Region

Crash of a Pilatus PC-6/B2-H2 Turbo Porter in Moruya: 1 killed

Date & Time: Sep 27, 2025 at 1420 LT
Operator:
Registration:
VH-XAA
Survivors:
No
Schedule:
Moruya - Moruya
MSN:
809
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine airplane departed Moruya Airport on a local skydiving flight with eight skydivers and one pilot on board. After all eight occupants jumped out, the pilot was returning to base when the airplane crashed in unknown circumstances 2 km north of the airfield. The pilot was killed and the airplane was destroyed. It was owned by Jump Aviation and operated by Skyone Moruya.

Crash of a Reims-Cessna F406 Caravan II in Oakey: 2 killed

Date & Time: Jul 20, 2025 at 1500 LT
Type of aircraft:
Registration:
VH-EYQ
Flight Type:
Survivors:
No
Schedule:
Warwick - Oakey
MSN:
406-0047
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Warwick Airport at 1426LT on a positioning flight to Oakey Airfield. On approach to runway 14, the twin engine airplane went out of control and crashed in a grassy area located 2 km from the airfield, bursting into flames. Both occupants were killed.

Crash of a Cessna 208 Caravan I off Rottnest Island: 3 killed

Date & Time: Jan 7, 2025 at 1600 LT
Type of aircraft:
Operator:
Registration:
VH-WTY
Flight Phase:
Survivors:
Yes
Schedule:
Rottnest Island - Perth
MSN:
208-00586
YOM:
2016
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
After takeoff from the Thomson Bay in Rottnest Island, the single engine seaplane banked left, causing the left wing tip to struck the water surface. The airplane water looped and plunged into the water, floating in a vertical attitude. Three passengers were seriously injured while one was unhurt. Two others (one Swiss and one Danish citizen) as well as the pilot were killed.

Crash of a Cessna 208B Grand Caravan on Lizard Island

Date & Time: Jan 8, 2024 at 0700 LT
Type of aircraft:
Operator:
Registration:
VH-NWJ
Survivors:
Yes
Schedule:
Lizard Island - Cairns
MSN:
208B-2161
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3706
Captain / Total hours on type:
2431.00
Aircraft flight hours:
8765
Circumstances:
At 0646LT, the single engine airplane departed Lizard Island Airport on a non-scheduled passenger service to Cairns. On board were the pilot and 9 passengers. After takeoff from runway 12, the pilot turned right, tracked south-southwest and made a departure call to Brisbane Centre air traffic control (ATC). At 1,750 feet above mean sea level, the pilot turned left onto the departure track in a cruise climb and engaged the autopilot. At 0652LT, passing 3,400 feet at an indicated airspeed of 102 kt, the pilot noted a change to the engine sound and that the aircraft was accelerating. The pilot checked the engine gauges on the Garmin G1000 multifunction flight display. They noted the values indicated on both the engine torque and interstage turbine temperature gauges were above the redline and the gas generator speed and fuel flow were not indicating, being marked with a diagonal red cross through the gauge locations. The propeller revolutions per minute was high but within the green operating range. Within 10 seconds, the pilot initiated a left turn with the purpose of returning to Lizard Island and broadcast a PAN PAN call on the area frequency advising their intentions. Despite trying to arrest it, the aircraft continued to climb and accelerate over the next 2 minutes reaching 4,000 feet and 166 kt. The pilot started troubleshooting the issue by moving the power, propeller control and emergency power levers with the only response coming from the propeller control lever. The pilot also partially moved the fuel condition lever through the gate from low idle to cut-off and noted the engine power cutting in and out and returned the condition lever to low idle. At the same time, the pilot conducted a large orbit around the island attempting a shallow descent while the engine continued to produce excessive power. Further manipulation of the propeller control lever somewhat reduced the engine thrust. The pilot updated ATC on their situation and progressively deployed the flaps to create drag in an attempt to slow the aircraft. After one orbit of the island, the pilot felt they were low enough to attempt a landing with a 2 NM (4 km) final approach to runway 12 and notified ATC of their intentions. The pilot reported they were concerned with the populated resort accommodation and maintenance buildings on the approach end of the runway and the possibility of injury to those on board and on the ground if the aircraft did not have the energy to make the runway. To ensure they cleared potential obstacles, the pilot elected to perform a powered-on approach. The pilot continued to adjust the propeller lever in an attempt to reduce the engine thrust. The final approach was started at 147 kt (the pilot operating handbook stated the normal approach speed with full flaps was 75–85 kt). The pilot was able to reduce the airspeed to 123 kt by the runway threshold and reported attempting to shut down the engine. The aircraft floated along the down-sloping runway, bouncing and touching down at around 100 kt, an estimated two-thirds of the way along the runway. The pilot applied maximum braking, but the aircraft exited the end of the runway at 92 kt. The aircraft continued across undulating sandy soil and low vegetation before the left wingtip struck the ground, which spun and flipped the aircraft, coming to rest inverted, 127 metres from the end of the runway. All 10 occupants escaped with minor injuries and the airplane was damaged beyond repair.
Probable cause:
The accident was the consequence of the following:
- Shortly after departure, the fuel control unit very likely malfunctioned resulting in an uncommanded engine acceleration event beyond limits, necessitating a return to the airport.
- The engine power was unable to be reduced and the engine was not successfully shut down on final approach. As a result, the aircraft could not be slowed sufficiently to prevent a runway overrun.
The following contributing factor was identified:
- While uncommanded engine acceleration or inability to reduce power events occur at a higher rate than any other type of fuel control unit malfunction in Pratt & Whitney Canada PT6A single-engine aircraft, there were no flight manual procedures addressing this type of occurrence. Consequently, there was limited awareness by pilots and operators on how to identify and safely respond to an uncommanded engine acceleration event.
Final Report:

Crash of a Cessna 421C Golden Eagle III off Sunshine Coast

Date & Time: Nov 10, 2023 at 0907 LT
Operator:
Registration:
VH-VPY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Sunshine Coast - Pago Pago
MSN:
421C-0688
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Copilot / Total flying hours:
1400
Copilot / Total hours on type:
100
Circumstances:
On the morning of 10 November 2023, a Cessna 421C, registered VH-VPY, departed the Sunshine Coast Airport, Queensland for a transpacific international ferry flight to Oakland, California in the United States. Two pilots were on board to conduct the flight, where the first leg was planned to stop at Pago Pago, American Samoa. The aircraft was configured with additional ferry fuel tanks to ensure sufficient fuel was available between the stops for the extended journey across the open ocean. Approximately 50 minutes after departure, the left engine failed and the pilots initiated a return to the Sunshine Coast. During the return leg the pilots identified that the aircraft was unable to maintain altitude and calculations based on the descent rate indicated they would be unable to reach the Sunshine Coast. The pilots notified air traffic control of their intention to ditch, who immediately engaged the national search and rescue service provider. After considering the configuration of the aircraft, the pilots elected not to follow the aircraft manufacturer’s guidance on ditching. They configured the aircraft to avoid a nose down attitude on touchdown and allowed their airspeed to slow before the aircraft contacted the water. Both occupants were uninjured and exited through the rear door. After deploying the emergency life raft, both pilots were retrieved by a rescue helicopter 32 minutes after ditching. The aircraft sank and was not recovered.
Probable cause:
Contributing factors:
- While flying over open water the left engine failed. The nature of the engine failure prevented the propeller from feathering and the excess drag from the windmilling propeller reduced the available performance of the aircraft.
- Following the engine failure, as it was not possible for the pilot to quickly jettison sufficient fuel from the ferry tank, the weight of that fuel further reduced aircraft performance, resulting in the aircraft ditching.
Other factor that increased risk:
- The aircraft was loaded in excess of the weight and balance limitations imposed by the special ferry flight permit, and in addition, an unapproved modification was made to the ferry fuel system. These actions removed the defences incorporated into the ferry permit approval process and increased the likelihood of an adverse outcome.
- Both pilots did not hold the appropriate approvals and ratings to conduct the ferry flight.
Other findings:
- The pilots were familiar with the survival equipment and were well prepared in the event of a ditching.
- While the pilot actions during the ditching were not consistent with the flight manual, the method utilized considered the aircraft configuration and its performance in the prevailing conditions. It could not be determined if this increased the likelihood of aircraft damage/breakup when compared to the manufacturer's procedure.
- Early communication between the pilots, air traffic control and the Australian Maritime Safety Authority’s Response Centre allowed rescue efforts to commence prior to ditching, increasing the chances of survival.
Final Report:

Crash of a Rockwell Gulfstream 695A Jetprop 1000 near Cloncurry: 3 killed

Date & Time: Nov 4, 2023 at 1430 LT
Operator:
Registration:
VH-HPY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toowoomba - Mount Isa
MSN:
96051
YOM:
1982
Flight number:
Birddog 370
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4900
Captain / Total hours on type:
102.00
Aircraft flight hours:
7566
Circumstances:
On the morning of 4 November 2023, a Gulfstream 695A, registered VH-HPY, was being operated by AGAIR on an instrument flight rules flight from Toowoomba to Mount Isa, Queensland. On board the aircraft were the pilot and 2 camera operators. The purpose of the flight was to conduct line scanning of fire zones located north of Mount Isa. About 1 hour and 50 minutes into the flight, while the aircraft was in cruise at flight level 280, air traffic control (ATC) lost radio contact with the pilot. Over the following 30 minutes, ATC made multiple attempts to re-establish contact, including using alternate frequencies and relaying messages via other aircraft in the vicinity. VH-HPY was observed diverging from track and ATC declared an uncertainty phase for the aircraft. About 20 minutes later, ATC called the pilot’s mobile telephone, and a brief conversation took place. During the conversation, the pilot’s speech was observed as slow and flat. In response, ATC upgraded the aircraft’s status to an alert phase and initiated their hypoxic pilot emergency procedures. About 10 minutes later, the crew of a nearby aircraft was able to establish contact with the pilot, having been requested to do so by ATC. The alert phase was downgraded to an uncertainty phase and, a short time later, ATC re-established direct contact with the pilot. The uncertainty phase was cancelled 1 minute later. The pilot confirmed that their oxygen system was operating normally, and they were issued a clearance to undertake line scanning north of Mount Isa. Over the following 4 minutes, the pilot repeated the clearance from ATC 4 times, seeming uncertain about the status of the clearance. The radio recordings during this period indicate that the pilot’s rate and volume of speech had substantially lowered from earlier communications and was worsening. The pilot’s final radio transmission displayed the slowest speaking rate of all their communications during the flight and contained stuttering and operational mistakes. Air traffic control did not attempt to re-establish contact with the pilot until about 18 minutes later, however no further responses from the pilot were received. A short time later, the aircraft departed controlled flight, initially entering a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, the aircraft likely transitioned into an aerodynamic spin, with a subsequent average rate of descent of about 13,500 ft/min. The aircraft collided with terrain 55 km south-east of Cloncurry. The 3 occupants were fatally injured, and the aircraft was destroyed by impact forces and a fuel-fed post-impact fire.
Probable cause:
Contributing factors
- The pilot's ability to safely operate the aircraft was almost certainly significantly degraded by the onset of altitude hypoxia.
- While in cruise at flight level 280, both power levers were probably reduced without an appropriate descent rate being initiated, resulting in a progressive reduction of airspeed.
- The aircraft entered a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, control input(s) were almost certainly made, probably an attempt to recover, that transitioned the aircraft from a high-speed descent to a spin condition that was likely unrecoverable and which continued until the impact with terrain.
- The pilot had a normalized practice of operating VH-HPY with a cabin altitude that required the use of supplemental oxygen. These flights were conducted without access to a suitable oxygen supply, significantly increasing the risk of altitude hypoxia induced incapacitation.
- The aircraft's pressurization system probably did not attain the required cabin altitude when operating at flight level 280 during the accident flight. The pilot probably knowingly continued the flight with a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply.
- The AGAIR aircraft VH-HPY pressurization system could not reliably attain the required cabin altitude during flight due to a known, long-term, unresolved intermittent defect. AGAIR management personnel were aware of the defect and, through a combination of inaction, encouragement and, in some instances direct involvement, permitted the aircraft to continue operations at an excessive cabin altitude. (Safety issue)
- AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurization defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue. (Safety issue)
- The AGAIR head of flying operations did not communicate critical safety information about the known intermittent pressurization defect on VH-HPY when they were phoned by air traffic control about concerns that the pilot may be impacted by hypoxia.
- After being told by the pilot that operations were normal, controllers likely reduced their vigilance about hypoxia and did not re-identify the possibility of hypoxia during the subsequent progressive deterioration of the pilot’s speech.
Other factors that increased risk:
- AGAIR Gulfstream 690 and 695 aircraft were operated with known defects without being recorded on the aircraft’s maintenance releases, likely as a routine practice. For VH-HPY, the absence of documented historical information limited the ability to assess the operational impact of the pressurization defect and the effectiveness of maintenance rectification activities. (Safety issue)
- The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario. (Safety issue)
Other finding:
- A 2019 Civil Aviation Safety Authority surveillance event of AGAIR triggered by concerns reported by an AGAIR pilot, including delayed rectification of airworthiness issues, did not include a crosscheck of maintenance releases against the aircraft logbooks, which limited the surveillance team’s ability to determine whether any non-reporting and improper deferral of defects had been taking place at that time.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Hillcrest

Date & Time: Apr 7, 2023 at 0605 LT
Operator:
Registration:
VH-HJE
Flight Type:
Survivors:
Yes
Schedule:
Bankstown – Brisbane
MSN:
31-7852074
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1473
Captain / Total hours on type:
204.00
Circumstances:
On 7 April 2023, the pilot of a Piper Aircraft Corporation PA-31-350 Chieftain (PA-31), registered VH-HJE and operated by Air Link, was conducting a freight charter flight from Archerfield, Queensland. The planned flight included one intermediate stop at Bankstown, New South Wales before returning to Archerfield, and was conducted under the instrument flight rules at night. The aircraft departed Archerfield at about 0024 local time and during the first leg to Bankstown, the pilot reported an intermittent fault with the autopilot, producing uncommanded pitch changes and associated rates of climb and descent of around 1,000 ft/min. As a result, much of the first leg was flown by hand. After landing at Bankstown at about 0248, a defect entry was made on the maintenance release; however, the pilot was confident that they would be able to hand fly the aircraft for the return leg and elected to continue with the planned flight. The aircraft was refueled to its maximum capacity for the return leg after which a small quantity of water was detected in the samples taken from both main fuel tanks. Additional fuel drains were conducted until the fuel sample was free of water. The manifested freight for the return leg was considered a light load and the aircraft was within weight and balance limitations. After taking off at 0351, the pilot climbed to the flight planned altitude of 9,000 ft. Once established in cruise, the pilot changed the left and right fuel selectors from the respective main tank to the auxiliary tank. The pilot advised that, during cruise, they engaged the autopilot and the uncommanded pitch events continued. Consequently, the pilot did not use the autopilot for part of the flight. Approaching top of descent, the pilot recalled conducting their normal flow checks by memory before referring to the checklist. During this time, the pilot completed a number of other tasks not related to the fuel system, such as changing the radio frequency, checking the weather at the destination and briefing themselves on the expected arrival into Archerfield. Shortly after, the pilot remembered changing from the auxiliary fuel tanks back to the main fuel tanks and using the fuel quantity gauges to confirm tank selection. The pilot calculated that 11 minutes of fuel remained in the auxiliary tanks (with an estimated 177 L in each main tank). Around eight minutes after commencing descent and 28 NM (52 km) south of Archerfield (at 0552), the pilot observed the right ‘low fuel flow’ warning light (or ‘low fuel pressure’) illuminate on the annunciator panel. This was followed soon after by a slight reduction in noise from the right engine. As the aircraft descended through approximately 4,700 ft, the ADS-B data showed a moderate deceleration with a gradual deviation right of track. While the power loss produced a minor yaw to the right, the pilot recalled that only a small amount of rudder input was required to counter the adverse yaw once the autopilot was disconnected. Without any sign of rough running or engine surging, they advised that had they not seen the annunciator light, they would not have thought there was a problem. Over the next few minutes, the pilot attempted to troubleshoot and diagnose the problem with the right engine. Immediately following power loss, the pilot reported they:
• switched on both emergency fuel boost pumps
• advanced both mixture levers to RICH
• cycled the throttle to full throttle and then returned it to its previous setting without fully closing the throttle
• moved the right fuel selector from main tank to auxiliary
• disconnected the autopilot and retrimmed the aircraft. This did not alter the abnormal operation of the right engine, and the pilot conducted the engine roughness checklist from the aircraft pilot’s operating handbook noting the following:
• oil temperature, oil pressure, and cylinder head temperature indicated normally
• manifold absolute pressure (MAP) had decreased from 31 in Hg to 27 inHg
• exhaust gas temperature (EGT) indicated in the green range
• fuel flow indicated zero.
With no indication of mechanical failure, the pilot advised they could not rule out the possibility of fuel contamination and chose not to reselect the main tank for the remainder of the flight. After considering the aircraft’s performance, handling characteristics and engine instrument indications, the pilot assessed that the right engine, while not able to generate normal power, was still producing some power and that this would assist in reaching Archerfield. Based on the partial power loss diagnosis, the pilot decided not to shut down and secure the engine which would have included feathering the propeller. At 0556, at about 20 NM south of Archerfield at approximately 3,300 ft, the pilot advised air traffic control (ATC) that they had experienced an engine malfunction and requested to maintain altitude. With maximum power being set on the fully operating left engine, the aircraft was unable to maintain height and was descending at about 100 ft/min. Even though the aircraft was unable to maintain height, the pilot calculated that the aircraft should have been able to make it to Archerfield and did not declare an emergency at that time. At 0602, about 12 minutes after the power loss on the right engine, the left engine began to run rough and the pilot observed the left low fuel flow warning light illuminate on the annunciator panel. This was followed by severe rough running and surging from the left engine which produced a series of pronounced yawing movements. The pilot did not run through the checklist a second time for the left engine, reporting that they completed the remaining item on the checklist for the left engine by switching the left engine’s fuel supply to the auxiliary tank. The pilot once again elected not to change tank selections back to mains. With both engines malfunctioning and both propellers unfeathered, the rate of descent increased to about 1,500 ft/min. The pilot advised that following the second power loss, it was clear that the aircraft would not be able to make it to Archerfield and their attention shifted from troubleshooting and performance management to finding somewhere to conduct a forced landing. ADS-B data showed the aircraft was at about 1,600 ft when the left engine malfunctioned. The pilot stated that they aimed to stay above the minimum control speed, which for VH-HJE was 72 kt. The aircraft was manoeuvred during the brief search), during which time the ground speed fluctuated from 110 kt to a low of 75 kt. It was calculated that in the prevailing wind, this would have provided an approximate indicated airspeed of 71 kt; equal to the aircraft’s clean configuration stall speed. The pilot declared an emergency and advised ATC that they were unable to make Archerfield Airport and would be conducting an off-airport forced landing. With very limited suitable landing areas available, the pilot elected to leave the flaps and gear retracted to minimize drag to ensure they would be able to make the selected landing area. At about 0605, the aircraft touched down in a rail corridor beside the railway line, and the aircraft’s left wing struck a wire fence. The aircraft hit several trees, sustaining substantial damage to the fuselage and wings. The pilot received only minor injuries in the accident and was able to exit through the rear door of the aircraft.
Probable cause:
The following contributing factors were identified:
- It is likely that the pilot did not action the checklist items relating to the selection of main fuel tanks for descent. The fuel supply in the auxiliary tanks was subsequently consumed resulting in fuel starvation and loss of power from the right then left engine.
- Following the loss of power to the right engine, the pilot misinterpreted the engine instrument indications as a partial power loss and carried out the rough running checklist but did not select the main tanks that contained substantial fuel to restore engine power, or feather the propeller. This reduced the available performance resulting in the aircraft being unable to maintain altitude.
- When the left engine started to surge and run rough, the pilot did not switch to the main tank that contained substantial fuel, necessitating an off‑airport forced landing.
- It is likely that the pilot was experiencing a level of fatigue shown to have an effect on performance.
- As the pilot was maneuvering for the forced landing there was a significant reduction of airspeed. This reduced the margin over the stall speed and increased the risk of loss of control.
- Operator guidance material provided different fuel flow figures in the fuel policy and flight crew operating manual for the PA-31 aircraft type.
- The operator’s fuel monitoring practices did not detect higher fuel burns than what was specified in fuel planning data.
- The forced landing site selected minimized the risk of damage and injury to those on the ground and the controlled touchdown maximized the chances of survivability.
Final Report:

Crash of a Boeing 737-3H4 in the Fitzgerald River National Park

Date & Time: Feb 6, 2023 at 1614 LT
Type of aircraft:
Operator:
Registration:
N619SW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Busselton - Busselton
MSN:
28035/2762
YOM:
1995
Flight number:
Bomber 139
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8233
Captain / Total hours on type:
1399.00
Copilot / Total flying hours:
5852
Copilot / Total hours on type:
128
Aircraft flight hours:
69187
Circumstances:
The air tanker, callsign Bomber 139, departed from Busselton Airport, Western Australia (WA) on a firefighting task to Fitzgerald River National Park, WA. There were 2 pilots on board, the aircraft captain in the left seat as the pilot flying and a copilot in the right seat as the pilot monitoring. At about 1614, during the go-around from a second partial retardant drop, the aircraft impacted a ridgeline at an elevation of about 222 ft and subsequently crashed, bursting into flames. The pilots suffered minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
The ATSB found that the accident drop was conducted at a low height and airspeed downhill, which required the use of idle thrust and a high descent rate. The delay in the engines reaching go-around thrust at the end of the drop resulted in the aircraft’s height and airspeed (energy state) decaying as it approached rising terrain, which was not expected or detected by the pilot flying. Consequently, the aircraft’s airspeed and thrust were insufficient to climb above a ridgeline in the exit path, which resulted in a controlled flight into terrain. The operator’s practice of recalculating, and lowering, their target drop speed after a partial load drop also contributed to the low energy state of the aircraft leading up to the collision with terrain.
The ATSB also found that the operator and tasking agency had not published a minimum drop height, which resulted in the copilot, who did not believe there was a minimum drop height, not making any announcements about the low energy state prior to the collision. The ATSB found the operator’s pilot monitoring duties were reactive to the development of a low energy state and did
not include call-outs either before or at the minimum target parameters to reduce the risk of a low energy state developing.
The ATSB benchmarked the WA, New South Wales and National Aerial Firefighting Centre standards against the United States Forest Service and United States National Wildfire Coordinating Group standards and found inconsistencies between the Australian agencies’ standards but not among the United States agencies’ standards. This was likely a result of each Australian state participating in the LAT program independently producing their own standards.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander on Moa Island

Date & Time: Oct 3, 2022 at 1338 LT
Type of aircraft:
Operator:
Registration:
VH-WQA
Flight Phase:
Survivors:
Yes
Schedule:
Saibai Island - Horn Island
MSN:
494
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2400
Captain / Total hours on type:
250.00
Aircraft flight hours:
14081
Circumstances:
On the afternoon of 3 October 2022, a Pilatus Britten-Norman Islander BN2A-21, registered VHWQA and operated by Torres Strait Air, was conducting a non-scheduled passenger air transport flight from Saibai Island Airport, Queensland (QLD) to Horn Island Airport, QLD. There was 1 pilot and 6 passengers (students) on board. About 19 km NE of Moa Island both engines began to surge. The pilot diverted towards Kubin Airport on Moa Island. As the aircraft passed to the south of the township of Saint Pauls, the pilot determined there was insufficient altitude remaining to reach the airport. As a result, the pilot conducted a forced landing on a road 7 km ENE of Kubin Airport. There were no reported injuries to the pilot or the passengers. The aircraft was substantially damaged.
Probable cause:
The ATSB found that the dual engine speed fluctuations and associated power loss was probably the result of fuel starvation. The mechanism was not conclusively determined, however it was identified that the pilot did not operate the aircraft's fuel system in accordance with the aircraft flight manual, and that the configuration and location of the aircraft’s fuel controls and tank quantity gauges were probably not conducive to rapid and accurate interpretation. The aircraft manufacturer released a service letter in June 2022 that detailed an optional modification to centralize the fuel system controls and gauges, however this modification was not fitted to VH-WQA. The ATSB considered that these factors increased the risk of inadvertent fuel tank selection.
Final Report:

Crash of a Cessna 404 Titan in Lockhart River: 5 killed

Date & Time: Mar 11, 2020 at 0919 LT
Type of aircraft:
Registration:
VH-OZO
Survivors:
No
Schedule:
Cairns – Lockhart River
MSN:
404-0653
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3220
Captain / Total hours on type:
399.00
Circumstances:
On 11 March 2020, a Cessna 404 aircraft, registered VH-OZO, was being operated by Air Connect Australia to conduct a passenger charter flight from Cairns to Lockhart River, Queensland. On board were the pilot and 4 passengers, and the flight was being conducted under the instrument flight rules (IFR). Consistent with the forecast, there were areas of cloud and rain that significantly reduced visibility at Lockhart River Airport. On descent, the pilot obtained the latest weather information from the airport’s automated weather information system (AWIS) and soon after commenced an area navigation (RNAV) global satellite system (GNSS) instrument approach to runway 30. The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach. After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30. During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.
Probable cause:
The accident was the consequence of a controlled flight into terrain.
The following contributing factors were identified:
• While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain.
In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
• After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
• Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
• When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for
an extended period. In accordance with the operator’s stabilized approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
• The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
• The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
• Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile. Although the operator had specified a flight profile for a straight-in approaches and stabilized approach criteria in its operations manual, and encouraged the use of stabilized approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimizing the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations.

Other factors that increased risk:
• Although an applicable height of 1,000 ft for stabilized approach criteria in instrument meteorological conditions has been widely recommended by organizations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilized approach criteria. (Safety issue)
• The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
- There was no requirement for piston-engine aeroplanes to be fitted with a TAWS, even though this was an ICAO standard for such aeroplanes authorized to carry 10 or more passengers, and this standard had been adopted as a requirement in many comparable countries.
- There was no requirement for turbine-engine aeroplanes authorized to carry 6–9 passengers to be fitted with a TAWS, even though this had been an ICAO recommended practice since 2007, and this recommended practice had been adopted as a requirement in many comparable countries. (Safety Issue)

Other findings:
• The forecast weather at Lockhart River for the time of the aircraft’s arrival required the pilot to plan for 60 minutes holding or diversion to an alternate aerodrome. The aircraft had sufficient fuel for that purpose; and the aircraft had sufficient fuel to conduct the flight from Cairns to Lockhart River and return, with additional fuel for holding on both sectors if required.
• There was no evidence of any organizational or commercial pressure to conduct the flight to Lockhart River or to complete the flight once to commenced.
• Based on the available evidence, it is very unlikely that the pilot was incapacitated or impaired during the flight.
• There was no evidence of any aircraft system or mechanical anomalies that would have directly influenced the accident. However, as a consequence of extensive aircraft damage, it was not possible to be conclusive about the aircraft’s serviceability.
• The aircraft was fitted with Garmin GNS 430W GPS/navigational units that could be configured to provide visual (but not aural) terrain alerts. However, it could not be determined whether the
terrain awareness function was selected on during the accident flight.
Final Report: