Control issues

Investigation summary

What happened

On 20 September 2025, the pilot of a Cessna 208 aircraft, registered VH-DVS, was conducting parachute operations for Far North Freefall Club at Tully Airport, Queensland. After successfully completing 2 parachute drops that morning, at 0950 local time the aircraft took off for the third load of the day with 17 parachutists on board. The plan was for the parachutists to conduct a 16-way formation filmed by a parachuting camera operator.

After the aircraft climbed to about 15,000 ft, the pilot signalled to the parachutists to exit. The camera operator stepped out onto a small step and held on to the fuselage outside and aft of the cabin door. As the first parachutist (P1) stepped out the door to assume the most forward (front float) position, their reserve parachute inadvertently deployed, dragging P1 backwards and dislodging the camera operator into freefall, causing them a minor injury. P1’s legs were injured as they struck and damaged the aircraft’s horizontal stabiliser. The parachute wrapped around the horizontal stabiliser and the elevator, suspending P1 beneath it. 

Thirteen parachutists exited the aircraft and 2 remained in the doorway, watching as P1 used a knife to cut sufficient reserve parachute lines to enable the parachute to tear free. P1 then deployed their main parachute, which tangled with the remnants of the reserve parachute. P1 was able to untangle the lines and regain sufficient control of the main parachute to land without further incident.

Despite control difficulties due to substantial damage to the horizontal stabiliser and part of the reserve parachute wrapped around the tail, the pilot safely landed the aircraft at Tully Airport.  

What the ATSB found

The ATSB found that as the first parachutist climbed out of the aircraft and into the front float position, their reserve handle snagged on the aircraft's flap, resulting in deployment of the reserve parachute. The parachute wrapped around the now-damaged tailplane, resulting in aircraft control difficulties.

The ATSB also found that, although it did not contribute to the accident, the pilot and aircraft operator did not ensure the aircraft was loaded within its weight and balance envelope. 

Furthermore, the ATSB found that the parachutists opened the roller door and clipped it open before exiting the aircraft. As a result, the roller door remained open during the descent, increasing the ease with which the pilot could have exited the aircraft if needed. Although not mandatory at the time of the accident, the parachutist had a hook knife attached to their chest strap, enabling them to cut enough reserve parachute lines for the parachute to tear free of the tailplane. Finally, in difficult circumstances, the pilot managed to control the aircraft and return to land safely.

What has been done as a result

To ensure aircraft are loaded within their weight and balance envelope, and this is documented on a load sheet, Far North Freefall Club (FNFF) has:

• engaged with the current software distributor about including balance in the manifest system
• commenced investigation of alternative software
• implemented a proprietary interim system that calculates and graphically displays the centre of gravity position on the aircraft’s weight and balance envelope, indicating whether it is within or outside limits.  

Additionally, FNFF distributed a circular to all company pilots reminding them of the requirement to use supplemental oxygen when the aircraft is at or above flight level 140, and of the risks of hypoxia. FNFF also mandated parachutists carry a hook knife.

Furthermore, FNFF updated the loadmaster checklist within its safety management system. The checklist is displayed around the drop zone to raise awareness of loadmaster roles and procedures in the event of an emergency. A circular has also been sent to all current company loadmasters to reinforce familiarity with in-aircraft emergency procedures.

In addition, the FNFF safety team is reviewing its standard operating procedures manual to ensure all procedures, including those relating to loadmaster training and emergency response, are clearly documented and up to date. FNFF is also preparing a training slideshow incorporating footage from the incident. This presentation will be shared across the wider skydiving community for educational purposes.

Finally, at the time of writing, the Australian Parachute Federation was in the process of developing a guide for loadmasters. The guide will detail the role and responsibilities, including during an emergency. It will take into consideration the range of complexity of various operations, and aircraft type and size. Training and assessment material will also be developed.  

Safety message

This accident highlights the importance of parachutists being mindful of their handles particularly when exiting the aircraft. Additionally, this accident demonstrates that carrying a hook knife secured to the parachute container could be lifesaving in the event of a premature reserve parachute deployment. It is also a reminder for pilots conducting parachute operations of the importance of wearing an emergency parachute and knowing how to deploy it. Parachute aircraft operators should also ensure, where possible, that there is a suitable open door for the pilot to exit in the event of an irretrievable loss of aircraft control. 

Furthermore, as fatal parachuting accidents have occurred due to aircraft being loaded outside the centre of gravity limits, this is a reminder for pilots and aircraft operators conducting parachute operations to ensure aircraft weight and balance calculations are conducted prior to each load.  

Finally, altitude hypoxia is an insidious and potentially deadly hazard associated with operations at high altitude. Although there is limited research into hypoxia for parachuting operations, effects of mild hypoxia can impair performance and judgement, critical for safe operations. Pilots conducting parachute operations are required to use supplemental oxygen at or above 14,000 ft, and should also do so during holding or delays above 10,000 ft, or when experiencing mild hypoxia symptoms. 

Summary video

The investigation

The occurrence

On 20 September 2025, the pilot of a Cessna 208 aircraft, registered VH-DVS, was conducting parachute operations at Tully Airport, Queensland. The aircraft and pilot had been hired by Far North Freefall (FNFF) skydive club based in Tully. In accordance with company policy, the pilot was wearing an emergency parachute.

After successfully completing 2 parachute drop loads earlier that morning, at 0950 local time, the aircraft took off for the third load of the day with 17 parachutists on board. The plan was for the parachutists to conduct a 16-way formation filmed by a parachuting camera operator. The parachute jump was part of the annual ‘Big Ways at the Beach’ multi-day event, hosted by FNFF, in which experienced parachutists completed large group formations in belly-to-earth[1] freefall. 

At 0954 local time, the pilot requested and received a clearance from Brisbane Centre air traffic control (ATC), to conduct parachute operations within 5 NM (10 km) of Tully Airport, up to flight level (FL) 150.[2] 

At 0959, the pilot advised ATC they were ‘3 minutes to drop’ and requested clearance to drop and then descend, which they received 14 seconds later. About 3 NM (5.6 km) prior to the drop point, the pilot illuminated a red light on the rear wall of the aircraft cabin to alert the parachutists.

At 1001, the pilot illuminated an orange light, indicating there was about 1 NM (1.9 km) to the drop. The camera operator and the first parachutist exiting (P1) then moved to the doorway and opened the roller door. The roller door was clipped open and remained open until after the aircraft landed. On reaching about FL 150, the pilot slowed the aircraft to 85 kt indicated airspeed and extended 10° of flap, before illuminating a green light at 1002. On seeing the green light, P1 tapped the camera operator on the shoulder. The camera operator then stepped outside the doorway, with their right foot on the camera step, their right hand on the handle above and aft of the door and their left hand on the bar at the top of the door frame. 

Parachutist 1 then crouched down and stepped out at the front of the doorway facing forwards, into the ‘front float’ position, with their right foot in the front corner of the door frame and their left knee under the wing (Figure 1).  

Figure 1: Parachutist 1 stepping out the door

Source: Jarrad Nolan, annotated by the ATSB 

Parachutist 1 then stood up outside the door, reaching for a small post on top of the fuselage with their left hand and lifting their left knee under the wing and flap. During this manoeuvre, P1’s left handle (pud[3]) snagged on the wing flap and rotated (Figure 2). 

Figure 2: Left pud (outlined in red) snagging on the flap and rotating

Source: Jarrad Nolan, annotated by the ATSB 

That movement dislodged the pud from the parachute container, deploying its reserve pilot chute (Figure 3). 

Figure 3: Pilot chute deployment 

Source: Jarrad Nolan, annotated by the ATSB

The pilot chute then pulled the reserve parachute and lines out of the container. As the reserve parachute inflated and the lines became taut, P1 was pulled off the side of the aircraft towards the tail, dislodging the camera operator into freefall (Figure 4 and 5). 

Figure 4: Reserve parachute inflating and dragging the parachutist rearwards

Source: Jarrad Nolan 

The reserve parachute wrapped around the left horizontal stabiliser and elevator and deflated as P1’s lower legs struck the stabiliser (Figure 5). P1 was then suspended beneath the tailplane (Figure 6). 

Figure 5: Parachutist 1 striking horizontal stabiliser as camera operator falls free

Source: Jarrad Nolan 

Figure 6: Reserve parachute wrapped around horizontal stabiliser with Parachutist 1 suspended beneath it

Source: Jarrad Nolan

Initially unaware of what had occurred, the pilot recalled feeling the aircraft suddenly pitch up and observed the airspeed rapidly decreasing. Assessing that the aircraft had stalled, the pilot pushed forward on the control column and applied some power. At that time, a parachutist called out that there was a canopy[4] wrapped around the tail. The FNFF senior pilot (on board as a parachutist), who was seated beside the pilot but facing rearwards, felt the aircraft shudder, and relayed to the pilot that there was a skydiver hung up on the tailplane. 

The pilot then reduced power and felt the controls vibrating. The pilot reported having to use significant forward pressure on the controls and right aileron input to maintain straight and level flight. To reduce some of the control pressure, the pilot applied full forward trim, which then jammed in that position for the remainder of the flight. 

After an initial hesitation, the loadmaster directed the other parachutists to exit. Over the next 15 seconds, 13 parachutists left the aircraft. The last 2 parachutists (the FNFF senior pilot and the loadmaster) remained in the doorway watching as P1 began to cut themselves free using a hook knife, retrieved from a pouch secured by a lanyard to the left side of their chest strap. 

P1 reported that they found the lines harder to cut than expected but managed to cut 11 lines in 50 seconds. The reserve parachute then tore, releasing P1 from the aircraft with part of the reserve remaining on the aircraft’s tail. The last 2 parachutists then exited the aircraft. 

Figure 7: Reserve canopy torn and parachutist detached from aircraft

Source: Jarrad Nolan 

At 1003 while in freefall, P1 used their main pilot chute handle to release the pilot chute out into the airflow, deploying their main parachute. However, during the main parachute deployment, the remaining reserve parachute lines twisted around the main parachute lines. Additionally, during the opening sequence, the right brake toggle[5] of the main parachute released (Figure 8).

The main parachute fully inflated with line twists, and after initially turning right, commenced a rapid left turn. After several rotations, P1 grabbed and pulled on the right brake line above the line twists to arrest the turn. The parachute stopped turning, and P1 was able to unwind the line twists and release the left brake toggle. Passing about 8,000 ft, the main parachute lines fully unwound from the reserve parachute lines and functioned normally for the remainder of the descent.  

Figure 8: Main parachute opening, left brake stowed and right brake toggle released, twisted main and reserve lines

Source: Adrian Ferguson

The pilot assessed they had limited pitch[6] control and with forward pressure could achieve a gradual descent. The pilot retracted the flap, which then allowed slightly more rudder, aileron and elevator control. The pilot reported maintaining about 120 kt airspeed during the descent and assessed that with the limited elevator movement available, they would be able to conduct a gentle flare for landing. The pilot also looked over their shoulder and saw the parachute remnant wrapped over the tail and the damage to the leading edge of the horizontal stabiliser. The pilot radioed the FNFF ground control assistant and advised them of the situation. 

At 1005, the pilot declared MAYDAY[7] to Brisbane Centre ATC, advising they had a canopy wrapped around the elevator ‘with minimal control input’. The pilot then advised ATC that their plan was to assess the aircraft’s controllability and try to land it, but if ‘the tail fell off’, they would attempt to advise ATC and ‘bail out’. 

The controller clarified details with the pilot and directed another aircraft in the area to remain clear. The controller then declared a distress phase,[8] alerted emergency services, and transferred other aircraft to a different Brisbane Centre frequency. 

Descending through about 2,500 ft, the pilot assessed that they would land the aircraft rather than exit and parachute to the ground. The pilot elected to conduct a straight-in approach with a slight tailwind to runway 36,[9] to minimise manoeuvring the aircraft clear of high terrain either side of Tully Airport. The pilot also assessed there was insufficient elevator control to be able to safely extend landing flap. 

As the aircraft crossed the threshold, the pilot initially reduced power, but this led the aircraft nose to drop significantly. The pilot then reintroduced power and flew level with the runway before reducing the throttle to idle and using both hands to apply full backpressure on the controls. The aircraft landed at 1010, having sustained substantial damage to the horizontal stabiliser (Figure 9). P1 landed 9 seconds later with minor lacerations and bruising to their left lower leg and a deep gash to their right lower leg. After receiving phone confirmation that the aircraft had landed safely, at 1018 ATC cancelled the distress phase. 

Figure 9: VH-DVS after landing, showing damage to the horizontal stabiliser

Source: Jarrad Nolan

Context

Personnel information

Pilot

The pilot held a commercial pilot licence (aeroplane), a class 2 aviation medical certificate and an instrument rating. They completed their most recent single engine aeroplane flight review and gas turbine engine design feature endorsement, as part of their jump pilot[10] authorisation in a Cessna 208 aircraft, on 21 June 2024.

The pilot had accrued 800 flight hours, 410 of which were operating Cessna 208 aircraft. They had been conducting parachute operations at Tully Airport for about 11 months and last conducted emergency procedures training for parachute operations in April 2025. 

Parachutist 1

The accident jump was the parachutist’s (P1’s) 2,013th over a 21-year period. P1 held an Australian Parachute Federation (APF)[11] Certificate E, and achieved the Australian Star Crest in 2011, required for participation in skydive formations of more than 10 people.[12] 

The parachutist’s equipment included:

• Sunpath Javelin Odyssey harness and container, SN 25429, manufactured December 2003.
• Airtec CYPRES 2 Expert automatic activation device, SN 96270 manufactured July 2014.
• Icarus Safire 2 139 main parachute, which was royal blue, fluoro yellow with a white centre cell.
• Bottom of container throwaway main deployment type.
• Performance Designs Optimum 143 reserve parachute, SN 25632, manufactured in October 2021. The reserve was repacked on 13 August 2025 by Freefall Support and valid for 12 months.
• A hook knife in a pouch attached to their chest strap and secured with a lanyard (Figure 10).

Figure 10: Parachutist’s hook knife and lanyard

Source: Supplied

P1 used puds – soft handles held in place with Velcro – for their reserve deployment and main cutaway handles, in preference to ‘D’ handles, which they reported had previously been snag points (Figure 11). The reserve handle was a ‘Phat Daddy Tube Style’, described as ‘a soft handle with the bulk required to get a good grip in an emergency’. The APF assessed that the bulky handle design ‘may have increased the risk of snagging if not adequately protected’.

Figure 11: Pud ‘Phat Daddy’ soft reserve handle (left) and D handle (right)

Source: www.sunpath.com

P1 commented that having a bright orange reserve parachute that was visually distinct from their main parachute meant that it was immediately obvious that it was their reserve that deployed prematurely. The APF reported that this type of deployment occurred far less frequently than premature deployment of a main parachute. 

P1 conducted their normal gear check when the red light illuminated, which comprised checking:

• 3 handles (main pilot chute, cutaway of main chute and reserve handle)
• 3 straps (leg and chest straps properly routed and tucked away)
• 3 rings properly assembled on shoulders
• 3 things: altimeter on the back of left hand, altimeter inside of right wrist and helmet done up. 

The accident jump was the parachutist’s first jump that day. P1 had an altimeter with a recording function, which showed that the reserve parachute tore free of the tailplane at 13,720 ft. After a freefall time of 26 seconds, the main parachute deployed at 10,780 ft. 

The front float position is the most forward person in line and whose ‘exit’ is from outside the aircraft. P1 preferred the front float position. This was their third jump in that position out of the 6 jumps they had done at Tully that week. P1 also reported that out of the 20‍–‍22 jumps they did the previous year at the Big Ways at the Beach event, they had been in the front float position for about 8 of them.

All the event jumps were practised first on the ground as a ‘dirt dive’ using a mock-up aircraft at the airport. The mock-up had outer pegs and inner bars, but not a wing or flap to simulate their position (Figure 12). 

Figure 12: Tully mock-up aircraft for practising ‘dirt dives’

Source: Far North Freefall, annotated by the ATSB

Senior pilot

The FNFF senior pilot was approved by the APF. According to the APF Jump Pilot Manual (JPM), senior pilot responsibilities included:

• oversight of all aircraft related aspects of FNFF
• ensuring the safe and legal operation of aircraft. 

Drop zone safety officer

The Far North Freefall (FNFF) chief instructor (parachuting) was the drop zone safety officer (DZSO) for the day’s operations at Tully. Due to wet weather earlier in the week, participants in the event had attended safety seminars. One seminar included reinforcing to parachutists to always be mindful of their handles. The DZSO reported that the front float position had specifically been mentioned in the seminar, because it required being as far forward as possible, with an associated risk of snagging equipment on the aircraft while reaching to stand up. It was regarded as a relatively difficult position to hold. 

The DZSO was in the ground control assistant role (with a handheld radio) during the accident flight, when the pilot radioed and said there was a parachutist on the tail. The DZSO then started counting the parachutes they could see in the air. Another jump pilot on the ground came to help and asked the pilot whether they had declared MAYDAY, and the pilot replied that the jumper had got free of the aircraft’s tail. The camera operator was the first parachutist to land and pointed out to the DZSO that P1 was under their main parachute, with the reserve trailing. 

After P1 landed, the DZSO handed the radio to the FNFF senior pilot, sent a car to pick up P1 and arranged for a doctor (who was also a parachutist), to provide first aid. P1 was then driven to hospital. 

Loadmaster

The APF JPM detailed the loadmaster (LM) role as follows.

(a) Each parachute operation must have a nominated Loadmaster for each load.

(b) As per APF Operational Regulations (Part 6), the Loadmaster is responsible for:

(i) conducting a pre-jump briefing before any parachute descents are made, which covers all relevant aspects of the descent, and which includes all persons on-board the aircraft including pilot and parachutists;

(ii) ensuring the airspace and [drop zone] DZ below is clear of conflicting air traffic and any necessary drop clearances have been obtained; and

(iii) confirming the integrity of the exit point.

The LM on the accident flight reported being unaware they were the appointed LM for that load until after landing. There were 3 parachuting instructors on the load who were also approved and experienced LMs. About 5 minutes before departure, all parachutists on the load met at the mock-up, where they revised the exit and checked each other’s equipment (buddy checks). The load was displayed nearby on the manifest screen, showing who was the appointed LM for that load. The LM had not checked the screen. However, they reported that the LM role on the accident load was minimal, as it:

• only contained experienced parachutists
• was not the first load of the day (requiring confirmation of the spot position)
• only required one exit as all the parachutists were in the single formation. 

Normally, communications between the pilot and parachutists were via the LM. On this load, the FNFF senior pilot (also the most experienced parachutist) was seated next to the pilot and therefore more readily able to communicate.

The LM’s role in an emergency was not included in the APF Operational Regulations or Training Operations Manual. However, the JPM Section 9.6 Emergency exit, stated:

In an airborne emergency such as a structural failure or fire, the pilot may decide that the chances of surviving a landing in the aircraft are non existent, and decide to order the evacuation of the aircraft. Each load must have a loadmaster who will start the aircraft evacuation once the pilot gives the command.

At lower levels, the parachutists will open their reserve parachutes as soon as they are clear of the aircraft. These parachutes are designed and packed to deploy quickly and only require a couple of hundred feet. 

Note: Emergency procedures for structural failure are not discussed in manuals or safety publications because there are to [sic] many variables and little that can be effectively done. It is mentioned here because, with parachutes on-board, there is a chance that lives can be saved by exiting the aircraft. This applies equally to you as a pilot if you are wearing a parachute.

Additionally, the APF Safety management system continuous improvement package 4 2019, Aircraft emergency and evacuation procedures, was provided to APF member organisations to discuss in safety meetings. Regarding the LM role in an emergency, it included the section ‘Communication’: 

The Pilot is in command.  Wait for the Pilot’s instructions. You can make the situation worse for the Pilot, i.e. if you move closer to the door and cause a shift in the centre of gravity or asymmetric drag, by opening the door or everyone yelling and asking what to do.

Load Master to be ready to make the call if the Pilot does not respond (the Pilot may not be prepared for the emergency or may not provide instructions). The Load Master needs to be ready to give instructions. However, do not rush this decision (unless a catastrophic emergency) as the Pilot may be assessing the situation, e.g. if there is a small electrical fire the Pilot may try to put out this fire with the extinguisher before having a forced landing with a full plane load or instructing everyone to exit.

The APF and FNFF did not specify an emergency exit command. 

The LM reported calling ‘get out, get out, get out’ but that ‘exit, exit, exit’ was the command they should have used. The FNFF senior pilot recalled shouting ‘go, go, go’. Another parachutist nearer the door also yelled and pointed parachutists to exit when they had briefly paused in the doorway. That parachutist reported that in hindsight it was the LM’s role, not theirs, to give the command, but the chief instructor advised that in this case, it facilitated a quick exit, which was correct action at the time. 

The LM and FNFF senior pilot remained in the doorway until P1 was free of the tailplane, before exiting the aircraft. However, both later reported that, in hindsight, they should have gone back to the front of the aircraft and relayed the situation to the pilot, although they reported the pilot was probably aware that the parachutist was clear, as the aircraft ‘bucked’ when the parachutist tore free.  

During their discussions with the parachutists after the incident, the FNFF chief instructor (parachuting) identified that there had not been a plan as to what the parachutists would do in the event of an emergency to ensure they assisted and remained clear of each other’s parachute after exiting. Further, that there was no documented training for the LM role and the requirements in the event of an emergency were not well understood. 

Aircraft

VH-DVS was a Cessna Aircraft Company 208, manufactured in 1988, serial number 20800131, modified under a Texas Turbines Conversions supplemental type certificate with a Honeywell TPE331-12JR-704TT engine and a Hartzell Propellers 4-blade HC‑E4N-5KL propeller. At the time of the accident, the airframe total time in service was 10,270.60 hours. The aircraft’s tail assembly (empennage) consisted of a vertical stabiliser, rudder, horizontal stabiliser and elevator. VH-DVS was unpressurised and equipped with supplemental oxygen for the pilot’s use.

VH-DVS was modified for parachuting with bench seats and single point restraints. Handrails, posts, a step and a roller door were also fitted to facilitate parachutists to exit the aircraft, along with a ‘Baz clip’ to secure the door open (Figure 13). 

Figure 13: Baz clip securing the roller door open

Source: Far North Freefall, annotated by the ATSB

Following an accident involving another Cessna 208 in 2001 (see the section titled Previous similar occurrences), in which the pilot’s emergency egress was delayed by the roller door (blind) closing, the designer of the blind amended the design to include:

• a device to lock the door in the open position
• a placard warning that the blind must be locked open during parachuting.   

The aircraft was also fitted with a light system controlled by the pilot. In accordance with FNFF procedures, the pilot was to illuminate the: 

• red light 3 NM from the drop position
• orange light 1 NM from the drop position, at which time door could be opened
• green light to indicate pilot approval to commence exit. 

Following the accident, the following maintenance was conducted:

• inspection of the fuselage to horizontal stabiliser attach fittings; no defects found
• inspection of the elevator control cable assembly; no defects found
• left and right elevator control surfaces replaced
• horizontal stabiliser assembly replaced.

Weight and balance

The Civil Aviation Safety Authority (CASA) legislative instrument EX105/23 – Part 105 (Parachute Operators and Pilots) Instrument 2023, as amended and in force on 1 July 2025, exempted compliance with paragraph 91.095(2)(a) of the Civil Aviation Safety Regulations (CASR) regarding the maximum number of passengers that may be carried, the seating configuration and restraints stated in the airplane flight manual. For the exemption to apply, the instrument included in Section 9, among other requirements:

1) If the aeroplane has been modified in a manner that affects any of the following:

(a) the maximum number of passengers that may be carried on the aeroplane in accordance with the [airplane flight manual] AFM; or

(b) the passenger seating, or method of passenger restraint, in accordance with the AFM;

  then the modification must have been approved:

(c) by an authorised person or an approved design organisation under regulation 21.437 of CASR; or

(d) otherwise in accordance with a Part 21 approval; or

(e) by an approval continued in force, according to its terms, under regulation 202.054 of CASR.

(2) The pilot in command must follow the procedures designed to ensure that the aeroplane:

(a) remains within its MTOW; and

(b) remains within its centre of gravity limits and requirements at all stages of the operation; and

(c) complies with all limits, restrictions and conditions imposed by the approval mentioned in subsection (1).

Additionally, Section 10 of the instrument required the pilot to comply with the conditions of the exemption and for the operator, in this case FNFF, to ensure the pilot did so. 

Regulation 91.805 of CASR also required the pilot to ensure at all times that an aircraft was loaded and operating within its weight and balance limits. 

The CASR Part 105 Manual of standards (MOS), Chapter 7 – Weight and balance required both the aircraft operator and the pilot to ensure a load sheet was completed before flight, unless the aircraft was carrying the same load for multiple parachute drops. The load sheet was required to be carried in the aircraft and a copy given to the chief parachuting instructor or drop zone safety officer (and retained for 3 months). Among other things, the load sheet was required to include: 

(g) the weights and moment arms of: 

(i) the occupants of the aircraft; and 

(ii) any cargo carried on the aircraft; and 

(iii) any removable equipment carried on the aircraft; and 

(iv) fuel and consumables carried on the aircraft (for example, water or ethanol); 

(h) the calculated load weight, and total moment, that demonstrates that the centre of gravity is within the approved limits; 

(i) the maximum allowable weight for the flight, having regard to the prevailing environmental conditions; 

(j) a statement by the person who is responsible for planning the loading of the aircraft, that the load and its distribution are in accordance with the aircraft loading system;

FNFF used BURBLE manifest software. Parachutists were required to use an app to check in each morning, and their weight was included in their personal details. BURBLE then verified that APF members had signed the required waiver, the reserve parachute was within the repack date, and the parachutist intended to do an appropriate jump for their certificate/licence.

A manifest person then re-checked the information in BURBLE. After check-in, parachutists could be manifested on a load, along with a coach and/or camera operator as needed. A DZSO, ground control assistance (GCA) and loadmaster would be assigned for each load. 

As parachutists were allocated to a load, their weights were added to the aircraft weight. The manifest person would then update the quantity of fuel on board. The chief instructor (parachuting) advised that their normal process was to use a standard fuel weight based on sufficient fuel to conduct 3 parachute drop loads (and required reserves). If BURBLE flagged that the aircraft was overweight with that fuel quantity, the manifest person would then use a more precise fuel figure.  

The aircraft had an iPad as an electronic flight bag (EFB), which included a load sheet based on the BURBLE manifest. The pilot reported that they would review the load sheet on the iPad and ensure the aircraft was below the maximum take-off weight.

Although BURBLE performed a weight calculation, it did not calculate the aircraft centre of gravity or balance, or have any means to allocate parachutists to a particular (loading) zone of the aircraft. Several other Australian drop zones used IBIS software, which could perform weight and balance calculations. Under a Memorandum of Understanding, FNFF was required to operate the aircraft in accordance with Section 5 – Aircraft operational procedures of the Skydive Australia operations manual. This section of the Skydive Australia operations manual provided procedures for calculating weight and balance with IBIS or OzRunways.[13] VH-DVS’s OzRunways EFB included the aircraft’s skydive configuration, allowing pilots to enter fuel and passenger weights in order to determine the aircraft’s take-off weight and centre of gravity position for each flight.

Emergency procedures 

Knife 

Part 105 – Parachuting from aircraft – MOS 5.40 Emergency equipment carried on jump aircraft, required a knife suitable for emergency situations be carried on board the aircraft and to be readily available to the pilot or parachute instructor. This was also required in the APF Operational regulations, section 5.2 – Aircraft: 

5.2.5 Knife in Aircraft

A knife, capable of cutting parachute harness webbing, must be readily available and appropriately stored in the aircraft.

There was at least one knife on board VH-DVS as required by the APF JPM. However, in this occurrence, there was no practical means of getting the onboard knife to the parachutist hung up on the tail. 

Skydive Australia’s emergency procedures checklist, a copy of which was in VH-DVS, included actions in the event of a parachutist being hung up by their restraint, or their parachute snagging on exiting the aircraft (Figure 14).

Figure 14: Skydiver hang up checklist 

Source: Skydive Australia Operations Manual

Emergency parachute

The APF’s Operational regulations, section 5.2 – Aircraft, also required an emergency parachute be made available to pilots: 

5.2.6 Pilot’s Emergency Parachute Availability

A parachute that complies with APF Equipment Standards and training in the proper use of that parachute must be made available to pilots of aircraft used in making descents.

The Skydive Australia operations manual required the pilot to wear an emergency parachute when conducting skydiving operations. There was no requirement for a pilot to have conducted a parachute jump; they were trained in its use verbally and by demonstration. Emergency parachutes had one parachute, which was large and designed to open very quickly. The pilot was wearing an emergency parachute, had been trained in its use, and reported that they would only exit if they had no control of the aeroplane. 

The APF JPM section 9.7 Emergency pilot rig use stated:

In the event that you decide to use the pilot emergency parachute, you must be prepared to follow the procedures you’ve been briefed on by the DZSO for the particular rig in use. Pilot rigs normally contain a round canopy, which achieve minimal air speed (~5 to 8 knots) and glide ratios of up to 1:1. The general procedure for use is as follows:

(a) prior to leaving the aircraft, grasp the ripcord handle. It is easier to locate it prior to exit as it may move once in freefall, and the associated disorientation may make it more difficult to find.

(b) once clear of the aircraft, pull the ripcord to full arms length,

(c) once the parachute is open, reach up and grasp the two small steering toggles (handles), or the coloured lines, on the risers above your shoulders.

(d) to steer, pull down one side to turn in that direction.

(e) fly towards a cleared area and try to land into the wind to minimise landing speed.

(f) for landing, it is highly recommended that you perform a Parachute Landing Roll (PLR).

Premature parachute deployment

The APF JPM Part 9 Emergency procedures, included 9.3 In-aircraft parachute deployment:

There are a number of situations where a ripcord may be accidentally pulled or a pin dislodged resulting in a container opening in the aircraft, on climb‐out, or on the step. An extremely hazardous situation exists when the door has been opened and a pilot chute is suddenly deployed finding its way outside.

Further, it stated that parachutists ‘are taught to protect their handles and equipment while inside the aircraft and during climb-out’ (Figure 15).

Figure 15: Jump pilot manual extract 

Source: Australian Parachute Federation

The emergency procedures continued: 

An accidental opening in the aircraft with the door open is potentially disastrous. If a pilot chute escapes while the door is open, it can be out and into the slip stream before reaction is possible. The jumpers will do their best to ensure the person attached is able to be expedited out the door as quickly as possible. In the past, this has resulted in the parachutist attached to the parachute being pulled through the side of the aircraft!

Keep a close watch for any premature openings and if one occurs, immediately apply maximum rudder to swing the tail clear of the deploying parachute and the person attached.

The APF produced a safety poster, which was on the wall at FNFF. The poster stated that premature deployments can be prevented by:

- Proper equipment maintenance

- Using compatible equipment

- Buddy checks

- Minimising excessive movement in aircraft

- Checking handles, pins, etc before emplaning and before exit

- Taking care and being conscious of equipment during climb-out. 

Tully Airport

Tully Airport was an aircraft landing area with one sealed runway 18/36, 936 m long. The airport elevation was 47 ft, with terrain about 2,200 ft above mean sea level to the east and west. The drop zone was adjacent to the northern end of the runway. 

The drop position for the day was heading south (180°), running centrally overhead Tully Airport, with the pilot illuminating the green light at 0.8 NM (1.5 km) before (north of) the aerodrome reference point. 

The weather at Tully Airport on the morning of the accident included 6–10 kt south‑easterly winds, cloud covering about half the sky, and an ambient temperature of 21°C. The nearest Bureau of Meterology weather station was at Innisfail, about 42 km north.

At 1000, the Innisfail METAR[14] stated that the wind was from 170° at 3 kt, visibility greater than 10 km, QNH 1,014 hPa,[15] temperature 25°C. At 1010 (the time the aircraft landed), the 1‑minute weather data at Innisfail included: temperature 27°C, wind (which had been variable for the past 5 minutes) from 245° at 1 kt and QNH 1,014.6 hPa.

Supplemental oxygen 

CASR Part 105 MOS required unpressurised aircraft operating a parachute descent to have supplemental oxygen in accordance with the Part 91 MOS Division 26.11 – Oxygen equipment and oxygen supplies. The aircraft was required to be fitted with, or carry, supplemental oxygen, which was required to be used by:

• flight crew for any period exceeding 30 minutes when the cabin pressure altitude was continuously at least flight level (FL)[16] 125 but less than FL 140
• flight crew for any period when the cabin pressure altitude was at or above FL 140
• passengers for any period when the cabin pressure altitude was at or above FL 150.

CASA advised that this was incorporated in Part 91 between 2003 and 2011 to align with the United States Federal Aviation Regulations. The European Union Aviation Safety Agency required crew members to use supplemental oxygen when between 10,000 ft and 13,000 ft for more than 30 minutes, and at all times when above 13,000 ft.  

Aircraft conducting parachute drops from FL 150 were usually between FL 140 and FL 150 for about 2 minutes. In the occurrence flight, due to the premature parachute deployment, the aircraft was between FL 140 and FL 150 for closer to 3 minutes. For jump pilots, that is a high workload period, involving slowing and configuring the aircraft for the drop, confirming the drop position, and communicating with parachutists, air traffic control, the ground control assistant and on the common traffic advisory frequency. 

The APF operational regulations required adherence to the Part 91 MOS oxygen requirements. However, the pilot did not use oxygen on the accident flight. 

Hypoxia

Hypoxia is the absence of an adequate supply of oxygen to the tissues. Hypobaric hypoxia is the most common form in aviation and is associated with breathing air at low barometric pressure. A deficiency in alveolar oxygen exchange due to low oxygen tension (partial pressure) of inspired air leads to inadequate oxygen supply to the blood and reduced oxygen available to the tissues. In an aviation context, acute hypobaric hypoxia is the ‘most serious single physiological hazard during flight at altitude’ (Gradwell and Rainford, 2006). 

The risk of hypoxia increases with altitude and time at altitude. Additionally, multiple ascents to altitude may have a compounding effect on hypoxia. There is considerable variation between individuals in the effects of hypoxia. Hypoxia can occur in susceptible individuals below 10,000 ft. Between 10,000 ft and 15,000 ft, brain function is mildly impaired and hypoxic symptoms are common. Above 15,000 ft, brain function exponentially deteriorates (Shaw, Cabre and Gant, 2021).  

Physical activity, cold, illness and certain drugs increase the onset speed and severity of hypoxia. Additionally, jump pilots require a class 2 aviation medical certificate, which is less stringent than class 1 medical certification, and may allow underlying cardio‑respiratory conditions that increase hypoxia risks to go undetected. 

Those experiencing hypoxia may have no signs or symptoms and may be unaware of any cognitive impairment. In unpressurised aircraft, hypoxia can be prevented by breathing supplemental oxygen.

Limited research has been conducted into the effects of ascents to FL 140 and FL 150 for jump pilots or parachutists. An article in the United States Parachute Association’s publication Parachutist, described a small study of parachutists using pulse oximeters. They found that in ascents to 14,500–15,000 ft above mean sea level, blood oxygen saturation levels, normally 95–100%, dropped into the 80s (%) during ascent, and, into the 70s on one flight in which air traffic control holding resulted in an additional 10 minutes at altitude (Galdamez, 2024). Although individual responses vary to reduced oxygen saturation levels, a finger‑mounted pulse oximeter can alert pilots and parachutists to reduced blood oxygen saturation levels, prompting the use of supplemental oxygen. 

Previous similar occurrences

Premature parachute deployment

The ATSB investigated a parachuting accident involving Cessna 208 VH-MMV at Nagambie, Victoria, on 29 April 2001 (AAIR200101903). The aircraft climbed to FL 140 with 11 parachutists and the pilot on board. As the first 4 parachutists exited the aircraft, the middle parachutist’s reserve pin dislodged on the top of the door frame and the pilot chute deployed. The pilot chute pulled the reserve parachute over the horizontal stabiliser. The reserve parachute risers and lines tangled around the left elevator and horizontal stabiliser, with the parachutist hanging below them. Eleven seconds later, the empennage separated from the aircraft and the left elevator and parachutist separated from the empennage. The parachutist fell to the ground and was fatally injured.

The remaining parachutists exited the aircraft before it descended through 9,000 ft. The pilot transmitted a MAYDAY call, shut down the engine and left their seat. However, the rear roller door (blind) had closed. After several attempts, the pilot raised the blind sufficiently to exit the aircraft at about 1,000 ft above ground level and deploy their parachute before landing safely. The aircraft impacted the ground and was destroyed by impact forces and post-impact fire.  

Parachutists striking aircraft

The Nagambie report referenced 3 previous premature parachute deployments and 2 occurrences in which a parachutist struck the aircraft. Table 1 details occurrences since 2001 in which a parachutist struck and damaged the aircraft.

Table 1: ATSB occurrences since 2001 in which a parachutist struck the aircraft

Weight and balance

There were 2 accidents in Sweden investigated by the Statens Haverikommission (SHK) involving aircraft conducting parachuting operations, in which the aircraft’s weight and balance was not calculated. 

On 14 July 2019, 8 parachutists and the pilot were fatally injured in an accident in Sweden involving a GippsAero GA8 aircraft. The SHK investigation found that the parachutists moved to the back of the aircraft in preparation for the jump, which altered the weight distribution, resulting in the aircraft stalling, before breaking up in flight. The aircraft was found to have been overloaded. The SHK also found that as the load sheet did not contain the weights of the parachutists or the total mass of the load, the pilot was unable to complete weight and balance calculations. 

On 8 July 2021, the pilot and 8 parachutists were fatally injured when a de Havilland DHC-2 aircraft collided with terrain shortly after take-off. The SHK found that:

Control of the aircraft was likely lost in connection with the wing flaps being retracted in a situation where the stick forces were high due to an abnormal elevator trim position, while the aircraft was unstable due to being tail-heavy and abnormally trimmed. Due to the low altitude, it was not possible to regain control of the aircraft. 

The investigation also found that the pilot had no ability to perform a weight and balance calculation with the available information.

Safety analysis

As the parachutist climbed out of the aircraft and into the front float position, their reserve handle snagged on the aircraft's flap, resulting in deployment of the reserve pilot chute and parachute. The parachutist was highly experienced, had performed their gear checks before exiting the aircraft, and attended safety seminars in the days prior to the accident, which included being mindful of their handles.

The parachutist was also experienced in the front float position and had practised getting into that position several times in the mock-up on the ground before the jump. However, the mock-up did not have a flap to simulate its position, reducing the likelihood that the snagging potential would be recognised. 

As the parachutist was pulled rearwards, they struck the camera operator, who was dislodged from the aircraft sustaining a minor shoulder injury. The parachutist’s lower legs struck and damaged the leading edge of the horizontal stabiliser, which, combined with the parachute wrapped around the horizontal stabiliser and elevator, resulted in the pilot experiencing difficulties controlling the aircraft. Although not required to be carried, the parachutist had a hook knife, which enabled them to cut themselves free of the aircraft. Without access to the knife, separation from the aircraft may not have been possible. Additionally, although the pilot was wearing an emergency parachute and the roller door was clipped open to aid exiting if control was lost, the pilot was able to maintain sufficient control to land the aircraft without further incident. 

The parachuting club at Tully was using manifest software that calculated the aircraft’s weight including the parachutists. However, it did not perform balance calculations to ensure the aircraft was loaded within its centre of gravity envelope. Additionally, the pilot was not using the available electronic flight bag tool to calculate weight and balance for each flight, and the senior pilot was not ensuring this was done. There was no evidence that the aircraft was out of balance or that this contributed to the occurrence. However, fatal accidents have occurred involving aircraft conducting parachute operations, in which the aircraft were operated outside the aircraft’s balance limits. 

Hypoxia poses a risk to both pilots and parachutists when operating above about 10,000 ft, noting that its specific effects are highly variable between individuals. There is limited research into the effects of short, repeated exposure to altitude associated with parachuting operations, or of the magnitude of additional risk in operating for 2‍–‍3 minutes between 14,000 and 15,000 ft. However, given individual responses to altitude exposure, use of supplemental oxygen at and above 14,000 ft as required by legislation, reduces hypoxia risks and any compounding effects of multiple ascents associated with parachute operations.   

Findings

From the evidence available, the following findings are made with respect to the premature parachute deployment involving Cessna 208, VH-DVS, over Tully Airport, Queensland, on 20 September 2025. 

Contributing factors

• As the parachutist climbed out of the aircraft and into the front float position, their reserve handle snagged on the aircraft's wing flap, resulting in deployment of the reserve parachute and entanglement with the empennage. The parachute wrapping around the horizontal stabiliser, combined with damage from impact with the parachutist's legs, resulted in aircraft control difficulties.

Other factors that increased risk

• The pilot and aircraft operator did not ensure the aircraft was loaded within the weight and balance envelope.
• The pilot did not use oxygen when the aircraft was at or above flight level 140 as required by regulations to reduce the risks of hypoxia.

Other findings

• The parachutists opened the roller door and clipped it open before exiting the aircraft. As a result, the roller door remained open during the descent, increasing the ease with which the pilot could have exited the aircraft if needed.
• Although not mandatory at the time of the accident, the parachutist had a hook knife attached to their chest strap, enabling them to cut enough reserve parachute lines for the parachute to detach from the tailplane.
• In difficult circumstances, the pilot managed to control the aircraft and return to land safely.

Safety actions

Safety action taken by Far North Freefall 

To ensure aircraft are loaded within their weight and balance envelope and this is documented on a load sheet, Far North Freefall Club (FNFF) has:

• engaged with the current software distributor about including balance in the manifest system
• commenced investigation of alternative software
• implemented a proprietary interim system that calculates and graphically displays the centre of gravity position on the aircraft’s weight and balance envelope indicating whether it is within or outside the limits. 

Additionally, FNFF distributed a circular to pilots reminding them of the requirement to use supplemental oxygen when the aircraft is at or above flight level 140, and of the risks of hypoxia. FNFF also mandated parachutists to carry a hook knife.

Furthermore, FNFF updated the loadmaster checklist within its safety management system. Copies of the checklist are displayed around the drop zone to raise awareness of loadmaster roles and procedures in the event of an emergency. A circular has also been sent to all current FNFF loadmasters to reinforce familiarity with in-aircraft emergency procedures.

In addition, the FNFF safety team is reviewing its standard operating procedures manual to ensure all procedures – including those relating to loadmaster training and emergency response – are clearly documented and up to date.

FNFF is also preparing a training slideshow incorporating footage from the incident. This presentation will be shared across the wider skydiving community for educational purposes.

Safety action taken by the Australian Parachute Federation

At the time of writing, the Australian Parachute Federation was in the process of developing a guide for loadmasters. The guide will detail the role and responsibilities, including during an emergency. It will take into consideration the range of complexity of various operations, and aircraft type and size. Training and assessment material will also be developed. 

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot and parachutists
• the aircraft operator
• Australian Parachute Federation
• Civil Aviation Safety Authority
• Airservices Australia
• witnesses
• video footage of the accident flight and other photographs and videos taken on the day of the accident
• recorded data. 

References

Galdamez L (2024, December) Studying hypoxia in skydivers, Parachutist, Volume 65, Number 12, Issue 782, 58–59 

Gradwell DP, Rainford DJ (2006), Ernsting’s aviation medicine, Edward Arnold (Publishers) Ltd London, Chapter 3.

Shaw DM, Cabre G and Gant N (2021) Hypoxic Hypoxia and Brain Function in Military Aviation: Basic Physiology and Applied Perspectives. Front. Physiol. 12:665821. doi: 10.3389/fphys.2021.665821

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 aircraft operator
• the aircraft owner
• the pilot and parachutists
• Australian Parachute Federation
• Civil Aviation Safety Authority. 

Submissions were received from:

• the aircraft owner
• the aircraft operator
• a parachutist
• Civil Aviation Safety Authority
• Australian Parachute Federation.

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.

Investigation summary

What happened

On 25 June 2025, the flight crew of a Jetstar Airways Airbus A321-251, VH-OYF, were conducting a scheduled passenger transport flight, JQ38, from Denpasar International Airport, Bali, Indonesia, to Sydney, New South Wales. The first officer was the pilot flying and the captain was the pilot monitoring.

During the landing at Sydney Airport, the aircraft floated for a prolonged period along the runway, was subject to a right crosswind and drifted left of the runway centreline. The captain responded by commanding a go-round which the first officer executed. 

The crew proceeded to continue with the published missed approach procedure and subsequently landed without further incident. 

What the ATSB found

The ATSB found that after the first officer initiated the flare manoeuvre, their control inputs resulted in a lateral deviation from the runway centreline when the aircraft floated for a prolonged period in crosswind conditions. 

After the captain commanded a go-around, they inadvertently manipulated their sidestick control, which resulted in a brief period where simultaneous control inputs occurred. The crew were alerted by a ‘dual input’ generated voice message and the captain took control. There was a moment of preoccupation which resulted in the first stage of flap being retracted out of sequence, however, there were no associated flight envelope exceedances or negative effects on aircraft performance. 

Safety message

Sound go-around decision-making is an effective defence against the hazards associated with low-level manoeuvring during the landing phase of flight, such as lateral runway excursions. If adequate safety margins cannot be maintained during an approach and landing, the correct and expected response is to go around.

Being go-around minded improves crew readiness and supports timely, coordinated actions during a period of high workload. This should involve crew members reviewing potential go‑around scenarios, procedures and responses prior to conducting an approach. 

When flight crews are faced with the unexpected need to execute a go-around even at the final stages of landing, effective crew resource management, with clear communication between flight crew, is essential. This promotes effective teamwork when responding to disruptions and increased workload under stress, ensuring that the aircraft remains on a safe flight path and is correctly configured for the relevant phase of flight.

The investigation

The occurrence

On the evening of 25 June 2025, a Jetstar Airways Pty Limited Airbus A321-251 registered VH‑OYF was operating on a schedule passenger transport Jetstar flight, JQ38, from Denpasar International Airport, Bali, Indonesia, to Sydney, New South Wales. The flight was scheduled to arrive at Sydney Airport the following morning at 0630 AEST.[1] The operating crew included the captain, first officer, 6 cabin crew and 234 passengers. For the flight to Sydney, the first officer was the pilot flying (PF) and the captain was the pilot monitoring (PM).[2]   

After departing Denpasar, the aircraft climbed to flight level (FL) 330[3] and later descended to FL310 after reaching Australian airspace due to turbulence en route. Due to the turbulence en route, the captain elected not to take any controlled rest on the nearly 6‑hour flight, while the first officer stated they would not usually take controlled rest in flight. 

Prior to descent, the flight crew briefed for the arrival at Sydney, recalling that the turbulent conditions and the crosswind for the approach and landing were the main considerations. 

At 0554, the flight crew commenced their descent to the west-south-west of Sydney Airport and was cleared for the approach for runway 16R[4] which was conducted in day visual meteorological conditions[5] using the autopilot. The flight crew recalled there was a 30 kt crosswind down to about 500 ft above mean sea level (AMSL) and the approach up to that point was ‘pretty normal.’ Air traffic control (ATC) advised the crew to expect an 8 kt right crosswind for landing and the first officer chose to land in the flap 3 configuration,[6] which was consistent with guidance for landing in ‘rough’ conditions. (The first officer was procedurally restricted to a maximum crosswind landing component of 20 kt).

The aircraft reached 500 ft at 0621:14 and the captain called ‘stable’ (see Stabilised approach criteria). The first officer disengaged the autopilot 5 seconds later as the aircraft approached 400 ft and recalled encountering turbulence which placed the aircraft ‘a little higher’ on the approach. At 0621:45 at 90 ft, the first officer pitched forward, which they observed resulted in a 900 ft per minute rate of descent. 

At 0621:51, the first officer initiated the flare at 50 ft and reduced the thrust levers to idle at around the final approach speed (VAPP)[7] of 150 kt, which included a wind correction of 5 kt. At this point the first officer recalled they ‘over flared’. The captain also observed that the first officer applied the flare technique that was consistent with the technique for landing in the flap full configuration. The aircraft subsequently floated for a prolonged period along the runway after the first officer’s flare manoeuvre.

During the prolonged float, the aircraft was subjected to the crosswind conditions for a greater length of time. After observing the centreline deviation, the captain commanded a go-around approximately 600 m past the runway threshold, just prior to touchdown. The captain recalled they were ‘startled by the need to go around’ as the approach seemed ‘benign’ aside from the crosswind. They also reported a sudden stress response at this time as they had to rapidly transition from landing to commencing the go-around.

In response to the captain’s command, the first officer set take-off/go-around thrust at 0621:59 (Figure 1), which initiated the published missed approach procedure for the 16R GBAS landing system (GLS)[8] approach in the aircraft flight management system. The first officer also referenced their primary flight display (PFD) to command a target pitch attitude of 15° nose up.   

At this point, the captain recalled they instinctively applied control inputs via their sidestick while the aircraft was just above the runway, and the crew were alerted to this by the aircraft’s ‘dual input’ voice message (see Sidestick priority logic). 

The captain then engaged their sidestick pushbutton, and the first officer recalled hearing the ‘priority left’ voice message and the captain announce, ‘I have control.’ The captain subsequently took control of the thrust levers and the first officer relinquished control and became PM after the aircraft achieved a positive rate of climb. It was the role of the PM to retract the flap ‘one step’ at this point (see Go-around procedure). 

Figure 1: Overview of go-around 

Source: Google Earth, annotated by the ATSB

The captain announced the active flight modes on their PFD, which prompted the first officer to call ‘positive climb.’ The captain subsequently instructed the first officer to retract the landing gear, which was accomplished 42 ft above the runway at 0622:20. 

At this time, the captain looked up to the flight control unit located on the cockpit glareshield to engage the autopilot. After this was actioned, they looked back to their PFD and was ‘startled’ when they noticed that the aircraft suddenly banked right and responded by disengaging the autopilot at 0622:22. They subsequently realised that the aircraft flight director was providing commands for the published missed approach procedure and subsequently re-engaged the autopilot at 0622:29. 

The captain then requested flap 1, but the first officer noticed they were still configured with Flap 3 and retracted the flap by one step and announced, ‘flap 2.’ This occurred at 0622:32 when the airspeed reached 174 kt, which was below the maximum flap 3 speed of 195 kt.

They continued to follow the missed approach procedure, and the first officer advised ATC they were going around. The crew were given instructions to track for a right downwind for runway 16R at 4,000 ft. The captain recalled conducting a welfare check on the first officer, briefed the cabin manager via the interphone and made an announcement to the passengers through the public address system. 

The captain elected to remain as PF for the remainder of the flight, with the first officer acting as PM. The crew then conducted a second GLS approach for runway 16R, landing at 0638 without further incident.

Context

Flight crew information

The captain held an Air Transport Pilot Licence (Aeroplane), class 1 aviation medical certificate, and had accrued 5,921 hours total flying time, 1,480 of which were in the Airbus A320 and A321 aircraft types.

The first officer held a Commercial Pilot Licence (Aeroplane), class 1 aviation medical certificate, and had 2,212 hours total flying time, 551 of which were on the Airbus A320 and A321 aircraft types.

Fatigue

The captain reported that they felt 'moderately tired' during the go-around, likely due to the back-of-the clock[9] flight, which departed Denpasar at 0057 local time in Sydney. They also stated there was limited opportunity for controlled rest during the flight and their nap prior to the flight was disrupted due to noise at the hotel. The first officer reported feeling 'ok, somewhat fresh.’  

The flight crew also reported they had an adequate rest opportunity the evening prior to the flight and obtained around 6 hours sleep in the previous 24 hours and around 13‍–‍14 ‍hours in the previous 48 hours. Their sleep during the rest opportunity was reported to be good quality and the conditions at the hotel where they spent the night were suitable and therefore conducive to obtaining restful sleep. Biomathematical modelling[10] of the flight crew’s roster for the 2 weeks leading up to the flight indicated a low likelihood of fatigue.

The ATSB considered that fatigue was unlikely to have affected the flight crew’s performance at the time of the occurrence.

Aircraft information

General

The Airbus A321-251NX is a modern, fly-by-wire aircraft, powered by 2 CFM International LEAP-1A32 turbofan engines and had seating for 232 passengers in a single-class layout. 

All the flight controls are electronically actuated with the pilots using sidesticks to fly the aircraft in pitch and roll during manual flight. The 2 sidestick controllers are not coupled mechanically, and they send separate sets of signals to the flight control computers. 

Sidestick priority logic

Jetstar Airways A320-A321 Flight crew operating manual (FCOM) contains the following description of the aircraft sidestick priority logic: 

At all times, only one flight crewmember should fly the aircraft. However, if both flight crewmembers use their sidesticks simultaneously, their orders are algebraically added.

The flight control laws limit the combined order to the equivalent of the full deflection of one sidestick.

In this case the two green SIDE STICK PRIORITY lights on the glareshield come on and "DUAL INPUT" voice message is activated.

 A flight crewmember can deactivate the other sidestick and take full control, by pressing and keeping pressed the sidestick pb (Figure 2).

A “PRIORITY LEFT” or “PRIORITY RIGHT” audio voice message is given each time priority is taken.

Figure 2: Airbus A320/A321 captain's side sidestick and sidestick pushbutton

Source: Operator, annotated by the ATSB

Post-flight maintenance

The operator reported that there were no corrective maintenance actions that were required to be carried out in relation to the occurrence. The aircraft subsequently operated a scheduled passenger service the following day.

Meteorological information

The pre‑flight briefing package provided to the flight crew from the operator’s flight dispatcher included the aerodrome forecast[11] for Sydney Airport. The forecasted weather conditions for the scheduled time of arrival 0630 local time on 26 June indicated:

• wind direction of 240° at 15 kt with gusts up to 25 kt
• CAVOK[12]
• moderate turbulence[13] below 5,000 ft.

One-minute weather data for Sydney Airport from the Bureau of Meteorology indicated a wind direction of 255° at 17 kt with gusts up 20 kt at the time of the occurrence.

Airport information

Runway 16R at Sydney Airport is oriented on a magnetic heading of 155° and has a declared length of 3,962 metres with a width of 45 metres. A precision approach path indicator system is installed and set to 3° with a threshold crossing height of 64 ft. 

For daytime operations, the runway centreline, aiming point and touchdown zone markings provide visual references to assist pilots with approach and landing (Figure 3).

Figure 3: Sydney Airport runway 16R markings

Source: Google Earth, annotated by the ATSB

Recorded information

The aircraft’s quick access recorder data which captured the incident approach indicated that, as the aircraft descended below 1,000 ft, it maintained an appropriate speed and flightpath with no sustained exceedances of the stable approach criteria throughout the approach. 

At 0621:59, the recorded data captured the captain’s control inputs commencing concurrently with the initiation of the go-around, while the first officer was actively manipulating their sidestick control. Simultaneous control inputs lasted for a duration of 6 seconds (Figure 4), while the aircraft’s pitch attitude remained below the aircraft’s pitch limit of 11.5° until the aircraft had climbed through about 50 ft. 

The recorded data further indicated that the wind direction and speed varied following the flare manoeuvre, however the crosswind component remained well below the first officer’s operational limitation. The wind direction and speed was 315° at 13 kt with a crosswind component of 5 kt when the go-around was initiated.

Figure 4: Graphical representation of the recorded quick access data

Source: Quick access recorder from VH-OYF, annotated by the ATSB

Following the initiation of the go-around, the landing gear was retracted at 06:22:20 and 12 seconds later, the flap was retracted to the flap 2 configuration[14] at 174 kt.

Operational information

Stabilised approach criteria 

Jetstar Airways A320-A321 Flight crew operating manual (FCOM) defined a stabilised approach criteria as being established on the correct lateral and vertical flight path by 1,000 ft height above airport (HAA), configured for landing, and within the stated tolerances with the required checklists completed by 500 ft HAA. The FCOM also stated that if these criteria could not be met, or if the approach became unstable below 1,000 ft HAA, a missed approach was required. 

The crew reported the approach was stabilised against these criteria, which was consistent with the available recorded data.

Touchdown zone 

The FCOM provided the following operational information regarding the touchdown zone: 

The touchdown zone commences at 300 m (1000 ft) beyond the threshold and will not normally extend further than 600 m (2000 ft) beyond the threshold.

It is a requirement that the touchdown is planned to occur within the touchdown zone. Should it become apparent that the aircraft will touch down further than 600 m (2,000 ft) beyond the threshold, and the PIC believes that the landing is safe to continue, the PF must apply maximum reverse thrust and sufficient braking to ensure the aircraft stops within the landing distance available. If the PIC decides that a go-around is required, they will without delay, call “Go-Around”. In all cases this must be completed before the PF initiates reverse thrust.

The captain stated that runway 16R in Sydney was long enough to stop the aircraft on the runway if they had continued with the landing during the occurrence. This would have involved requesting maximum reverse and manual braking as necessary after the aircraft touched down. 

The FCOM did not specifically reference runway centreline tracking during a visual approach, however the captain stated that it was their personal expectation that a deviation from the runway centreline would lead them to calling for a go-around. 

Transfer of control  

The operator described procedures for transfer of control within the FCOM as follows:

The pilot relinquishing control of the aircraft shall say “You have control”. The pilot assuming control shall ensure that they have clear and unobstructed access to the flight controls and, when ready, say “I have control”. Only then is the pilot relinquishing control permitted to remove their hands and feet from the flight controls.

In critical phases of flight the PIC must be alert and positioned such that they can assume immediate control of the aircraft.

Following the occurrence, the captain stated the preferable method to conduct a go‑around at low level would have been to announce ‘I have control’ and initiate the go‑around themselves. They stated that their primary consideration when conducting a go‑around at low level was to avoid the risk of tail strike. 

Go-around procedure 

The FCOM defined the go-around procedure for the A320/A321, which specified the task sequence, memory-based crew actions and applicable guidance relating to techniques and navigation (Figure 5).

Figure 5: Jetstar Airway A320/A321 go‑around procedure below acceleration altitude

Source: Operator, annotated by the ATSB

Following the occurrence, the captain stated that although they could have taken over and landed, they believed that going around was considered the safest option. The first officer also stated, at about that time, that they were in the mindset of preparing to initiate a go-around themselves. 

Related occurrences

The following ATSB investigation highlights the importance of pilots maintaining their readiness for a go-around on every approach as it is typically a period of high workload requiring effective crew coordination. 

ATSB Investigation

On the morning of 18 May 2018, an Airbus A320 aircraft, registered VH-VQK, was being operated on a regular public transport flight by Jetstar Airways. The flight departed from Sydney for Ballina/Byron Gateway Airport, New South Wales.

The flight crew conducted a go-around on the first approach at Ballina because the aircraft’s flight path did not meet the operator’s stabilised approach criteria. On the second approach, at about 700 ft radio altitude, a master warning was triggered because the landing gear had not been selected DOWN. The flight crew conducted a second go‑around and landed without further incident on the third approach.

The flight crew did not follow the operator’s standard procedures during the first go‑around and subsequent visual circuit at 1,500 ft. In particular, the flaps remained at flaps 3 rather than flaps 1 during the visual circuit. This created a series of distractions leading to a non‑standard aircraft configuration for a visual circuit. Limited use of available aircraft automation added to the flight crew’s workload.

Safety analysis

During the approach to Sydney airport, with the first officer acting as the pilot flying (PF), the flight crew reported experiencing a crosswind of up to 30 kt until descending through about 500 ft above mean sea level. The crew were advised by air traffic control to expect a right crosswind component of 8 kt for landing, which was within the first officer’s operational crosswind limit of 20 kt. The captain confirmed the approach was ‘stable’ at 500 ft and the first officer continued the approach as PF.

At 50 ft, the first officer initiated the flare manoeuvre prior to landing. They recalled they ‘over flared,’ and the aircraft subsequently floated for an extended period along the runway. During this time, the first officer’s control inputs did not counteract the effect of the crosswind, and the aircraft drifted left of the centreline. After observing the lateral deviation from the centreline, the captain commanded the first officer to conduct a go‑around. 

This occurred just prior to the aircraft touching down when the flight crew would normally be focused on landing. The flight crew did not expect a go-around at the time and had to rapidly shift their focus to conducting the missed approach procedure. The captain recalled being ‘startled’ by the unexpected need to discontinue the landing, however they were more likely experiencing ‘surprise.’ Surprise is a cognitive-emotional response to something unexpected, which results from a mismatch between one’s mental expectations and perceptions (Rivera, Talone, Boesser, Jentsch, & Yeh, 2014). But their decision was consistent with the expectation that an approach be discontinued if the aircraft departed from the correct lateral flight path.

The unexpected change from landing to conducting a go-around close to the ground also resulted in the captain experiencing a sudden stress response at this time. When experiencing acute stress, people can respond quickly to a situation, but without conscious decision‑making (Wickens, Helton, Hollands, & Banbury, 2022). After the go‑around was commanded, there was a rapid increase in pitch attitude, engine thrust and airspeed, and in response the captain instinctively and inadvertently manipulated their sidestick while the first officer was flying, resulting in a dual-input alert. 

The captain reported they only realised they had manipulated their sidestick when they heard the dual input alert. Their primary consideration during the go-around was to avoid an excessive rotation rate to avoid a tail strike, which did not occur. Additionally, operator procedures directed captains to be alert and be positioned to ‘assume immediate control of the aircraft’ during critical phases of flight. 

Following the dual input alert, the captain took full control by engaging their sidestick push‑button and announced ‘I have control’, and the first officer assumed the role of pilot monitoring. A consequence of the control handover during the initial stages of the go‑around was the momentary interruption of sequential crew actions during the go‑around procedures. Interruptions typically disrupt the chain of procedure execution so abruptly that pilots turn immediately to the source of the interruption without noting the point where the procedure was suspended (Loukopoulos, Dismukes, & Barshi, 2009). 

Additionally, there was a further disruption (rapid task switching) associated with the first officer and captain exchanging pilot flying and pilot monitoring roles. As a result, some of the procedural items were completed out of sequence (flap 3 retraction occurred after gear retraction). 

Pilots are highly vulnerable to errors of omission when they must attend to multiple tasks. If one task becomes demanding, their attention is absorbed by these tasks demands and they can forget to switch their attention to other tasks (Loukopoulos, Dismukes, & Barshi, 2009). Although the flap retraction occurred out of sequence during the go-around, there were no associated flight envelope exceedances or negative effects on aircraft performance.  

Findings

From the evidence available, the following findings are made with respect to the control issues during landing and go-around involving Airbus A321, VH-OYF, at Sydney Airport, New South Wales, on 26 June 2025.

Contributing factors

• During the landing after crossing the threshold, the first officer’s control inputs resulted in a lateral deviation from the runway centreline during a prolonged float.
• After calling for a go-around, the captain inadvertently manipulated their sidestick while the first officer was the pilot flying, which resulted in a simultaneous control input and the go-around procedure being completed out of sequence.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Jetstar Airways Pty Limited
• Bureau of Meteorology
• the flight crew
• recorded data from the quick access recorder from VH-OYF.

References

Loukopoulos, L., Dismukes, R., & Barshi, I. (2009). The perils of multitasking. AeroSafety World, 4(8), 18-23.

Rivera, J., Talone, A., Boesser, C., Jentsch, F., & Yeh, M. (2014). Startle and surprise on the flight deck: Similarities, differences, and prevalence. In Proceedings of the human factors and ergonomics society annual meeting (Vol. 58, No. 1, pp. 1047-1051). Sage CA: Los Angeles, CA: SAGE Publications.

Wickens, C. D., Helton, W. S., Hollands, J. G., & Banbury, S. (2022). Engineering psychology and human performance, 5th edn. Routledge, doi: 10.4324/9781003177616.

Submissions

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

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

• Civil Aviation Safety Authority
• the flight crew
• Jetstar Airways Pty Limited
• Bureau of Meteorology.

Submissions were received from:

• the flight crew
• Jetstar Airways Pty Limited.

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

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

Investigation summary

What happened

At 1021 on 7 April 2025, a Bankstown Helicopters Robinson R44 helicopter, registered VH‑EWM (EWM), with a pilot and 2 passengers on board, departed from Bankstown Airport, New South Wales, for a local scenic flight around Sydney Harbour. Shortly after 1028, as EWM was entering the Parramatta River helicopter lane behind an EC120 helicopter, the occupants of EWM experienced a sudden onset of turbulence followed by an uncontrolled descent. 

In response, the pilot applied full collective, which resulted in a low rotor speed condition as the helicopter descended towards the water. The pilot was able to manoeuvre the helicopter and complete a forced landing on the river shoreline.

What the ATSB found

The ATSB found that it is likely that EWM entered the rotor wake from a preceding heavier EC120 helicopter, which resulted in the control difficulties, an uncontrolled descent, low rotor speed warning and the forced landing. 

What has been done as a result

Following review of the draft report, the Civil Aviation Safety Authority undertook proactive safety action to improve existing guidance about helicopter wake vortices in Advisory Circular 91-16. The updated advisory circular was released on 17 July 2025 and can be found at the link: AC 91-16 v1.2 - Wake turbulence.

Safety message

Flight tests have demonstrated that helicopter wake turbulence is comparatively larger and less predictable in its behaviour than for aeroplanes of the same weight. Helicopter rotor vortices can descend, remain level or climb, and the duration of their persistence can increase significantly in conducive weather conditions. The United States Helicopter Safety Team website recommends remaining 3 rotor disks clear of a hovering or taxiing helicopter and allowing 3 NM and/or 2 minutes for the rotor wake from a preceding helicopter to dissipate.

The investigation

The occurrence

At 1021 local time on 7 April 2025, a Bankstown Helicopters Robinson R44 Raven 1 helicopter, registered VH‑EWM (EWM), with a pilot and 2 passengers on board, departed from Bankstown Airport, New South Wales for a local scenic flight around Sydney Harbour. Bankstown Tower air traffic control (TWR) cleared EWM to depart via ‘Choppers West’, which was a standard procedure for helicopters departing to the north when runway 29 was active at Bankstown. 

The pilot reported that they climbed to about 1,000 ft above mean sea level.[1] The pilot’s plan was to join the Parramatta River on the west side of the Ryde Bridge and descend to 500 ft to follow the helicopter lane[2] along the south side of the river to Sydney Harbour (Figure 1).

Figure 1: Key locations

Source: Google Earth, annotated by the ATSB

About 1 minute after EWM departed, an Airbus EC120B helicopter departed Bankstown, also following the Choppers West departure. Shortly after the EC120 departed, TWR advised the EC120 pilot that there was ‘R44 traffic 1 NM ahead’, to which the EC120 pilot reported that they had the traffic sighted. Bankstown TWR then advised the pilot of EWM that they were not receiving their transponder data, which the pilot acknowledged. The pilot of EWM then turned their transponder off and on in an attempt to transmit transponder information, but no data was received from it throughout the incident flight.

As the 2 helicopters tracked north towards the Parramatta River, the EC120 flew to the west of EWM and passed it before reaching the river. The EC120 then turned right to join the Parramatta River helicopter lane, tracking towards the Ryde Bridge and Sydney Harbour, and passed over the Ryde Bridge at a recorded radar altitude of 600 ft. 

The pilot of EWM reported that they descended the helicopter to 500 ft as they approached the river. Just before the pilot turned EWM right to join the helicopter lane, another larger helicopter (the EC120) suddenly appeared in front of them (Figure 2). The pilot of EWM estimated the EC120 was about 500‍–‍600 ft (150‍–‍180 m) in front of them and about 100 ft above them. While there was no recorded altitude for EWM, primary radar data indicated that EWM entered the lane about 9 seconds behind the EC120.[3] Primary radar data for EWM was lost about 10 seconds later, just after 1028, indicating it had descended below radar coverage.

Figure 2: Primary radar return (left) and loss of primary radar return (right) for VH‑EWM

Source: Airservices Australia, annotated by the ATSB

The pilot of EWM made a radio broadcast that they were entering the helicopter lane as they crossed the Ryde Bridge behind the EC120. They then experienced what they described as very strong turbulence from a vertical motion in the atmosphere. A passenger later described it as ‘like heavy turbulence … rolling left and right’ followed by ‘diving towards the water’.

The pilot noted that the helicopter was descending through 400 ft and responded by raising the collective lever.[4] However, the helicopter continued descending towards the water as it tracked behind and below the EC120. A passenger recalled the pilot announced ‘brace for impact’ as the helicopter approached the water. The pilot applied full collective to avoid the water, which caused the rotor speed to decay sufficiently for the low rotor speed warning horn to activate. They also reported feeling that they could not escape what they believed to be the rotor wake from the EC120. The pilot then sighted a suitable forced landing area at Cabarita Park and, using the helicopter’s remaining airspeed and rotor speed, manoeuvred the helicopter to the shoreline for a landing.

Following the landing, the pilot rolled the engine throttle back to idle and proceeded through their after‑start checks and confirmed normal operations on the ground. The pilot then conducted a hover check and again confirmed normal operations. The pilot attempted radio contact with their operations base but received no reply. They then conducted a return flight to Bankstown without further incident. 

Context

Pilot information

The pilot held a commercial helicopter pilot licence, issued on 26 November 2024, with a single‑engine helicopter class rating and low‑level rating. The pilot held a class 1 aviation medical certificate with no restrictions and expiration date of 30 May 2025. The pilot had accumulated about 112 hours flying experience and the incident flight was the pilot’s first commercial flight.

Helicopter information

The incident helicopter, EWM, was a piston‑engine 2‑bladed Robinson Helicopter Company R44 Raven 1 with a maximum take‑off weight of 1,089 kg. The weight and balance data provided by the operator indicated it was within limits for the flight. 

The Airbus EC120B was a turbine-engine 3‑bladed helicopter with a maximum take‑off weight of 1,715 kg. Therefore, the EC120 was about 57% heavier than EWM at their respective maximum take‑off weights.

The maintenance release for EWM indicated the helicopter was operated by Bankstown Helicopters in the operational category of Part 133 Air Transport. The maintenance release current at the time of the incident was issued on 3 April 2025 at 4,349 hours total time in service with an expiry date of 3 April 2026 or 4,400 hours. A maintenance test flight was certified on the maintenance release as conducted on 3 April with ‘nil defects evident.’ 

After the incident, the operator’s maintenance organisation inspected the helicopter and found no defects. As the flight hours remaining on the helicopter were close to the next overhaul, the operator elected to remove the helicopter from service and have the maintenance organisation complete the overhaul. 

Meteorological information

The METAR[5] recordings for Bankstown Airport at 1000 and 1030 indicated that the wind was westerly at a speed of 9 kt at 1000 and 7 kt at 1030. No cloud was detected. These conditions were consistent with the Bankstown Airport forecast for 8 kt westerly winds. The pilot reported their assessment of the weather was 5 kt of variable wind and CAVOK[6] conditions, but when they encountered the turbulence over the Ryde Bridge it felt like 40 kt of wind.

Rotor wake turbulence

In 1996, the United States Federal Aviation Administration (FAA) produced a report on the subject of Flight test investigation of rotorcraft wake vortices in forward flight. They used a laser doppler velocimeter to measure the vortices and small probe aircraft to test the actual flying conditions. Smoke generation was used to visualise the wake vortices for the probe aircraft. Their investigation concluded that:

• The measured vortex circulation diminished with decreasing airspeed for helicopter airspeeds below 40 knots. At these lower speeds, the wake vortex structure begins to break down and changes to a distinct downwash.
• Vortex duration depends strongly on ambient weather conditions and a variance of 300% was observed on those days most conducive[7] to vortex persistence and duration compared with those observed on typical days.
• Typically, helicopters with higher gross weight, larger rotor diameters, and larger numbers of rotor blades generated vortices of larger core diameters.
• Probe tests revealed that helicopter vortices did not descend in the same predictable manner as for fixed‑wing aircraft. Some vortices descended; some remained level; and some initially descended, levelled off, and then ascended above the altitude of the generating helicopter.

Figure 3: Rotor wake vortices visualised with smoke generators

Visualisation of the wake vortices behind an S‑76A helicopter in forward flight with smoke generators from the FAA (1996) flight tests. Source: Reddit

Meiris (n.d.) provided an article for the United States Helicopter Safety Team website, on the subject of Avoiding helicopter wake turbulence. The article referenced the FAA 1996 flight test report and provided the following recommendations:

As a result of these findings and the studies conducted regarding helicopter downwash in a hover, a few guidelines have been developed to increase awareness around helicopter wake turbulence:

• For hovering flight or a hover taxi, stay three rotor diameters away.

• For forward flight, a minimum of 3 nm [NM] separation is recommended, especially from larger helicopters. The investigation we discussed previously discovered that even at 3nm [NM], the planes encountered uncommanded pitch and roll oscillations.

• Leave 2 minutes for the rotor vortices to dissipate behind a helicopter in forward flight.

Related occurrences

The French Bureau of Enquiry and Analysis for Civil Aviation Safety investigation BEA2019-0234, Accident to a paraglider involving the Airbus - EC135 - T2 PLUS registered F-HTIN, examined a fatal paraglider accident in 2019. The paraglider’s wing collapsed after encountering the rotor wake from an Airbus EC135 helicopter, which drifted with the wind from the helicopter’s flightpath onto the paraglider (Figure 4).

Figure 4: Simulation of rotor wake drifting onto the paraglider

Source: YouTube – Bureau of Enquiry and Analysis for Civil Aviation Safety, annotated by ATSB

The 2022 United States National Transportation Safety Board investigation WPR22LA072 found that the pilot of a Cessna 120 attempted a go‑around about 20 seconds behind the passage of a Bell UH‑1H helicopter. During the go‑around the Cessna encountered wake turbulence, resulting in a loss of control and collision with terrain (Figure 5). The report indicated light wind conditions of 4 kt at the airport.

Figure 5: Loss of control accident from rotor wake

Source: YouTube – Aviation Safety Network, annotated by ATSB

Safety analysis

Primary radar data and the pilot’s report indicated that EWM entered the Parramatta River helicopter lane and passed over the Ryde Bridge about 9 seconds behind and slightly below the EC120 helicopter. At this point, EWM encountered heavy turbulence, an uncontrolled descent and a low rotor speed when the pilot applied full collective to avoid a collision with the water.

The uncontrolled descent and low rotor speed condition resulted in the pilot conducting a forced landing on the shoreline of the Parramatta River. 

The incident occurred under relatively calm wind conditions and EWM operated in a serviceable condition for the return flight. Subsequent maintenance inspections of the helicopter found no fault. Furthermore, EWM passed overhead the Ryde Bridge in sufficient proximity to a preceding heavier 3‑bladed helicopter to be subject to a rotor wake induced upset. Therefore, the ATSB concluded that the sudden onset of turbulence and uncontrolled descent were likely the result of EWM encountering rotor wake turbulence from a preceding EC120 helicopter. 

Findings

From the evidence available, the following findings are made with respect to the wake turbulence encounter and forced landing involving Robinson R44, VH-EWM, about 15 km north‑east of Bankstown Airport, New South Wales, on 7 April 2025. 

Contributing factors

• It is likely that the incident helicopter entered the rotor wake from a preceding heavier helicopter, which resulted in control difficulties, an uncontrolled descent, low rotor speed warning and a forced landing.

Safety actions

Safety action by the Civil Aviation Safety Authority

Following review of the draft report, the Civil Aviation Safety Authority undertook proactive safety action to improve existing guidance about helicopter wake vortices in Advisory Circular 91-16. The updated version of the advisory circular was released on 17 July 2025 and can be found at the link: AC 91-16 v1.2 - Wake turbulence.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Airservices Australia
• Civil Aviation Safety Authority
• the operator and maintenance organisation for VH-EWM
• the pilot and passengers of the incident flight

References

Bureau of Enquiry and Analysis for Civil Aviation Safety. (2021). Accident to a paraglider involving the Airbus - EC135 - T2 PLUS registered F-HTIN on 11 May 2019 at Le Conquet (Finistère). https://bea.aero/fileadmin/user_upload/BEA2019-0234.en.pdf

Federal Aviation Administration. (2023). Aeronautical information manual. http://www.faa.gov/air_traffic/publications

Federal Aviation Administration. (1996). Flight test investigation of wake vortices generated by rotorcraft in forward flight (DOT/FAA/CT-94/117). https://apps.dtic.mil/sti/tr/pdf/ADA318103.pdf

Meiris, J. (n.d.). Avoiding helicopter wake turbulence. https://ushst.org/avoiding-helicopter-wake-turbulence/

National Transportation Safety Board. (2022). Aviation investigation final report (WPR22LA072). Investigation docket https://data.ntsb.gov/Docket?ProjectID=104480

Submissions

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

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

• Civil Aviation Safety Authority
• the maintenance organisation for VH-EWM
• the operator and pilot of the incident flight.

No submissions were received.

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 occurrence

Prior to the occurrence flight

On 10 March 2025, a Bell 421EP, registered VH-VJF and operated by Coulson Aviation as HT204, was tasked with ground crew support operations on the Canning Peak fire, a sub‑fire of the West Coast fire complex in Tasmania. 

At about 0830, the Tasmanian Fire Service briefed pilots on the weather and taskings for the day while at Strahan Airport. The Air Attack Supervisor (AAS) reported that the 2 Bell 412 helicopters were tasked with the insertion of crews into the fireground (HT201) and then firebombing[1] in support of those crews with a 150-ft longline and bucket[2] (HT204).

At about 0900, both helicopters departed Strahan Airport for Tullah, which was the designated staging area[3] for the activities. Approximately 25 minutes later both helicopters arrived at Tullah. The pilot of HT204 reported shutting down the helicopter and waiting until they were required for firebombing operations. The pilot of HT201 reported picking up a crew and completing an insertion into the fireground before returning to Tullah and remaining on standby in case an extraction was required. 

First fuel cycle

At about 1215, HT204 was tasked with firebombing operations in direct support of ground crew who were undertaking hot and cold trailing.^[4] 

At 1226 local time the pilot departed Tullah for hotspots located west of the Murchison River on the south‑east end of the fire. The pilot was the only person on board. The pilot reported that the weather conditions on departure were calm, with a temperature of 22°C and light, variable winds. 

When reaching the dip site^[5] the pilot completed one fuel cycle, approximately 10 bucket loads, under relatively stable conditions. The pilot described the dip site as a narrow section of river, approximately 50–60 m wide, with tall trees lining the bank (see also Dip site). The drop zone was located approximately 1 km west of the dip site. 

The pilot then returned to Tullah to pick up an air crew officer (ACO) at 1400 and continued onto the designated air base in Zeehan, which had a sports oval being used as a refuel base (Figure 1).

Figure 1: First fuel cycle and return to Tullah

White line: flight path of the first fuel cycle and return to Tullah. Purple line: flight path from Tullah to Zeehan. Source: Google Earth, annotated by the ATSB

Zeehan air base

During the approach to Zeehan, the pilot noted a significant weather change, with winds shifting to a westerly direction at approximately 30 knots. 

While on the ground, the helicopter was refuelled for the next cycle. At about 1440 the pilot departed Zeehan and returned to the Canning Peak fireground. 

Second fuel cycle and occurrence

The pilot recalled that various dip sites along the river looked similar. Flight data (Figure 2) indicated the pilot initially conducted a descent into an incorrect dip site. The pilot recognised this and undertook reconnaissance to find the intended dip site. Once reaching the dip site, the pilot resumed bucketing operations. 

Figure 2: Second fuel cycle flight path

Source: Google Earth, annotated by the ATSB

The pilot reported that, at about 1525, while filling the third bucket load of water, the helicopter had been in a stable hover at about 150 ft above the water, when it unexpectedly sank. The pilot recalled the helicopter sinking approximately 50 ft. To recover control, the pilot applied forward cyclic and upward collective inputs to transition to forward flight and stabilise the helicopter, while aiming to avoid an over-torque event. 

Prior to this manoeuvre, the pilot reported they were unable to jettison the longline, which they attributed to pressing on the button’s ring guard instead of its centre, and the longline subsequently became taut. The helicopter then came to an abrupt stop and the pilot heard a ‘loud clunking noise’. The pilot then recovered the helicopter to a stable hover approximately 30 ft above the water and initiated rearward flight to release the water and retrieve the bucket from the river. The pilot observed an engine torque split[6] and once the bucket and longline were recovered they initiated a climb to clear the surrounding trees. 

The pilot reported that once they had cleared the trees, the torque split levelled back out. They conducted a range of tests to assess controllability and engine performance, including minor adjustments to engine torque. The pilot noted that the tail rotor control pedals felt stiff, however they continued to provide adequate input for sufficient helicopter control. 

The pilot contacted the AAS on the fire common traffic advisory frequency (FCTAF) stating they had a bucket issue and a flight control issue.  

The air attack pilot (who flew the helicopter with the AAS on board) oriented the helicopter to view HT204. The AAS recalled HT204 gaining altitude and tracking away from the Murchison River, over the fire, heading on a bearing south‑west uphill and back to Zeehan. They noted the helicopter was climbing slowly and appeared to be flying irregularly during this period. They reported they had not seen the occurrence as the dip site HT204 was using was beneath and behind the air attack helicopter. 

The AAS contacted the pilot on the FCTAF. The pilot of HT204 reported issues with the helicopter pedals and when asked what their intention was, the pilot reported they were heading back to Zeehan. The AAS acknowledged this and reported they would follow HT204 back. 

The pilot of HT204 assessed available landing options but elected to continue toward Zeehan rather than commit to an off-field landing. This decision was influenced by a previous experience where a potential landing site, assessed from approximately 500 ft, had appeared suitable but proved unsuitable upon reaching around 30 ft. The pilot considered that committing to a landing carried the risk of being unable to complete it safely.

The AAS and air attack pilot discussed possible landing options nearby. However, given the impaired controllability of HT204 and the smaller prepared landing areas on the fireground, they agreed the best action would be to return to Zeehan. 

Return flight

The pilot of HT204 reported that, during the return flight to Zeehan, airspeed was maintained between 65 and 70 kt[7] due to the tail rotor pedals feeling stiff. This would reduce strain on the tail rotor by operating the helicopter at a lower power setting.

The pilot reported continuing the flight toward Zeehan with a plan that, should the situation deteriorate further, the flight would be changed to Strahan Airport as an alternative. Throughout the remainder of the flight, pedal inputs were minimised in an effort to avoid exacerbating the condition.

The AAS described the helicopter’s flight en route to Zeehan as appearing abnormal. In addition to the notably reduced speed, HT204 appeared to be yawing from side to side and maintained an unusually low height above ground. They reported that due to the pilot sounding stressed they did not contact the pilot further.

The AAS recalled contacting the air base manager at Strahan and the air operations manager and advised them of an unknown mechanical malfunction with HT204. They reported that the pilot was still in control, and that they were following HT204 back to Zeehan.

Landing at Zeehan

At about 1548, the pilot conducted a shallow approach to set up a vertical descent to the oval in Zeehan with the bucket and longline attached. During the landing sequence, the ACO secured the bucket and longline and moved it away and forward of the landing zone. The pilot then released the line and allowed the helicopter to sink, utilising available power, which resulted in what they stated ‘appeared to be a satisfactory landing with minimal pedal input required’.

After landing, during the shutdown procedure, the pilot was unable to roll the engine throttles back to idle. While disconnecting the longline from the hook, the ACO observed significant damage to the helicopter’s fuselage structure aft of the external hook. 

The pilot of HT201 recalled that they landed and shut down their helicopter in Zeehan. They observed HT204 still running and the pilot underneath the helicopter assessing damage. They discussed the issue of not being able to roll the engines back and the pilot of HT201 suggested pulling the helicopter’s T-handles.[8] The T-handles were pulled to shut down the engines. 

Context

Pilot information

The pilot held a Commercial Pilot (Helicopter) Licence, with a single engine class rating for helicopters. They held type ratings for the Bell 212, 412 and 427. The pilot’s total aeronautical experience was over 3,000 hours of which 120.6 hours were on the Bell 412. In the previous 90 days the pilot had flown 50.3 hours, all on the Bell 412. 

The pilot was qualified to conduct helicopter firefighting operations and had low‑level and sling operation ratings.

The pilot last completed an aerial application proficiency check on 11 November 2024, which was valid for 12 months, and a low-level helicopter flight review on 4 December 2023. 

The pilot held a valid Class 1 aviation medical certificate, valid to July 2025. The certificate specified that the pilot was to wear distance vision correction while flying, which was being worn on this occasion.

Helicopter information

General information

The Bell Helicopter Company 412EP is a medium‑lift[9] utility helicopter commonly used for firefighting, search and rescue and transport operations. The helicopter had a 4-blade main rotor and 2‑blade tail rotor and was powered by 2 Pratt & Whitney PT6T-3DF turboshaft engines. The helicopter was manufactured in Canada in 2004 and first registered in Australia in 2020. The helicopter was owned by NSW Rural Fire Service (RFS) and operated by Coulson Aviation Australia. 

VH-VJF had accumulated about 4,819 flight hours total time in service and had a current certificate of airworthiness and registration. The helicopter’s technical log indicated no outstanding defects at the time of the accident. 

The helicopter’s multi-role configuration enabled it to be utilised in a range of aerial firefighting tasks, including reconnaissance, winching operations and firebombing using either a belly tank or external bucket system (Figure 3).

Figure 3: NSW RFS Bell 412 EP VH-VJF

Source: Lesley de Robllard, annotated by the ATSB

On the day of the accident, the helicopter was configured for firebombing operations and was fitted with an external load system, a vertical reference door, and a 150‑ft longline attached to a Bambi bucket[10] (see Bucket and longline information). In addition to these items, the helicopter also had a forward looking infrared (FLIR) camera mounted on the left‑hand side of the helicopter above the skids.

External load system

VH-VJF was equipped with an Onboard Systems International cargo hook suspension system. The system attached to an existing Bell hard point and hung at approximately the centre of gravity. It extended through an opening in the lower fuselage, which was fitted with a protective rubber ring around the edge (Figure 4). This protective ring was used to reduce the risk of damage if the hook hit the edge of the opening.

Figure 4: Onboard Systems International cargo hook suspension system on the Bell 412

Source: Onboard Systems International, annotated by the ATSB

The release of the hook could be initiated electrically or mechanically. Normal release was completed by pilot actuation of a push button on the side of the cyclic (Figure 5, left). The button is guarded by a small ring to prevent inadvertent pilot activation. When this button is pressed the latch of the cargo hook is opened. 

In addition to the electrical release, in an emergency a mechanical release can be completed by pushing a small pedal located between the 2 tail rotor pedals at the pilot’s feet (Figure 5, right). This activated a manual release cable attached to the cargo hook.

The cargo hook suspension system was required to be inspected annually or after 100 hours of external load operations, whichever came first. The system was last inspected on 20 February 2025. 

Figure 5: Electrical and mechanical external load release systems

Left: the electrical release found on the cyclic grip. Right: mechanical release between the 2 pedals. Source: Coulson Aviation, annotated by the ATSB

Coulson Aviation required pilots to test the electrical and manual release system prior to conducting flights for the day. The pilot recalled testing both the electrical and mechanical release the morning of the accident. They stated that both systems were in working order. In addition to the tests, the pilot recalled that when landing at Zeehan after the accident, the electrical release was used to drop the longline and bucket without issue. 

Coulson Aviation reported that both the electrical and mechanical releases of the hook were tested following the accident. Both were reported as serviceable. 

Vertical reference door

The Bell 412EP helicopters are usually flown from the right-hand seat. This configuration is used when pilots are conducting either winching or reconnaissance operations. The helicopters can be modified to include a vertical reference door, which is designed to provide the pilot with a side bubble window and instruments for longline operations from the left-hand seat.

VH-VJF was modified with a vertical reference door in accordance with the Transwest vertical reference door supplement type certificate. This included a bubble window, viewing slot, and instruments and warning lights installed in the door (Figure 6).

Figure 6: Instruments and warning lights installed in the vertical reference door

Source: Coulson Aviation, annotated by the ATSB

In addition to the instruments and warning lights, the type certificate required the installation of several systems to be placed on the left side of the helicopter. This included: 

• a force trim switch, cargo release switch and automatic flight control system (AFCS) release switch mounted on the left cyclic
• the torque meter and tachometer from the left-hand instrument panel moved to the vertical reference door
• an additional mechanical cargo release pedal between the left side pedals.

During the occurrence flight and other firebombing operations, the pilot was operating the helicopter from the left-hand seat, utilising the left cyclic and referencing the flight instruments through the vertical reference door. While conducting the water collection, the torque indicator was visible through the bubble window and could be monitored during the lift. 

Bucket and longline information

The bucket and longline were attached to the external load system via a bow shackle (Figure 7, left). 

The bucket was a Bambi Max bucket with a nominal capacity of 240 US gallons (910 L). The empty weight of the bucket was 137 lb (62 kg) and the maximum gross weight was 2,140 lbs (970 kg).

The collapsable bucket was equipped with multiple selectable drop valves. Pilots were able to use the bucket to split water loads into multiple drops (Figure 7, right) and had the capability to shed the load rapidly.

Figure 7: Longline attachment and Bambi Max bucket

Source: Coulson Aviation, annotated by the ATSB

The longline was constructed from high-strength synthetic fibre rope selected for its high tensile strength, low stretch characteristics, light weight, and resistance to heat and abrasion. The line incorporated an electrical cable along the line to control bucket release. The 150-ft length provided vertical separation between the helicopter and the load to reduce rotor downwash disturbance during water pick‑up. 

Forward looking infrared (FLIR) camera

FLIR cameras are used on aerial firefighting aircraft to provide thermal imaging of fire grounds, enabling crews to detect heat sources through smoke, darkness, or challenging terrain. This capability allows operators to identify fire hotspots, monitor fire spread, and support decision-making for resource deployment and suppression strategies.

On the Bell 412s, the FLIR camera was mounted on the left side, just above the skids. Coulson Aviation stated that although the cameras could be removed, they would generally be kept on the helicopters throughout all operations, allowing the ability for the crews to be re-tasked for reconnaissance missions. Some pilots indicated to the ATSB that the camera could partially obscure visibility during bucketing.

Helicopter damage

The ATSB did not examine the helicopter or equipment. Coulson Aviation conducted an examination of the helicopter the morning after the occurrence. The following damage was identified:

• The #1 engine control tube had sheared at the lower tube end bell crank, resulting in a complete loss of pilot input to the engine.
• The #2 engine control tube bell crank attachment bracket had detached from the helicopter structure’s securing rib, restricting pilot control of the engine.
• The tail rotor control rod on the right-hand side of the external hook’s bell crank airframe attachment had broken away, with the primary structure also separated.
• The main transmission oil cooler pressure line exhibited significant contact damage, however, no splits or leaks were identified.
• The fuel tank interconnect braided hoses sustained minor contact damage.
• Multiple aft fuselage drain lines were damaged.

Images of the helicopter indicated that the structural fuselage honeycomb aluminium skin, adjacent to and aft of the external hook, was deformed and had separated from the primary structure (Figure 8).

Figure 8: Helicopter aluminium skin damage

Source: Coulson Aviation, annotated by the ATSB

Images revealed indications consistent with contact between the longline and the rear cross tubes of the helicopter. In addition, inspection of the cargo hook and associated bumper stop components identified visible signs of impact damage (Figure 9).

Figure 9: External load system damage

Source: Coulson Aviation, annotated by the ATSB

In addition, the ring in the middle of the Bambi bucket spoke assembly was fractured in 4 places (Figure 10).

Figure 10: Bambi Max damage to spoke assembly

Source: Coulson Aviation, annotated by the ATSB

Multiple instances of cable bruising and stretching were reported to have been observed on the bucket cable wiring and attachment eye ends. The ATSB was unable to substantiate the presence of cable bruising and stretching based on the images provided of the cables.   

Weather data

On departure from Strahan Airport, the meteorological aerodrome report (METAR)[11] reported wind west‑north-west at 6 kt, visibility greater than 10 km and no cloud cover. 

The Tasmania Fire Service (TFS) incident action plan indicated that weather on the Canning Peak fire would change from north-westerly to west-south‑westerly by mid‑morning with winds reaching 10 kt by the afternoon (Table 1).

 Table 1: Canning Peak fire forecast

The AAS reported that on the day of the accident the wind was calm, there was no turbulence and ‘great’ visibility. A change in wind direction was noted from mid-morning changing from northerly to south-westerly, however this was expected based on the forecast. They recalled the area in which the aircraft were working in was protected from south‑westerly winds due to the topography. They reported no feedback from pilots regarding the weather or any other environmental conditions on the day. 

The pilot of HT201 reported there were blue skies and fairly light winds on the day of the accident. They recalled that although they were not bucketing on this day, during previous bucketing operations in the same valley, the wind conditions were variable and the wind would shift ‘back and forth’. 

 A weather station atop Mt Inglis, approximately 15 km north of the operating area (Figure 11), recorded south‑south-westerly winds at 5.7 kt gusting to 11.4 kt at the time of the accident. 

Figure 11: Canning Peak weather station location to dip site

Source: Google Earth, annotated by the ATSB

Fireground information

The West Coast fire complex originated from 24 individual ignitions sparked by dry lightning strikes on 3 February 2025, across Tasmania’s remote western and north‑western regions. These separate fires were grouped into a single complex for coordinated management due to their proximity, shared weather influences, and overlapping spread patterns. 

There were 4 primary firegrounds that accounted for the majority of the burnt area: the Canning Peak fireground, the Yellowband Plain fireground, the Mount Donaldson fireground, and the Corinna Road fireground. Each represented a distinct sector with unique terrain, vegetation types, and behavioural characteristics. These firegrounds collectively contributed to the complex’s total footprint of nearly 95,000 hectares.

Canning Peak fireground

The Canning Peak fireground was located in a more elevated and vegetated zone close to the Cradle Mountain area and in proximity to sections of the Overland Track. This sector featured rugged alpine-influenced terrain that complicated direct ground access, leading to heavy reliance on aerial suppression tactics. 

Figure 12: Canning Peak fireground

Black outline indicates area which has been burnt by fire. Source: Tasmania Parks and Wildlife Service, annotated by the ATSB

Day of accident

On the day of the accident HT201 was the designated winching helicopter and HT204 was part of the bucketing helicopters on the fireground. There were 6 helicopters (3 x AS350, 1 x Bell 412 (HT204), 1 x Bell 212, 1 x BK 117) bucketing within a 2 km proximity of each other intermittently. In addition, the air attack helicopter was on scene overhead.

The helicopters were distributed across 4 separate circuits, with 5 separate dip points, seperate individual and shared targets and some shared ground crew. 

Dip site

The pilot reported that the general location for a dip site was provided prior to commencing operations on the fireground, with selection of the specific section of river within that area being at their discretion. The pilot advised that they chose this dip site location on the river as it was relatively wider than other areas and they had used this section as a dip site on the days preceding the accident.

HT204’s dip site was approximately 700 m from the next nearest dip site with working helicopters. The dip site was approximately 1 km south‑east of the drop zone, along the Murchison River. Google Earth images indicate the river width at the dip point was approximately 20 m (Figure 13).

Figure 13: Dip site location on Murchison River

Source: Google Earth, annotated by the ATSB

The pilot described the dip site as a narrow section of river, approximately 50–60 m wide, with tall trees lining the bank. They reported that there were limited locations deep enough to operate the bucket, which constrained where they could dip and they stated they had used the same dip point on the days prior.

In addition, the river contained very little water at the time, allowing clear visibility to the riverbed. They stated that they could not recall whether any tree branches or rocks were present in the riverbed during the operation. Despite the presence of tall trees, the pilot indicated that the area was accessible to the aircraft and considered it one of the better dip sites along the river. They also noted that the turnaround time from the dip point to the fireground was approximately one minute. 

The AAS described the dip site as a section of river with trees approximately 30–60 m tall on either side. They recalled that the pilot was the only one using the dip point and the only helicopter in the circuit. In previous weeks, when different crews had flown the same helicopter on similar missions, no pilots had reported any problems with the dip point. Based on the dips that were observed, the occurrence pilot appeared to be performing them safely and adequately.

Recorded data

Multiple independent data sources, including TracPlus satellite-based tracking logs, FlightAware ADS-B derived positions, and OzRunways electronic flight bag recordings, were cross‑referenced and correlated to reconstruct the helicopter’s flights throughout the day and to approximate the entry and exit angles into and out of the bucketing site.

TracPlus

The helicopter was fitted with a TracPlus surveillance system, which provided real-time tracking through a satellite or mobile phone network. It reported position, altitude, and speed at set time periods, in this case every 15 seconds. 

OzRunways

The OzRunways application recorded the helicopter’s position at regular intervals of approximately 5 seconds throughout the day, capturing parameters including latitude, longitude, groundspeed, track, and truncated altitude (in 100 ft increments) where connectivity permitted. However, no position data was recorded during the bucketing operations (Figure 14). This absence of recorded data was likely attributable to the helicopter operating at very low levels, down to around 150 ft above ground level, while conducting repeated drops in mountainous terrain.

Figure 14: OzRunways flight data

Source: Google Earth, annotated by the ATSB

FlightAware

The FlightAware flight tracking data captured the helicopter’s en route flight to the bucketing site, as well as the subsequent low-level manoeuvres involving repeated water dips and drops. Position reports were recorded at irregular intervals ranging between approximately 8 seconds and 40 seconds[12] during these operations.

In addition to the TracPlus data, FlightAware was incorporated into the data analysis. The differing sampling rates and coverage characteristics of the 2 systems together produced a more complete reconstruction of the helicopter’s flight circuit during the second fuel cycle (Figure 15).

Figure 15: Second fuel cycle data from TracPlus and FlightAware

Pink line: TracPlus data. Blue line: FlightAware data. Source: Google Earth, annotated by the ATSB

Further investigation

To date, the ATSB has conducted the following activities:

• interviewed the pilot and other Coulson Aviation personnel
• interviewed the air attack supervisor from Tasmania Parks and Wildlife Service
• 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.

The investigation is continuing and includes:

• 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.

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 2026 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

Overview of the investigation

The ATSB commenced an investigation into a flight control issue involving a Virgin Australia Boeing 737-8FE aircraft, registered VH-VIE, which occurred near Perth Airport, Western Australia (WA) on the afternoon of 31 July 2021. The flight was a scheduled passenger service from Perth WA to Brisbane, Queensland.

During initial climb, the crew detected that the aircraft had commenced an uncommanded descent. The Captain disconnected the autopilot, leaving the autothrottle engaged while descending through 1,536 ft and manually trimmed the aircraft using the electrical stabiliser trim. Shortly afterwards, the crew received an enhanced ground proximity warning system (EGPWS) ‘DON’T SINK’ alert. The aircraft was re-established in a climb configuration.

At 2,144 feet, the Captain re-engaged the autopilot. Six minutes later, at 17,888 feet, the autopilot automatically disengaged. The autothrottle then also disengaged for reasons undetermined. To test if there was a problem with the A system autopilot, the crew engaged the B system autopilot and re-engaged the autothrottle. Shortly afterwards, air traffic control (ATC) queried the crew if their operations were normal. While responding to ATC, the crew detected the ‘STAB OUT OFF TRIM’ light illuminated and advised ATC to standby for further details. The crew then began the associated Quick Reference Handbook Non-Normal Checklist and while doing so, the B system autopilot automatically disengaged. The crew followed the checklist by not re-engaging the autopilots and autothrottle, and continued to manually fly the aircraft.

Once in cruise, the crew contacted ATC advising that they were unable to fly at reduced vertical separation minima (RVSM)^[1] and requested a block level ^[2] clearance of flight level (FL) 380 to FL400 due to stable atmospheric conditions. The crew then discussed the risks of continuing the flight to Brisbane. After liaising with company engineers, referring to company documentation and examining the weather at the departure, alternate and arrival airports, the crew decided to continue to Brisbane. The crew also assessed their fitness to fly, and distributed different phases of flight to each other to manage workload and fatigue. They communicated with their Chief Pilot and requested an off-duty company pilot, who was flying to Brisbane as a passenger, to join them in the cockpit to provide additional support if required.

A post-flight engineering inspection found that the circuit breaker for the automatic flight control system (AFCS) stabiliser trim was in the tripped position and the STAB OUT OF TRIM light was faulty. Engineers reset the circuit breaker, but were unable to replicate the fault during testing. The faulty light was replaced, but was considered unrelated to the tripped circuit breaker. The reason for the tripped circuit breaker was not established. A verification flight ensured that the AFCS was commanding the stabiliser without any issues. No further faults were detected.

As part of the investigation the ATSB:

• interviewed the flight crew
• examined the recorded flight data and the operator’s and aircraft manufacturer’s procedures
• examined the crew’s in-flight decision making.

The ATSB found that at all stages of the flight, the flight crew acted in accordance with operator’s and aircraft manufacturer’s procedures, and had considered and managed the risks associated with continuing the flight.

Reasons for the discontinuation

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues or important safety lessons. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

__________

1.  Reduced vertical separation minima (RVSM): the reduction of vertical space between aircraft from 2,000 to 1,000 feet at flight levels from 29,000 feet up to 41,000 feet.
2.  Block level: a section of airspace with specified upper and lower limits on a specific track, in which cleared aircraft are permitted to manoeuvre.