Missed approach

Investigation summary

What happened

On 22 August 2025, a GippsAero GA8, operated by Air Kimberley and registered VH‑LHC, entered the circuit in preparation for landing at Djarindjin/Lombadina Airport, Western Australia. At about this time, the pilot identified an uncommanded 3-inch drop in engine manifold pressure. After briefly liaising with the chief pilot via phone, the pilot conducted an orbit between the base and final legs of the circuit to prepare for the landing. 

Crossing the threshold, the pilot identified that they were between 20 and 25 kt above the target approach speed. Approximately two-thirds of the way down the runway, the pilot assessed there was insufficient runway remaining to land, commenced a go-around and attempted to climb away. However, the airspeed reduced and the pilot assessed that they did not have sufficient power to climb and elected to level the aircraft and conduct a turnback to land on the reciprocal runway. The pilot used the mixture control to reduce the engine’s power and landed without further incident.  

What the ATSB found

During the approach, the securing mechanism for the aircraft’s throttle linkage failed, resulting in a loss of throttle control and a constant partial power setting. The approach then continued at a higher-than-normal speed that did not permit the aircraft to land safely.

During the subsequent go-around, the pilot assessed there was insufficient power to climb. This was due to the throttle failing to open to at least 75% in accordance with the manufacturer’s requirement, likely due to the spring that opened the throttle in the event of a disconnection not being fitted.

Additionally, the ATSB found that there were multiple inconsistencies between the throttle linkage hardware fitted to VH-LHC and that laid out in the aircraft documentation. Although the ATSB could not determine whether the inconsistencies contributed to this incident, they increased the risk of throttle disconnection due to unintended interactions between components in the linkage. 

What has been done as a result

In response to the ATSB advice noting the inconsistencies between the linkage assembly and the manufacturer’s prescribed configuration, the maintenance organisation, BOAB Engineering (BOAB), conducted a review of the 3 GA8 aircraft that it was responsible for. 

BOAB identified various inconsistencies related to incorrect throttle body lever arms, missing torsion springs and incorrectly located or missing spacers. At the time of writing, BOAB advised that the correct parts had been ordered and that the linkage assemblies would be re-assembled in accordance with the manufacturer’s requirements.

Safety message

Partial power loss can be more complex to manage than a complete power loss. The response to a complete power loss is definitive and standardised but the response to a partial power loss may be dependent on the amount of power lost and reliability of the remaining power. CASA's guidance is to treat a partial power loss as though it is a complete power loss and to ensure that the aircraft is landed as soon as possible. Where engine power is available pilots can consider using it to extend available flight time to identify a better landing site with the awareness that the power may reduce or fail at any time. 

This occurrence also demonstrates the importance of being aware of and adhering to the manufacturer’s assembly requirements. Reconnecting a component’s attachment hardware on a like-for-like basis may not ensure compliance with the manufacturer’s requirements and can increase the risk of an adverse outcome.   

 

The investigation

The ATSB scopes its investigations based on many factors, including the level of safety benefit likely to be obtained from an investigation and the associated resources required. For this occurrence, the ATSB conducted a limited-scope investigation in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

The occurrence

On the morning of 22 August 2025, a GippsAero GA8, operated by Air Kimberley and registered VH‑LHC, departed Broome, Western Australia, for a charter flight to Djarindjin/Lombadina Airport (Figure 1) with the pilot, one passenger and freight on board. 

Figure 1: VH-LHC flight location

Source: Google Earth and FlightRadar24, annotated by the ATSB

Approximately 55 minutes after departing Broome, the pilot joined the downwind leg of the circuit for runway 28 at Djarindjin/Lombadina Airport. Shortly after joining the circuit, at about 1251 local time, the pilot identified an uncommanded 10 kt reduction in airspeed and a drop from approximately 20 inches of mercury (inHg) of engine manifold pressure to 17 inHg. In response, the pilot moved the aircraft throttle lever across its full range of movement but did not hear or feel a response from the engine and reported no change to the manifold pressure. 

At this time, the pilot contacted the operator’s chief pilot via mobile phone for guidance. The pilot reported that in the brief conversation they outlined the issue that they were encountering. While the pilot could not remember the details of the chief pilot’s response the general guidance provided was to land as safely as possible and to call back when they were on the ground. 

Following this conversation, the pilot elected to conduct an orbit to extend the approach (Figure 2) and allow themselves more time to assess the problem and conduct pre‑landing checks and procedures. They intended to conduct the approach normally but with an extended final approach. The pilot also considered the early use of a second stage of flap to slow the aircraft. However, they decided against it due to the unknown reliability of the engine’s performance and extended the second stage of flap as part of the normal pre-landing process on final approach.    

Figure 2: Downwind, final approach, go‑around and return

Note: Due to the light and variable winds at the time of the occurrence, the aircraft ground speeds were within 5 kt of the airspeeds that would have been presented to the pilot. Source: Google Earth, FlightRadar24 and Bureau of Meteorology, annotated by the ATSB

The pilot recalled, and recorded data confirmed, that the aircraft was at about 100 kt, 20‍–‍25 kt faster than planned, when crossing the threshold. Approximately two-thirds of the way down the runway, the pilot identified that the aircraft was ‘floating,’¹ had insufficient runway remaining to land the aircraft, and elected to conduct a go-around. The pilot initiated a climb, retracted one stage of flap and felt the airspeed start to reduce from 84 kt at the time the go‑around was initiated, to 68 kt as they turned off the runway heading. The pilot reported reaching approximately 300 ft above ground level, assessed that there was insufficient performance to safely continue the climb and levelled the aircraft. 

The pilot’s planned forced landing option when taking off from runway 28 at Djarindjin/Lombadina was a beach on the western side of scrubland beyond the end of the runway (Figure 2). However, the pilot assessed that this was not suitable and subsequently turned to the left for a return to runway 28. 

During the turn, the aircraft maintained altitude and accelerated from 68 to 88 kt. The pilot reported that, after the turn, they were unsure if the engine would continue producing power long enough to complete a circuit. They subsequently decided to land on runway 10, the reciprocal runway. Having determined that they were able to reduce the engine’s power using the mixture control, the pilot brought the mixture to near the cut‑off position and conducted a turnback to runway 10, slowing the aircraft through 75 kt to 70 kt before landing. 

After landing, the pilot increased engine power by returning the mixture to rich and taxied off the runway. Subsequently, after consultation with the company’s maintenance provider, it was determined that the throttle linkage had disconnected at the engine. 

Context

Pilot information

The pilot held a Commercial Pilot Licence (Aeroplane) with a command instrument rating and a valid class 1 aviation medical certificate. The pilot reported that at the time of the occurrence they had 869 hours of total aeronautical experience with 385 of these being on the GA8 and 48 in the last 90 days. 

Operational information

Emergency procedures

The GA8 pilot’s operating handbook contained relevant procedures for the operation of the aircraft in the event of an emergency. The manual did not contain a specific procedure for the management of partial power, however there were procedures for both a precautionary landing with engine power and an emergency landing without engine power. 

The procedure for a precautionary landing with power included an indicated airspeed of 75 kt on approach with stage 1 flap extended. The procedure for landing without engine power included an indicated airspeed on final approach of between 64 and 71 kt depending on aircraft weight. In normal operation the approach speed was 71 kt.

The procedure for landing without engine power required the pilot to switch off the ignition, fuel shutoff valve, and the master electrical buses, to move the throttle to the closed position, the mixture to the idle cut off position and the propellor to coarse. 

The procedure for a precautionary landing with power required the mixture to be moved to the idle cut‑off position and the ignition, fuel shut‑off valve and bus 1 and 2 master switches to be moved to the off position after touchdown.  

Management of partial power loss

Management of a partial power loss is more complex than a complete power loss. The response to a complete power loss should be definitive and standardised while the number of factors that could lead to a partial power loss and the unreliability of any remaining power meant that a situationally specific response is required. 

While the manufacturer did not provide guidance on the management of partial power loss in the GA8, both the Civil Aviation Safety Authority (CASA) and the ATSB have published general guidance on the subject – CASA in its flight instructor manual and the ATSB in Managing partial power loss after takeoff in single-engine aircraft (AR-2010-055 - Number 3). The guidance contains 3 key points:

• a partial power loss event should be treated like a complete power loss and a landing should be conducted as soon as possible
• any available power may be used to extend the flight time to locate a better landing area
• this should be done with the consideration that the power may degrade further or be lost at any time.

Throttle operation

The GA8 flight manual advised that a normally aspirated engine had a manifold pressure range between 10 and 30 inHg. However, the range available for use was dependent on the altitude at which the aircraft was operating.

The pilot stated that when approaching Djarindjin/Lombadina on descent they typically set 20 inHg, reducing this to 18 inHg passing the threshold during the downwind leg of the circuit and then to 15 inHg when making the turn onto the base leg.

Meteorological information

An aerodrome meteorological report for Djarindjin/Lombadina was issued at 1300 local time, approximately 5 minutes after VH-LHC crossed the threshold on its first approach. The wind recorded was from 050° at 4 kt with 9,000 meters visibility, temperature 30°C and no recorded rainfall.

One-minute wind observations between 1250 and 1300 showed variable wind direction at 2‍–‍5 kt. 

Aircraft information

General information

The GA8 is a single‑engine aircraft manufactured by GippsAero² of Victoria, Australia. It is fitted with a Textron Lycoming IO-540-K1A5 piston engine and can seat up to 8 people, including the pilot. VH-LHC (serial number GA8-04-057) was manufactured and registered in 2004. At the time of the occurrence, it had accumulated 11,768 hours total time in service. For this flight, the aircraft was configured for a single passenger next to the pilot and with the rear passenger seats removed and appropriate securing equipment in place for carriage of freight. 

Throttle cable attachment assembly

The throttle cable assembly translated movement of the throttle lever in the cockpit to the throttle body on the engine. The throttle body attachment consisted of a rod end and throttle body lever arm bolted together with a series of washers and spacers used to ensure appropriate geometry was maintained. The geometry of the washers and spacers allowed both the rod end and throttle body lever arm to move freely and limited interaction with the other components. If the geometry was not correctly maintained, the rod end could forcefully contact the penny washer and, as the rod end moved through its arc of motion, induce a rotation in the penny washer and subsequently, in the bolt. This interaction could result in a loosening or disconnection of the linkage.

Figure 3 shows the exploded diagram of the linkage from the aircraft manufacturer’s illustrated parts catalogue (IPC) and an exemplar assembly provided by the manufacturer.

Figure 3: Throttle cable attachment assembly

Source: Manufacturer, modified and annotated by the ATSB

The threaded end of the bolt specified in the IPC (AN3-11) is drilled allowing a split pin to be used as a secondary securing mechanism. However, the specified nut (MS21042-3) is a reduced hex nut that uses interference with an out of round section to lock the nut onto the bolt and consequently does not require a split pin. This combination, while permitted and approved, was not commonly used as a reduced hex nut is typically used in combination with a non-drilled bolt. When consulted, the manufacturer could not advise why this hardware combination had been prescribed for the aircraft. However, they advised that some elements of the design for this aircraft had been reproduced from the design of another aircraft, including the specified bolt. 

The throttle body lever arm on the GA8 was developed by GippsAero by modifying the design of the standard arm supplied by the engine manufacturer. The modification made the arm approximately 12 mm shorter than when used for other applications with the same engine. This modification altered the arc through which the arm moved to ensure that the geometry between the throttle cable and the throttle body was correct. The manufacturer’s review of the images of VH-LHC’s throttle arm identified that a standard lever arm was fitted rather than the GippsAero lever arm. 

Figure 4 shows the throttle lever arm as fitted to VH-LHC in comparison to an exemplar of the shortened lever arm as prescribed for the aircraft by GippsAero in the IPC. Note the throttle positions shown in the images are not the same and the image has been rotated to show the difference in length between the lever arms.

Figure 4: Throttle lever arm comparison

Source: Operator and aircraft manufacturer, modified and annotated by the ATSB

Spring‑loaded mechanism

The certification standard for the GA8 required that if the engine control separated, it must be designed so that the aircraft is capable of ‘continued safe flight and landing’. This requirement was implemented by the United States Federal Aviation Administration (FAA) in response to a 1981 National Transportation Safety Board (NTSB) study of single‑engine aircraft accidents involving separation of throttle linkages and subsequent loss of propulsive power. The NTSB recommendation (A-81-6) to the FAA was to: 

Establish a requirement that, when throttle linkage separation occurs in a small single engine aircraft the fuel control will go to a setting which will allow the pilot to maintain level flight in the cruise configuration; (Class 11, Priority Action) 

In response, the FAA introduced a requirement under regulation 23.1147(g) that: 

For reciprocating single-engine airplanes, each power or thrust control must be designed so that if the control separates at the engine fuel metering device, the airplane is capable of continued safe flight and landing

For the GA8 to comply with this requirement, the throttle body linkage was fitted with a torsion spring with sufficient tension to drive the throttle to at least 75% of the full throttle setting. The torsion spring is mounted directly to the throttle body as shown in Figure 5 and can subsequently drive the throttle to the required position in the event of a disconnection anywhere along the throttle linkage.

Figure 5: Spring location

Source: Manufacturer, modified and annotated by the ATSB

In 2011, GippsAero published service bulletin SB-GA8-2011-64 in response to reports of throttles failing to open sufficiently. The service bulletin required that spring tension be tested and if it was not able to open the throttle sufficiently, a stiffer spring was required to be installed. This service bulletin was completed on VH-LHC on 28 February 2011 at 5,150.5 hours. 

Post‑occurrence examination

The ATSB was provided with an image taken by the pilot immediately after the occurrence (Figure 6). It shows the throttle body lever arm at approximately 25% travel with the through bolt from the rod end disconnected from the lever arm. Only the bolt and penny washer from the cable attachment assembly were visible in the image. The remaining components including the nut, washer and spacers were unable to be identified.

Figure 6: Post‑occurrence image of throttle body and throttle cable attachment assembly

Source: Operator, annotated by the ATSB

Following reconnection of the linkage using new hardware, the ATSB requested the nut and bolt from the maintainers, however they were unable to provide either. They reported that the nut was not recovered during the repair and the bolt could not be located. The maintainers reported that damage to the bolt threads was identified when it was removed.

A subsequent review of the IPC identified that the correct securing mechanism was a reduced hex nut and not the castellated nut and split pin that had been fitted during the repair (see the section titled Engine change for further information).

Following the occurrence, the ATSB and the manufacturer reviewed the available imagery. The manufacturer stated that the imagery appeared to show an incorrect configuration of the throttle cable attachment assembly, with markings on the end of the throttle body lever arm indicating that at least one of the spacers had been incorrectly located. The ATSB also identified, and the manufacturer confirmed, that the spring on the throttle mechanism was missing (Figure 7). 

Figure 7: Post‑occurrence imagery identifying location of throttle mechanism spring

Source: Operator and manufacturer, annotated by the ATSB

Maintenance information

Engine change

In June 2025, VH-LHC’s engine was removed due to detonation damage. The engine including the frame and ancillary components, such as hoses and baffles, were removed and a serviceable engine and propeller from another GA8 were installed. The aircraft was released back into service on 3 June 2025. The maintainer who conducted the engine change was contracting to the maintenance organisation and had not previously (and did not subsequently) work on this aircraft. 

They reported that when they disconnected the linkage there were thick section washers fitted to either side of the rod end, a penny washer under the bolt and the linkage was secured with a castellated nut and split pin. They reported reusing the hardware from the removed engine with a new split pin and that their post‑installation checks identified no issues with the movement of the throttle.

The maintainer stated that, based on their experience and the presence of the hole in the bolt, the use of a castellated nut and split pin was logical, and they did not refer to the aircraft documentation to confirm the hardware configuration. 

Related occurrences

A review of the ATSB’s occurrence database did not identify any similar occurrences, however the manufacturer identified a continuing airworthiness notice (CAN) issued in 2007 by the New Zealand Civil Aviation Authority (CAA) related to a similar issue and a review of the CASA defect reporting database identified a similar issue from an aircraft in Botswana in 2017.

New Zealand Civil Aviation Authority Continuing Airworthiness Notice 76‑001

On 5 July 2007, the NZ CAA released a CAN on all GA8 aircraft for an inspection of the throttle cable and the throttle lever installation. A CAA investigation had been prompted by reports of a sluggish feel in the throttle operation of a GA8. The investigation identified that the linkage bolt was rotating, resulting in a loosening of the nut securing the mechanism. Contact between the penny washer and the rod end resulted in movement of the rod end causing the penny washer, and subsequently the bolt, to rotate. 

As published, the CAN contained a recommendation for an updated configuration of the linkage assembly intended to increase the approach angle between the penny washer and the rod end. In February 2026, the CAA advised that the manufacturer’s configuration addressed the issue and subsequently the CAN had been removed from the NZ CAA website. In response to the draft ATSB report, the CAA advised that the CAN was pending revision and reissue, following the release of the ATSB report.

Figure 8 compares the reconnected linkage configuration on VH-LHC (left) with the manufacturer’s exemplar configuration (right). The spacers shown in the manufacturer’s configuration provide increased clearance between the penny washer, rod end and the throttle body lever arm compared to the washers used in the reconnected configuration. 

Figure 8: Throttle linkage assembly comparison

Source: Operator and manufacturer, annotated by the ATSB

The pre-occurrence configuration of the linkage fitted to VH-LHC was unable to be determined. However, the reconnected configuration showed a limited clearance between the rod end and the penny washer due to the missing spacers. This lack of clearance meant that the rod end was likely to contact the penny washer when the throttle was moved through the full range of motion. 

As identified by the CAA’s investigation, this creates a risk of interaction between these parts and potential for loosening and disconnection of the linkage. In comparison, the spacers used in the manufacturer’s configuration separate the rod end from the penny washer to prevent interaction. 

CASA defect report

A review of the CASA defect reporting database identified a report from 8 May 2017 related to aircraft A2-FTW,³ as follows:

Loosened nut and insecure throttle control cable rod-end and bolt discovered, caused by engine vibration.

New nut installed and tightly secured to the throttle control linkage on fuel injector.

Safety analysis

Approach

The pilot reported that the flight to Djarindjin/Lombadina was uneventful until the aircraft entered the circuit. During the downwind leg of the circuit, the pilot observed an uncommanded drop in manifold pressure from 20 to 17 inHg and was no longer able to control engine power using the throttle lever. Once the pilot made the base turn, the 17 inHg manifold pressure was above the 15 inHg setting they would have typically been using. Imagery of the throttle linkage captured by the pilot following the occurrence showed the linkage disconnected and the securing nut missing with the throttle arm near to, but not at, the idle position. The consequence of the linkage disconnection was that movement of the throttle lever in the cockpit could not be translated to the throttle lever arm on the engine resulting in a loss of throttle control. 

As the approach progressed, the pilot reported, and recorded data showed, that the aircraft was 20–25 kt above the recommended approach speed of 75 kt as it crossed the threshold. At that speed, the pilot assessed that there was insufficient runway available to slow the aircraft and make a safe landing.

Go-around

After the pilot identified that there was insufficient runway remaining to land safely, they commenced a go-around and the aircraft’s speed immediately started to reduce. The pilot reported that the aircraft was correctly configured for climb with one stage of flap, propeller pitch at full fine and that other than the limited power there were no issues that should have adversely affected climb performance. Unable to use the throttle to increase the power from the engine, the aircraft continued to slow, and so the pilot levelled the aircraft. The pilot then commenced a left turn and the engine was producing sufficient power for the aircraft to accelerate through the turn while maintaining altitude. 

Aircraft certification standards required that, in the event of a throttle linkage disconnect, the engine side of the throttle linkage move to a position that would enable ‘continued safe flight and landing’. The manufacturer therefore required that a torsion spring be installed on the throttle linkage that would open the throttle to at least 75% of the open position in the event of a disconnection. 

The image captured by the pilot immediately following the occurrence showed the throttle in a low power position, well below the 75% open position that was required by the manufacturer. Due to the number of factors that can impact the relationship between throttle position and observed manifold pressure, it was not possible to determine what the manifold pressure should have been if the throttle was open to 75%. However, as available power increases as the throttle opens, the position of the throttle arm below the 75% open position meant that there was less power available than that required by the manufacturer to sustain ‘continued safe flight and landing’.

It was further identified and confirmed by the manufacturer that the torsion spring was not visible in the imagery captured immediately after the occurrence. The ATSB considered 2 possible scenarios for the missing torsion spring. The first was that the spring had been present and had failed since the last maintenance activity or during the occurrence and the second was that the spring was not fitted at the time of the engine change.

As the spring was fitted around the shaft, in the event of a failure, the spring would have been retained on the shaft and been visible. Additionally, it is very unlikely that the spring would have failed at the time of the linkage disconnection as in the event of a disconnection the tension on the spring would have been released to drive the throttle arm to at least the 75% open position.

While it could not be conclusively determined if the required torsion spring was fitted at the time of the occurrence, it was considered very likely that it was not fitted due to:

• the visible lack of the spring 
• the fact that the spring would have been retained should it have failed 
• the limited time between maintenance and the occurrence for the spring to become detached and be lost
• the fact that the throttle did not open, which is the purpose of the spring being fitted. 

Installation inconsistencies

There were several inconsistencies between the throttle linkage installation on VH-LHC and the arrangement outlined in the aircraft documentation, as follows:

• the manufacturer identified that the throttle arm fitted was not correct for the aircraft
• the maintainer reported using a castellated nut with split pin, rather than the specified reduced hex nut
• the throttle opening spring was very likely not fitted 
• the spacers were likely not fitted correctly prior to the occurrence. 

As shown by the New Zealand Civil Aviation Authority Continuing Airworthiness Notice, changes to the throttle linkage geometry can lead to undesirable interactions between components within the linkage, most notably the rod end and the penny washer. This can subsequently loosen the linkage and could result in complete disconnection. 

The ATSB could not determine whether the inconsistencies between the recommended, and actual throttle linkage configurations contributed to the disconnection. This was primarily due to limited evidence about the sequence of the disconnection but was also influenced by the limited and incomplete information about the pre-occurrence linkage configuration. The likely configuration of the throttle linkage was determined based on manufacturer review of the available imagery, the recollection of the maintainer who completed the engine installation approximately 4 months before the occurrence and imagery of the reassembled linkage following the occurrence. 

The individual impact of each of these inconsistences could not be determined.  However, the combination of the inconsistencies, and their potential impact on the geometry of the linkage and subsequent interaction between the components, increased the risk of a disconnection.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  These findings should not be read as apportioning blame or liability to any particular organisation or individual.

From the evidence available, the following findings are made with respect to the engine malfunction involving GippsAero GA8, VH-LHC, at Djarindjin/Lombadina Airport, Western Australia, on 22 August 2025. 

Contributing factors

• During the approach, the securing mechanism for the aircraft’s throttle linkage failed resulting in a loss of throttle control and a constant partial power setting. The approach then continued at a higher-than-normal speed that did not permit the aircraft to land safely.
• During the subsequent go-around, the pilot assessed there was insufficient power to climb. This was due to the throttle failing to open to at least 75% in accordance with the manufacturer’s requirement, likely due to the spring that opened the throttle in the event of a disconnection not being fitted. 

Other factors that increased risk

• There were multiple inconsistencies between the throttle linkage hardware fitted to VH-LHC and that laid out in the aircraft documentation. This increased the risk of throttle disconnection due to unintended interactions between components in the linkage. 

Safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Safety action taken by BOAB Engineering

In response to the ATSB advice noting the inconsistencies between the linkage assembly and the manufacturer’s prescribed configuration, the maintenance organisation (BOAB) conducted a review of the 3 GA8 aircraft that it was responsible for. 

BOAB identified various inconsistencies related to incorrect throttle body lever arms, missing torsion springs and incorrectly located or missing spacers. It advised that the correct parts had been ordered and that the linkage assemblies would be re-assembled in accordance with the manufacturer’s requirements.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of the occurrence flight 
• the operator of VH-LHC
• the maintenance organisation for VH-LHC
• the maintainer who completed the engine change on VH-LHC
• GippsAero
• New Zealand Civil Aviation Authority
• Civil Aviation Safety Authority
• Bureau of Meteorology
• Flight Radar 24
• Federal Aviation Administration
• National Transportation Safety Board.

Submissions

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

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

• the pilot of the occurrence flight 
• the operator of VH-LHC
• the maintenance organisation for VH-LHC
• the maintainer who completed the engine change on VH-LHC
• GippsAero
• Transport Accident Investigation Commission (New Zealand)
• New Zealand Civil Aviation Authority
• Civil Aviation Safety Authority.

Submissions were received from:

• New Zealand Civil Aviation Authority
• the maintainer who completed the engine change on VH-LHC.

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.

Footnotes

1	Float: a term used to describe when the aircraft continues flying when the pilot intends to touch down but is unable due to the wing generating excess lift.
2	The manufacturer was previously known as Gippsland Aeronautics.
3	A2 is the national aircraft registration identifier of Botswana.

Investigation summary

What happened

On the afternoon of 9 August 2025, an Aero Commander 500-U, registered VH-LRI, and operated by 360° Aviation Group, was being repositioned from Bacchus Marsh Airport to Moorabbin Airport, Victoria, with a single pilot on board. At the same time, a Cessna 172, registered VH-EUE and operated by CAE Melbourne Flight Training, was being used to conduct circuit training at Moorabbin Airport with a flight instructor and a student pilot on board.

During the approach to Moorabbin, the Aero Commander crossed through the centreline of the intended runway 17R and instead aligned with the parallel runway 17L, behind the Cessna 172. Separation between the aircraft reduced as they proceeded on final before air traffic control (ATC) observed the aircraft in close proximity. ATC then instructed the Aero Commander to climb and the Cessna 172 to continue landing and the aircraft were deconflicted. The Aero Commander subsequently conducted a visual circuit and landed without further incident, and the Cessna 172 continued circuit training.

What the ATSB found

The ATSB found that the pilot of the Aero Commander configured their GPS navigation unit to provide guidance to the runway. However, due to the waypoint and track selected, the guidance provided was significantly offset from the runway’s centreline. As a result, the pilot inadvertently intercepted the final approach path of the parallel runway behind the Cessna 172.

It was also found that after identifying that the aircraft were in close proximity, air traffic control quickly issued instructions to both pilots, deconflicting the aircraft and directing them away from other traffic.

What has been done as a result

360° Aviation Group disseminated information to flight crew about the potential for misleading indications when using the aerodrome reference point for navigation at Moorabbin Airport. In addition, CAE Melbourne Flight Training advised that it was incorporating ADS-B in/out capability into the Cessna 172s in its fleet that were not currently equipped. 

Safety message

Pilots are reminded of the importance of comprehensive preparation when planning a flight to an unfamiliar aerodrome. This is particularly the case when flying into a Metropolitan Class D airport due to their typical high traffic volumes, complex runway layouts, and use of local landmarks and procedures. When arriving during tower hours, advising air traffic control that you are unfamiliar with the airport alerts them to the fact that you may require additional guidance. They can also then direct extra attention to monitor your progress if their workload allows. It is also important to ask for clarification if an instruction from air traffic control is not understood, or if there is confusion or uncertainty about how the flight is progressing.

Airservices Australia publishes a number of resources for pilots operating into Class D airports. General information regarding operating in Class D airspace can be found in Operating in Class D airspace safety net and pilot safety information specific to each airport is available on the Airservices Industry Hub. The Civil Aviation Safety Authority (CASA) also publishes the Stay OnTrack series of booklets designed to help pilots flying under visual flight rules (VFR) in busy metropolitan areas.

The investigation

The ATSB scopes its investigations based on many factors, including the level of safety benefit likely to be obtained from an investigation and the associated resources required. For this occurrence, the ATSB conducted a limited-scope investigation in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

The occurrence

On the afternoon of 9 August 2025 an Aero Commander 500-U, registered VH-LRI and operated by 360° Aviation Group, was being repositioned from Bacchus Marsh Airport to Moorabbin Airport, Victoria, with a single pilot on board. At the same time, a Cessna 172, registered VH-EUE and operated by CAE Melbourne Flight Training, was being used to conduct circuit training[1] at Moorabbin Airport with a flight instructor and a student pilot on board (Figure 1). Both aircraft were operating under the visual flight rules (VFR).[2] 

Figure 1: Aircraft flight paths

Source: Flight data overlaid on Google Earth, annotated by the ATSB

Weather conditions at the airport included clear skies, greater than 10 km visibility and a light southerly wind. At 1321, the pilot of VH-LRI contacted Moorabbin Airport air traffic control (ATC) as the aircraft approached Brighton to request a clearance to enter the control zone. The western circuit controller cleared the aircraft to enter the control zone and continue toward the airport, instructing the pilot to join an oblique base for runway 17R.[3] The controller also advised the pilot that they were ‘number 1’, indicating that there was no traffic ahead that was approaching the same runway.

The pilot of VH-LRI recalled that at this time they configured their GPS navigation unit to assist them in orienting with the runway. To achieve this, they set the destination waypoint as ‘YMMB’, the airport code for Moorabbin Airport (see the section titled Aerodrome reference point), and an inbound track of 170° corresponding to the approximate heading of runway 17R. This inbound track was 770 m offset to the east from the runway 17R extended centreline (Figure 2). They also carried an electronic flight bag (EFB) displaying navigation charts and showing the orientation of the runways.

Figure 2: Aircraft flight path relative to inbound track and runway centrelines

Source: Google Earth, annotated by the ATSB

At 1325, the western controller observed VH-LRI on the base leg of runway 17R and cleared the aircraft to land. By this time VH-EUE was on final approach to runway 17L. The pilot of VH-LRI recalled using a combination of visual references, and GPS navigation indications, to inform when they were approaching the centreline of runway 17R and should commence a turn to intercept the final approach course. They also recalled that, while expecting to be aligning with the western runway closest to the coast, they observed that their GPS unit was aligning them to the left of where they expected. 

Approximately 12 seconds later, VH-LRI crossed the final approach course of runway 17R and turned to join final approach for runway 17L (Figure 3), aligning with the runway at 1325:26. The pilot of VH-LRI recalled that, at around that time they observed VH-EUE in front of them. Recognising that they had been advised not to expect preceding traffic they realised that they were not aligned with the correct runway.

Figure 3: VH-LRI and VH-EUE flight paths on final approach

The ATSB has connected the data points from each flight at the same time to show the relative positions of the aircraft at the corresponding time. Source: Flight data overlaid on Google Earth, annotated by the ATSB

The western circuit controller reported that when looking toward the final approach area of the runways they observed that VH-LRI and VH-EUE were closer to each other than expected. They alerted the eastern circuit controller to the situation and, at 1325:41, asked the pilot of VH-LRI over the radio to confirm they were on final for runway 17R. Observing the aircraft commence a left turn, they immediately asked the pilot why they were doing so, to which the pilot responded that they were orbiting. The controller then advised the pilot that they could not orbit and instructed them to join upwind for runway 17R and climb to 1,500 ft. They further advised the pilot that there was traffic low, on short final for the other runway and to make sure they joined upwind for runway 17R. The pilot read back this instruction, discontinued the orbit and commenced a climb back toward the airport.

At the same time as the western circuit controller contacted the pilot of VH-LRI, the eastern circuit controller contacted the occupants of VH-EUE to advise that there was an aircraft in their vicinity approaching the incorrect runway. In response, the instructor of VH-EUE advised that they would go around. The controller instructed them not to go around, and instead to continue their approach, clearing them for a touch-and-go landing. The instructor read back the instruction and continued toward the runway. 

During the radio exchanges, at 1325:48, the proximity between the aircraft reduced to 52 ft vertically and 264 m horizontally. While the instructor on board VH-EUE did not see VH-LRI until it had passed on their left and had commenced climbing, the pilot of VH-LRI advised that they maintained visual contact with the Cessna throughout the final approach.

Following the deconfliction, VH-LRI climbed to 1,500 ft, conducted a visual circuit for runway 17R and landed without further incident. The instructor and student on board VH‑EUE completed a touch-and-go landing and continued circuit training. The instructor reported they were not aware of the proximity of VH-LRI until reviewing flight data after the flight. They also reported that the student pilot was solely focused on operating the aircraft at the time and was not aware that any incident had occurred.

Context

Pilots

The pilot of VH-LRI held a commercial pilot licence (aeroplane) issued in 2022 and a class 1 aviation medical certificate. They had accumulated 2,058 flight hours, of which 32 hours were operating the Aero Commander 500. In the previous 90 days, the pilot had accumulated 110 flight hours. They completed an instrument proficiency check in October 2024.

The pilot advised that they had flown into Moorabbin as pilot in command once previously, approximately 9 months before. They reported that they had talked to their chief pilot and another pilot at the operator familiar with Moorabbin Airport for advice prior to the flight. They further reported that they reviewed the En Route Supplement Australia (ERSA) and satellite imagery to familiarise themselves with the runway layout and procedures at Moorabbin and considered themselves sufficiently prepared.

The flight instructor on board VH-EUE held a commercial pilot licence (aeroplane) and a class 1 aviation medical certificate. They had accumulated 1,818 flight hours, of which 1,124 hours were operating the Cessna 172. In the previous 90 days, the pilot had accumulated 82 hours. The student pilot had accumulated 18 hours, all in the Cessna 172 and all within the last 90 days. 

Aircraft

Aero Commander VH-LRI

VH-LRI was an Aero Commander 500-U aircraft fitted with 2 Lycoming IO-540-E1A5 engines, each driving a Hartzell constant speed propellor. The aircraft was manufactured in 1967 and first registered in Australia in 1991. It was subsequently registered with the operator in August 2025.

At the time of the occurrence, the aircraft had accumulated 5,543 hours total time in service. The last periodic inspection was conducted in May 2025, and the maintenance release showed no outstanding items. The aircraft was equipped with both ADS-B out and in capability, including a traffic awareness and alerting system. The pilot recalled hearing the aural traffic alert activate prior to Brighton due to traffic in the area. However, they did not recall hearing any alert on approach to the airport.

Cessna 172S VH-EUE

VH-EUE was a Cessna 172S fitted with a Lycoming IO-360-L2A engine powering a McCauley propellor. The aircraft was manufactured and registered with the operator in 2006. The ATSB did not request any information on the aircraft’s maintenance history. The operator advised that the aircraft was not equipped with ADS-B out or in capability, however recorded flight data was downloaded from the aircraft’s avionics.

Moorabbin Airport

Runway layout

Moorabbin Airport has numerous runways (Figure 4), with the preferred runways being the north-south parallel runways of 17/35. Two additional parallel runways 13/31 were also available, while the shortest of the runways, runway 04/22, was not available unless operationally required. At the time of the occurrence, runways 17L and 17R were nominated as the duty runways.

Figure 4: Moorabbin Airport runway layout

Source: Google Earth, annotated by the ATSB

The En Route Supplement Australia (ERSA) (Figure 5) contained information on the physical characteristics of each runway, including that the magnetic heading was 164° for runways 17L and 17R. The runway designations represented the magnetic heading of the runway to the nearest 10°. However, the magnetic variation at Moorabbin Airport had increased approximately 1° over the previous 40 years and therefore the magnetic heading of the runways had drifted slightly since they were originally named.

Figure 5: En Route Supplement Australia (ERSA) extract

Source: Airservices Australia, annotated by the ATSB

Aerodrome reference point

The airport’s aerodrome reference point (ARP) was the designated geographical location of the airport, and the location associated with the International Civil Aviation Organisation (ICAO) airport code YMMB in aircraft navigation databases. The ARP for Moorabbin Airport was located on the eastern side of the airport, near the runway 22 threshold and 440 m away from the runway 17R centreline. This location was published in the ERSA as a latitude and longitude and shown graphically on the aerodrome plan.

Air traffic control

During tower hours, Moorabbin Airport operated as a Class D aerodrome. Pilots were required to establish and maintain 2-way communications with the tower and receive a clearance prior to entering the control zone. When operating in the airspace, aircraft operating under the visual flight rules (VFR) were given traffic information with respect to all other flights, but did not receive a separation service. Pilots were responsible for sighting and maintaining separation from other aircraft. If a pilot was unable to see, or lost sight of, other aircraft notified as traffic they were required to immediately advise ATC.

When operating parallel runways, Moorabbin Airport operated simultaneous independent circuits with each circuit utilising a different radio frequency. The eastern circuit, on runway 17L, was predominantly for circuit training and used the radio frequency 118.1 for communications between flight crew operating in the circuit and ATC. The western circuit, on runway 17R, was typically used for aircraft arriving from and departing to the west and used the radio frequency 123.0. Pilots operating in one circuit were not expected to monitor the radio frequency of the other circuit and the Aeronautical Information Package (AIP) stated that:

Operations will be regulated independently in each circuit, with an ATC clearance required to enter the opposite circuit or airspace.

At the time of the occurrence, 3 controllers were on duty in the control tower. One controller was controlling the eastern circuit while another was controlling the western circuit. A third controller was responsible for ground movements on a separate frequency. The controllers communicated with pilots in their circuit on a headset. They also had an awareness of activity in the other circuit via speakers in the tower broadcasting each frequency. In addition, the controllers were positioned physically close to each other and could communicate directly when required.

The tower was equipped with a tower situational awareness display (TSAD) which provided radar information that could be used to assist when providing control services. The western circuit controller advised that information provided by this system was limited and therefore it was not typically utilised for monitoring aircraft within the circuit area. Instead, each aircraft was monitored visually, using binoculars to assist. They further advised that at the time of the occurrence the airport was busy with multiple aircraft arriving and departing, in addition to aircraft transiting outside of the control zone to the west. There were also multiple aircraft established in the eastern circuit in addition to VH-EUE. As such, the controllers’ workload required them to direct attention to each aircraft in turn.

Related occurrences

The ATSB database contained 73 instances of aircraft approaching or landing on the incorrect runway at Moorabbin between 2015 and July 2025. During the course of this investigation the ATSB was advised of a similar occurrence that occurred on 13 August 2025 involving the same aircraft, but with a different pilot and without confliction with other traffic. The pilot of this flight advised that they had similarly configured their GPS navigation unit to provide guidance to the aerodrome reference point without realising its distance from the runway. In addition, it was reported to the ATSB that due to the high number of training flights at Moorabbin Airport, aircraft inadvertently entering into the other circuit occurred relatively regularly and was something controllers were alert for.

Safety analysis

Planning the flight to Moorabbin Airport, the pilot of VH-LRI identified that having flown there only once previously, the flight required additional planning and preparation. This included:

• consulting pilots familiar with Moorabbin Airport
• reviewing the information in the En Route Supplement Australia (ERSA)
• studying satellite imagery of the airport.

Additionally, in flight they utilised their electronic flight bag (EFB) to display the runway configuration and setup their GPS navigation to provide guidance. All of these measures were intended to improve the pilot’s situation awareness when approaching an unfamiliar aerodrome.

However, when reviewing the ERSA, the pilot did not identify that the aerodrome reference point (ARP) was located distant from the runway 17R centreline. Additionally, they did not identify that the magnetic heading of the runway differed slightly from that implied by its designation. Consequently, the inbound track configured for guidance was offset and deviated away from the runway centreline. At the point that the aircraft crossed the runway 17R centreline, the navigation unit would have indicated that the aircraft was still significantly to the right of the configured inbound track. Therefore, it is likely that the navigation indications contributed to the pilot flying through the runway centreline of 17R and joining final for 17L behind VH-EUE. VH-LRI was not advised of VH-EUE as traffic by air traffic control (ATC) as the other aircraft was operating in the eastern circuit, which required an additional clearance to enter. In addition, VH-EUE was not equipped with ADS-B out and therefore would not have been detected by a traffic awareness system.

VH-LRI was being periodically visually monitored by the western circuit controller as it approached the airport. During this time, both the eastern and western controllers’ attention was also directed to other traffic. Therefore, both controllers were likely looking away from the final approach path when VH-LRI crossed the runway 17R centreline and entered the eastern circuit. The deviation was not detected until visual contact was re‑established by the western circuit controller, by which time the aircraft was already on final approach for runway 17L.

While the distance between the aircraft reduced as they converged on the same final flightpath, as the pilot of VH-LRI reported that visual contact was maintained, there was likely no significant risk of a collision. However, upon intervention by ATC, the initial instinct of the pilot of VH-LRI was to orbit to the left, while the instructor on board VH‑EUE intended to climb. Initiation of a climb by VH-EUE would have increased the risk of collision between the aircraft, while an orbit would have placed VH-LRI in conflict with other aircraft in the eastern circuit. Therefore, the timely issuing of instructions contrary to the pilots’ intentions deconflicted the aircraft and directed them away from other traffic.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  These findings should not be read as apportioning blame or liability to any particular organisation or individual.

From the evidence available, the following findings are made with respect to the approach to incorrect runway involving Aero Commander 500-U, VH-LRI, at Moorabbin Airport, Victoria, on 9 August 2025. 

Contributing factors

• Due to unfamiliarity with the airport, the pilot of the Aero Commander configured their GPS navigation unit to provide guidance to the runway. However, due to the waypoint and track selected, the guidance was significantly offset from the runway’s centreline, resulting in the pilot inadvertently intercepting the final approach path of the parallel runway in proximity to a Cessna 172.

Other findings

• Identifying that the aircraft were in close proximity, air traffic control quickly issued instructions to both pilots, deconflicting the aircraft and directing them away from other traffic.

Safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. All of the directly involved parties are invited to provide submissions to this draft report. As part of that process, each organisation is asked to communicate what safety actions, if any, they have carried out to reduce the risk associated with this type of occurrences in the future.

Safety action by 360° Aviation Group

360° Aviation Group disseminated information to flight crew about the potential for misleading indications when using the aerodrome reference point for navigation at Moorabbin Airport.

Safety action by CAE Melbourne Flight Training

CAE Melbourne Flight Training advised that it was incorporating ADS-B in/out capability into the Cessna 172s in its fleet that were not currently equipped.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot and operator of the Aero Commander
• the flight instructor and operator of the Cessna
• the air traffic controllers
• recorded data from aircraft avionics
• Airservices Australia
• Bureau of Meteorology. 

Submissions

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

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

• the pilot and operator of the Aero Commander
• the flight instructor and operator of the Cessna
• the air traffic controllers
• Airservices Australia
• Civil Aviation Safety Authority.

Submissions were received from:

• the operator of the Aero Commander
• the operator of the Cessna
• Airservices Australia
• Civil Aviation Safety Authority.

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

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. About ATSB reports ATSB investigation reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines. Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2025   Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

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 ATSB scopes its investigations based on many factors, including the level of safety benefit likely to be obtained from an investigation and the associated resources required. For this occurrence, the ATSB conducted a limited-scope investigation in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

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

AO-2018-042 (537.01 KB)

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

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  These findings should not be read as apportioning blame or liability to any particular organisation or individual.

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 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 the afternoon of 13 June 2025, a Pilatus PC‑12, registered VH‑NWI and operated by Armada Aviation, was being used to conduct a charter air transport flight from Essendon Airport, Victoria, to Launceston Airport, Tasmania. On board were a pilot and 4 passengers.

During the approach to Launceston, the aircraft deviated left from the final approach course and intercepted the extended centreline of the adjacent taxiway. The aircraft then continued towards the taxiway where a Cessna 152 (C152) was holding for departure. Approaching the taxiway, the pilot conducted a low-level right then left turn to realign with the runway, before commencing a missed approach. During the manoeuvre the aircraft passed in close proximity to the C152. Following the missed approach, the aircraft conducted a visual circuit and landed without further incident.

What the ATSB found

The ATSB found that the final approach was conducted in clear conditions almost directly into the sun, exposing the pilot to glare. Subsequently, the pilot misidentified the taxiway as the runway and aligned the aircraft with the taxiway's extended centreline. The pilot then corrected the aircraft's flight path at a low level rather than conducting an immediate missed approach. During the manoeuvre the aircraft passed in close proximity to an aircraft on the taxiway.

It was also found that after identifying that the approaching aircraft was aligned with the taxiway, the instructor on board the aircraft on the taxiway made a radio broadcast, likely alerting both the pilot and air traffic control to the situation.

What has been done as a result

Armada Aviation circulated a notice to its aircrew advising them of hazards associated with a visual approach, such as sun glare. Additionally, it made the following changes to its operating procedures:

• Updated the final decision to proceed to landing to include a requirement that the runway was confirmed and clear by 400 ft above ground level, or the approach minima.
• Added a top of descent safety briefing to ensure pilots brief other risks associated with the visual approach segment following an instrument approach, including lighting configuration and sun position.
• Updated the checklist of the final phase of flight to include checking that the runway was confirmed and clear.

Safety message

Sun glare can reduce a pilot’s visual effectiveness even when meteorological visibility is good. When flying visually in such conditions, pilots should crosscheck against available flight and navigation instruments in conjunction with external indicators, such as airport lighting, to verify that the aircraft is on the intended flight path.

If a discrepancy is identified below an appropriate stabilised approach height, an immediate missed approach should be conducted. Low-level manoeuvring outside of the published approach and associated obstacle clearance increases the risk of collision with terrain or objects on the ground.

The investigation

The ATSB scopes its investigations based on many factors, including the level of safety benefit likely to be obtained from an investigation and the associated resources required. For this occurrence, the ATSB conducted a limited-scope investigation in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

The occurrence

On 13 June 2025, a Pilatus PC-12, registered VH‑NWI and operated by Armada Aviation, was being used to conduct a charter air transport flight from Essendon Airport, Victoria, to Launceston Airport, Tasmania (Figure 1). On board were a pilot and 4 passengers.

Figure 1: Occurrence flight

Source: Google Earth annotated by the ATSB

At 1511 local time, the aircraft commenced the instrument approach procedure for runway 32L[1] at Launceston. The weather at the time was predominately clear skies with few[2] clouds at 3,000 ft, variable wind up to 5 kt and visibility greater than 10 km.

At approximately the same time, the occupants (instructor and student) of a Cessna 152 (C152) on the ground at Launceston contacted air traffic control (ATC) to request taxi clearance for departure on a training flight. Due to the closure of a section of the taxiway (see Figure 4 and the section titled Construction works), the C152 was required to backtrack the runway and vacate onto taxiway A at the runway 32L threshold. The aircraft then turned 180° on the taxiway and stopped with the nose of the aircraft at holding point A. At 1515, the C152 reported to ATC that they had completed the taxi and were clear of the runway.

By this time VH‑NWI was established on the final segment of the approach, approximately 7 NM (13 km) from the runway. Shortly thereafter, ATC cleared the aircraft to land, later reporting that at this time they observed the aircraft established on the final approach. The pilot reported that throughout the final approach, they were looking into the sun and consequently they ‘couldn’t really see much at all’. 

ATC reported again sighting the aircraft when it was approximately 4 NM (7 km) from the runway. At this point the aircraft was approximately 1,340 ft above ground level (AGL) and still aligned with the final approach course (Figure 2).

Figure 2: Final approach flight path

Recorded altitude resolution ± 12.5 ft, over underlying terrain elevation, rounded to nearest 5 ft. Source: ADS-B flight data overlaid on Google Earth, annotated by the ATSB

The pilot advised that, during the approach, they used the autopilot to manage the aircraft’s flight path until approximately 1,000 ft AGL. At this point they disconnected the autopilot and transitioned to looking outside. The pilot recalled that they were still looking into the sun and only seeing one feature on the ground that stood out. Identifying it as the runway, they began visually flying the aircraft towards it. Recorded flight data showed that at approximately 750 ft AGL, the aircraft began to deviate left until it intercepted the extended centreline of taxiway A. From this position the aircraft continued to descend towards the taxiway. At 1519, when the aircraft was approximately 120 ft AGL, weather cameras at the airport recorded images showing both the aircraft on final and the C152 at the holding point (Figure 3).

Figure 3: Weather camera images at 1519

Combination of 2 images: Left image camera bearing 135° (SE) at 1519:04, right image camera bearing 225° (SW) at 1519:02. Source: Bureau of Meteorology, annotated by the ATSB

The instructor on board the C152 recalled that upon looking for the approaching aircraft, they saw that it was lined up with the taxiway. At 1519:12, they made a radio broadcast on the Launceston Tower frequency advising ‘He’s landing on the taxiway’. Following the call, VH-NWI passed above and behind them. It then reappeared on their left side, after conducting a right, then left, turn to align with the runway.

A review of flight data showed that VH-NWI continued to descend as it tracked the taxiway extended centreline until 1519:16, at which point it commenced a right turn (Figure 4). During the turn, the aircraft passed over the taxiway at a height of approximately 45 ft AGL, 15 m behind holding point A, at which the C152 was positioned. Subsequently, the aircraft descended further as it flew over the grassed area between the taxiway and the runway before turning left to align with the runway centreline. During the realignment manoeuvre, the aircraft descended to approximately 15 ft AGL. 

Figure 4: Low-level manoeuvre and missed approach

Recorded altitude resolution ± 12.5 ft, over underlying terrain elevation, rounded to nearest 5 ft. Source: ADS-B flight data overlaid on Google Earth, annotated by the ATSB

The pilot recalled that when not far from the runway environment they became aware that they were approaching the taxiway and in response turned the aircraft towards the runway. They further reported that they were not aware of the C152 at the holding point. While they recalled hearing a radio broadcast as they were moving towards the runway, they did not know who had made it. 

ATC reported that upon hearing the broadcast from the C152 they observed VH-NWI on short final lined up with taxiway A, after which it immediately made a right turn to align with the runway. At 1519:22 they instructed the pilot to go around.[3] The pilot later reported that they heard the instruction from ATC, by which time they had decided to initiate a missed approach. Flight data recorded that the aircraft commencing a climb away from the runway at 1519:31. Following the missed approach, the pilot conducted a visual circuit and the aircraft landed without further incident. Subsequently, the C152 departed.

Context

Pilot

The pilot held an air transport pilot licence (aeroplane) issued in 2013 and a class 1 aviation medical certificate. They had accumulated 4,251 flight hours, of which 659 hours were operating the Pilatus PC‑12. In the previous 90 days, the pilot had accumulated 26 hours, all in the PC‑12. They completed an instrument proficiency check in January 2025.

The pilot reported that they had flown into Launceston Airport a number of times previously, both during the day and at night. They did not recall any prior occasion where sun glare had been an issue during final approach.

Aircraft

VH-NWI was a Pilatus PC‑12, powered by a Pratt & Whitney PT6A‑67B turbine engine driving a 4‑bladed, variable pitch Hartzell propeller. The aircraft was manufactured in 1995 and first registered in Australia in 2002. It was subsequently registered with the operator in 2014.

At the time of the incident, the aircraft had accumulated 8,674 hours total time in service. The aircraft was being maintained in accordance with the operator’s system of maintenance and the PC‑12 maintenance manual. The last periodic inspection was conducted in April 2025, and the maintenance release showed no outstanding items.

Launceston Airport

Runway environment

Launceston Airport had a single grooved asphalt runway 14R/32L (Figure 5). The runway was 45 m wide and approximately 2 km long with a runway heading of 313°. The airport had previously operated a parallel grass runway 14L/32R which had been decommissioned however, the remaining runway had not been renamed to remove the left / right designation. The En Route Supplement Australia (ERSA) provided information on Launceston Airport and identified the single operational runway and the decommissioned runway.

Access to the ends of the runway was via taxiway A located on the western side. The taxiway was 23 m wide and ran the length of the runway. The taxiway surface was a lighter colour compared to that of the asphalt runway.

Figure 5: Launceston Airport runway environment and lighting

Source: Google Earth, annotated by the ATSB

Aerodrome and approach lighting

Launceston Airport was equipped with runway edge lighting, approach lighting, taxiway lighting and precision approach path indicator (PAPI)[4] systems. Approach lighting was installed leading to runway 32L with a PAPI on both sides of the runway. Runway 14R had no approach lighting, and a single PAPI on the left of the runway. When activated, the intensity level of each lighting component could be set between 1‍–‍6, with 1 being the lowest intensity, and 6 being the highest. During tower hours, this setting was controlled by ATC via a panel in the control tower. Outside tower hours the settings were preset.

On the day of the occurrence, all aerodrome lighting was initially inactive. At 1331 local time, the PAPIs for both runway 14R and 32L were activated at an intensity setting of 5. At 1506, 13 minutes prior to the occurrence, the runway edge lighting, taxiway lighting and the approach lighting for runway 32L were activated with an intensity setting of 4. At the same time, the intensity of the PAPIs was reduced to 4. Airservices advised that this intensity setting was selected due to decreasing ambient light associated with winter conditions at that time of day.

The pilot could not recall whether the airport lighting was on during the first approach. During the second approach and landing, they recalled that the lighting was on and thought that it looked dim and was difficult to see.

Construction works

At the time of the incident construction works were being conducted in the area adjacent to the southern apron. These works required the closure of taxiway A between taxiway B and taxiway E (Figure 6). Barriers, unserviceability markers and lighting was deployed at the ends of the closed section of taxiway to prevent access. The presence of works and the taxiway closure were advised both via NOTAM[5] and the airport’s automatic terminal information service (ATIS).[6] The pilot reported being aware that the taxiway was closed.

Figure 6: Airport construction works

Source: Google Earth, inset supplied, annotated by the ATSB

Sun effect during the approach

Sun position

At 1517, the time that the aircraft began to deviate from the final approach course, the sun was positioned 10° to the left of the runway heading and 12° above the horizon. 

Glare

Glare occurs when unwanted light enters the eye. Direct glare comes directly from a light source whereas veiling glare occurs when light is reflected from crazing[7] or dirt on the windscreen. The ATSB research report Limitations of the See-and-Avoid principle examined the effect of glare on pilots stating:

It has been claimed that glare which is half as intense as the general illumination can produce a 42 per cent reduction in visual effectiveness when it is 40 degrees from the line of sight.

When the glare source is 5 degrees from the line of sight, visual effectiveness is reduced by 84 per cent (Hawkins 1987). In general, older pilots will be more sensitive to glare.

Direct glare from the sun and veiling glare reflected from windscreens can effectively mask some areas of the view.

The pilot reported that the aircraft was equipped with a tinted sun visor. They had placed this between their eyes and the sun during the approach however this did not sufficiently reduce the direct glare. Consequently, they reported that for most of the final approach, when not required for power adjustments, they held their right hand in front of their face to block the sun.

They further reported that the windscreen was not crazed or dirty and that the aircraft had been recently washed. They were wearing reading correction glasses which did not provide glare protection and were not wearing any headwear that could be used to shield the sun. 

Stabilised approach criteria

The operator’s procedures defined criteria for stabilised approaches. If an approach was not stable below 300 ft above aerodrome elevation, an immediate missed approach was required to be conducted. These criteria included that:

From 500 ft AGL on the descent, the aircraft shall be:

 - on the correct flight path with only small changes in heading and pitch required to maintain the correct flight path

 - the indicated airspeed is not more than Vref [landing reference speed] (-0/+ 10 kts)

 - the aircraft is in an acceptable landing configuration

 - sink rate is no greater than 600 fpm [feet per minute]; if an approach requires a sink rate greater than 1000 fpm, a special briefing should be conducted

 - power setting is appropriate for the aircraft configuration and is not below the minimum power for approach as defined by the aircraft operating manual

 - all briefings and checklists have been completed.

Safety analysis

The pilot conducted the final approach segment in clear conditions with the sun low in the sky and 10° to the left of runway heading. This exposed them to direct sun glare during the approach. To reduce the effect of the glare they used the aircraft’s visor and their right hand to block the sun. However, some glare remained, and their raised hand likely impacted their view of the runway and associated lighting. Consequently, the pilot misidentified the taxiway as the runway and aligned the aircraft with the taxiway centreline.

During the subsequent segment of the approach, the aircraft’s navigation instruments were likely indicating that the aircraft was to the left of the intended flight path. However, the pilot was looking outside during this time and therefore did not detect the deviation. Furthermore, they did not observe the C152 positioned on the taxiway, likely due to the continued reduced visibility throughout the approach.

The instructor on board the C152 broadcast over the radio after identifying that the approaching aircraft was aligned with the taxiway. Shortly after this broadcast, the aircraft commenced a turn towards the runway. While continuation to landing on the taxiway would likely have resulted in the aircraft passing over the C152, it would probably have resulted in a collision with obstacles associated with the airport’s construction works. As the aircraft commenced its turn toward the runway after the broadcast was made, it is likely that the broadcast contributed to the pilot’s recognition of the situation. However, they advised that they remained unaware that there was an aircraft on the taxiway.  

During the manoeuvre, the aircraft passed behind and in close proximity to the C152. Conducting such a manoeuvre carried a risk of collision with both the C152 and other objects on the ground. Moreover, this manoeuvre was not in accordance with the operator’s stabilised approach criteria where only small heading changes were permitted below 500 ft above ground level (AGL). Upon recognising that the aircraft was not on the intended flight path, an immediate missed approach was required to be conducted. The broadcast from the C152 instructor also alerted air traffic control (ATC) to the situation, prompting them to instruct the pilot to discontinue the landing.

Consideration was given to whether the designation of the landing runway at Launceston Airport as the left runway may have led the pilot to misidentify the taxiway as the left of 2 parallel runways. However, this was not reported by the pilot. Furthermore, they had prior experience operating at the airport and were therefore familiar with the runway layout.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  These findings should not be read as apportioning blame or liability to any particular organisation or individual.

From the evidence available, the following findings are made with respect to the passing in close proximity to an aircraft on a taxiway during approach involving a Pilatus PC‑12, VH‑NWI, Launceston Airport, Tasmania, on 13 June 2025. 

Contributing factors

• The final approach was conducted in clear conditions almost directly into the sun, exposing the pilot to glare. Subsequently, the pilot misidentified the taxiway as the runway and aligned the aircraft with the taxiway's extended centreline.
• The pilot corrected the aircraft's flight path at a low level rather than immediately conducting a missed approach. During the manoeuvre, the aircraft passed in close proximity to an aircraft on the taxiway.

Other findings

• After identifying that the approaching aircraft was aligned with the taxiway, the instructor on board the aircraft on the taxiway made a radio broadcast, likely alerting both the pilot and air traffic control to the situation.

Safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk.  All of the directly involved parties are invited to provide submissions to this draft report. As part of that process, each organisation is asked to communicate what safety actions, if any, they have carried out to reduce the risk associated with this type of occurrences in the future.

Safety action by Armada Aviation

Armada Aviation circulated a notice to its aircrew advising them of hazards associated with a visual approach, such as sun glare. Additionally, it made the following changes to its operating procedures:

• Updated the final decision to proceed to landing to include a requirement that the runway was confirmed and clear by 400 ft above ground level, or the approach minima.
• Added a top of descent safety briefing to ensure pilots brief other risks associated with the visual approach segment following an instrument approach, including lighting configuration and sun position.
• Updated the checklist of the final phase of flight to include checking that the runway was confirmed and clear.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot and operator
• the pilot and operator of the aircraft on the taxiway
• Bureau of Meteorology
• Launceston Airport
• Airservices Australia
• recorded data from the electronic flight bag (EFB) on the aircraft. 

References

Australian Transport Safety Bureau (ATSB) (2004). Limitations of the see-and-avoid principle, /sites/default/files/media/4050593/see_and_avoid_report_print.pdf, ATSB, accessed 13 June 2025

Hawkins, F.H. (1987). Human Factors in Flight, Gower, Aldershot.

Submissions

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

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

• the pilot and operator
• the pilot and operator of the aircraft on the taxiway
• Launceston Airport
• Airservices Australia
• Civil Aviation safety Authority.

Submissions were received from:

• the operator.

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

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2025   Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

Investigation summary

What happened

On 15 April 2025, an Embraer ERJ 190-100, registered VH-UZD, was conducting a passenger transport flight from Sydney, New South Wales, to Launceston, Tasmania. After commencing approach to Launceston, the flight crew received multiple caution messages including a SLAT FAIL caution. The flight crew discontinued their approach and after completing the relevant checklists elected to divert to Melbourne, Victoria, as it was the longest available runway in the region. The remainder of the flight was uneventful, and the aircraft landed safely.

Post-flight troubleshooting determined that a torque tube in the left wing slat drive system had disconnected as it had been incorrectly assembled when it was last refitted.

What the ATSB found

The ATSB identified a similar occurrence with another of the operator’s Embraer ERJ 190‑100 aircraft, VH-UYB, where a torque tube in the left wing flap drive system had disconnected as it had been incorrectly assembled when it was last refitted.

The occurrences were similar in that the locking bolts that secured the torque tubes to their actuators had not been fitted correctly into the holes of the splined shafts, since the torque tubes had been incorrectly positioned during installation.

In both occurrences, those carrying out and certifying for the torque tube installations did not identify that they had been incorrectly assembled.

These errors occurred at different maintenance providers, and reportedly from January 2005–August 2011 in the worldwide fleet of Embraer 170, 175, and 190 aircraft (all sharing similar componentry), there have been 5 similar occurrences related to incorrect torque tube installation.

What has been done as a result

The operator, Alliance Airlines, issued a maintenance notice that detailed the flap torque tube disconnect affecting VH-UYB and the slat torque tube disconnect affecting VH-UZD. This notice reiterated the aircraft maintenance manual information for the correct installation of flap and slat torque tubes.

The maintenance organisation added an additional task card that is automatically issued when work is scheduled on the E190 slat system torque tubes that provides guidance in addition to the aircraft maintenance manual to mitigate the incorrect assembly of torque tubes on their splines. A similar additional task card was being developed for the E190 flap system torque tubes.

Safety message

Historical occurrence and technical information provide an opportunity to review known errors prior to commencing particular maintenance activities, thereby reducing the possibility of further errors occurring. When an error does occur, this information also provides a means to bolster the actions taken to prevent re-occurrences.

This information can be available from multiple sources including the manufacturer, national aviation authorities (such as CASA or the FAA), accident investigation authorities, and the safety management systems of operators and maintenance organisations. 

The investigation

The ATSB scopes its investigations based on many factors, including the level of safety benefit likely to be obtained from an investigation and the associated resources required. For this occurrence, the ATSB conducted a limited-scope investigation in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

The occurrence

Previous maintenance

In November 2024, an Embraer ERJ 190-100 aircraft, registered VH-UZD and operated by Alliance Airlines, commenced a heavy maintenance[1] check by Rockhampton Aviation Maintenance in Rockhampton, Queensland. A team comprising 2 aircraft maintenance engineers (AMEs) was tasked with inspecting and lubricating the leading-edge slat drive system (see Embraer E190 slats and flaps). This involved removing, cleaning, lubricating, and refitting each slat torque tube in turn. A licensed aircraft maintenance engineer (LAME) briefed the AMEs on what was required.[2] The LAME was familiar with the task but was unaware of any historical issues with the task (see Maintenance requirements). The work was carried out in a new facility with good lighting. Access to the components was good, and a purpose-built platform allowed the work to be carried out with the relevant components at eye level.

Prior to commencing work, brakes internal to the power drive units (PDUs) (which drive the flap and slat torque tubes) were electrically released as required by the aircraft maintenance manual (AMM) procedure. The AMEs printed a copy of the relevant AMM procedure, and worked together on the torque tube driving the left-wing outboard actuator for slat number 4. The PDU brakes were also required to be released prior to installing the torque tubes, however, it could not be established whether this took place (the PDU brakes reapply when power is removed). After refitting the outboard actuator torque tube, a push-pull check was carried out to ensure it was locked in place, as required by the AMM. Unknown to the AMEs, when this torque tube was refitted, it had not been positioned far enough onto the actuator’s splined shaft for the locking bolt to secure it (Figure 1, lower right). The locking bolt was inadvertently installed beyond the end of the spline (shown in grey) rather than through the hole as required.

One AME then continued work on the left wing and the other moved to the right wing slat drive system to work alone. The remaining slat torque tubes were correctly fitted.

After this work was completed, the LAME inspected the installation of the torque tubes and their locking bolts, and a second LAME carried out an independent inspection[3] of the work. The heavy maintenance check was completed in March 2025, and the aircraft was returned to service. 

Figure 1: Aircraft maintenance manual torque tube installation illustration

Source: Embraer

Flight control event

On 15 April 2025, 50 flights after returning to service from heavy maintenance, the aircraft was being operated on a passenger transport flight from Sydney, New South Wales, to Launceston, Tasmania, by Alliance Airlines for QantasLink. After commencing approach to Launceston, the flight crew received multiple caution messages[4] on the aircraft’s engine indicating and crew alerting system (EICAS) including a SLAT FAIL caution. The flight crew discontinued the approach and requested clearance from air traffic control for vectors[5] so they could action the relevant quick reference handbook (QRH) checklists for the caution messages.

The flight crew completed the QRH checklist. As the slat failure would require landing with the slats and flaps up, the flight crew elected to divert to Melbourne Airport, Victoria, as it had the longest available runway in the region. The flight crew declared a PAN PAN[6] and commenced the diversion to Melbourne. After climbing to 19,000 ft the aircraft was flown to Melbourne at 220 kt as required by the QRH because of the slat failure. The aircraft landed at Melbourne without further incident.

Post-flight inspection

Post-flight inspection determined that the torque tube for the left wing slat number 4 outboard actuator had disconnected as the locking bolt fitted to the torque tube had not passed through the corresponding hole in the actuator’s splined shaft when it was last refitted (Figure 2).

Figure 2: VH-UZD left wing outboard actuator for slat number 4 and torque tube, shown disconnected after the occurrence flight

Source: Alliance Airlines, annotated by the ATSB

Context

Aircraft information

The Embraer ERJ 190-100 IGW (E190) is a narrow-body aircraft used for air transport operations and powered by 2 General Electric CF34-10E5 turbofan engines. VH-UZD was manufactured in Brazil in 2008 and registered in Australia on 31 January 2022.

Embraer E190 slats and flaps

The E190 is fitted with devices to increase the lift produced by its wings during take-off and landing. On the leading edges of the wings there are 8 slat panels and on the trailing edges of the wings there are 4 flap panels (Figure 3), where each set (slats/flaps) extends and retracts together.

Figure 3: Embraer E190 slats and flaps

Source: Embraer, annotated by the ATSB

Slat and flap extension and retraction is controlled from the cockpit by using the slat/flap control lever (SFCL). When the SFCL is moved from its 0 (up) position,[7] the flap and slat power drive units (PDUs) drive torque tubes which in turn drive actuators, transferring the rotary motion of the torque tubes to linear motion that extends the slats and flaps (Figure 4 and Figure 5).

Each PDU has 2 internal brakes that are engaged under spring force and released electrically, such that the brakes would re-engage when power is removed. There are 26 torque tubes in the slat drive system and 22 torque tubes in the flap drive system.

In the event of a slat or flap failure, redundant detection and protection systems prevent them operating in such a way that may compromise safety of flight.

Figure 4: Embraer E190 slat drive system

Source: Embraer, annotated by the ATSB

Figure 5: Embraer E190 flap drive system

Source: Embraer, annotated by the ATSB

Maintenance requirements

The slat and flap torque tubes are removed periodically for the actuator splines to be lubricated with grease. They may also need to be removed to replace associated components. A detailed visual inspection of the slat and flap drive system is also carried out periodically and includes a requirement to check that the torque tubes are correctly secured in place by their locking bolts. No detailed visual inspections of the slat system had been required between the heavy maintenance in November 2024 and the occurrence flight.

The procedure to remove and install the slat and flap torque tubes is detailed in the aircraft maintenance manual (AMM). As part of this procedure, the slat or flap PDU brakes are disengaged electrically to eliminate any residual torque in the system that may impede (through friction) the removal of the torque tubes. For the same reason, the brakes must also be disengaged for their installation.[8] Embraer advised the ATSB of the importance of removing residual torque for the installation.

Rockhampton Aviation Maintenance noted during its investigation into the occurrence that excessive amounts of grease on the actuator splines can produce hydraulic resistance to re-assembly of the torque tube and therefore no more than what is required to lubricate the splines should be applied. It could not be determined whether this occurred during the maintenance of VH-UZD. The installation procedures for torque tubes in the AMM requires the old grease to be removed, new grease to be applied, and any unwanted grease to be removed prior to assembly.

The torque tubes interface with other components via splined shafts and are secured by locking bolts in conjunction with castellated nuts and split pins to prevent their inadvertent disconnection. There are 24 locking bolts in the slat drive system and 18 locking bolts in the flap drive system, all with this configuration.

The AMM describes and illustrates a ‘push-pull’ check to determine the locking bolt has been correctly installed and had showed representative examples of correct and incorrect installation (Figure 1).

The torque tube locking bolts pass through holes close to the end of each actuator’s splined shaft. A correctly installed torque tube is visually apparent by less exposed splines (Figure 6). If a slat torque tube is incorrectly positioned[9] on a slat actuator the locking bolt will not capture the splined shaft and can lead to the torque tube disconnecting and slat failures.

Figure 6: Exemplar slat torque tube correctly fitted (upper image) and incorrectly fitted (lower image) to a slat actuator 

A slat actuator and torque tube were correctly and incorrectly assembled on a workbench to create these images. Source: The maintenance organisation, annotated by the ATSB

Actions taken to prevent installation errors

In 2010 the AMM was amended to include the previously mentioned illustration (Figure1) showing the correct and incorrect installation of slat and flap torque tubes along with the push-pull test. This revision also added the requirement to release the PDU brakes.

Embraer communicated these changes by publishing a service newsletter SNL 190‑27‑0050 noting reports of incorrect slat or flap torque tube installation, advising that the AMM had been revised to mitigate future occurrences, and provided an overview of the revisions. This information was also published in Embraer’s safety magazine[10] (available to operators of E190s) and was contained in a document[11] published by the National Civil Aviation Agency of Brazil.

In October 2017 Embraer published an update on the issue in a document[12] that reiterated the previous actions taken to mitigate these occurrences. This document noted that from January 2005–August 2011 in the worldwide fleet of Embraer ERJ170, 175, 190, and 195 aircraft[13] there were 483 reports of slat or flap system failures. Of these, 5 were occurrences related to incorrect torque tube installation. Additionally, the document stated that the subject of incorrect torque tube installation was presented to civil aviation authorities in Europe and the Americas. It was concluded that no additional actions were required, as there were a small number of exposed aircraft, and there had been no reported events since the AMM was revised in 2010, and the manufacturer considered the issue closed.

Related occurrences

Incorrect flap torque tube installation

In late 2024, an Embraer ERJ 190-100 aircraft, registered VH-UYB and operated by Alliance Airlines for QantasLink, commenced a heavy maintenance check at a facility in Singapore. The torque tube driving the left wing flap actuator number 2 (see Embraer E190 slats and flaps) was removed to carry out flap actuator torque limiter checks. When fitted, the torque tube had not been positioned far enough onto the actuator’s splined shaft for the locking bolt to secure it.

On 10 November 2024, 35 flights after returning to service from heavy maintenance, the aircraft departed for a passenger transport flight. After take-off, the flight crew received a FLAP FAIL caution on the EICAS as the flaps were retracting. The flight crew initiated a turnback and the aircraft landed safely.

Engineering personnel later found that the locking bolt for the left wing flap actuator number 2 torque tube had not passed through the corresponding hole in the actuator splined shaft when it was last refitted (Figure 7).

Figure 7: VH-UYB left wing flap actuator 2 and torque tube

Source: Alliance Airlines, annotated by the ATSB

Other flight control event involving VH-UZD

On 18 April 2025, VH-UZD was operating from Adelaide, South Australia, to Canberra, Australian Capital Territory. When flaps were selected down, the slats began to extend but the flaps did not deploy, and the crew received multiple failure warnings. The flight crew diverted to Melbourne. Post-flight troubleshooting determined that the flap power drive unit (PDU) torque limiter had tripped, which is a problem unrelated to the investigation occurrence or the recent heavy maintenance check.

Safety analysis

Incorrect fitment of actuator torque tubes

When the torque tube for the left wing slat number 4 outboard actuator was refitted to VH-UZD in November 2024, it had not been positioned far enough onto the actuator’s splined shaft for the locking bolt to secure it in place. After re-entering service and conducting 50 flights, the torque tube disengaged from the actuator, and the slat system failed. Protection systems ensured the safety of flight was minimally affected.

Similarly, when another E190, VH-UYB, was under heavy maintenance at a different facility at around the same time, the torque tube driving the left wing flap actuator number 2 was incorrectly assembled in that the locking bolt had not passed through the hole in the actuator’s splined shaft. The torque tube disengaged 35 flights after the aircraft re-entered service and the flap system failed. 

Non-detection of the error

The 2 AMEs who fitted the torque tube in VH-UZD did not identify that the torque tube had been incorrectly fitted. Further, the LAME checking this work and the second LAME carrying out the independent inspection of this work did not identify that it had been incorrectly assembled. The similar error affecting VH‑UYB also apparently remained undetected by those carrying out and certifying for the work.

As far as could be established, there were no physical or environmental factors that may have influenced the incorrect assembly of the torque tube. The work on VH-UZD was carried out in a new facility with good lighting, and access to the work area was good and could be carried out with the relevant components at eye level.

Ultimately, it is likely that not knowing the subtle difference in appearance of an incorrectly assembled slat torque tube (that is, as little as about 6.35 mm more of the actuator spline visible) contributed to the error not being detected by the 2 AMEs and the 2 LAMEs involved. Further, the remaining torque tubes in the slat drive system were correctly assembled, however their subtly different appearance did not trigger recognition that the original torque tube had been incorrectly assembled.

Available relevant information

Installation of the slat and flap drive system torque tubes is a simple task, but errors have occurred. Embraer noted that from January 2005–August 2011 in the worldwide fleet of Embraer 170, 175, 190 aircraft (all sharing similar componentry) there were 5 occurrences related to incorrect torque tube installation. The Embraer 190 has 24 locking bolts in the slat drive system and 18 in the flap drive system representing a total of 42 opportunities to incorrectly secure the torque tubes.

In 2010, Embraer made amendments to the aircraft maintenance manual to reduce the possibility of assembly errors. These were intended to remove any residual torque loads during removal and installation (by releasing the PDU brake), highlight the possibility of error with an illustration, and through the addition of the push-pull check, provide a means to detect an installation error.

These changes were communicated in multiple documents, such as a service newsletter, that were available to operators and maintainers of E190s. Review of such documents can assist in highlighting known issues and thereby prevent reoccurrence.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  These findings should not be read as apportioning blame or liability to any particular organisation or individual.

From the evidence available, the following findings are made with respect to the flight control event involving Embraer E190, VH-UZD, 29 km south-east of Launceston Airport, Tasmania, on 15 April 2025. 

Contributing factors

• During scheduled maintenance, the locking bolt for the left outboard slat torque tube was not passed through the hole in the actuator’s splined shaft as the torque tube had been incorrectly positioned. The aircraft was released from maintenance, and 50 flights later, the torque tube disconnected, causing the slat system to fail.
• Both licensed aircraft maintenance engineers inspecting the left outboard slat torque tube did not identify that it had been incorrectly assembled.

Safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Safety action taken by Alliance Airlines

On 17 April 2025, Alliance Airlines issued a maintenance notice that detailed the flap torque tube disconnect affecting VH-UYB on 11 November 2024 and the slat torque tube disconnect affecting VH-UZD on 15 April 2025. This notice reiterated the aircraft maintenance manual information for the correct installation of flap and slat torque tubes.

Safety action taken by Rockhampton Aviation Maintenance

The maintenance organisation added an additional task card that is automatically issued when work is scheduled on the E190 slat system torque tubes. This task card provides guidance in addition to the aircraft maintenance manual to highlight the possibility of hydraulic lock caused by lubricant and the importance of releasing the PDU brake. Additionally, this task details a dimensional check to confirm the correct installation of torque tubes on their splined shafts. A similar additional task card was being developed for the E190 flap system torque tubes.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Alliance Airlines
• Centro de Investigação e Prevenção de Acidentes Aeronáuticos (Brazil)
• Civil Aviation Safety Authority
• Embraer
• Rockhampton Aviation Maintenance
• licenced aircraft maintenance engineer that made the final certification of the work
• both aircraft maintenance engineers.

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:

• Alliance Airlines
• Centro de Investigação e Prevenção de Acidentes Aeronáuticos (Brazil)
• Civil Aviation Safety Authority
• Embraer
• Rockhampton Aviation Maintenance
• licenced aircraft maintenance engineer that made the final certification of the work
• both aircraft maintenance engineers.

Submissions were received from:

• Embraer
• Rockhampton Aviation Maintenance.

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

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. About ATSB reports ATSB investigation reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines. Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2025   Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

The occurrence 

The day before the accident

On 31 August 2024, the pilot of a Cessna U206F, registered VH-TDQ and operated by Fly Esperance, departed Esperance Airport, Western Australia (WA). The aircraft was ferried to a private aircraft landing area (ALA), 50 NM (93 km) north‑west of Esperance to conduct a non‑scheduled air transport flight to a private ALA about 21 NM (39 km) south‑east of Moora. The 3 passengers and pilot would spend the night at the property with the intention of returning the following day. 

On the first arrival at the destination ALA, the pilot made an approach to the westerly runway and configured the aircraft with 20° flap[1] for landing. During the first landing attempt, the aircraft bounced and the pilot conducted a go-around.[2] On the second landing attempt, the pilot configured the aircraft in a 40° full-flap configuration and landed without incident.

Accident flight

On the morning of 1 September 2024, the customers requested two 15-minute local flights for the family members they had been visiting. The pilot consulted the operator’s chief pilot by phone who approved the flights. The pilot then collected the passenger’s weights and assigned them to each flight.

The pilot gathered the passengers of both flights together and conducted a group safety briefing before the passengers on the first flight boarded the aircraft. With 5 passengers on board, the pilot took off on the western runway and departed about 1050 local time, tracked to the north before returning to the ALA a short time later (Figure 1). About 2 NM (3.7 km) north and within sight of the ALA, the pilot assessed that the aircraft was too high and conducted a left orbit to reduce height. 

The pilot reported they were advised the previous day by the local agricultural pilots to utilise the uphill slope for landing using the easterly runway and recalled, as there were no other aircraft in the vicinity, directly joining the base leg of the circuit for the easterly runway. They observed a 75 kt airspeed on final approach before configuring the aircraft for a full flap final approach for landing.

Figure 1: VH-TDQ flight track 

Source: Google Earth, annotated by the ATSB

The pilot landed the aircraft about 80 m (Figure 2) past the end of the easterly runway and bounced twice before they applied full power and commenced a go-around. The pilot was unable to recall their airspeed at the time of the flap reduction, however reported that the aircraft had probably dissipated a considerable amount of speed during the bounces prior to initiating a go‑around. As the aircraft began the initial climb the pilot reduced the flap setting, unknowingly mis-selecting the 10° setting.

Figure 2: Aircraft landing area

Source: Google Earth, annotated by the ATSB

As the flap retracted, the aircraft lost height and the pilot was unable to maintain control. The aircraft dropped the right wing and the right wingtip grazed the ground in the adjacent field. 

The right wingtip then raised above the crop height, however the propeller and landing gear remained partially in the crop (Figure 3) increasing drag and reducing speed. Shortly after, the aircraft touched down on its landing gear with the propeller making full contact with the crop and stopping the engine. The aircraft came to a stop upright, about 250 m from the runway, with the flaps extended in the 10° position. The pilot recalled at this point they switched off the aircraft’s fuel and electrics.

Figure 3: Aircraft landing gear marks in field adjacent to the runway

Source: Fly WA Group, annotated by the ATSB

The pilot then checked on the welfare of the passengers and as a precaution, instructed them to evacuate the aircraft.

The pilot successfully egressed the front seat and middle-row passengers through the forward left cabin door. They then proceeded to the right side of the aircraft to assist the 2 passengers in the rear seats egress through the right-side cargo doors. 

On approaching the rear of the aircraft, the pilot observed that the extended flap had blocked the forward half of the cargo door and therefore believed they would not be able to open the rear half of the cargo emergency exit. After an unsuccessful attempt to retract the flaps, the pilot reported they were no longer operational. They did not attempt to open the rear cargo door further and instructed the rear seat passengers, an older person and young child, to egress over the middle row seat and then through the pilot’s forward left cabin door. 

The aircraft received minor damage to the right fibreglass wingtip and aileron. No injuries were reported, and all passengers successfully evacuated the aircraft. 

Context

Pilot information

The pilot held a commercial pilot licence (aeroplane), issued in August 2016. At the time of the accident, the pilot had about 390 hours of total flying experience, with 134.4 hours as pilot in command and about 30 hours on the Cessna 206. The pilot had operated for 49.4 hours in the last 90 days and held a current class 1 medical certificate that was valid until 29 July 2025.

The pilot was employed by the operator in June 2024 and had flown scenic flights from Jandakot, Western Australia (WA), before gaining full time employment with the same operator to conduct flights from the operator’s Esperance base, where the pilot had been located since August 2024.

During their initial employment with the operator, the pilot received about 13 hours of line training. The training included: 

• emergency procedures
• remote airfields
• short fields
• maximum all-up weight flight. 

The pilot’s logbook indicated a check flight was conducted by the operator’s chief pilot on 19 July 2024. They then began commercial flights for the operator about 1 week later. 

Although they had held a commercial licence since 2016, this was the pilot’s first aviation employment, having completed training and private flying before gaining employment with the operator. The logbook also indicated that prior to the pilot’s employment with the operator, limited flying was conducted, with a total of 4.2 hours flown in the 12 months before commencing with the operator.

Aircraft information

General information

The Cessna U206F is a single piston engine, high winged, 6-seat, unpressurised aircraft with fixed landing gear. The aircraft was powered by a Teledyne Continental IO-520 engine. 

VH-TDQ was manufactured in the United States in 1975 and first registered in Australia in August 1975. Fly Esperance became the registration holder on 29 April 2023. 

Cessna 206 variants

The Cessna 206 was produced between 1963 and 1986. In 1998, Cessna restarted production of the Cessna 206 and the aircraft remains in production.

The original model, named the Cessna 206 Super Skywagon, was produced between 1963 and 1965 and featured the rear right side double cargo doors. Subsequent models (Table 1) were also manufactured with the double cargo doors and included numerous different models between 1963 and 1986. Cessna aircraft company halted production of 206 aircraft between 1987 and 1997. Production resumed in 1998 with the current model 206H.

Table 1: Cessna 206 models manufactured with the double cargo doors

Year	Cessna 206 model name
1963/65	206 Super Skywagon
1966*	U206A 206 Super Skywagon
1967*	U206B Super Skywagon
1968*	U206C Super Skywagon
1969*	U206D Super Skywagon
1970/71*	U206E Skywagon 206/Stationair
1972-76*	U206F Stationair
1977-86*	U206G Stationair
1998-current*	206H Stationair

* Indicates model was also manufactured with a turbo variation

Aircraft flaps

The Cessna 206 has an electrically‑controlled flap system. This requires the battery master[3] to be on and also requires the cargo doors to be completely closed. Closed cargo doors trigger a micro‑switch, located in the doorframe, which completes the electrical circuit and then allows flap movement. As the Cessna 206 flaps extend across the closed forward cargo door (see Cabin layout and exits), this provides a protection so the flaps cannot be inadvertantly extended into an open cargo door and damage the aircraft. 

The flap control lever in the Cessna U206F is located on the pilot’s right side (Figure 4) and is clearly visible from the pilot’s seat. The lever allows the flaps to be set in any position between 0° (flaps fully retracted) and 40° (full-flap extension) with an adjacent placard marking the flap position. 

The pilot described on numerous occasions during an interview with the ATSB ‘hitting or flicking’ the flap selector lever, identifying that the flap selection was sometimes made without the time taken to confirm the flap selection was in the correct position. 

The operator’s chief pilot reported they had not observed the pilot manipulating the lever like this during the 13 hours of in command under supervision (ICUS) flying they completed with the pilot.

Figure 4: Cessna U206F cockpit

Source: Pilot, annotated by the ATSB

Cabin layout and exits

VH-TDQ was operated in a 6-person configuration with 2 front row (pilot) seats, 2 middle row seats and 2 rear seats (Figure 5).

Figure 5: Cessna 206 standard cabin seating configuration 

Source: TSB investigation report A18W0129, adapted by ATSB to match occurrence aircraft 

VH-TDQ included 2 emergency exits, the pilot’s forward left cabin door and a double ‘clam shell’ style cargo door located at the rear right of the aircraft cabin. Passengers seated in the middle row seats are able to access the pilot’s forward left door when the pilot’s seat is moved into a forward position. The forward part of the cargo door overlaps the rear cargo door as a preventative measure to stop the rear door (rear hinged) from opening in flight and damaging the aircraft. The rear cargo door cannot be opened independently of the front cargo door.

Wing flap extension greater than 10° results in the flap blocking the forward part of the cargo door (Figure 6) and restricts the opening to about 8 cm. When the aircraft wing flaps remain extended, the forward cargo door must be opened as far as possible to then allow the rear door to be opened. Further detail is discussed below in Cessna 206 rear passenger emergency egress.

Figure 6: Cessna 206H showing extended flap blocking forward cargo door

Source: ATSB

Meteorological information

The pilot reported that they assessed the local weather conditions via their NAIPS[4] account on the morning of the occurrence flight and recalled that the predicted wind at the aircraft landing area (ALA) was calm.

Bureau of Meteorology data from the nearest recorded locations at the time of the occurrence indicated local winds between 12–14 kt in a south-westerly direction (Figure 7).

Figure 7: Weather reporting locations in relation to the private aircraft landing area

Source: Google Earth, annotated by the ATSB

Aeroplane landing area information

The ALA was on privately‑owned farming land and was regularly used by agricultural pilots to conduct spraying of crops in the local area. The elevation of the ALA was about 800 ft above mean sea level (AMSL) and the runway orientation was about 120/300°[5] and had a gradual slope that increased towards the east, rising about 40 ft over the length of the runway. It was surrounded by waist-high crops, had a gravel surface and a useable length of about 570 m. The ALA did not have a windsock, nor was there a wind indicating device located nearby.

Prior to operating at the ALA, the operator spoke with the landowners to gain understanding of the recent landing area conditions, as they had not flown to the location previously. They were put in contact with the agricultural pilots who had been recently operating from the field and received a landing area condition report. The operator assessed that the area was suitable for the Cessna 206.

Standard circuit pattern

A circuit is the specified path to be flown by aircraft operating in the vicinity of an aerodrome (Figure 8). It comprises of upwind, crosswind, downwind, base and final approach legs.

Figure 8: Standard left-hand circuit pattern

Source: SKYbrary, modified by the ATSB

The Civil Aviation Safety Authority (CASA) Advisory Circular AC 91-10v1.3 advised pilots that joining a base leg of a circuit is not a standard procedure. Stating:

CASA recommends that pilots join the circuit on either the crosswind (midfield) or downwind leg. However, pilots who choose to join on base leg should only do so if they have familiarised themselves with the weather conditions to be expected and aerodrome serviceability.

The AC advised that pilots who join the base leg of the circuit increase the risk of a downwind landing and may conflict with other traffic using the into-wind runway. It also stated that late go‑around decisions and landings on a closed runway were more common.

Recorded data

Flight Radar 24 data[6] indicated that when the pilot commenced the left-hand orbit approaching the ALA, that the aircraft was about 2,000 ft AMSL and at the conclusion of the orbit, as the aircraft joined the base leg, it remained at about 2,000 ft AMSL, about 1,200 ft above the ALA. As the aircraft became established on final approach for the easterly runway, the aircraft height was recorded as 1,500 ft AMSL, 700 ft above the ALA and 1.6 NM from the runway threshold.

Flight Radar 24 showed that the aircraft’s ground speed had slowed to around 75 kt on the base leg of the approach to landing. As the aircraft turned onto final approach the ground speed increased, reaching 92 kt and indicated about 85 kt ground speed at the last data recording on short final for the easterly runway.

Video footage from a passenger seated in the rear left seat was obtained by the ATSB. Video footage showed that the initial touchdown point (Figure 2) was about 80 m past the runway threshold, reducing the remaining runway length to about 490 m. The footage also showed that during the go-round, the aircraft began to lose height shortly after the flaps were retracted and that this was followed by a roll to the right.

Operator’s internal review

On the day of the accident, the operator’s chief pilot attended the accident site, gathered images, reviewed the aircraft damage and debriefed with the pilot.

The chief pilot advised that post‑accident aircraft testing was carried out later that day and the flaps were tested and found to be operational.

From the pilot’s report, flight data and images gathered, the operator completed a detailed internal review of the accident. A summary of the findings included:

• the aircraft’s approach became unstable due to the excess speed

• the speed was more appropriate for a 20° flap setting

• the excess speed likely resulted in the aircraft ‘floating’ and landing long on the runway

• after an initial bounce on landing the pilot continued the approach to land before a second bounce

• inadvertent incorrect flap setting reduced the aircraft climb performance.

Cessna 206 procedures

Unstable approach procedure

The Cessna 206F aircraft flight manual (AFM) advised pilots that the approach speed for a full‑flap, short field landing should be 75 mph (65 kt).

The operator’s exposition stated that the airspeed for the stabilised approach criteria below 1,000 ft is not more than VREF[7] (65 kt) + 5 kt.

Data from Flight Radar 24 showed the aircraft ground speed had slowed to 75 kt on the base leg of the circuit, before increasing to 92 kt ground speed on final approach. The pilot reported the airspeed on final was 75 kt prior to selecting full flap for the landing. 

Go-around procedure 

The Cessna 206F AFM emergency section provided the balked landing (go-around) procedure:

Power – Full throttle and 2850 RPM

Wing Flaps – Retract to 20°

Airspeed 90 MPH (78 kt)

Wing flaps – Retract slowly

Cowl flaps – Open.

Additionally, the AFM provided further detail when conducting a go-around:

In a go-around climb, the wing flap setting should be reduced to 20° immediately after full power is applied. After all obstacles are cleared and once a safe altitude and airspeed are obtained, the wing flaps should only then be retracted further.

On initiating the go-around the pilot inadvertently reduced flap to the 10° setting resulting in a reduction of lift produced by the wing.

Ditching and forced landing procedure

The Cessna 206 ditching and forced landing procedure described in the AFM instructed pilots to configure the aircraft to the full-flap position so as to impact with water or terrain at the slowest possible speed. This procedure did not mention the retraction of the flaps on completion of the ditching or forced landing

Operator’s passenger safety briefing 

The operator’s exposition stated that pilots shall brief passengers about the following matters and confirm they have an understanding:

• the pilot in command is responsible for passenger safety

• safety instructions and directions from the pilot in command must be followed

• smoking tobacco, electronic cigarettes or any other substance on the aircraft is prohibited

• when seatbelts are to be worn, and how to use them

• seat backs are to be upright during take-off and landing

• how and when to adopt the brace position

• how to approach and move away from the aircraft

• entry and egress from the aircraft, including in emergency situations

• where and how to stow baggage and personal effects

• use of survival equipment / ELT as appropriate

• use of life jackets and life rafts (if carried for the operation) and that life jackets must not be inflated inside the aircraft

• restriction on the use of PEDs (personal electronic devices) and when they can be used

• communications and headset use

• if the passenger is in a flight crew seat, the requirement to ensure controls are not manipulated or interfered with

• the location of the Safety Briefing Card located at each seat.

The pilot recalled that they conducted a group briefing of the passengers prior to the first planned local area flight, with the intention of providing the passengers for the second flight an additional briefing before they boarded. 

The pilot reported they briefed the passengers on the aircraft’s seatbelts, location of the fire extinguisher, life jackets, first-aid kit and provided instruction to the front seat passenger regarding remaining clear of the flight controls. They also explained the use of both the forward left cabin door and the double cargo emergency exit doors, highlighting the red handle to open the rear cargo door. The pilot did not indicate that the passengers were briefed on actions in the event of the emergency exit being obstructed.

The adult passenger seated in the rear seat recalled seeing the handle for the forward cargo door, however they were unsure if the rear cargo door had a handle. As discussed (see Cessna 206 rear passenger emergency egress), the emergency handle is not readily visible from the rear seats in older Cessna 206 aircraft when the cargo doors are closed.

Regulatory information on emergency egress

The Cessna 206 was first certified in 1963 by the United States (US) Federal Aviation Administration (FAA). FAA regulation 14 CFR 23.2315 stated that an aeroplane is designed to: 

(a)(2) Have means of egress (openings, exits, or emergency exits), that can be readily located and opened from the inside and outside. The means of opening must be simple and obvious and marked inside and outside the airplane.

There have been a number of revisions made to this FAA design standard over the years. However, once an aircraft has been certified, the design standard under which it was certified continues to apply.

Part 90 of Civil Aviation Safety Regulations (CASR) 1998 - Additional airworthiness requirements Subpart 90.005 sets out the airworthiness requirements for an aircraft that are in addition to the type certification basis for the aircraft.

Under regulation 90.020 of CASR 1998, the Manual of Standards (MOS) sets out the additional airworthiness standards required for CASR Part 90 including, access to emergency exits.

Part 90 of the MOS stated that the minimum opening of an emergency exit must be unobstructed at all times. 

CASR 90.135 stated that each passenger must have access to at least one exit that meets the requirements prescribed by Part 90 of the MOS.

Cessna 206 rear passenger emergency egress

Background

When configured as a 6 seat-passenger aircraft, the cargo door provided the closest emergency exit for passengers seated in the rear seats and an alternate exit if the pilot’s left front cabin door became obstructed.

As discussed above in Aircraft information, when the flaps are extended, they physically block the forward cargo door from being opened beyond about 8 cm, not enabling egress.

The internal forward cargo door handle has 3 positions:

• when the lever is horizontal (with the lever facing forward), the door is locked
• turned clockwise 90° to the vertical position, the door is closed
• turned clockwise another 30°, the door is opened.

With the forward door handle in the locked position the door is unable to be opened from the outside. The pilot reported that the rear seat passengers attempted to open the forward cargo door, however due to the extended flap were unable to push the door open. As the passengers were unaware of the location of the rear door handle (see Operator’s passenger safety briefing), no attempt was made to open the rear cargo door.

For the earlier models (pre-H model), including VH-TDQ, the rear door handle is a red lever (Figure 9) located in the leading edge of the rear door, which is rotated forward (to horizontal position) to open. When the forward cargo door is blocked by the flaps and the rear door handle is in the horizontal position, the rear door can only be partly opened as the horizontal handle cannot pass the forward door. The handle must then be re-stowed in the vertical position to allow the rear cargo door to pass the obstructed forward cargo door. In an emergency situation, this can and has delayed or prevented egress from the aircraft. Once the forward cargo door is slightly opened, it is possible to access the rear door handle from outside the aircraft and open the door using this process.

The pilot advised the ATSB they were aware that the forward cargo door became blocked with the flaps in an extended position. They also advised that they were aware of the requirement to open the forward cargo door before the rear door could be opened and understood the operation of both the cargo door handles. However, the pilot believed that when the flaps remained extended and blocked the forward cargo door, that the rear cargo door was unable to be opened. 

The operator’s chief pilot also reported that if the forward cargo door was blocked by the flap that passengers would be forced to egress the aircraft via the pilot’s forward left cabin door, which would be difficult for passengers seated in the rear seats.

Figure 9: Cessna U206G Cargo door

Source: TSB investigation report A18W0129, annotated by the ATSB

Cessna 206F aircraft flight manual

The emergency section of the aircraft’s flight manual contained instructions for the operation of the cargo door emergency exit which stated:

If it is necessary to use the cargo door as an emergency exit and the wing flaps are not extended, open the forward door and exit. If the wing flaps are extended, open the door in accordance with the instructions on the placard [see Figure 10] which is located on the forward cargo door.

Cessna cargo door latch service bulletin

In 1991, to assist in operating the rear cargo door from inside the aeroplane during night operations, Cessna issued Service Bulletin SEB 91-4 Cargo door latch improvement. The service bulletin recommended the installation of a return spring in the rear cargo door handle, automatically returning the handle to the closed position after opening. This assisted the rear cargo door to move freely past the blocked forward cargo door.

The service bulletin was not mandatory and was not installed on VH-TDQ.

Placard alternative

Prior to the service bulletin, due to demonstrated difficulties opening the cargo doors when the aircraft flaps remained extended during emergency situations in both Australia and overseas, the Civil Aviation Authority (CAA)[8] issued Airworthiness Directive 206/47 in 1988 that required the improvement of existing emergency exit placards for Cessna 206 aircraft in Australia (Figure 10). The placard drew attention via bold letters to step 3, to ensure the rear door handle was returned to the original position (vertical) before attempting to open the rear door (step 4). 

In 1991, when Cessna issued Service Bulletin SEB 91-4, the CAA issued Airworthiness Directive Cessna 206/47 amendment 2, which allowed SEB 91-4 to be an alternate means of compliance to the CAA emergency exit placarding. 

In 2011, CASA subsequently issued Airworthiness Directive Cessna 206/47 amendment 3, which clarified which Cessna 206 models the airworthiness directive applied to. This was due to SEB 91‑4 being incorporated by the manufacturer in some newer models, and because other models did not have the cargo door. SEB 91-4 remained as an alternate means of compliance. 

The placard was installed on VH-TDQ.

Figure 10: Forward cargo door placard 

Source: CASA Airworthiness Directive 206/47 Amendment 3

Canadian type certificate and airworthiness directive

In 1998, Cessna resumed manufacturing the 206 model aircraft with the 206H. The H model featured larger and more visible cargo door handles and incorporated SEB 91-4 for the return spring in the rear cargo door handle into the design. The forward cargo door remained blocked with flaps extended on this variant.

The 206H was certified under the US Federal Aviation Regulations 23.807. Transport Canada (TC) disagreed with the certification, stating that:

The design of the doors did not satisfy the (FAA) certification requirements that the method of opening the doors be simple and obvious and the door be readily opened, even in darkness.

As a result, in 2000 TC issued a type certificate reducing the Cessna 206H occupancy to 5 passengers.

In 2019, the Transport Safety Board of Canada issued safety advisory A18W0129-D1-A1 that stated that between 1999 and 2003, TC, the FAA and Cessna, had worked together in an effort to come up with a design change that could be applied to the Cessna 206H, which could also be used to retrofit older models of the Cessna 206 fleet. However, the matter remained unresolved and no acceptable solution was found.

In 2020 TC issued Airworthiness Directive CF-2020-10, applicable to Cessna 206 models that featured the double cargo door, stating that:

Earlier versions of the model 206 registered in Canada that feature the cargo doors have not been subject to occupancy limits, other limitations or corrective action requirements related to the cargo doors. These earlier versions of the model 206 have continued to operate in Canada without corrective or mitigating action despite the fact that the method of opening the cargo doors is essentially the same as the method for the 206H and T206H models. There is objective evidence that difficulty opening the cargo doors has contributed to fatalities during accidents in Canada involving the model 206.

The AD CF-2020-10 limited earlier model Cessna 206 to 5 occupants and required the removal of one of the middle row seats if either rear seat was to be occupied. The removal of a middle row seat provided access for passengers seated in the rear seats to the pilot’s forward left cabin door (Figure 11) for evacuation in the event the rear cargo door could not be opened quickly enough for egress. The AD also clearly stated that the vacant space left by the removal of a middle row seat must not be used for storage of cargo or baggage. 

Figure 11: Seating configuration for Canadian Cessna 206  

Source: TSB investigation report A18W0129, adapted to indicate seat removal, annotated by the ATSB

The AD also provided an alternative means of compliance through a supplemental type certificate (STC),[9] STC SA1470GL, for the installation of an additional door, on the forward right side of the cabin and was applicable to all models of the Cessna 206. This commercially available alternative means of compliance allowed Canadian registered aircraft to remain in the original 6‑seat configuration. If installed, the additional door provided immediate egress option for the passenger in the front right seat and an additional emergency egress for passengers seated in the middle row.

Australian acceptance of type certificate and supplemental type certificates

Since 1990 CASA has provided for the automatic acceptance of foreign aircraft type certificates and STC’s issued by a national aviation authority of recognised countries[10] including European Union Aviation Safety Agency (EASA).

CASA has accepted the type certificate of the national aviation authority issuing state (United States), for the following models of the Cessna 206: 206, P206, P206A, P206B, P206C, P206E, U206, U206A, 206H, U206B, U206C, U206D, U206E, U206F, U206G, T206H, TU206A, TU206C and TU206G (P206 models are not manufactured with the double cargo door).

ATSB safety recommendation

In 2020, after ATSB investigation (

), into an accident involving a Cessna U206G on Fraser Island, Queensland, the ATSB issued CASA with safety recommendation AO-2020-010-SR-018 recommending that CASA take safety action to address the certification basis for the design of the cabin doors in the Cessna 206, as wing extension beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress.

In response CASA issued Airworthiness Bulletin 52‑006 in 2021, with a subsequent reissue in 2025. The bulletin advised pilots and operators of the impeded access from the cargo door emergency exit with the flaps extended and made recommendations that:

• Pilots should be aware that lowering the flaps may obstruct this exit and significantly increase the difficulty of opening the forward door section of the rear cargo door. All passenger pre-flight briefings should include a practical demonstration of how to open and egress the aircraft through a flap obstructed cargo door. This will require a demonstration with flaps lowered to at least 20 degrees to demonstrate the condition. Care should be taken to not damage the flap or door during this demonstration.

• Additionally, in the event that an emergency landing or water ditching is required, pilots should consider retracting the flaps if possible after the emergency landing or if operationally feasible, limit the amount of flap extension to a maximum of 10 degrees. This would of course be a judgement made by the pilot in command based on operational factors, severity of the emergency/damage to aircraft and if there are occupants seated in the rear of the aircraft.

• It is strongly recommended that registered operators and operators of affected Cessna 206, T206, TU206 and U206 aircraft series, review TC AD CF-2020-10 and give due consideration to compliance with the intent of this document, however compliance is not mandatory under CASR Part 39, because the AD is not from the state of design.

The ATSB investigation also issued Cessna a safety recommendation AO-2020-010-SR-017. The safety recommendation was to address the concern that although the Cessna 206 AFM ditching procedure required pilots to extend the flaps to the full-flap position, which resulted in a slower landing speed, this significantly impeded the emergency egress via the cargo door emergency exit and there was no warning in the AFM of the additional risk. In response, Cessna provided a temporary revision to only the Cessna 206H model AFM, providing a warning stating:

FLAP POSITIONS OF 10 DEGREES OR GREATER MAY IMPEDE EVACUATION FROM THE CARGO DOOR. FAILURE TO ADHERE TO ALL SAFETY INSTRUCTIONS CAN RESULT IN BODILY INJURY OR DEATH. 

Cessna advised the warning would be incorporated into the next revision of the Cessna 206H AFM and a placard, with the same warning would be produced for older Cessna 206 models that featured the double cargo doors. In November 2024, mandatory service bulletin SEB-11-05 was released for all Cessna 206, and U206 models prior to the 206H, for the installation of the placard on the cockpit instrument panel or another location directly visible to the pilot. The service bulletin had not been released at the time of the occurrence. 

Cessna 206 modifications to allow cargo door to open with flaps extended

Since the release of AD CF-2020-10, in 2020 TC also approved STC SA20-34 which allows the forward cargo door corner to be hinged (Figure 12). This allows the door to fold on a hinge and fully open with flap extended in any position and therefore creating no restriction to the rear cargo door.

Figure 12: Cessna split cargo door

Source: Coast Dog Aviation, annotated by the ATSB

Additionally, on 2 May 2023, TC approved STC SA23-21 to provide an additional handle that is installed internally on the forward cargo door. The handle is accessible to the rear seat passengers, which, when activated jettisons the front cargo door from the aircraft. The removal of the door provided egress to the middle row occupants when flaps remained extended. The release of the door from the aircraft also improved visibility of the rear cargo door handle and simplified opening the rear cargo door for occupants seated in the rear seats.

Both STC SA20-34 and STC SA23-21 are approved as alternative means of compliance to TC CF-2020-10 and allowed Canadian registered aircraft to retain the 6 seat configuration.

VH-TDQ was not modified with the approved STC’s for the cargo door and a second forward right side door was not fitted (STC SA1470GL) and the aircraft remained in the original 6 seat configuration.

Related occurrences 

ATSB conducted a search of aviation investigation databases and other sources to identify accidents involving Cessna 206 aircraft (Appendix 1 – Cessna 206 occurrences). This search specifically looked at accidents where the impact was considered likely survivable, however where difficulties opening the cargo door resulted in significant delays during the emergency egress, or the cargo door had not been opened. 

The ATSB identified 10 occurrences that included 23 fatalities between 1985 and 2020 globally. Highlighted during the search were multiple occurrences of Cessna 206 accidents that involved fatalities when Cessna 206 aircraft were equipped with floats and operated on water. 

In March 1999, near Pitt Island, New Zealand, a Cessna 206 had an engine failure and ditched in the sea. The pilot was aware of the issue with the extended flap blocking the cargo doors and ditched the aircraft with the flaps retracted. Consequently, all the occupants escaped from the aircraft and swam to shore (New Zealand Transport Accident Investigation Commission, investigation report 99‑001) .

In January 2020, during a landing at a beach landing area on Fraser Island, Queensland, the Cessna U206G aircraft veered significantly to the left. Once airborne it was identified that the rudder was jammed in the full‑left position and the pilot had to apply full opposite aileron to maintain control. Shortly after, possibly due to fuel starvation the aircraft collided with water. Unable to open the pilot’s door the trainee pilot kicked the cargo door to force it open past the extended flap (ATSB investigation AO-2020-010).

Safety analysis

Introduction

On the morning of 1 September 2024, the pilot of a Cessna U206F, registered VH-TDQ, departed a private aircraft landing area (ALA), 21 NM (39 km) southeast of Moora, Western Australia (WA) with 5 passengers on board for a 15-minute local area flight. On return to the ALA the pilot conducted a full flap landing on the easterly runway and bounced twice. The pilot then commenced a go-around, however as the aircraft began the initial climb, the pilot inadvertently reduced the flap setting 10°. The aircraft lost height and the right wing dropped, making contact with terrain, removing the right wing tip and damaging the right aileron. The aircraft then lost speed and landed upright in a field adjacent to the runway. 

Unstable approach

As the pilot approached the ALA and was about 2 NM (3.7 km) north, they assessed that the aircraft was too high and elected to conduct a left orbit with the intention of reducing the aircraft’s height. However, no reduction in height was recorded during the orbit. 

The pilot conducted a non-standard approach to the easterly runway by joining the circuit on a base leg. This resulted in a reduction of available time for the pilot to assess the vertical descent profile effectively and likely contributed to the pilot mis-managing the short field landing with additional speed and height on the final approach.

Contributing factor The pilot conducted a non-standard base leg join to the circuit for landing. This reduced the time available for the pilot to configure the aircraft, reduce the airspeed and prepare for a short field landing.

A combination of additional speed on final approach, the effects of a tailwind and the aircraft in the full-flap landing configuration, likely extended the aircraft’s flare. This resulted in the aircraft landing past the intended touchdown point. This also contributed to the aircraft bouncing on landing and further reduced the runway available to safely stop and likely resulted in the pilot‘s decision to go-around.

Contributing factor Due to excessive speed on approach for a full flap, short field landing, the aircraft landed long and bounced twice.

Go-around

After the aircraft bounced a second time, the pilot commenced a go-around and applied full power to climb away. As the aircraft increased speed and began the climb out, the pilot intended to reduce the flap setting to 20° to reduce drag, but inadvertently reduced the flap setting to 10°. This resulted in a flap configuration below the prescribed setting for the aircraft’s balked landing (go‑around) procedure. 

The aircraft had not achieved the required airspeed for the lower than intended flap setting and this developed into a lack of sufficient lift and a loss of climb performance. This resulted in the aircraft losing height and directional control which caused right wingtip contact with the ground. 

Contributing factor The pilot mis-selected the flap setting during the attempted go-around. As a result, the aircraft could not achieve adequate climb performance.

Passenger evacuation

After the aircraft came to a stop, the pilot instructed the passengers to evacuate. The front seat passenger and middle row passengers were able to egress through the pilot’s forward left cabin door. However, due to the flaps remaining extended in the 10° position, the forward half of the right-side cargo door (emergency exit) could not be fully opened. While the rear cargo door could have been opened (either from the inside or the outside), the blocking of the forward door increased the difficulty of opening the rear cargo door and caused confusion about how to evacuate the rear seat passengers.

From the inside, the rear door handle was not easily visible to passengers in the rear seats due to its obscured position and location relative to the middle row seats and the forward cargo door only able to be partially opened. Although the pilot reported providing a safety briefing to the passengers, and an aircraft placard provided instructions for the operation of the cargo door emergency exit when the flaps remained in an extended position, the adult rear seat passenger was not fully aware of the location of the rear cargo door handle.

Due to the forward cargo door being blocked by the extended wing flaps, and a rear door handle that was not easily accessible to the pilot outside the aircraft and not easily visible to passengers in the rear seats, the 2 rear seat passengers could not enact the opening of the rear emergency exit, and ultimately were required to climb over the middle row seats and egressed via the pilot’s forward left cabin door.

While this delayed a timely evacuation, in this case the rear passengers were an older adult and a young child but both capable of climbing over seats, and the pilot was able to assist from outside the aircraft. However, in emergency situations where the passengers may be less able-bodied or the pilot is incapacitated or unable to assist, the functioning of aircraft emergency exit systems must be quickly apparent and passengers must have enough awareness of their operation to ensure timely and unassisted evacuation.

Other factor that increased risk With the flaps extended in the 10° position when the aircraft came to rest blocking the full opening of the forward cargo door, the rear seat passengers were unable to open the rear cargo door to enable an emergency exit.

In this case, there was an additional chance to evacuate via the rear emergency exit as the pilot could walk around to the outside of that exit.

As pilots of small passenger aircraft are responsible for the emergency egress of passengers, it is essential that the pilot has a full understanding of the operation of the emergency exits. Instructions for the operation of cargo door emergency exit when the flaps remained in an extended position were available on an aircraft placard.

The pilot understood that the operation of the rear cargo door was reliant on the forward door being open, and was also aware that extended flaps may block the forward cargo door. However, the pilot was unaware the rear cargo door could be opened after the forward cargo door had been made ajar (blocked by flaps). As a result, the pilot first tried (unsuccessfully) to retract the flaps, even though this was not required to open the rear cargo door. When that failed, likely due to the door remaining ajar preventing the micro‑switch activation of power to the flap system as designed, the pilot instructed the occupants to egress via the forward cargo doors over the middle row seats.

In this case, as the aircraft was not on fire nor floating on water, this lack of knowledge did not result in a worse consequence. However, in other circumstances, the inability to egress rear seat passengers from the rear emergency exit could have serious consequences.

Other factor that increased risk The pilot was unaware that the rear cargo door on the Cessna 206 could be opened from the outside when the front cargo door was blocked by the extended flaps.

Previous ATSB and international investigations have highlighted the difficulty occupants of the Cessna 206 face egressing via the cargo door emergency exit when the aircraft flaps remain extended. While it is possible to open the rear cargo door from outside the aircraft when the forward door is blocked by the extended flaps, without training or demonstration the process is not simple or obvious. The pilot had limited experience on the aircraft type and was unaware of the process. 

Although CASA Airworthiness Bulletin 52-006 advised operators to brief passengers on emergency egress with flaps blocking the forward cargo emergency exit, the chief pilot also was unaware it was possible to open the rear cargo door when the forward cargo door was blocked by the flaps. This meant that they were unable to educate company pilots on the additional complexity operating the rear cargo door with flaps extended.

Although the company operations manual stated that pilots were required to brief passengers entry and egress from the aircraft, including in emergency situations, the operator did not provide further documentation to pilots that the passenger briefing should also demonstrate the cargo door operation with the flaps extended as recommended by CASA Airworthiness Bulletin 52-006.

The knowledge involved to demonstrate this would have provided the pilot with the correct understanding of the operation of those doors as was needed in this case. Further, had such a demonstration been conducted, it is likely that passengers seated in the rear of the aircraft would have also been aware of the location of the rear cargo door handle and process when the flaps remained extended. 

Passenger briefings therefore lacked in this regard, and in an emergency event where passengers were required to open the rear cargo/emergency doors quickly with the flaps extended, this increased the risk that the rear seat passengers would not be able to egress at all or quickly enough to escape injury.

Other factor that increased risk The operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended.  (Safety Issue)

Safety advisory notice The Australian Transport Safety Bureau advises Cessna 206 pilots and operators that due to the difficulties occupants have encountered egressing the rear cargo door as identified in several transport safety investigations, to ensure they are familiar with CASA‑issued Airworthiness Bulletin 52‑006, and ensure passengers are provided with a thorough safety briefing demonstrating the cargo door emergency egress when the wing flaps remain in the extended position.

Cessna 206 emergency egress

The Cessna 206 cargo door emergency exit has featured in numerous transport safety investigations across the world. To date, Transport Canada remains the only regulatory body that has made significant changes that improve the ease of use during an emergency. 

Transport Canada’s decision to issue an amended type certificate for the Cessna 206H when production was restarted, limited the aircraft to 5 occupants, with the required removal of a middle row seat if either rear seat was to be occupied. The subsequent release of the airworthiness directive CF-2020-10 mandated the same limitations and meant that occupants of older model Cessna 206 aircraft, particularly those seated in the rear seats, had improved access to the pilot’s forward left cabin door emergency exit. The removal of the middle row seat also improved the visibility and access to both cargo door handles for middle and rear seat occupants. 

The Civil Aviation Safety Authority (CASA) required that the aircraft emergency exits remain unobstructed at all times. Passengers seated in the rear seats of the Cessna 206 with the double cargo door are obstructed by either: 

• the middle row seats, when attempting to access the pilots forward left cabin door
• the flap blocking the forward cargo door when the flaps remain extended.

The majority of aircraft accidents happen during take-off or approach and landing phases of flight. During normal operation, these phases of flight usually require an amount of flap extension, therefore it becomes likely that, in the event of an accident or incident, the flaps would remain extended and hinder the use of the cargo door emergency exit. 

Previous investigations into the Cessna 206 that included fatalities of pilots who had a required knowledge of the use of an emergency exit, have found that the extended flaps blocking the cargo door contributed to the occupant’s inability to exit the aircraft during emergency egress.

The successful ditching of a Cessna 206 in New Zealand in 1999 indicated the increased occupant survivability potential when both emergency exits are clear of any obstruction.

Transport Canada has approved several modifications that provided an exemption to the occupancy limitations set out by the type certificate and airworthiness directive. This allowed the aircraft to maintain its intended 6 passenger configuration. The modifications are commercially available and improve the functionality of the emergency exits and provide access to an alternative or unobstructed emergency exit with the flaps extended.  

The extended flap blocking the forward cargo door has contributed to fatalities in previous accidents. The Cessna 206 ditching and forced landing procedure both prescribe a full-flap landing. However, unless the pilot is able to retract the flaps after the ditching or landing, the flaps would remain extended blocking the forward cargo door.

Transport Canada’s required restriction of the Cessna 206 occupancy, or the approved emergency exit modifications, reduces the risk created by the extended flaps preventing the immediate and unobstructed use of the rear cargo door emergency exit. This significantly improves the occupant’s likelihood of successful egress, during an emergency.

In Australia, CASA has provided warnings regarding the obstruction of the emergency exit and strongly recommended operators to comply with the changes that Transport Canada made. However, the aircraft’s certifying state (United States) has not mandated these changes. 

The ATSB and international transport safety investigations have highlighted the increased difficulty faced by occupants attempting to egress the Cessna 206 when the flaps remain extended. Existing approved emergency exit modifications are available to reduce the risk created by the extended flap preventing the immediate and unobstructed use of the rear cargo emergency exit. 

The approved modifications for the cargo door emergency exit would likely have resulted in occupants of the rear seats successfully opening the forward cargo door and therefore improving the ease of operation of the rear cargo door handle for the occupants or pilot. Alternatively, with a middle row seat removed, rear seat occupants’ path to the forward left cabin door would have been unobstructed.

Other factor that increased risk The aircraft did not have the modifications detailed by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations. (Safety Issue)

Safety advisory notice The Australian Transport Safety Bureau strongly encourages operators and owners review Transport Canada Airworthiness DirectiveCF-2020-10, and consider either the removal of a middle row seat to improve rear seat occupants’ access to the pilot’s forward left cabin door or the fitment of approved Cessna 206 emergency exit modifications to reduce the risk created by the extended flap preventing the immediate and unobstructed use of the rear cargo doors during an emergency exit.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.  Safety issues are highlighted in bold to emphasise their importance. A safety issue is a safety factor that (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

From the evidence available, the following findings are made with respect to the collision with terrain during go‑around involving Cessna U206F, VH-TDQ, 39 km south-east of Moora, Western Australia, on 1 September 2024. 

Contributing factors

• Due to excessive speed on approach for a full flap, short field landing, with a tail wind component, the aircraft landed long and bounced twice.
• The pilot conducted a non-standard approach to the landing area by conducting a base leg join to the easterly runway which had a gradual upslope. This reduced the time available for the pilot to configure the aircraft, reduce airspeed and prepare for a short field landing.
• The pilot mis-selected the flap setting during the attempted go-around. However, the aircraft could not achieve adequate climb performance.

Other factors that increased risk

• The aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations. (Safety issue)
• The operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended. (Safety issue)
• The pilot was unaware that the rear cargo door on the Cessna 206 could be opened from the outside when the front cargo door was blocked by the extended flaps.
• With the flaps extended in the 10° position when the aircraft came to rest blocking the full opening of the forward cargo door, the rear seat passengers were unable to open the rear cargo door to enable an emergency exit.

Safety issues and actions

Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues. The ATSB expects relevant organisations will address all safety issues an investigation identifies.  Depending on the level of risk of a safety issue, the extent of corrective action taken by the relevant organisation(s), or the desirability of directing a broad safety message to the Aviation industry, the ATSB may issue a formal safety recommendation or safety advisory notice as part of the final report. All of the directly involved parties are invited to provide submissions to this draft report. As part of that process, each organisation is asked to communicate what safety actions, if any, they have carried out or are planning to carry out in relation to each safety issue relevant to their organisation.  Descriptions of each safety issue, and any associated safety recommendations, are detailed below. Click the link to read the full safety issue description, including the issue status and any safety action/s taken. Safety issues and actions are updated on this website when safety issue owners provide further information concerning the implementation of safety action.

The operator’s pre-flight passenger briefing

Safety issue number: AO-2024-049-SI-01

Safety issue description: The operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended.

Safety advisory notice to operators and pilots of Cessna 206

SAN number:

AO-2024-049-SAN-001

The Australian Transport Safety Bureau advises Cessna 206 pilots and operators that due to the difficulties occupants have encountered egressing the rear cargo door as identified in several transport safety investigations, to ensure they are familiar with CASA issued Airworthiness Bulletin 52‑006, and ensure passengers are provided with a thorough safety briefing demonstrating the cargo door emergency egress when the wing flaps remain in the extended position. 

Cessna 206 emergency exit modifications

Safety issue number: AO-2024-049-SI-02

Safety issue description: The aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations

Safety advisory notice to operators and pilots of Cessna 206

SAN number:

AO-2024-049-SAN-002

The Australian Transport Safety Bureau strongly encourages operators and owners review Transport Canada Airworthiness Directive CF-2020-10, and consider either the removal of a middle row seat to improve rear seat occupants access to the pilots forward left cabin door or the fitment of approved Cessna 206 emergency exit modifications to reduce the risk created by the extended flap preventing the immediate and unobstructed use of the rear cargo doors during an emergency exit.

Safety action not associated with an identified safety issue

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Safety action by Fly Esperance Pty Ltd

Following the occurrence Fly Esperance has made the following amendments to its operations manual: 

• Added CASA pictorial publication ‘non-controlled aerodrome circuit procedures’ to its Circuit and landing procedures and uncontrolled aerodromes section to better clarify the process.
• Added a table to show the recommended aircraft speed and landing weight with the flaps retracted and extended.
• Pilots will now carry portable GPS aircraft tracking devices to improve aircraft tracking when outside ADSB coverage.
• Greater emphasis on training including ICUS training, highlighting what can happen when standard procedures are not followed.   

The changes to the company operations manual are part of a larger amendment that will be under review by CASA in due course.

Glossary

AD	Airworthiness Directive
AFM	Aircraft flight manual
ALA	Aircraft landing area
AMSL	Above mean seal level
ATSB	Australian Transport Safety Bureau
AWB	Airworthiness Bulletin
CAA	Civil Aviation Authority (Australia)
CASA	Civil Aviation Safety Authority
CASR	Civil Aviation Safety Regulations
FAA	Federal Aviation Association
ft	Feet
kt	Knots
MOS	Manual of Standards
NAIPS	National Aeronautical Information Processing System
NM	Nautical miles
SEB	Service Bulletin
STC	Supplemental type certificate
VREF	Landing reference speed

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of the accident flight
• Fly WA Group
• the chief pilot of Fly WA Group
• Civil Aviation Safety Authority
• passengers of the accident flight
• Textron Aviation
• Bureau of Meterology
• Flight Radar 24
• accident witnesses
• video footage of the accident flight and other photographs and videos taken on the day of the accident
• United States Federal Aviation Administration
• Transport Canada
• Transport Safety Board of Canada

References

Australian Transport Safety Bureau. (2021). Collision with water involving Textron Aviation Inc. (Cessna) 206, VH-AEE, near Happy Valley, Fraser Island, Queensland, on 29 January 2020. Retrieved from /publications/investigation_reports/2020/aair/ao-2020-010#safetysummary0

Canada, T. (2020, April). Airworthiness Driective CF-2020-10. Retrieved from https://wwwapps.tc.gc.ca/Saf-Sec-Sur/2/cawis-swimn/AD_dl.aspx?ad=CF-202…

Canada, T. (2024, June). https://www.bst-tsb.gc.ca/eng/enquetes-investigations/aviation/2024/a24…. Retrieved from https://www.bst-tsb.gc.ca/eng/enquetes-investigations/aviation/2024/a24…

Civil Aviation Safety Authority. (2009). Advisory Circular AC21-30(2). Retrieved from https://www.casa.gov.au/sites/default/files/2021-08/advisory-circular-2…

Civil Aviation Safety Authority. (2017). Manual of Standards. Retrieved from Part 90: https://www.legislation.gov.au/F2010L03095/latest/text

Civil Aviation Safety Authority. (2024). Civil Aviation Safety Regulations. Retrieved from Part 90: https://www.legislation.gov.au/F1998B00220/latest/text/2

Civil Aviation Safety Authority. (2025, January). Advisory Circular AC 91-10 v1.3. Retrieved from Operations in the vicnity of non-controlled aerdromes: https://www.casa.gov.au/operations-vicinity-non-controlled-aerodromes

Civil Aviation Safety Authority. (2025). Airworthiness Bulletin 52-006. Retrieved from https://www.casa.gov.au/sites/default/files/2025-01/awb_52-006_issue_2_…

Civil Aviation Safey Authority. (2011). AIRWORTHINESS DIRECTIVE AD 206/47 amndt 3. Retrieved from https://services.casa.gov.au/airworth/airwd/ADfiles/under/cessna206/CES…

Federal Aviation Administration. (1990). Supplemental Type Ceretificates. Retrieved from SA1470GL: https://drs.faa.gov/browse/STC/doctypeDetails?modalOpened=true

Federal Aviation Administration. (2024). Delegated Organisations. Retrieved from https://www.faa.gov/other_visit/aviation_industry/designees_delegations…

Federal Aviation Administration. (2024, July 29). Federal Aviation Administration Current Regulations. Retrieved from Federal Aviation Administration: https://www.faa.gov/other_visit/aviation_industry/designees_delegations…

Transport Accident Investigation Commission, N. Z. (1999). Accident Investigation 99-001. Retrieved from https://www.taic.org.nz/sites/default/files/inquiry/documents/99-001.pdf

Wikipedia. (n.d.). Cessna. Retrieved from Wikipedia: https://en.wikipedia.org/wiki/Cessna

Submissions

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

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

• the pilot of the accident flight
• Fly Esperance chief pilot
• Textron Aviation
• Civil Aviation Safety Authority.

Submissions were received from:

• the pilot of the accident flight
• Fly Esperance chief pilot
• Civil Aviation Safety Authority.

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

Appendices

Appendix 1 – Cessna 206 occurrences

Year	Injuries	Summary	Link	Country of Occurrence
2020	2 Persons on board (pob) 2 minor injuries	During a landing at a beach landing area on Fraser Island, Queensland, the Cessna U206G aircraft veered significantly to the left. Once airborne it was identified that the rudder was jammed in the full‑left position and the pilot had to apply full opposite aileron to maintain control. The engine subsequently stopped, possibly due to fuel starvation and the aircraft collided with water. Unable to open the pilots door the trainee pilot kicked the cargo door to force it open past the extended flap.AO-2020-010	ATSB AO-2020-010	Australia
2018	5 pob 3 fatalities	During a landing on water, a float equipped U206G nosed over. The pilot and one passenger survived. The three remaining passengers, who received no injuries during the accident, were unable to escape the fuselage and drowned. The passengers were found with their seatbelts unfastened but had not opened the cargo door, which was blocked by 20˚ flap.	TSB A180129	Canada
2012	5 pob 1 fatality	During a landing on water, the float equipped 206 nosed over. The flaps were extended blocking the cargo door. The pilot and three passengers escaped by bending the cargo door. The fourth passenger, found in her seat with the seatbelt on, likely died through injuries caused by the accident.	NTSB ANC12FA073	United States
2010	5 pob 4 fatalities	During cruise, the engine failed, and the pilot conducted a ditching into Lake Michigan. The pilot did not lower the flap; however, the cargo door had not been opened. The pilot survived. Two passengers were found outside the aircraft however, their life jackets had failed. Of the two passengers found inside the cabin, one had removed their seatbelt.	NTSB  CEN10FA465	United States
2003	2 pob 1 fatality	During the landing on water, the float equipped 206 flipped over. Contrary to instructions provided by the pilot, the passenger made their way to the rear of the aircraft, was unable to exit, and drowned.	TSB aviation occurrence A03Q0083	Canada
2001	5 pob 1 fatality	During the landing, the aircraft collided with a hole in the runway, nosed over and slid into a river. The pilot and three passengers escaped with minor injuries, however, one of the passengers drowned trying to escape the aircraft.	Aviation Safety Network Wikibase Occurrence 45813	Venezuela
1999	6 pob	During an aerial surveillance air transport flight around Pitt Island, New Zealand the aircraft had a sudden engine failure and ditched in the sea. The pilot and four passengers escaped from the aircraft and swam to shore without the aid of life-jackets. Aircraft flaps were not extended during the ditching.	Transport Accident Investigation Commission, New Zealand 99-001	New Zealand
1997	3 pob 2 fatalities	During the landing on water, the float‑equipped aircraft flipped as the landing gear had not been retracted. Two passengers were unable to exit the aircraft and drowned. The door handle was found in the upright closed position.	TSB Aviation investigation report A97C0090	Canada
1996	6 pob 4 fatalities	During the take-off on water, the aircraft capsized. The pilot and three passengers drowned in the rear of the aircraft, when the pilot could not open the cargo door. Two passengers escaped through the pilot door. There was evidence that an adult had attempted to open the cargo door.	TSB Aviation investigation report A96Q0114	Canada
1989	5 pob 4 fatalities	During the landing on a dam, the float‑equipped 206 nosed over as the landing gear had not been retracted. The pilot and one passenger survived, but three passengers were fatally injured.	Aircraft Accident Investigation Board – Norway 06/99	Norway
1985	5 pob 3 fatalities	During the landing on a dam, the float‑equipped 206 nosed over as the landing gear had not been retracted. The pilot and one passenger survived, but three passengers were fatally injured.	ATSB  198503550	Australia

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 Australian Transport Safety Bureau (ATSB) has commenced an investigation into the weather diversion from Sydney Airport to an emergency alternate airport involving Qantas B787-9, registered VH-ZNJ, on 18 February 2023. 

During approach, the aircraft encountered moderate turbulence and high wind conditions and the approach became unstable. The crew conducted a missed approach and advised ATC of minimum fuel conditions. The crew diverted the aircraft to Williamtown where ground handling equipment was not sufficient for the aircraft size. The investigation is continuing.

A final report will be published at the conclusion of the investigation. Should any safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.