Australian Transport Safety Bureau

Australian Transport Safety Bureau Australia's national transport safety investigator for aviation, marine and rail. Australia's national transport safety investigator.

We improve transport safety for the greatest public benefit through independent investigations and influencing safety action.

An ATSB occurrence brief details an engine failure and collision with terrain involving a Cirrus SR20 at Shellharbour Ai...
05/06/2026

An ATSB occurrence brief details an engine failure and collision with terrain involving a Cirrus SR20 at Shellharbour Airport, NSW.

--What happened--
On 3 April 2026, the pilot of a Cirrus SR20 planned a private solo flight from Bankstown to Shellharbour, New South Wales. The pilot was planning to complete circuit practice and then return the aircraft to Bankstown.

During cruise to Shellharbour at 2,400 ft AMSL, while operating in autopilot mode, the fuel mixture was leaned[1] and the pilot observed multiple brief power reductions shortly thereafter. The vibrations lasted 1–2 seconds and did not persist, and the pilot elected to continue to Shellharbour as planned.

Having completed 3 non-eventful circuits on runway 24 at Shellharbour, a fourth circuit was commenced. While the aircraft was established on downwind, the pilot switched fuel tanks to conserve fuel. A landing and subsequent take‑off for a fifth circuit was then commenced. During upwind at approximately 350–450 ft AMSL, the pilot observed several momentary power losses followed by a sustained loss of power and a significant vibration. The engine was fluctuating between the production of power and loss of power.

The pilot was aware of the low altitude and low airspeed and conducted a forced landing in a vacant paddock to the west of the airfield. Prior to landing, the pilot confirmed that the throttle was in the full position with an accompanying rich fuel mixture and the fuel pump in the on position. Just prior to touching down, the aircraft entered an aerodynamic stall and collided with terrain resulting in substantial damage to the left wing and undercarriage. The pilot sustained minor injuries.

The post-flight engineering inspection revealed an induction leak at the no. 1 position induction pipe and a brief rough running magneto. Engineers replaced the no. 2 fuel injector nozzle and 2 of the magneto plugs.

--Cirrus airframe parachute system--
The Cirrus airframe parachute system (CAPS) is designed to safely lower the aircraft and its occupants to the ground, under parachute, in the event of a life-threatening emergency where activation is determined to be safer than continued flight, such as medical incapacitation or airframe failure. In this instance, due to the aircraft’s low altitude, the pilot did not deploy the parachute.

--Safety message--
During emergency operations at low altitude, pilots are encouraged to be decisive when selecting the appropriate landing area, as well as vigilant in maintaining the speed required for a forced landing to avoid a stall prior to touchdown. Should the aircraft enter an aerodynamic stall, execute the stall recovery technique.

[1] The mixture is leaned for stages of flight that would require less fuel to maintain efficient engine operation.

--About this report--
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

A Piper Chieftain took off with an unsecured fuel cap, and the pilot had to conduct a single-engine landing in Meekathar...
04/06/2026

A Piper Chieftain took off with an unsecured fuel cap, and the pilot had to conduct a single-engine landing in Meekatharra, Western Australia, after the right engine was starved of fuel.

Our final report into the engine fuel starvation and single-engine ...

An ATSB occurrence brief details a partial pilot incapacitation involving a Cessna 402C north-east of Cunderdin, WA.--Wh...
03/06/2026

An ATSB occurrence brief details a partial pilot incapacitation involving a Cessna 402C north-east of Cunderdin, WA.

--What happened--
On 23 April 2026, the pilot of a Cessna 402C aircraft was conducting a passenger transport operation from Jandakot to Laverton, Western Australia, with 5 passengers on board. Prior to departure the pilot used the aircraft heater to defrost the windshield for approximately 7 minutes and recalled turning the heater off at approximately 0640.

Following the aircraft’s departure, while in the initial cruise phase of the flight, the pilot noticed a moderate oil leak from the left engine cowling vents. The pilot monitored aircraft performance, observed no abnormal indications, and determined the leak was likely from residual oil. The flight continued as planned at this stage, while the pilot continued to monitor the situation.

At approximately 0731, the pilot began to feel lightheaded and ‘zoned out’ momentarily. They then observed the carbon monoxide (CO) detection placard on the instrument panel had changed colour, indicating that CO was present (the image shows a photo of the placard in the aircraft on the left, along with CASA's exemplar placard showing no detection on the top right, and a placard showing detection on the bottom right).

The pilot immediately opened all available air vents, opened the cabin air controls, and confirmed the cabin heater was off.

Approximately 2 minutes later, observing no change to the CO indication, the pilot contacted air traffic control (ATC), requested traffic information, and amended their destination to Merredin. The pilot then commenced descent, communicated the change of plan to the nearest passenger, and asked the passenger to instruct all other passengers to open the air vents above their seats.

The pilot continued to self-monitor during descent, and determined their condition was not deteriorating. The wellbeing of the passengers was also confirmed, with none reporting ill effects of CO.

Once established in the circuit at Merredin, the pilot opened the aircraft’s storm window[1] and observed no change to the CO indicator and the aircraft landed safely.

Once on the ground, the pilot observed the oil leaks on the left engine. An engine inspection showed numerous components and hoses were covered in oil and a shallow pool of oil had formed at the bottom of the cowling. The upper cowling also showed signs of oil splatter on the inside forward of the vents.

--Engineering inspection--
The aircraft was subsequently inspected by an engineer flown out to Merredin with the replacement aircraft. No obvious correlation could be made between the oil leak and the CO detector. Ground runs were performed with no abnormal indications or subsequent oil leaks (beyond residual streaks).

As a further precaution, the operator removed the aircraft from service to conduct further engineering assessments. The heater was operated on the ground with the aircraft windows closed, and the engines not running. CO ingress was measured with a handheld CO monitor around the glareshield/demister and excessive CO was observed to ingress into the cabin.

The heater was subsequently removed for closer inspection. A loose item, that looked like a silver crush washer, was discovered inside the heater once the combustion liner cap was removed, and the cap was also found to be dented. The inspection determined the aircraft heater was defective, damaged, and potentially incorrectly reinstalled during servicing.

--Safety action--
The operator removed the heater from operation and returned the aircraft to service.

--Safety message--
Carbon monoxide is a colourless and odourless gas that is dangerous to humans, and its presence may not be detected until the development of physical symptoms and cognitive effects. However, sometimes these physical and cognitive effects also impair a pilot’s ability to understand that they may be affected by CO, leading to partial or complete incapacitation.

The aircraft was fitted with a disposable CO chemical spot detector. While these type of detectors are commonly used in general aviation aircraft, they have known limitations. They have a limited shelf-life when removed from their original packaging, which may be further affected by factors such as exposure to harsh direct sunlight, cleaning chemicals, and halogens. In addition, they are a passive device, which relies on the pilot regularly monitoring the changing colour of the detector to show elevated levels of CO.

The use of an attention‑attracting carbon monoxide detector in the cockpit provides pilots with the best opportunity to detect carbon monoxide exposure before it adversely affects their ability to control the aircraft or become incapacitated. The ATSB safety advisory notice 'Are you protected from carbon monoxide poisoning?' strongly encourages operators and owners of piston-engine aircraft to install a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. If not provided, pilots are encouraged to carry a personal carbon monoxide detection and alerting device: https://www.atsb.gov.au/publications/safety-advisory-notice/2022/aviation/are-you-protected-carbon-monoxide-poisoning

Should any smell or sensation of illness develop, pilots should check their CO detector, ensure cabin heat has been turned off, open all fresh air vents and windows, make prompt decisions to land as soon as possible, such as in this case, and use all available resources for assistance. Further information on CO poisoning and detectors can be found here:https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/cobroforweb.pdf

[1] A small triangular cockpit side window that be opened for ventilation.

--About this report--
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

The ATSB’s ongoing investigation of a forced landing accident involving a Cessna Conquest charter aircraft in Broome is ...
02/06/2026

The ATSB’s ongoing investigation of a forced landing accident involving a Cessna Conquest charter aircraft in Broome is examining operational and maintenance procedures, survivability, and aircraft design factors.

We have released a preliminary report from our on-going investigati...

An ATSB occurrence brief details an object falling from a Robinson R44 north-east of Sydney Airport.--What happened--On ...
27/05/2026

An ATSB occurrence brief details an object falling from a Robinson R44 north-east of Sydney Airport.

--What happened--
On the afternoon of 2 May 2026, a Robinson R44 Raven II helicopter was being prepared for a 30 minute ‘doors‑off’ sightseeing flight experience in Sydney, New South Wales, with 2 passengers in the rear seats. The flight was to be operated with the left and right rear doors removed from the helicopter, allowing passengers a wider view and an open-air experience. Both left and right front doors remained on the helicopter and the front left seat was vacant.

After receiving a video-based safety briefing, a ground crewmember boarded the passengers, tethered the passengers’ phones and provided a specific door-off briefing, which included use of the communication headsets and the need for keeping all parts of the body inside the cabin during the flight.

The pilot reported that the departure from Sydney Airport was normal and the helicopter climbed to cruising height and tracked north to the city before following the harbour to North Head. After rounding the head and turning north, the pilot pointed out for interest another aircraft that was tracking parallel to the helicopter. At that moment, the rear right passenger placed their head through the open doorway for a better view. As the helicopter was travelling at around 80 kt indicated airspeed at that time, the slipstream immediately caught and pulled the passenger’s headset rearward, away from their head and leaving it hanging outside the helicopter cabin – retained by the connecting cable. The passenger was able to retrieve the headset using the cable, however the right ear cup cushion detached from the unit and was lost from the helicopter.

After the passenger re-donned the headset, the remainder of the flight was uneventful, and the helicopter sustained only minor scuffs and scratches from the headset contact.

--Related occurrences--
The US National Transportation Safety Board has undertaken several investigations into accidents and serious incidents resulting from loose objects striking a helicopter’s tail rotor.

• Headset lost from doors-off flight, striking tail rotor: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85842/pdf

• Jacket lost through open window, striking tail rotor: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90007/pdf

• Jacket lost through opened door, striking tail rotor: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56984/pdf

• Life vest lost through opened door, striking tail rotor: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/22002/pdf

--Advisory--
The helicopter manufacturer published Safety Notice SN-30 in 1994 (revised in 2009) warning of the danger that loose objects present to the safety of flight – particularly with doors-off operations:https://robinsonstrapistorprod.blob.core.windows.net/uploads/assets/rhc_sn30_29b3fbf588.pdf

--Safety message--
While many helicopters (including the R44) can be approved for operation with one or more doors removed, doing so eliminates a key defence against objects and items being lost from the helicopter interior. As any item lost has the potential to strike and damage the tail and/or main rotors, doors-off flight inherently increases the operating risk environment, such that countering precautions must be taken.

While the operator’s existing operational procedures provided several sound physical and instructional defences against inadvertent passenger-related loss of items from the helicopter, this occurrence illustrates that it is indeed possible (and human) to ‘get caught up in the moment’ and briefly forget instructions given in briefings and during boarding. In this context, all helicopter operators providing doors-off flight experiences should consider whether further precautions may be applicable and desirable for their own operations.

--About this report--
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

An ATSB occurrence brief details a Cessna 172 hard landing resulting in tail strike at Archerfield Airport, Queensland.-...
22/05/2026

An ATSB occurrence brief details a Cessna 172 hard landing resulting in tail strike at Archerfield Airport, Queensland.

--What happened--
On 12 April 2026, a student pilot, the sole occupant of a Cessna 172R, was conducting solo circuits at Archerfield Airport, Queensland. Prior to this, dual training (with an instructor) was conducted for about half an hour. The flight was the third time the student had flown solo, and an instructor was responsible for supervising their flight. There was a quartering headwind at about 8 kt.

The solo circuits were initially conducted on runway 28L prior to the pilot requesting a ‘full-stop landing’[1] to complete the flight. At this point the air traffic controller (tower) changed the runway assignment to runway 28R.

The pilot then conducted three unsuccessful landing attempts to runway 28R. Each of these attempts resulting in the aircraft either ‘bouncing’[2] or ‘porpoising’[3] followed by the student conducting a go-around. The student pilot reported that during one of the attempted landings a significant ‘bounce’ occurred.

The controller reported to the operator that the second landing attempt involved the aircraft porpoising, resulting in a tail strike and what appeared to be a possible propeller strike.

The supervising instructor reported observing that the third landing was a hard landing. noting the nose wheel came into contact with the runway first. The earlier landing attempts were not fully visible by the instructor due to them not having a clear line of sight.

After the third attempt to land, the supervising instructor contacted the air traffic control tower and communicated directly with the student, via the tower frequency, to provide the student verbal assistance, helping to facilitate a safe landing on the fourth attempt.

A post-flight inspection of the aircraft by the operator revealed the tail tie-down hook was missing, with evidence of a tail strike and firewall deformation.

--Safety message--
While conducting training flights, students can experience a high workload, particularly during solo flights and landing. Maintaining a calm mindset is important in order to adjust the aircraft’s profile and airspeed accordingly and determine if a go‑around is necessary.

All pilots, regardless of their experience levels, should be prepared to undertake a go‑around rather than continuing if they are not confident that a successful landing can be achieved. This occurrence also serves as a reminder that after any hard landing or other related incident where the integrity of the airframe or structure may be compromised, an engineering inspection can detect damage that may not be immediately apparent.

[1] A ‘full-stop landing’ in pilot training means the pilot does not intend to take off again immediately.

[2] A bounced landing is a condition where the aircraft lands on the runway, but instead of rolling on the surface after touchdown, it rebounds/bounces off the ground.

[3] ‘Porpoising’ refers to the manoeuvre that can occur after a bounced landing that is improperly recovered, in which the aeroplane comes in nose first setting off a series of cyclic vertical motions.

--About this report--
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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