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Significant safety investigations

The following is a summary of the significant safety investigations that were completed and published during 2019–20 across aviation, marine and rail.


Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia on 28 June 2017 (AO-2017-069)

On 28 June 2017, the pilot of a SOCATA TB-10 Tobago aircraft, registered VH-YTM, was conducting a community service flight from Mount Gambier Airport, South Australia, to Adelaide, South Australia. The flight was organised by the charity Angel Flight to transport a passenger for medical treatment and an accompanying family member. The aircraft took off at 1020 Central Standard Time as a private flight operating under visual flight rules. After reaching a height of 300 ft, the aircraft descended and impacted terrain about 70 seconds after take-off. The pilot and both passengers were fatally injured and the aircraft was destroyed.

Figure 1: Accident site, showing the engine and propeller location, the left and right wing impact marks and the main wreckage

Source: South Australia Police, annotated by ATSB

The full ATSB investigation report (AO-2017-069) is available on the ATSB website at www.atsb.gov.au.

Collision with terrain following an engine power loss involving Cessna 172M, VH-WTQ, 12 NM (22km) north-west of Agnes Water, Queensland on 10 January 2017

On 10 January 2017, at about 1030 Eastern Standard Time, a Cessna 172M, registered VH‑WTQ, departed Agnes Water aeroplane landing area (ALA), Queensland on a passenger charter flight to a beach ALA on Middle Island. There was a pilot and three passengers on board.

At about 1038, the pilot was conducting an airborne inspection of the beach ALA to ensure that it was suitable for a landing. During the inspection, when the aircraft was at about 60 ft above mean sea level (AMSL), the aircraft’s engine had a sudden and total power loss.

After conducting initial checks, the pilot elected to conduct a significant left turn to the beach. During the continued turn, the aircraft impacted the beach with little or no control and a significant descent rate. One of the rear-seat passengers was fatally injured and the other three occupants sustained serious injuries. The aircraft was destroyed.

The full ATSB investigation report (AO-2017-005) is available on the ATSB website at www.atsb.gov.au.

Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 (AO-2017-013)

On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore.

After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.

Figure 2: CQA air display flight track, showing the first pass in yellow, the second in magenta and the third in red

Source: Google Earth, modified by the ATSB

The full ATSB investigation report (AO-2017-013) is available on the ATSB website at www.atsb.gov.au.

Loss of control and collision with terrain involving Cessna 441, VH-XMJ, 4 km west of Renmark Airport, South Australia on 30 May 2017 (AO-2017-057)

On 30 May 2017, a twin‑engine Cessna 441 Conquest II (Cessna 441), registered VH-XMJ and operated by AE Charter (trading as Rossair) departed Adelaide Airport, South Australia for a return flight via Renmark Airport, South Australia.

On board the aircraft were:

  • an inductee pilot undergoing a proficiency check, flying from the front left control seat
  • the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
  • a Civil Aviation Safety Authority (CASA) flying operations inspector, observing and assessing the flight from the first passenger seat directly behind the inductee pilot.

Each pilot was qualified to operate the aircraft.

The flight departed Adelaide at about 1524 local time and flew to the Renmark area for exercises related to the check flight, followed by a landing at Renmark Airport. After a short period of time running on the ground, the aircraft departed from runway 25 at about 1614.

A distress beacon broadcast was subsequently received by the Joint Rescue Coordination Centre and passed on to air traffic services at 1625. Following an air and ground search the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.

Figure 3: Accident site and wreckage of VH-XMJ

Source: News Corp Australia, annotated by the ATSB

The full ATSB investigation report (AO-2017-057) is available on the ATSB website at www.atsb.gov.au.


Collision with floodwater involving freight train 6792, Little Banyan Creek, Queensland on 7 March 2018 (RO-2018-007)

At 0152 on 7 March 2018, freight train 6792, operated by Aurizon, departed Cairns, Queensland, for a journey on Queensland Rail’s North Coast Line. A condition affecting the network (CAN) due to wet weather had been declared, and the train crew were required to operate at controlled speed for a significant part of the journey, which meant they were to be able to stop short of an obstruction within half the distance of clear line that was visible ahead.

At 0612, the train rounded the curve prior to the Little Banyan Creek rail bridge, which was under 0.6 m of flowing water. With a sighting distance of about 60 m to the bridge, the train’s speed (50 km/h) was significantly in excess of the controlled speed, and the train entered the floodwater. The train crew were not injured, but there was some damage to the train’s rolling stock, caused by immersion in water.

Figure 4: Little Banyan Creek rail bridge

Source: QR

The full ATSB investigation report (RO-2018-007) is available on the ATSB website at www.atsb.gov.au.


Loss of containers overboard from YM Efficiency, 16 NM east-south-east of Newcastle, New South Wales on 1 June 2018 (344-MO-2018-008)

At about 0035 on 1 June 2018, YM Efficiency was en route to Sydney, steaming slowly into strong gale force winds and very rough seas off Newcastle when it suddenly rolled heavily. As a result, 81 containers were lost overboard and a further 62 were damaged. The ship also sustained structural damage to its lashing bridges, superstructure and accommodation ladder. The ship spent a further 5 days at sea before berthing in Sydney on 6 June.

At the time of publication, searches including remote underwater surveys had identified 66 containers with a few washed ashore or close offshore. Five containers have been removed with 15 containers yet to be found. The accident resulted in substantial debris washing ashore on New South Wales beaches.

Figure 5: Damaged containers in bays 52 and 56

Source: ATSB

The full ATSB investigation report (344-MO-2018-008) is available on the ATSB website at www.atsb.gov.au.