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ATSB calls on CASA to enhance tools and guidance for air displays

written by WOFA | November 21, 2019

The Australian Transport Safety Bureau (ATSB) has called on the Civil Aviation Safety Authority (CASA) to make further improvements to regulations covering air displays.

The recommendation was included in the ATSB’s final report into the crash of Grumman G-73 Mallard amphibious aircraft VH-CQA on January 26 2017 during an air display over Perth’s Swan River.

After conducting two low-level passes over the Swan River and nearby foreshore without incident, the aircraft aerodynamically stalled while positioning for a third pass and hit the the water. The pilot and a passenger on board the aircraft were both killed in the accident.

The ATSB final report said the the manner in which the pilot returned to the display area after the second pass was not in accordance with the display procedures and increased the risk of mishandling the aircraft in an area of relatively close proximity to the public.

Further, it said having a passenger on board the aircraft was “contrary to the requirements of the display instrument and increased the severity of the outcome”.

“During the final positioning turn, CQA rolled left, pitched nose-down and collided with water,” the ATSB final report said.

“Analysis of recorded flight and video data, and witness reports identified that the aircraft stalled in the positioning turn for the third pass.


“Such a loss of control in this aircraft type at the relatively low operating altitude meant the situation was unrecoverable before contact with the shallow water.”

The ATSB final report said CASA “did not have an effective framework to approve and oversight air displays”.

Although CASA’s air display manual provided guidance to organisers conducting an air display, it “did not inherently provide the processes and tools needed for CASA to approve and oversee one”.

The ATSB final report said that unlike the accreditation models adopted by some other countries, “CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays”.

Finally, the report found “CASA did not have a structured process to ensure that risks were both identified and adequately treated”.

“The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed,” the ATSB final report said.

Following the accident, CASA published a revised manual of guidance for air displays in September 2017, which provided further detail on the key roles and their responsibilities and introduced a requirement to conduct a risk assessment as part of the application process.

The associated participant form was then updated in April 2018.

While the ATSB final report acknowledged the changes improved existing guidance, it said they only partially addressed the safety issue and called for more work to be done.

“The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays,” the ATSB final report said.

ATSB executive director for transport safety Nat Nagy said air displays had inherent and unique risks that pilots, organisers and regulators had responsibilities in addressing.

“It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks,” Nagy said in a statement.

“Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.”

The full report can be read on the ATSB website.


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