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Significant safety investigations

The following is a summary of the significant safety investigations that were completed and published during 2020–21 across aviation, marine and rail.


VFR into IMC and loss of control involving Wittman Tailwind, VH-TWQ, Tooloom National Park, New South Wales, on 12 January 2020 (AO-2020-004)

On the afternoon of 12 January 2020, the pilot of an amateur-built Wittman Tailwind aircraft, registered VH-TWQ (TWQ), departed Evans Head Airport, New South Wales, with one passenger on board. The pilot was conducting a private flight under the visual flight rules from Evans Head, to Boonah, Queensland.

The pilot flew in a north-north-westerly direction towards Boonah via the Richmond River valley. At 1353, the pilot commenced a 180° turn overhead the township of Kyogle and diverted, due to the weather, south back down the valley to Casino Aerodrome, landing at 1406.

At 1454, the pilot took off from Casino and flew in a west-north-westerly direction. At 1512 TWQ commenced a series of rapid descents and climbs followed by a descending left turn. The turn and descent continued until TWQ collided with terrain. The pilot and passenger were fatally injured, and the aircraft was destroyed.

Figure 1: Accident flight departure, destination and accident locations

Source: Google Earth, annotated by the ATSB

The full ATSB investigation report (AO-2020-004) is available on the ATSB website at www.atsb.gov.au.

Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, New South Wales on 31 December 2017 (AO-2017-118)

On the afternoon of 31 December 2017, the pilot and five passengers of a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO, boarded the aircraft for a return charter flight from Cottage Point to Rose Bay, New South Wales. Shortly after take-off, the aircraft conducted a 270° right turn in Cowan Water and then entered Jerusalem Bay, below the height of the terrain. The aircraft stopped climbing, continued along the bay and then made a very steep right turn. The aircraft’s nose then dropped and the aircraft collided with the water. All on board were fatally injured and the aircraft destroyed.

Figure 2: Engine and forward fuselage deformation post-accident (top) with pre-accident nose to rear fuselage angle (bottom)

Source: ATSB (upper) and image provided by previous passenger (lower)

The full ATSB investigation report (AO-2017-118) is available on the ATSB website at www.atsb.gov.au.

Loss of control and collision with water involving Eurocopter EC120B, VH-WII, Hardy Reef, Whitsundays, Queensland, on 21 March 2018 (AO-2018-026)

On 21 March 2018, a Eurocopter EC120B helicopter, registered VH-WII and operated by Whitsunday Air Services, departed Hamilton Island Airport, Queensland on a charter flight to Hardy Reef. On board were the pilot and four passengers.

The pilot conducted the approach to the pontoon landing site at Hardy Reef into wind. During the approach, the pilot slowed the helicopter to allow birds to disperse. The pilot was then planning to yaw the helicopter left into the intended landing position, and there was about 20 kt crosswind from the right of the intended position.

When the helicopter was yawing left into position, just over the pontoon, the pilot noticed a message illuminate on the helicopter’s vehicle engine multifunction display (VEMD) and elected to conduct a go-around. During the go-around, after the helicopter climbed to about 30–40 ft, there was a sudden and rapid yaw to the left. In response to the unanticipated rapid yaw, the pilot lowered the collective but was unable to recover the situation.

In the limited time available after the unsuccessful action to recover from the rapid left yaw, the pilot did not deploy the helicopter’s floats and conduct a controlled ditching. The helicopter collided with the water in a near-level attitude, with forward momentum and front-right corner first. Almost immediately, the helicopter rolled to the right and started rapidly filling with water. The pilot and two of the three rear seat passengers evacuated from the helicopter with minor injuries. Although the impact forces were survivable, the other two passengers were unconscious following the impact and did not survive the accident.

The helicopter sank and, associated with unfavourable weather conditions in the days following the accident, subsequent searches were unable to locate and recover the helicopter.

Figure 3: Pilot recollection of approach to Hardy Reef pontoon

Source: Google Earth, annotated by the ATSB

The full ATSB investigation report (AO-2018-026) is available on the ATSB website at www.atsb.gov.au.

Loss of control and collision with water involving Bell UH-1H, VH-UVC, 5 km south-west of Anna Bay, New South Wales, on 6 September 2019 (AO-2019-050)

On 6 September 2019, at 1430 EST, the pilot of a Bell Helicopter Company UH-1H helicopter registered VH‑UVC (UVC) departed Archerfield Airport, Queensland, on a private flight with four passengers for Bankstown, New South Wales.

Following a refuelling stop at Coffs Harbour, New South Wales, the pilot contacted Williamtown air traffic control (ATC), while north-east of Broughton Island, and requested clearance to track south via the visual flight rules (VFR) coastal route. The initial radio calls between the pilot and Williamtown ATC, occurred about six minutes prior to the published time of last light. The radio calls indicated that the helicopter was being affected by turbulence and as a result the pilot was having difficulty maintaining a constant altitude. In response, the controller issued a clearance for the aircraft to operate between 2,400 and 3,500 ft.

Once past Anna Bay, and about 11 minutes past published last light, UVC was observed on Williamtown ATC radar to make a left turn to the south, depart the coastal route and head offshore, on a direct track to Bankstown Airport. The turn likely resulted in the pilot losing visual cues and encountering dark night conditions.

The helicopter continued to track offshore to the south-west for about 90 seconds, maintaining between about 2,500 and 3,200 ft before commencing a rapidly descending, left spiral turn. It disappeared from Williamtown radar coverage about 12 minutes after published last light. Attempts by the controller to contact the pilot were unsuccessful and authorities were subsequently advised of a missing helicopter.

On 25 September 2019, wreckage from the destroyed helicopter was located in about 30 m of water, 5 km south‑west of Anna Bay. Two of the five persons on board the helicopter were confirmed to have received fatal injuries. The bodies of the pilot and two of the passengers were not found but they were presumed to have similarly not survived the accident.

Figure 4: UVC flight parameter variation over the final 150 seconds of flight

Source: ADS-B data (Aireon) with ATSB analysis

The full ATSB investigation report (AO-2019-050) is available on the ATSB website at www.atsb.gov.au.


Derailment of XPT ST23, Wallan, Victoria, on 20 February 2020 (RO-2020-002)

On 20 February 2020, passenger train ST23 departed Central Station in Sydney, New South Wales at 0741, just after the scheduled departure time of 0740. ST23 was to travel through New South Wales, and into Victoria to its destination in Melbourne. The service was scheduled to stop at several stations en route to arriving at its final destination at Southern Cross Station (Melbourne) at 1830 that evening. ST23 comprised leading power car XP2018, five passenger cars of varying configuration, and a trailing power car.

At about 1943, ST23 was approaching the northern end of Wallan Loop at about the track’s line speed. A brake application was made a short distance before the turnout, probably between 50 and 153 m from the points. This slowed the train a small amount before it entered the turnout travelling at a speed probably between 114 and 127 km/h. The train was not able to negotiate the turnout to the crossing loop track at this speed and derailed. The leading power car rolled onto its left side. All vehicles derailed excepting the rear power car.

Figure 5: Aerial photograph of derailment site

Source: ATSB

The ATSB interim investigation report (RO-2020-002) is available on the ATSB website at www.atsb.gov.au.

Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Queensland, on 10 January 2018 (RO-2018-002)

On 10 January 2018, a Queensland Rail (QR) Citytrain suburban passenger train (TP43) was en route to Brisbane Domestic Airport, Queensland, with a scheduled crew change at Bowen Hills. While the train was stopped at Bowen Hills, the departure signal (ME25) at the northern end of No.2 platform was displaying a yellow aspect, which meant that at that time the next signal (ME45) was displaying a red aspect (stop indication).

After departing the platform, TP43 exceeded its limit of authority by passing signal ME45, which was still displaying a red aspect (stop indication). After receiving a signal passed at danger (SPAD) alarm, the network control officer broadcast an emergency stop command to the driver of TP43. The train was stopped 220 m past signal ME45, and 126 m prior to a conflict point. At the time that TP43 came to a stop, another suburban passenger train had just cleared the conflict point.

Figure 6: Automatic warning system (AWS) magnet and signal ME45 displaying a red (stop) aspect

The front-of-train image from TP43 shows the AWS magnet, and signal ME45, which was displaying red aspect (stop) indication. The AWS magnet was located 79.5 m from signal ME45.

Source: Queensland Rail, annotated by the ATSB

The full ATSB investigation report (RO-2018-002) is available on the ATSB website at www.atsb.gov.au.

Level crossing irregularity involving passenger train 3MA8, North Geelong, Victoria, on 8 January 2019 (RO-2019-002)

On 8 January 2019, as The Overland passenger train, 3MA8, approached the Thompson Road level crossing at North Geelong, Victoria, the train crew noticed that the flashing lights had not activated and the boom gate had not lowered as expected. While the crew noticed the irregularity, it was too late to take substantive action and the train passed through the level crossing unprotected. The crew reported that several road vehicles were in the vicinity of the level crossing at that time, but none were in the danger zone.

Figure 7: Aerial view of Australian Rail Track Corporation (ARTC) and V/Line responsibility boundaries

Source: VicTrack, annotated by the ATSB

The full ATSB investigation report (RO-2019-002) is available on the ATSB website at www.atsb.gov.au.


On 18 June 2018, during cargo discharge operations while alongside Port Kembla, New South Wales, a fire broke out in the internal cargo handling spaces of the self-unloading (SUL) bulk carrier Iron Chieftain.

The ship’s crew initiated an emergency response but shipboard efforts to control the fire were ineffective. The fire soon established itself and spread to the exterior of the ship, setting the discharge boom on deck alight. The ship’s crew were evacuated and shore firefighting services from Fire and Rescue New South Wales (FRNSW) took charge of the response to the fire. The fire was contained and eventually extinguished about five days after it started.

The ship sustained substantial structural damage, including breaches of two fuel oil tanks, and key components of the SUL system were largely destroyed. The ship was declared a constructive total loss and subsequently dispatched to be recycled. There were no serious injuries or pollution of the sea reported.

Figure 8: Iron Chieftain on fire at Port Kembla

Source: ATSB

The full ATSB investigation report (346-MO-2018-011) is available on the ATSB website at www.atsb.gov.au.

Engine room fire on board MPV Everest, Southern Ocean, 5 April 2021 (MO-2021-003)

On the evening of 31 March 2021, the Bahamas-flagged multipurpose vessel MPV Everest departed a location approximately 100 nautical miles (NM) off Mawson research station in the Australian Antarctic Territory, bound for Hobart, Tasmania. There were 37 crew and 72 expedition staff on board for the 3,328 NM passage to Hobart. The ship had been on location for the previous 17 days to effect a changeover of Australian Antarctic Division (AAD) station personnel and conduct station resupply and refuelling operations via helicopter.

At about 0925, recorded data from the ship’s integrated automation system (IAS) showed a routine fuel transfer to top-up the port fuel oil settling tank (located in the port engine room) was started. About an hour later, the ship’s master and doctor were in the master’s office, located one deck below the navigation bridge, which overlooks the main and upper accommodation decks aft. Shortly before 1100, they saw large flames erupting from the open louvres in the port engine room’s exhaust casing located one deck above the upper accommodation deck, aft of the accommodation block. The fire was extinguished and no injuries on board were reported. The investigation is continuing.

Figure 9: MPV Everest in Antarctica

Source: Australian Antarctic Division

The ATSB preliminary investigation report (MO-2021-003) is available on the ATSB website at www.atsb.gov.au.

Loss of containers overboard involving APL England, 46 NM south-east of Sydney, New South Wales, on 24 May 2020 (351-MO-2020-002)

At 0610 AEST, during heavy weather, the vessel’s main engine tripped, resulting in loss of propulsion for a short time. During this period, the vessel was rolling heavily – up to 25 degrees – causing 50 containers to fall onto the deck and into the sea. Sixty-three containers were damaged but remained on board.

The investigation is continuing and will include review and analysis into vessel cargo systems, maintenance, weather preparations, procedures and personnel actions.

Figure 10: Looking forward and aft from navigation bridge at about 0700


The ATSB preliminary investigation report (351-MO-0202-002) is available on the ATSB website at www.atsb.gov.au.