots discontinued the take-off but their attempts to recover control of the helicopter were unsuccessful. The helicopter came to rest in an upright position on the helideck, having spun more than 90° counterclockwise from its initial heading, and sustaining substantial damage. The pilots and ship’s crew were unharmed.

What the ATSB found

The investigation did not identify any airworthiness issues with the helicopter and it was considered that the loss of control was not attributable to a mechanical issue. 

The ATSB found that the vibration was likely the result of the helicopter entering ground resonance, a phenomenon that dissipates when airborne, while it was in the process of departing from the ship. The discontinuation of the take‑off, after the onset of the vibration, probably resulted in the loss of control and subsequent damage to the helicopter.

What has been done as a result

The operator has added new guidelines on ground resonance to its procedures. The guidelines include procedures for recognising and recovering from ground resonance and feature case studies and video resources for training purposes. 

The operator has also developed an updated procedure for training and checking flight briefings that will include confirming the roles of each pilot, procedures for transferring aircraft control between pilots, and actions to be followed in the event of an actual emergency.

Safety message

The occurrence highlights the dangers of ground resonance, a potentially catastrophic phenomenon that can occur in helicopters with fully articulated rotor systems. Typically, the onset of ground resonance is sudden and if the pilot does not take immediate corrective action, a loss of control can rapidly occur. 

The occurrence also highlights the importance of proper coordination between a helicopter’s pilots when responding to abnormal or emergency situations. This is particularly pertinent for situations where the pilot flying is not the pilot in command. Ideally, the pilots’ individual roles and responsibilities for emergency response and flying duties should be well established prior to the flight. 

The investigation

The occurrence

At about 0730 local time on 25 February 2025, the 229 m bulk carrier Star Coral arrived at the Blossom Bank pilot boarding ground, about 200 km north‑east of Mackay, Queensland (Figure 1). The ship waited to embark a coastal marine pilot by helicopter for its inbound transit of the Great Barrier Reef via Hydrographers Passage.[1] It was in ballast and bound for Hay Point to load coal. 

Figure 1: Blossom Bank pilot boarding ground and Hydrographers Passage

Source: Australian Hydrographic Office, annotated by the ATSB

Meanwhile, at Mackay Airport, a twin‑engine Agusta A109E helicopter, operated by Flyon Helicopters and registered VH‑XUM (XUM), with 2 pilots on board, embarked the marine pilot scheduled to conduct the ship’s pilotage. The marine pilot transfer (MPT) flight to Star Coral was the first scheduled for the helicopter and its pilots that day. These flights were normally conducted as a single‑pilot operation. However, on this occasion, the pilot flying, a pilot recently engaged by the operator under its ‘in‑command‑under supervision’ (ICUS)[2] program, was under the supervision of a company check pilot (pilot supervising). 

The pilots’ plan was to transfer Star Coral’s marine pilot and then proceed to a nearby outbound ship to collect its marine pilot for return to Mackay.

At 0759, the helicopter departed Mackay Airport under the control of the pilot flying. En route, the pilots established communication with Star Coral’s master via VHF[3] radio. The master advised that the ship was rolling about 3° on its inbound heading due to a 2 m south‑easterly swell. Subsequently, the pilots requested the master to reposition the ship on a heading[4] of 270° to reduce rolling. At 0853, the pilot flying landed the helicopter on the ship’s helideck, situated on the number 5 cargo hold hatch cover (Figure 2). The marine pilot exited the helicopter and proceeded to the ship’s bridge. 

Figure 2: Landing position of VH-XUM aboard Star Coral

This figure is a representation of the helicopter’s orientation relative to the wind during the take‑off. Source: Flyon Helicopters and Star Coral, annotated by the ATSB

Meanwhile, the helicopter remained on the helideck at flight idle[5] while its pilots radioed the outbound ship’s pilot to coordinate the transfer. After some discussion, the pilots elected to keep the helicopter on the deck of Star Coral until the outbound ship had departed the compulsory pilotage area.

After about 5 minutes, as the 2 ships were about to pass each other, the helicopter pilots began conducting their pre‑take‑off checks. The pilots observed a 20 to 28 knot headwind (relative to the helicopter) and noted that the ship was rolling less than 2°. The pilot flying conducted a brief for a performance category 1[6] take‑off, which involved establishing the helicopter in a hover 35 ft above deck height before departing. Both pilots later recalled that everything seemed normal as the take‑off checks were completed. 

At about 0900, the pilot flying raised the collective[7] and observed the engine torques increasing through 50%. The pilot flying recalled the aircraft became light on its oleos as though it was ‘right at the point of lifting off’. Meanwhile, the pilot supervising was observing the outbound ship passing. A few seconds later, both pilots felt a sudden and substantial vibration. 

The pilot supervising immediately looked down at the controls and recalled that the pilot flying was holding the cyclic[8] in an abnormally aft position. Concerned that the main rotor might have struck the tail boom, the pilot supervising decided to assume control of the helicopter and took hold of the cyclic and collective unannounced. Meanwhile, the pilot flying was still attempting to lift off, unaware of the pilot supervising’s decision to take control. The pilot supervising recalled that the pilot flying had centred the cyclic and ‘must have’ lowered the collective by the time the pilot supervising took hold of the controls. In contrast, the pilot flying stated that the pilot supervising rapidly lowered the collective after the vibration started, causing the aircraft to descend from being light on its oleos and bounce heavily on the helideck.

Moments later, the cyclic became uncontrollable as the vibrations suddenly worsened into a violent, vertical oscillation of the airframe. The pilot supervising tried to stabilise the helicopter but was unable to control the cyclic movement. Subsequently, the pilot supervising elected to shut down the engines. 

The pilot supervising initially struggled to reach the engine mode switches (located on the centre console) due to the severe vibrations but subsequently managed to shut down engine number 2. The vibrations slightly eased and moments later, they were able to also shut down engine number 1. The vibration dissipated and the helicopter came to rest in an upright position on the helideck, having spun more than 90° counterclockwise from its initial heading. The sequence, from the attempted take‑off to shut‑down occurred within a period of about one minute.

Soon after, the pilots exited the wreckage and inspected the damage. The tail rotor was separated from the helicopter and had come to rest on the main deck between cargo hatches 4 and 5. Items of debris, including main rotor fragments, laid scattered on the deck along with some hydraulic fluid pooled beneath the substantially damaged fuselage (Figure 3).  

Figure 3: Helicopter wreckage 

Source: Star Coral

Apart from a thumb sprain to the pilot supervising and some bruising to both pilots’ upper leg areas, where they had been struck by the cyclic, neither were significantly injured and no‑one on board Star Coral was injured.

Context

Helicopter information

The helicopter was an Agusta A109 E variant, manufactured in 2006 and issued serial number 11684. It was registered in Australia in 2006 and began services under the operator’s Air Operator’s Certificate (AOC) in 2023. 

The Agusta A109E is a multipurpose helicopter equipped with 2 Pratt & Whitney PW206‑C turbine engines. It has a fully articulated 4‑blade main rotor system, a 2‑blade tail rotor and retractable tricycle landing gear. Able to carry up to 7 occupants, it has a maximum allowable take‑off weight of 2,850 kg. 

The helicopter was able to perform flight performance class 1 operations by adherence to Category A procedures[9]. While the helicopter was normally operated from the right crew seat, it was fitted with dual controls. A left seat‑approved pilot in command (PIC) was permitted to occupy either seat during training flights. Each set of controls could not be operated independent of the other. 

The helicopter’s wreckage was recovered from the ship 2 days after the incident and transported to a secure hangar at Mackay Airport. Prior to its removal, photographs of the wreckage and the accident area were taken. There were no indications that the main rotor or tail rotor had struck any part of the ship during the accident. 

Based on its inspections, the operator advised that no engine faults or exceedance alarms had been recorded by the helicopter’s electronic engine management systems. Additionally, no faults or defects had been reported by any of XUM’s pilots or maintainers leading up to the occurrence flight. 

Post-accident activities

There was no recorded flight data available to determine the flight control inputs and their effect on the motion of the helicopter during the occurrence.[10] The pilots’ accounts, a witness statement from the master of Star Coral and photographs of the wreckage were the main sources of evidence. 

The ATSB also sought the manufacturer’s input for this occurrence. The manufacturer advised that its preliminary assessment of the available evidence suggested that the helicopter damage appeared consistent with a ground resonance phenomenon (see the section titled Ground resonance).

The licenced maintenance organisation for XUM carried out an examination of the wreckage at the Mackay hangar. On advice from the manufacturer, the examination included inspection of specific components commonly associated with ground resonance. These included main rotor dampers, landing gear struts and tyres. The operator advised the ATSB that the inspection did not identify any airworthiness issues that may have contributed to the occurrence. The operator did not provide the inspection report or findings to the manufacturer for its assessment.

Pilot flying 

The pilot flying obtained a New Zealand commercial helicopter licence (CPL) in 2011 and started flying commercially in 2014. They converted their CPL over to an Australian CPL in 2016 and held a grade 2 flight instructor rating and a class 1 aviation medical certificate. They had experience flying both single and twin-engine helicopters in various operations. Prior to joining the operator’s in‑command‑under‑supervision (ICUS) program in September 2024, they had no previous experience on the A109E, or with marine pilot transfers (MPT). 

Under the ICUS program, the pilot was required to accrue 200 hours on the A109E before they could be assessed to fly the helicopter unsupervised on daytime VFR[11] MPT operations. At the time of the occurrence, the pilot had completed the operator’s training requirements and accrued around 50 hours flight time on the A109E. They had also been cleared to conduct unsupervised MPT operations on single‑engine Eurocopter AS350 helicopters.

Pilot supervising

The pilot supervising was the operator’s head of flying operations and held an air transport pilot (helicopter) licence, issued in 2014, and a class 1 aviation medical certificate. They were approved under the operator’s training and checking system to conduct check and supervision flights on the A109E.

The pilot supervising had been flying helicopters for 26 years in various operations and had accumulated over 10,000 hours flying time, including 3,800 hours in the A109E. They first started MPT operations in 2007 and commenced working with the operator in December 2016.   

Star Coral

Star Coral was built in 2009 by Jansu Newyangzi Shipbuilding, China, registered in The Bahamas and classed with Bureau Veritas. The ship was owned by Panormos Shipping, The Bahamas, and managed and operated by Charterwell Maritime, Greece. 

At the time of the occurrence, the 229 m ship had a mean draught of 6.51 m and the helideck height was about 18 m above the waterline.   

In a written witness statement, the master reported that:

• shortly after the helicopter started to take off, it began to pound on the helideck before it spun and the tail rotor separated

• during the sequence, the helicopter became airborne for no more than 2 seconds.

Ground resonance

Ground resonance can be defined as a vibration of large amplitude resulting from a forced or self‑induced vibration of a helicopter in contact with the ground.[12] The phenomenon is normally associated with helicopters equipped with fully articulated main rotor systems consisting of 3 or more rotor blades. It is more common on helicopters with sprung landing gear than those with skids. Typically, ground resonance occurs during landing, take‑off and ground manoeuvres.[13]

In fully articulated rotor systems, drag hinges allow each blade to advance or lag in the plane of rotation to compensate for the stresses caused by the acceleration and deceleration of the rotor hub. Such rotor systems are typically fitted with lead‑lag dampers to limit the extent of this movement and help prevent excessive vibrations. However, if for any reason one or more of the blades assumes a dragged position different to the others, the blades will move out of phase and the rotor will become imbalanced, transmitting an oscillation throughout the entire airframe.[14]

The risk of ground resonance arises when the unbalanced forces in the rotor system cause the fuselage to oscillate on its landing gear at or near its natural frequency. Ground resonance will occur if the helicopter’s damping systems are unable to compensate for the oscillation.[15] Unless corrective action is taken, the amplitude of the oscillation will increase until the helicopter becomes uncontrollable.[16] Ground resonance can also be induced when the helicopter is in light contact with the ground, if the landing gear oscillation frequency is in sympathy with the rotor head vibration.[17]

Ground resonance is commonly precipitated by the helicopter making hard or asymmetric contact with the ground, landing on a slope or sudden control movements by the pilot.[18] It can also result from other factors such as improper blade balancing and tracking, or damage to any of the blades.[19] Hard contact with the ground by some part of the landing gear when the main rotor is in an unbalanced state can further aggravate the condition.[20]

Additionally, improper maintenance of the helicopter’s main rotor and fuselage damping systems, or incorrect tyre pressures, can induce or worsen ground resonance.[21]

Flight control inputs that may induce ground resonance typically involve sudden control movements or a mishandling of the cyclic that causes the fuselage to bounce.[22]

The helicopter manufacturer advised that the application of certain cyclic commands, such as extreme aft cyclic input, could theoretically reduce the main rotor damper effectiveness in respect to the damping action on the blades’ regressive lead‑lag dynamic.

Recovery technique

The onset of ground resonance can be recognised by a rocking motion or oscillation of the fuselage while on the ground.[23] The United States Federal Aviation Administration (FAA) Helicopter Handbook[24] documented 2 widely accepted recovery techniques: 

• if the condition arises when there is insufficient rotor speed for take‑off, the only option is to lower the collective to reduce the pitch of the blades. The rotor rpm[25] should also be reduced as soon as possible.[26]

• If the rotor speed is in the normal operating range for flight, the Helicopter Handbook recommends lifting the helicopter off the ground to allow the rotor blades to rephase themselves automatically. 

Additionally, the FAA cautioned that:

If a pilot lifts off and allows the helicopter to firmly re‑contact the surface before the blades are realigned, a second shock could move the blades again and aggravate the already unbalanced condition. This could lead to a violent, uncontrollable oscillation.  

In practice, a pilot experiencing ground resonance typically has seconds to identify the condition and take corrective action. 

Similar occurrences

The ATSB reviewed several investigation reports relating to previous A109E accidents attributed to ground resonance. The incidents reviewed occurred outside of Australia between 2006 and 2025 and the contributing factors were found to be operational. Technical factors which may have caused or exacerbated ground resonance were not identified. 

Details of the previous incidents bear similarity to the occurrence involving XUM, particularly in respect to subsequent damage to the helicopter (Figure 4). 

Figure 4: Previous occurrences of ground resonance involving the Agusta A109E

Source: Leonardo Helicopters

Flight manual procedures

The A109E rotorcraft flight manual (RFM) listed fault conditions and corrective actions for emergencies and malfunctions that might occur during take‑off.

The RFM included the caution below for ground resonance within the normal flight procedure for take‑off. This was not part of the emergency and malfunction procedures.

The RFM procedure for ground resonance was consistent with recovery techniques published by the FAA. The RFM reference to the helicopter being ‘free of ground resonance’ was intended to indicate  that, like all helicopters, the A109E was designed and certified to applicable standards so that the rotor and fuselage systems do not vibrate at the same frequency under normal conditions.   

Operator procedures

As an AOC holder, the operator maintained a CASA‑approved[27] operations manual/exposition[28] to promulgate general policy and standardised procedures for MPTs on the A109E. The version of the operations manual current at the time of the occurrence was issued by the operator in November 2023.

Ground resonance

The operator’s normal procedures and emergency checklists for the A109E were derived from the RFM and did not contain any procedures related to ground resonance. 

Crew coordination in response to abnormal situations

While MPT flights were predominantly conducted by a single pilot, the helicopter was certified for operations with either a single pilot or 2 pilots. In either case, the normal procedure and emergency checklists remained the same, except that 2‑pilot checklist procedures were to be based on challenge and response. 

Normal handover and takeover procedures provided that:

In the case where the pilot flying (PF) is not the PIC and the PIC determines that the PF is not maintaining adequate control of the aircraft, the PIC may elect to take control, in which case they will signal their intention by saying ‘I have control’ upon which the PF will immediately relinquish control and the roles will reverse.

In abnormal or emergency situations, the PIC was responsible for ensuring the aircraft was flown and kept under control. The operations manual emphasised the importance of cockpit resource management (CRM) standards throughout the situation, in accordance with the below procedure:

Note: In the above procedures PM stands for ‘pilot monitoring’, NR refers to main rotor speed and IAS means indicated airspeed. 

In the context of rapidly escalating emergencies such as ground resonance, pilots have limited time to perform the procedure. 

Pilot in command responsibility during training flights

As the holder of a certificate that authorised air transport and aerial work operations, the operator was required to have in place a training and checking system (TACS). A training and checking manual (TACM) sets out policies and procedures for conducting training flights. It provided that a check pilot supervising ICUS training was to be the PIC. Check pilots were to ensure that pilots involved in training exercises were made aware of who was acting as the PIC through proper handover of control procedures. 

While an ICUS pilot might be considered the PIC for flight‑time logging purposes, the pilot supervising was deemed the PIC and responsible for the safety of the flight. The TACM stated that in the event of an actual emergency during flight training:

If the flight examiner or check pilot deems it necessary to take physical control of the aircraft at any stage after the occurrence of the emergency, then they shall do so in accordance with the hand‑over and take‑over procedures specified in the Operations Manual - Hand over and take‑over procedures.

The flight examiner or check pilot must be prepared and ready to assume physical control of the aircraft at any stage, particularly during critical manoeuvres such as during take‑off and landing.

As such, beyond the normal handover of control procedures, there were no special provisions in the TACM for the allocation of PIC responsibility and PF duties during ICUS flights. 

Briefings

For 2‑pilot operations or training flights, the operator’s procedures did not require pilots to brief who would assume PF duties in the event of an abnormal or emergency situation during critical phases of flight. 

Operational limits

Under the operator’s operations manual, the A109E was permitted to conduct daytime MPT operations up to a wind strength of 30 knots, with a maximum crosswind of 20 knots. The operational limit for ship’s pitch was 4° up and 2° down while the maximum permissible roll was 4°. The manufacturer did not have input into these operator‑defined limits. 

The pilots reported that the conditions at the time of the occurrence (20‍–‍28 knot headwind, 2° roll and minimal pitching) were within the operator’s limits for MPTs.

Safety analysis

Prior to the accident, VH‑XUM (XUM) made an uneventful landing on Star Coral and remained on the deck for several minutes without incident. There was no evidence that the helicopter was operating abnormally or experienced any instability during this period. 

Examination of the accident site did not reveal any evidence to suggest that the occurrence resulted from the main rotor or tail rotor striking the ship. Star Coral’s master reported that the tail rotor separated after the helicopter started contacting on the deck, indicating that contact with the tail boom by the main rotor was a consequential rather than causative factor. 

In that context, it is most likely that the helicopter encountered ground resonance. Assessment of the damage to the helicopter following the occurrence revealed significant similarities to that seen in previous A109E incidents attributed to this phenomenon. 

It is well established that ground resonance only arises when the helicopter is in contact with the ground. Both pilots asserted that the helicopter did not become airborne prior to the vibrations while the master reported that it became airborne for about 2 seconds. However, it is more likely this occurred after the vibration worsened and the helicopter started rebounding on the helideck. 

The exact cause of the vibration could not be determined. The possibility of causative operational factors such as flight control inputs or environmental factors could not be ruled in or out. 

Similarly, while the operator’s post‑accident inspection of the helicopter (including examination of its rotor and fuselage damping systems) did not reveal any apparent defects, causative technical factors could not be discounted.

However, the sudden lowering of the collective after the onset of the vibration likely aggravated the situation. The helicopter was almost certainly light on its oleos when the vibration began. Therefore, a sudden lowering of the collective would have caused the helicopter to come down firmly on the helideck. The United States Federal Aviation Administration (FAA) Helicopter Handbook describes that such an impact when the rotor is already in an unbalanced state can cause the rotor blades to move further out of phase, resulting in violent uncontrollable oscillations. This description is consistent with the occurrence sequence described by the pilots and the master. 

The pilots’ accounts of who lowered the collective differed. The recollection of the pilot flying that their intention was to lift the helicopter off the deck in response to the vibration was not consistent with a lowering of the collective. In contrast, the pilot supervising did not immediately identify the source of the vibration and later shut down the engines, believing the main rotor may have struck the tail boom. In this context, lowering of the collective would be a natural and expected response. Therefore, it is most likely that the pilot supervising lowered the collective while the pilot flying was attempting to lift the helicopter off the helideck.

In isolation, the immediate responses taken by each pilot following the sudden onset of the significant vibration were understandable. However, since the helicopter’s rotor speed was in the normal operating flight range, continuation of the take‑off would probably have resulted in the vibration dissipating (as detailed in the FAA Helicopter Handbook).

The operator had adequate procedures for responding to abnormal and emergency situations. However, the rapidly escalating nature of this occurrence meant that there was virtually no time to implement them. There was no requirement for the pilots to conduct a pre‑flight or pre‑take‑off brief about who would assume flying duties in the event of an emergency on take‑off. Therefore, the normal procedures for handover and takeover of control were assumed to apply.

However, the time between observing the vibrations and the loss of control severely limited the time available for a formal transfer of control between the pilots. As a result, neither of these procedures were followed and each pilot responded to the situation separately. 

Findings

From the evidence available, the following findings are made with respect to the loss of control during marine pilot transfer operations, involving an Agusta A109E, VH‑XUM and bulk carrier Star Coral, about 200 km north‑east of Mackay, Queensland, on 25 February 2025.

Contributing factors

• During take‑off, the helicopter likely experienced ground resonance, resulting in the rapid onset of significant vertical oscillations through the airframe.
• Discontinuing the take‑off after the onset of the vibration, with the rotor speed in the flight range, probably resulted in the loss of control and substantial damage to the helicopter.

Safety actions

Safety action by Flyon Helicopters 

Following this occurrence, the helicopter’s operator, Flyon Helicopters, established ground resonance guidelines for its pilots. Forming part of its exposition, the guidelines were purposed to raise awareness of ground resonance and provide information about how to recognise and respond to the phenomenon. They included response procedures and featured case studies and video resources. The procedures were to be implemented into the operator’s training framework for new and current pilots. 

Flyon Helicopters advised the ATSB that it also planned to implement an additional briefing procedure in its training and checking manual (TACM). The briefing is to be conducted by the training or checking pilot prior to any training or checking flight. It will include:

• the objectives and scope of the flight, including the intended lesson plan or sequence
• the training/checking outcomes
• the roles of each pilot, including the allocation of aircraft command responsibility
• procedures for transferring aircraft control between pilots
• actions to be followed in the event of an actual emergency
• procedures to be used in the simulation of emergencies
• procedures for the conduct of unusual operations
• the method to be used to simulate instrument flight conditions, if required
• human factors/non‑technical stills and threat and error management.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilots and operator of VH-XUM
• the master and manager of Star Coral
• the helicopter manufacturer, Leonardo Helicopters

References

Lemmens Y, Troncone E, Dutré S, Olbrechts T. (2012). Identification of Helicopter Ground Resonance with Multi-body Simulation, 28^th International Congress of the Aeronautical Sciences

United Kingdom Ministry of Defence, AP3456 Central Flying School Manual of Flying Vol 12 - Helicopters

Salini S N, Haradev G S, Ranjith M. (2020). Ground Resonance: Nonlinear Modelling and Analysis, 6th Conference on Advances in Control and Optimization of Dynamical Systems (ACODS), India

United States Federal Aviation Administration. (2019). Helicopter Flying Handbook

Schafer J. (1980). Helicopter Maintenance

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 pilots and operator of VH-XUM
• the master and manager of Star Coral
• the ship’s flag State administration, The Bahamas
• the helicopter manufacturer, Leonardo Helicopters
• Agenzia Nazionale per la Sicurezza del Volo (ANSV)
• Civil Aviation Safety Authority
• Australian Maritime Safety Authority 

Submissions were received from:

• the pilots of VH-XUM
• the ship’s flag State administration, The Bahamas
• the helicopter manufacturer, Leonardo Helicopters
• Agenzia Nazionale per la Sicurezza del Volo (ANSV)

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. Terminology 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.

The ATSB is investigating a misaligned take-off involving a Bombardier Inc DHC-8-315, registered VH-TQM, at Mildura Airport, Victoria, on 25 February 2025.

Just prior to first light, the aircraft was inadvertently lined up with the edge lights for runway 09 rather than the runway centreline. During the take-off roll the aircraft struck and damaged multiple runway edge lights. Once the flight crew identified their incorrect position, they realigned the aircraft with the centreline and continued the take-off. On arrival in Melbourne, it was identified that the aircraft had sustained minor damage.

The draft report internal review process has been completed. The draft report has been distributed to directly involved parties (DIPs) to check factual accuracy and ensure natural justice. Any submissions from those parties will be reviewed and, where considered appropriate, the draft report will be amended accordingly.

Following the external review process, any submissions and amendments to the draft report are internally reviewed. Once approved, the final report is prepared for publication and dissemination and released to DIPs prior to its public release.

The 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 that appropriate safety action can be taken.

Preliminary report released 27 February 2025

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 7 January 2025 a Cessna 208 Caravan Amphibian (floatplane), registered VH-WTY and operated by Swan River Seaplanes, was being utilised for non-scheduled passenger air transport flights to and from South Perth and Rottnest Island, Western Australia. 

At about 0840, the pilot and 10 passengers prepared for the flight to Rottnest Island. Prior to boarding at South Perth, passengers watched a safety briefing video and were fitted with life jackets. At 0915 the aircraft departed, before climbing to a cruising altitude of about 1,600 ft. The aircraft orbited to the north of Rottnest Island, then landed in a south-south-west direction on the waters of Thomson Bay at 0926 (Figure 1). Passengers recalled that the flight was uneventful. The passengers alighted the aircraft onto a pontoon and were then conveyed to the island onboard a tender vessel. The aircraft remained at Thomson Bay throughout the day, with the pilot remaining on the island.

Figure 1: Map showing Rottnest Island and key locations in Thomson Bay (inset)

Source: Google Earth, annotated by the ATSB

At 1116, the chief pilot of Swan River Seaplanes sent the pilot a text message stating that winds were forecast to increase that afternoon, and included an image from a weather website, showing that winds at Rottnest Island were 25 kt with gusts to 34 kt.

The pilot responded that they may need to return to South Perth earlier than the planned 1600 departure time. The chief pilot indicated they agreed with this, stating that if necessary the passengers could return via ferry. The pilot responded to this text with a thumbs up.

CCTV recordings showed that at about 1305, the tender vessel used by Swan River Seaplanes to ferry passengers to and from the pontoon in Thomson Bay departed from alongside the aircraft. The video appeared to show the pilot travel north on the vessel from the pontoon. The vessel was then returned to shore where it was docked at a jetty on Rottnest Island at about 1320.

At about 1330, the pilot sent a text message to the chief pilot of Swan River Seaplanes, stating that the wind had reduced but the swell remained high at the normal departure location. The pilot stated they planned to depart taking a quartering crosswind closer to shore, where they perceived conditions were calmer. The chief pilot responded to this message stating they trusted the pilot’s judgement, encouraging the pilot to resist any perceived pressure to depart. Following this exchange, there was no further discussion around rescheduling the departure time.

At about 1500 the pilot requested the coxswain take them out in the tender vessel to the area normally used for floatplane departures from Thomson Bay to inspect the sea conditions. The coxswain recalled perceiving that conditions were rough, with swell about knee to waist high, and wind of at least 30 kt. The coxswain recalled that the pilot determined the conditions to be unsuitable for the planned departure, and requested to be taken closer to the southern shore of Thomson Bay. The coxswain recalled that conditions were calmer in this location, and the pilot had planned to depart on an easterly track towards Phillip Rock. 

At 1511, one of the directors of Swan River Seaplanes texted the pilot and asked about the wind conditions. The pilot responded that conditions were ‘ok but rough’, however the swell was ‘not too bad’ closer to shore. The pilot also noted in that text message conversation that the aircraft would be ‘pretty light’ for the departure. 

At about 1540, the passengers for the flight from Rottnest Island to South Perth were conveyed via the transfer vessel to the pontoon where the aircraft was moored. There were 6 passengers for the return flight, all of whom had travelled to Rottnest on the flight earlier that morning. Passengers described conditions onboard the vessel and pontoon as rough and windy. Each passenger was fitted with a life jacket before boarding the aircraft.

Once all passengers were boarded, the pilot signalled to the coxswain to release the mooring lines securing the aircraft to the pontoon. The aircraft then drifted before the pilot started the engine and taxied the aircraft to the south then north-west, before lining up for an easterly take‑off (Figure 2). At 1558, while taxiing the aircraft, the pilot was recorded making a broadcast on the Rottnest Island Common Traffic Advisory Frequency, announcing an intention to depart from Thomson Bay to the south-east.

Figure 2: VH-WTY take-off track with approximate location of key events 

Source: Google Earth, annotated by the ATSB

Flight data showed at 1600:20 engine power was applied for the take-off. Over the following 32 seconds, the aircraft travelled along the surface of the water in an easterly direction. Witness video and the fight data showed that at 1600:52,[1] as the aircraft approached the western tip of Phillip Rock it became airborne with a high nose attitude. At 1600:58, the aircraft rolled rapidly to the left with the left wingtip and then fuselage impacting the water. Further description of the aircraft behaviour during the take-off sequence is described in Recorded information. 

Survivors and other witnesses recalled the aircraft remained partially afloat in a perpendicular orientation, with the aircraft nose resting on the sea floor. The survivors reported that all cabin doors were submerged. The rear windows were not submerged. Four passengers moved into a pocket of air in the rear cabin and one of the passengers opened the top section of the rear right door. They and another passenger exited through this door. The coxswain of the tender vessel broke the rear left aircraft window, and 2 passengers recalled escaping through this broken window.

The pilot and the 2 other passengers remained in the aircraft, which later sank. Western Australia Police Force (WA Police) divers recovered the 3 deceased occupants in the evening of 7 January 2025.

Context

Pilot information

The pilot held a commercial pilot licence (aeroplane), with a current single-engine class rating and endorsements including for floatplane operations. The pilot had a current Class 1 medical certificate, with no restrictions.

The pilot had a total aeronautical experience of over 1,900 hours, including almost 1,400 hours on floatplanes and over 2,600 water landings. The pilot had about 700 hours experience in the Cessna 208 Caravan Amphibian, including over 60 hours accrued since commencing with Swan River Seaplanes in October 2024. Since commencing with the operator, the pilot had conducted 102 water landings, 12 of which were at Thomson Bay.

Aircraft information

VH-WTY (Figure 3) was a Cessna 208 Caravan Amphibian[2] floatplane, powered by a single Pratt & Whitney Canada (P&WC) PT6A-114A turboprop engine and a 3-bladed McCauley constant speed propeller. The aircraft was fitted with Wipline Model 8750 amphibious floats which enabled operation from both land and water. It was configured in a 13-seat interior layout. The aircraft was manufactured in the United States in June 2016, then registered in Australia in September 2016. It had accumulated about 1,125 hours total time in service at the time of the accident. Further aircraft information is detailed in VH-WTY maintenance history below.

The aircraft had 2 crew entry doors at the front of the cabin, next to the pilot (left) and copilot (right) seats. The crew entry doors had interior and external handles, which could be set to OPEN, CLOSE and LATCHED positions. The doors were also equipped with separate locks, and with lock override knobs inside the aircraft. To close the door, aircraft operating procedures instructed pilots to place the handle in the CLOSE position and pull the door closed, before rotating the handle to the LATCHED position. When unlocked and in the LATCHED position, the crew entry doors could be opened from either inside or outside the aircraft by rotating the handle to the OPEN position.

There were also 2 doors towards the rear of the cabin, each with a horizontal clamshell opening. Each rear door included separate handles for the upper and lower sections, and the upper section had to be opened first by pulling the handle inwards before rotating it from CLOSED to OPEN. When the lower section of the right rear door opened, a set of integral airstairs deployed.  Information about passenger use of these exits following the accident is described in Seating arrangement and occupant injuries below.

Figure 3: VH-WTY

Source: www.JetPhotos.com, Sebastian Sowa

Location information

Rottnest Island is located 18 km offshore the West Australian coast. The island has a sealed runway with 1,293 m available for the take-off run at Rottnest Island Airport. The runway is oriented east-west.

Thomson Bay is situated on the eastern side of Rottnest Island and is the main landing point for marine vessels visiting the island. Phillip Rock is a rocky outcrop about 400 m offshore the eastern tip of Thomson Bay.

The operator had received approval to conduct water landings and departures into and out of Thomson Bay. Swan River Seaplanes pilots reported that flights to Rottnest Island would normally utilise the sealed runway at the airport, and that Thompson Bay would only be utilised if forecast weather (wind direction and wind speed) would make the sealed runway unsuitable. The approval included a designated landing area, located in the south-eastern end of Thomson Bay, with the south-western area of the landing area subject to a 5 kt marine traffic limitation (Figure 4). Company pilots reported that it was normal practice to depart from Thomson Bay along a southerly track and to become airborne prior to the 5 kt limitation.

An initial review of flight data by the ATSB showed results consistent with these recollections. There were 6 flights which departed from Thomson Bay after Swan River Seaplanes commenced operations with VH-WTY on 2 January, comprising 3 flights on 4 January, 2 flights on 5 January, and the accident flight on 7 January. All these flights departed with a southerly track, except for the accident flight which departed with an easterly track (Figure 5). 

Figure 4: Thomson Bay approved floatplane landing area

Source: Google Earth and Rottnest Island Authority, annotated by the ATSB

Figure 5: Recorded departure tracks for VH-WTY within Thomson Bay displaying the difference between the accident flight and the previous flights

Source: Google Earth, annotated by the ATSB

Weather and sea conditions

The Bureau of Meteorology automated weather information service (AWIS) located at Rottnest Island Airport provided meteorological observations at one-minute intervals. At 1600, the AWIS reported winds of 25 kt from 210° (approximately south-south-westerly). The temperature was 24°C.

Witnesses to the accident recalled strong gusty winds in Thomson Bay throughout the afternoon of the accident. Video recordings taken on the afternoon of the accident showed that the sea was calm close to the southern shore of Thomson Bay. Further into the bay, however, waves were larger and more frequent. The sea state around the aircraft during the take-off run was choppy, with some white caps. Video showed that beyond the eastern end of Thomson Bay, sea conditions became significantly worse, with larger and more frequent white caps (Figure 6). 

Figure 6: Aerial view shortly after the accident near to the impact point showing the rougher sea state outside of Thomson Bay (top), with surface photography from a vessel in Thomson Bay (bottom left) and a witness on the shore (bottom right) showing conditions shortly before the accident. 

Note: The police video (top image) was captured at about 1627, approximately 26 minutes after the accident.

Source: Western Australia Police Force, ferry operator and witness video, modified by the ATSB

Site and wreckage information

Accident site information and wreckage recovery

Analysis of witness video and information recorded by avionics and navigational equipment onboard the aircraft showed that the aircraft collided with the sea approximately 70 m south-east of Phillip Rock. The right float and part of the left float separated from the aircraft after the collision, and these were later recovered by WA Police and members of the public. The rear section of the left float remained tethered to the aircraft by the fly wire and sea rudder control cables.

The aircraft drifted approximately 800 m north of Phillip Rock until being tethered to the sea floor by WA Police divers. Their dive video showed that the main body of the aircraft remained largely intact following the collision (Figure 7). On 9 January 2025, commercial salvors lifted and recovered the aircraft using barges and a crane (Figure 8), before it was transported to a secure storage facility near Perth for further examination. 

Figure 7: The aircraft sank inverted onto the sea floor within Thomson Bay 

Source: Western Australia Police Force

Figure 8: VH-WTY recovery from Thomson Bay

Source: ATSB

Wreckage examination

Examination of the aircraft wreckage at the secure facility identified:

• The wings, fuselage and floats did not display any physical markings that the aircraft had struck landmass or a submerged object prior to the collision with the sea.
• The engine controls were attached to the associated engine components and were free to move through their full range of movement.
• The propeller blades were intact and attached to the propeller hub. They could be rotated through 360º about the feathering axis, indicating internal damage to the feathering mechanism. The investigation will include further analysis to determine the significance of this damage.
• All 3 propeller blades were significantly bent toward the blade face. The significance of this was not able to be determined due to the propeller assembly resting on the sea floor prior to recovery.
• The primary flight controls could not be moved due to structural damage from the accident. The flight pushrods, bellcranks and control cable hardware were examined for continuity and correct assembly. No pre-existing damage or defects were identified.
• The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.
• The instrument panel and combing appeared undamaged. All circuit breakers were pushed in except those corresponding to the strobe light and stall warning.
• The wings were swept back, with significant damage to both wings outboard of the ailerons. The left wing section, outboard of the aileron pushrods, was separated during the accident sequence and not recovered.
• Video footage from WA Police divers for the recovery of the deceased occupants showed that the left (pilot) crew door was in the LATCHED position and the right crew door was in the LATCHED position. The upper section of the right rear door was open but the lower section, incorporating the airstairs, remained closed. Both sections of the left rear door were closed (with ATSB examination showing both handles in the CLOSED position).[3] The ATSB examined the functionality of all doors and determined that they could be unlatched and opened. Some doors were difficult to open, most likely due to structural damage to doorframes following the accident. 

Engine examination

• P&WC provided an engineering specialist to complete an internal borescope inspection of the engine. No evidence of pre-accident damage was identified.
• The engine was removed from the aircraft in preparation for detailed teardown examination at the P&WC facilities in Canada. The ATSB analysis will consider the report from that examination.

Recorded information

The ATSB recovered the Garmin G1000 avionics equipment from VH-WTY. Using the flight data recovered from the G1000, witness video recordings of the accident, and automatic dependent surveillance broadcast (ADS-B) data[4] the following was identified:

• Engine power was applied to commence the take-off at 1600:20, with the aircraft about 600 m from the western tip of Phillip Rock, and at a heading of 108°.
• Fifteen seconds into the take-off the aircraft had accelerated to 40 kt and was about 400 m from Phillip Rock. The aircraft transitioned onto the step[5] and the nose was lowered. The aircraft heading was manoeuvred on a course between Phillip Rock and the eastern tip of Thomson Bay.
• About 200 m from Phillip Rock, and with a recorded airspeed of 46 kt, the aircraft appeared to cross a wave or swell. Video footage showed the aircraft appearing to bounce on the water, becoming airborne momentarily before settling back onto the water.
• Over the next few seconds, the left wing rose on 2 occasions as the aircraft approached Phillip Rock, with the left float separating from the water. On each occasion, the aircraft struck waves and the right float did not separate from the water.
• There was a gradual reduction in engine power for about 20 seconds, commencing prior to the aircraft becoming airborne.
• About 30 m from Phillip Rock, the aircraft had accelerated to a recorded airspeed of 57 kt, and again appeared to strike waves.
• At 1600:52, the aircraft then became airborne, with a nose high attitude and on a heading of about 110°. Over the next few seconds, the aircraft maintained a nose-up attitude of between about 15°–18°. The aircraft climbed to about 16 ft above the surface of the water. The right wing then dropped, followed by an apparent aerodynamic stall of the left wing, with the aircraft rolling to the left.
• A witness video recording at about the time the aircraft separated from the water showed that the flaps were extended for take-off. The video also indicated the water rudders were extended.
• At 1600:56 the engine torque increased rapidly.
• At 1600:58 the left wingtip struck the water then followed by the fuselage. 

Seating arrangement and occupant injuries

Surviving passengers recalled watching a safety briefing video prior to boarding the flight to Rottnest Island on the morning of the accident, with the pilot providing an additional safety briefing in the aircraft prior to departing from South Perth. Passengers recalled that there was no briefing provided prior to the departure from Thomson Bay, with the pilot asking if the passengers recalled the briefing from the morning. Passengers reported that the safety video and pilot briefing were thorough and provided adequate information on the use of seatbelts and the location and use of the aircraft exits.

One passenger additionally recalled that during boarding the aircraft prior to the departure from Thomson Bay, the pilot requested the passenger assist with closing and latching the left rear door. The passenger considered that the pilot’s instructions for closing the door were crucial for the passenger to subsequently open the right door after the aircraft struck the water. 

The ATSB identified multiple safety information cards for the Cessna 208 Caravan in the aircraft wreckage, which showed information including the location of the aircraft exits, and how to unlatch and open the aircraft doors.  

Surviving passengers recalled wearing life jackets during the accident flight. The life jackets worn by passengers were designed for constant wear in a pouch, with a belt securing the pouch around the waist. The life jackets were designed to be donned and inflated when required in an emergency. The life jackets could be inflated using a gas-cylinder inflation system or using an oral inflation system. 

Surviving passengers recalled that the seating positions (Figure 9) for the accident flight were as follows:

• The pilot was seated in the normal position in the front left seat, and there was no passenger seated in the front right (copilot) seat.
• Two passengers were seated in the second row, with the central seat vacant. The passenger seated in the left seat was fatally injured in the accident. The passenger in the right seat recalled escaping through the rear left window, which had been broken by the coxswain of the operator’s tender vessel.
• Two passengers were seated in the third row, with the central seat vacant. The passenger seated in the right seat was fatally injured in the accident. The passenger seated in the left seat was pulled from the aircraft through the left rear window by the coxswain of the operator’s tender vessel.
• Two passengers were seated in the fourth row, with the central seat vacant. Both passengers in the fourth row survived the accident. The passenger seated in the left seat of the fourth row opened the top section of the right rear door, through which they exited the aircraft along with the passenger seated in the left seat of the fourth row. 

The investigation will consider the post-mortem examination reports for each of the fatally injured occupants, including in support of analysis of the accident survivability.  

Figure 9: Cessna 208 seating plan showing the occupant location for those who survived (green) and those who sustained fatal injuries (red)

Passengers were able to exit the aircraft using the top section of the right rear door (upper inset) and left rear window (lower inset).

Source: Textron Aviation, modified by the ATSB 

Swan River Seaplanes

Swan River Seaplanes conducted Part 135 of CASR air transport operations for the purpose of passenger flights from the Swan River to Rottnest Island and Margaret River, Western Australia. It also operated flights around Perth, Western Australia, departing and landing on the Swan River. The operator reported commencing flights to Rottnest Island in October 2017, with operations from Thomson Bay commencing in January 2023. 

Swan River Seaplanes had cross-hired VH-WTY, commencing passenger‑carrying flights in the aircraft on 2 January 2025. Swan River Seaplanes operated another Cessna 208, registered VH‑UOZ, however due to maintenance requirements this aircraft had been unavailable for operations since December 2024. 

Swan River Seaplanes had 3 line pilots including the chief pilot. Another pilot, who conducted check and training for the operator, had also previously conducted line flights but was not operating in that function at the time of the accident. 

VH-WTY maintenance history    

Maintenance documentation for VH-WTY showed that:

• The aircraft had been operated in the Whitsunday region of Queensland (Qld) since arrival into Australia. In the period between 29 June 2021 to 20 October 2023, it had not been operated and was inactive at Shute Harbour Airport, Qld.
• It was then flown to Caloundra, Qld where it stayed for 31 days, and then flown to Sunshine Coast Airport, Qld where it remained for 37 days. It was not operated during these periods except for a relocation flight where it was flown to Bankstown Airport, New South Wales (NSW) on 3 March 2024.
• The aircraft had been inactive at Bankstown, NSW, from 4 March 2024 to 27 December 2024, with no recorded flights. Maintenance releases and logbooks did not show evidence of engine or airframe preservation having been performed for the periods of storage of the aircraft.
• On 27 December 2024, a special flight permit was issued by an authorised approver on behalf of the Civil Aviation Safety Authority, for a ferry flight to Jandakot, Western Australia (WA). This permit was required due to the expiry of the maintenance release on 20 October 2024.
• Maintenance documentation showed that a new battery was installed in the aircraft at Bankstown on 27 December 2024.
• On the morning of 28 December 2024, a 12-minute flight was recorded for the Bankstown Airport flying circuit.
• From 28 December to 29 December 2024, the aircraft was flown from Bankstown Airport, NSW to Jandakot Airport, WA.
• The aircraft and engine logbooks identified that from 30 December 2024 to 1 January 2025, the airframe, floats and role equipment (life jackets, fire extinguisher and first aid kit) were inspected. From the records, a new elevator pushrod bearing was installed, and new rudder pulleys were installed for the left and right floats. Engine work included a compressor power recovery wash and desalination rinse. Additionally, the chip detector plugs were recorded to have been inspected with no defects listed.

Further investigation

To date, the ATSB has conducted the following activities:

• interviewed Swan River Seaplanes personnel and survivors of the accident
• examined the aircraft wreckage
• reviewed information recorded by avionics equipment onboard VH-WTY
• reviewed the forecast and observed weather conditions at Rottnest Island
• reviewed video recordings from witnesses, CCTV and other sources.

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

• information recovered from mobile devices
• the recorded data from the aircraft engine
• the results of the engine teardown by Pratt & Whitney Canada
• weather and sea conditions in Thomson Bay on the day of the accident
• the information available to the pilot for Thomson Bay operations on the day of the accident
• the operator’s procedures and other risk controls for assessing the suitability of planned floatplane departures from Thomson Bay
• the history, identification and assessment of Thomson Bay for floatplane operations
• the aircraft maintenance history
• pilot training records, medical information and recent history
• pilot and passenger injuries and post-mortem reports
• the safety briefings provided to passengers, the location and availability of exits after the accident, and the performance of the aircraft seatbelts
• regulatory oversight and surveillance for the floatplane operations from Thomson Bay and for the maintenance of VH-WTY.

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 acknowledges the support of the Western Australian Police Force and those involved with the recovery of VH-WTY.

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. Terminology 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.

The ATSB assisted the New South Wales Police Force with an investigation into a collision with water involving a TL Ultralight Sting S4, registered 23-1677, 5 km north-west of Scotts Head, New South Wales, on 4 January 2025. This assistance was initiated at the request of Recreational Aviation Australia (RAAus).

While reportedly conducting flying training, the aircraft collided with water resulting in fatal injuries to the 2 occupants. The aircraft was destroyed.

As part of an investigation by the Coroner’s Court of New South Wales, the ATSB provided assistance to the NSW Police by conducting an onsite technical examination of the recovered airframe. The ATSB found that the predominantly composite airframe was significantly disrupted, consistent with a relatively high energy impact with the water. Almost all of the major airframe components, flight controls, linkages, and control surfaces were available and examined by the ATSB, which did not identify any pre-existing defects that could have contributed to a premature, in-flight component failure.

Information on ATSB investigation of sport aviation accidents is available here.

Any enquiries relating to the investigation should be directed to the New South Wales Police Force.

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 4 December 2024, at about 0530 local time, a Robinson R44 Raven II helicopter, registered VH-XIX, departed from Griffith Regional Airport, New South Wales to conduct a ferry flight to a property approximately 50 km east of Young. Onboard were the operator’s Griffith base manager and a loader[1] (acting as pilot for the ferry flight). They arrived at a paddock on the farm at 0744, landing next to a chemical tank. They were met by the farm manager of the property, and the pilot for the day, who had arrived shortly before by motor vehicle from Crookwell. The tasking for the day was the aerial application of herbicide across 2 properties, to be conducted under Part 138 of the Civil Aviation Safety Regulations.

The base manager, pilot, loader and farm manager discussed the day’s work and then prepared the helicopter for spraying operations, including refuelling the helicopter, attaching the spray booms and mixing herbicide. At 0912, the pilot and base manager, who had sprayed the paddocks previously, flew the helicopter on a reconnaissance mission of the intended paddocks returning 5 minutes later. 

The helicopter was loaded with herbicide and, at 0921, the pilot departed for application of the first load of the day. The pilot applied 10 loads consecutively. Each load took around 10 minutes to apply, with the pilot returning for the helicopter to be replenished with herbicide, and fuel as required, before immediately departing again. 

Toward the end of this activity, the farm manager from an adjacent property arrived and discussed the task for the second property with the base manager. During this time, the pilot departed for the 11th and planned final load of the job on the first farm. After 15 minutes, the base manager realised the helicopter should have returned and tried, unsuccessfully, to contact the pilot via ultra‑high frequency radio in the work vehicle. The base manager then checked a flight tracking application on their mobile phone that showed the helicopter had not moved from its last indicated location for a couple of minutes. The base manager and second farm manager departed in the farmer’s vehicle toward the intended spray area, while the loader stayed to monitor the work vehicle’s radio. 

Prior to the flight, high tension powerlines that ran through the middle of the intended spray area had been identified as a hazard to the operation. The base manager and farmer headed to a location near the powerlines but could not find the helicopter. After further searching, they located the wreckage of the helicopter in a gully. They made their way down to the helicopter and found the pilot had exited the helicopter and moved approximately 1 m away but was seriously injured. Emergency services attended, however, the pilot succumbed to their injuries. 

Context

Pilot information

The pilot held a commercial pilot licence (helicopter) with a single-engine helicopter class rating. The pilot had 1,035 hours total aeronautical experience, of which 637 hours were on the R44 type. Most of the pilot’s recent flying had been on the R44. The pilot also held a gas turbine design feature endorsement, and numerous piston and turbine type ratings. In addition, the pilot held aerial application, low-level, and sling operational ratings. The pilot had spent approximately 3 years flying agricultural helicopters in New Zealand where they also obtained a mountain flying operational rating.[2]

The pilot held a valid class 1 aviation medical certificate and was reported as appearing well rested and fully alert for the flight. 

Helicopter information

The Robinson R44 Raven II is a 4-seat helicopter, powered by a single Textron Lycoming IO‑540‑AE1A5 piston engine driving a 2 blade semi-rigid main rotor system and 2 blade tail rotor system. The helicopter was manufactured in the United States in 2003 and first registered in Australia in May 2003. It was issued with a special certificate of airworthiness in the restricted category in January 2017. The certificate permitted VH-XIX to be used in agricultural operations and aerial surveying, among other similar operations. 

A periodic inspection and minor maintenance tasks were carried out on 30 October 2024. At the time of the accident, the helicopter had accumulated about 5,820 hours. The helicopter was configured with an agricultural spray system, which consisted of 2 fibreglass chemical tanks, a flexible hose and stainless-steel tubing distribution system, a petrol‑powered water pump, valving systems, and 2 cantilevered carbon fibre spray booms, one each on either side of the fuselage. 

Meteorological information 

The closest Bureau of Meteorology weather station was at Young Airport, 50 km to the west of the accident site, which reported winds of 7–8 kt from the north-west and a temperature of 28°C in 30‑minute windows around the time of the accident. Cloud cover[3] was measured as few at 3,500 ft and broken at 4,800 ft. Cowra weather station, 53 km to the north, reported winds of 4‍–‍7 kt varying between northerly and westerly and a temperature around 28–30°C. Cloud cover was not recorded.

Wunderground.com is a weather network designed to provide public access to community weather stations. A weather station at Boorowa, 14 km south-south-west of the accident site, reported wind, in 5-minute windows, of 6.8 km/h (3.6 kt) gusting to 7.3 km/h (3.9 kt), from the south‑south‑‍west and a temperature of 19°C around the time of the accident. Another weather station at Frogmore, 8 km to the north-east, reported wind of 0.9 km/h (0.5 kt) gusting to 1.9 km/h, (1.0 kt) from the north-north-west, with a temperature of 22°C.

Wreckage and impact information

The wreckage was located about 1,200 m south-south-east of the base of operations for that day, in a steep gully towards the southern end of the target spray area. The area was in hilly terrain and contained high dry grass with scattered large alive and dead eucalyptus trees.

The first items in the debris trail were the stabiliser assembly, right side carbon fibre spray boom and broken branches. These items were located next to a dead tree, with freshly broken branches on one side, near the top (Figure 1).

The helicopter was orientated on its left side and facing the direction of the travel. The main fuselage had sustained minor impact damage, with the exception of the cabin, which was significantly disrupted. Outboard sections of both main rotor blades had been liberated during the accident sequence. For the tail rotor assembly, one liberated tail rotor blade, and sections of the tailcone were scattered to the right of the ground path. Despite the disruption, all components of the helicopter were accounted for.

Two ground scars, consistent with the landing gear skids, were located between the tree and the wreckage in the gully. The ground marks were indicative of the upright helicopter sliding along the ground, prior to reaching the edge of the gully.

Figure 1: Wreckage site

Note: Ground scars from the helicopter skids are highlighted red. 

Source: ATSB

While the ATSB conducted a preliminary examination of the wreckage at the site, due to access restrictions, the wreckage was relocated to a secure facility for detailed examination. This further examination identified:

• no evidence of pre-impact defects with the flight controls or structure
• approximately 55 L of low-lead aviation fuel in the fuel system, which was visibly clear of contaminants and tested negative to the presence of water
• the engine was able to be rotated, contained oil and there were no obvious defects upon external examination
• the fuel gascolator, engine oil, hydraulic fluid, and intake air filters were clear of particles
• the air intake hose had no signs of collapse, delamination or restriction
• the main and tail rotor gearboxes contained oil, with no metal contamination on the respective chip detectors.[4]

Recorded data

The helicopter had analogue instrumentation and did not record any flight or engine parameters.

A SpotTrace device was carried inside the helicopter, which broadcast the device’s position every couple of minutes when movement was detected. Anybody with access rights could see the position of the tracking device using a computer or mobile phone application. The SpotTrace device broadcast the position of the helicopter from shortly after take‑off that morning, until the helicopter stopped moving, in a position coincident with the collision with terrain.

To assist with aerial application tasks, the helicopter was also fitted with a Tracmap GPS guidance device with recording capability. The flight tracks from the day of the accident were recorded and downloaded, including information about when the spray valve was open (Figure 2 in orange), up until a couple of minutes before the accident. Due to the sudden removal of power, some data collected towards the end of the flight was not able to be downloaded. A chip level recovery[5] was conducted from the device but it contained no further information.

Figure 2: Tracmap spray runs completed

Note: The last few minutes of the flight and spray runs were not recorded. 

Source: Google Earth Pro, annotated by the ATSB using operator and onboard data sources

Further investigation

To date, the ATSB has conducted witness interviews, collected documentation and recorded data, and examined the site and wreckage.

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

• witness accounts
• recorded data
• the wreckage
• helicopter documentation
• operational records
• pilot medical records, qualifications and experience.

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 Young branch of the NSW Police Force during the onsite stages of the investigation.

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. Terminology 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.