On the night of 14 July 2023 an aerial gentle show was scheduled to be carried out over the waters of Victoria Harbour, Docklands, Victoria utilizing a swarm of 500 Damoda Newton V2.2 remotely piloted plane (RPA).
At 1830 the Distant Pilot in Command (RPIC) launched the swarm. Shortly after, the RPIC recognized each visually and from a number of errors on the bottom management station (GCS) pc, that a number of plane had been out of place.
Regardless of this, the plane routinely commenced the transition from the launch location in direction of the present space. Because the plane transitioned, additional errors with rising severity appeared on the GCS pc. Plane had been noticed to be out of place and colliding within the air, with a number of plane breaching the geofence.
Because the errors cascaded, the RPIC commanded the plane within the swarm to loiter (maintain place) and tried to return these with probably the most important errors to the launch web site individually. While a number of plane had been within the loiter, the GCS pc misplaced connection to nearly 400, with the bulk descending into the harbour beneath.
427 of the five hundred plane within the swarm had been misplaced into the water, with divers subsequently recovering 236.
What the ATSB discovered
The ATSB decided that shortly after launch, the swarm encountered wind circumstances that exceeded the plane’s revealed functionality. That was not recognized by the RPIC as they had been unaware that the wind velocity affecting the plane was displayed on the GCS pc. Moreover, whereas the GCS pc displayed the wind velocity, it didn’t have the performance to actively alert the pilot to exceedances.
Consequently, the RPIC allowed the flight to proceed towards the present space, the place wind speeds greater than twice the revealed restrict had been encountered. In these circumstances the plane had been unable to take care of place, leading to plane collisions, breaches of the working space, and activation of failsafe modes that led to most of them descending to the water.
The RPIC didn’t make use of all processes obtainable to them to gather related wind data previous to launching the swarm. There have been additionally plenty of components on the day that induced the RPIC to have the next than regular workload that affected their choice‑making capability, and was more likely to be underneath strain to conduct the present. It was additionally discovered that the operator had no process in place to confirm that pilots had been conversant in all related capabilities of the GCS software program.
Lastly, whereas not contributory to the accident, the investigation additionally recognized that the flight crew didn’t adjust to operational limitations set by the regulator and contained inside their very own documentation.
What has been achieved in consequence
Operator
The operator suggested that in response to this accident it undertook an in depth evaluation of its working procedures and made a number of modifications, together with:
modifications to the crewing necessities to have 2 Civil Aviation Security Authority‑accredited pilots working each present
introduction of wind velocity take a look at flights utilizing particular person plane prior to point out launch to determine precise circumstances within the present space
institution of a number of go/no-go factors in the course of the launch sequence permitting for extra clearly outlined cease factors
introduction of sterile cockpit procedures to restrict exterior interactions with the flight crew in crucial phases within the lead‑as much as present launch.
Moreover, the ATSB issued a security advice that the operator develops a course of to make sure that future software program modifications are communicated and understood by all pilots earlier than commencing operations.
Producer
The producer suggested that updating the bottom management station software program to incorporate an lively alert for wind velocity exceedances was technically attainable and that this characteristic was being thought of for future software program releases. The ATSB issued a security advice to the producer that such alerting be carried out.
Security message
In Remotely Piloted Plane System (RPAS) swarm operations the flight crew are extremely depending on the bottom management station software program, its performance and the info it gives for protected operation. It’s subsequently crucial that the flight crew be conversant in all functionalities and perceive the knowledge being offered to them. Performance that actively alerts crew to exceedances in flight‑crucial parameters can help crew consciousness.
Operators ought to have methods in place to make sure that pilots are conversant in new performance when launched. To help flight crews, operators ought to be sure that operational documentation, together with checklists, carry the related prompts for flight crews to collect all mandatory data to help their choice‑making processes.
Moreover, the impression of human components on RPAS operations ought to be actively thought of and managed. Whereas the chance profile could differ from that of crewed operations, components comparable to workload and operational strain can equally impression RPAS operations.
As RPAS operations proceed to quickly develop and diversify, compliance with operational pointers and limitations set or accredited by the regulator are critically necessary to minimise threat to each the operation and the general public. That is notably necessary the place RPAS are being operated in increased threat environments, comparable to public shows in constructed‑up areas.
The prevalence
Check flight
Late within the night of 13 July 2023, the Distant Pilot in Command (RPIC) and copilot of a Damoda Newton V2.2 Remotely Piloted Plane (RPA) swarm operated by the Australian Site visitors Community Pty Restricted (ATN) arrived at a pre-arranged launch web site on North Wharf at Docklands, Melbourne, Victoria (Determine 1). They had been to conduct a restricted take a look at of a swarm RPA show (drone present) which was to happen the next night in help of a sporting occasion on the Docklands Stadium.
Determine 1: Operational space and launch web site
Supply: Google Earth, annotated by the ATSB
The RPIC and copilot set out 10 plane [1] on the launch web site and ready the bottom management station (GCS) to check the present program. The first operate of the flight was to check for potential interference from the launch web site and the encompassing space. Shortly earlier than the launch time, the RPIC recognized that the wind circumstances had been properly above the 15.6 kt restrict that the plane may safely function in and the take a look at was downscaled to a hover take a look at. The hover take a look at concerned 10 plane launching to a peak of 10 m and hovering for a short while earlier than touchdown.
The hover take a look at was efficiently accomplished with the GCS system recording minimal interference from the launch web site. Nevertheless, the RPIC reported that as a part of this course of the launch location programmed for the present was recognized to be incorrect and that this location wanted to be up to date earlier than the present the next night.
Flight preparation
At roughly 1400 native time on 14 July 2023 the RPIC and copilot returned to the launch web site to arrange for the present that was scheduled for 1830. On surveying the supposed working space, the RPIC recognized that the mast of a ship moored on the wharf immediately adjoining to the launch space was an impediment for the swarm because it transitioned from the launch space to the present space. The mast was measured at roughly 15 metres tall, requiring the peak of the swarm’s transition between the launch and the present to be elevated.
Shortly after arriving, the copilot and RPIC had been met onsite by 4 members of the present help crew. A fifth member, who was to help in establishing and conducting security checks on the five hundred plane, was late. Following launch, the help crew had been to observe the exclusion zone [2] surrounding the present space for intruders.
The RPIC briefed the crew on a number of matters, together with the operational plan for the show, the necessities for the launch grid and establishing the plane. The help crew then commenced setting out the launch grid and plane as per the present plan. The RPIC recalled that setting out the plane took barely longer than anticipated as a result of wind interfering with the method of measuring out the grid. Throughout the set‑up the RPIC took a number of floor stage wind readings with a handheld anemometer. The pilot recalled that these readings had been returning 8–10 kt of sustained wind, with frequent gusts as much as 12 kt.
All through the set‑up the RPIC was interrupted on a number of events by duties usually assigned to the copilot. This included:
further briefings to help personnel
a number of interactions with the shopper who wished to substantiate whether or not the present would be capable of go forward within the prevailing circumstances
interactions with different stakeholders and senior administration of the operator’s firm who had been in attendance to view the present.
Establishing the grid took roughly 2 hours, after which the RPIC gave the help crew a 30‑minute break whereas they accomplished a walkthrough of the grid to make sure that the situation and identification of every plane aligned with the set‑up plan.
At 1740, the RPIC began display screen recording on the bottom management station (GCS) pc. This recorded all exercise on the display screen of the GCS pc and audio inside vary of the pc’s microphone (see the part titled Floor Management Station).
All through the 50 minutes main as much as the present the recording captured interactions between the RPIC and copilot, and with help crew and stakeholders. It additionally recorded a variety of operationally crucial data. An in depth abstract of occasions captured within the recording will be present in Appendix A, with key occasions summarised beneath.
At 1750 the primary recorded wind velocity studying was taken, giving 14 kt. At 1754 and 1817 additional readings are taken at 12 kt and 14 kt respectively. At 1805 and following the 1816 studying the pilot and copilot mentioned the prevailing wind circumstances. The copilot acknowledged that they believed that circumstances had been appropriate to launch the swarm. In response, the RPIC recognized that the readings that they had had been solely at floor stage and so they had not examined for gusts on the supposed peak of the present. No additional wind velocity readings had been taken and there was no additional dialogue of the wind velocity recorded earlier than the present.
At 1756 the RPIC was recorded dictating a voice to textual content message to the shopper’s consultant with an replace concerning the standing of the present. They suggested that the circumstances had been on pattern with the forecast and so they anticipated the present to go forward at that time. At 1816 the RPIC recognized that the consultant had requested them for an replace by 1815 as as to whether the present would go forward. At 1817 the RPIC was recorded dictating an additional textual content message to the shopper that they had been good to launch.
At 1759 the RPIC recognized that to reprogram the present place to keep away from the boat mast in entrance of the launch space required the help of one other firm pilot as that they had not used that software program performance earlier than. Nevertheless, they had been unable to contact the opposite firm pilot for an additional 8 minutes, regardless of prearranging for them to be obtainable at 1800 to help.
Between 1807 and 1817 the RPIC and the opposite firm pilot went by the method of transferring the present, performing the present digital preview and decoding the outcomes of the preview. The RPIC utilized the related correction to the present place, rising the present peak and transferring the present to the left. The RPIC recognized that the elevated present peak now exceeded the 120 m restrict of the approval, however the different firm pilot recognized that the encompassing buildings offered some shielding. The RPIC elected to proceed the present.
At 1817, following the completion of the present repositioning, the RPIC recognized that they wanted to work by the pre‑flight guidelines previous to launch. The pilot and copilot labored by the objects on the pre‑flight guidelines. On a number of events they’re interrupted by exterior communications from stakeholders and help crew.
At 1827 the RPIC instructed the copilot to make an airband broadcast in accordance with the pre‑flight guidelines. The copilot questioned the necessity for the published however was overruled by the RPIC and made the related transmission. The RPIC then accomplished the verification that the present program had been efficiently uploaded to all 500 plane. At 1829 the copilot learn out the final pre‑launch objects on the guidelines and the RPIC confirmed that that they had been accomplished.
Flight
Launch
The plane had been programmed to take off and ascend right into a hover in a collection of 10 layers of fifty plane (Determine 2). The plane would then transfer out over the water transitioning into the present space flying by a collection of waypoints to make the related patterns of the present earlier than returning and touchdown again on the grid. The entire present was deliberate to take about 10 minutes from take-off to return.
At 1830:15 the RPIC commanded the present to launch on the GCS. Following a ten second countdown the plane powered up and the take‑off sequence commenced. The plane took off as programmed, with the ten layers of plane stacked over the take‑off grid (Determine 2). Nevertheless, 15 seconds after the primary plane launched the GCS recorded 45 plane with errors, indicating that plane had been out of place. Over the next 30 seconds the GCS recorded an additional 78 plane displaying as out of place.
Transition to the present space
At 1831:11 the swarm commenced its transition into the present space, however inside 30 seconds greater than half of the plane within the present had been indicating errors, most for being out of place. At 1831:43 and 1831:48 the RPIC tried to command the swarm to loiter, the primary try was unsuccessful as that they had not chosen the plane to ship the command to. The second try was profitable with the loiter command reaching all of the plane that had been linked to the GCS pc.
At roughly the identical time because the second loiter command was issued, a number of plane offered with crucial errors indicating an autopilot failure. This was shortly adopted at 1831:55 by the RPIC figuring out that there was a ‘fly‑away’. Additional errors of various severity ranges continued to current on the GCS. After confirming that the copilot had the fly‑away plane underneath their management, the RPIC directed the copilot to disarm[3] that plane.
By this time over 400 plane had been presenting errors on the GCS. Between 1832:30 and 1832:50 the GCS quickly misplaced connection to nearly 400 of the plane within the swarm. When the connection was misplaced plane had been in a number of totally different modes, with many displaying loiter as per the RPIC’s command, some making an attempt to return to the launch space and others, predominantly these with crucial errors, displaying land in place.
Of the remaining plane linked to the GCS, 7 plane had been making an attempt to proceed with the present, which the RPIC then commanded to return dwelling, whereas the rest had been indicating various ranges of errors.
9 minutes and 56 seconds after the present was commanded to launch, the final operational plane returned to the launch level.
Divers contracted by the operator tried to get better the plane from the harbour over the next days. The divers recovered 236 of the 427 plane that entered the water, with 191 unrecovered.
Determine 2: CCTV footage of present
Supply: Metropolis of Melbourne, cropped and annotated by the ATSB
Context
Plane data
Overview
The swarm consisted of 500 Newton V2.2 remotely piloted plane manufactured by Shenzhen Damoda Clever Management Know-how Co., Ltd. (Damoda).
The Newton V2.2 is a quadcopter designed particularly for gentle present operations (Determine 3). It measured 360 mm sq., sat 109 mm excessive, and weighed 725 grams. Mounted centrally on the underside of the plane was a single color‑altering LED gentle outputting a most of 16 watts. With a single battery the plane was designed for a present time of between 16 and 18 minutes and with a most hover endurance of roughly 26 minutes. The variety of plane throughout the swarm could possibly be diversified relying on the person present necessities, as much as a most of 1,024.
Determine 3: Damoda Newton V2.2
Supply: Operator, annotated by the ATSB
To conduct a present every plane was programmed with a collection of timed waypoints and lightweight color modifications. The plane operated independently by these waypoints with minimal separation distances of roughly 1.5 m in the course of the present. Plane weren’t fitted with sensors to permit unbiased collision avoidance, counting on positional and time‑based mostly accuracy to forestall collisions.
The plane had been put in with a firmware bundle to allow operations. Because of the flight crucial nature of the firmware, the operations guide required a flight take a look at be carried out following a firmware replace and {that a} document of this flight be made within the plane upkeep log.
Batteries
For the present every plane was fitted with a removeable Lithium Polymer (LiPo) battery that weighed 300 g and had a most vitality capability of 42.56Wh. Upon set up the plane had a pink button that might protrude from the physique of the plane to point that the battery was mounted accurately. For a swarm of 500 RPA these batteries equated to a complete vitality capability of 21.28kWh.
Plane limitations
The producer’s wind velocity restrict for the Newton V2.2 was 8 m/s (equal to fifteen.6 kt or 29 km/h), this wind restrict was frequent to all Damoda plane. Along with the wind velocity restrict the plane additionally had an ingress safety or IP[4] ranking of 63. This ranking indicated that the plane had been mud tight and will resist water spray however weren’t designed to function in rain or be immersed in water and they’d not float.
Plane positioning
Because of the shut proximity of the swarm plane, uncorrected GNSS place data was not sufficiently correct. To acquire excessive accuracy GNSS positions the plane had been linked to a community containing a Actual Time Kinematic (RTK) receiver. By utilizing an unbiased stationary receiver in proximity to the plane the positional accuracy will be improved from a number of metres to centimetres as required for present operations. At 1822, 8 minutes earlier than the present was attributable to launch, all plane had been displaying between 23 and 28 satellites linked and a excessive accuracy RTK place repair.
Previous to the present, the operator arrange a spectrum analyser to establish potential interference within the GNSS sign that will trigger the plane to malfunction or be out of place. The RPIC suggested that previous to the present no abnormalities had been recognized within the sign that might have affected the aircrafts’ capability to precisely place themselves.
GNSS spoofing
GNSS spoofing is the method of tricking a receiver into reporting an incorrect place. Spoofing a sign requires 2 steps, first the incoming sign to the receiver must be jammed after which the receiver should lock onto an independently generated false sign offering incorrect data. Within the lead‑as much as the show the GCS pc exhibits the place of every plane on the bottom and in flight. These positions had been proven over a base map and corresponded with areas recorded by CCTV footage (Determine 4). If the sign to the plane had been spoofed these areas wouldn’t have aligned.
Determine 4: Comparability of GCS and recorded plane positions
Observe: The satellite tv for pc basemap picture as proven on the GCS isn’t an correct illustration of the particular buildings across the launch web site. This picture was taken earlier in 2023 however the ATSB was unable to substantiate the precise date. Supply: Metropolis of Melbourne and operator annotated by the ATSB.
Plane modes
The Newton V2.2 could possibly be operated in 6 totally different flight modes, G (guided), S (stabilised), L (loiter), R (return to launch), LD (land) and AH (altitude maintain). A mode could possibly be chosen for a person plane, it could possibly be commanded for all plane within the swarm or it could possibly be routinely modified by logic throughout the plane within the occasion that sure circumstances had been met. Handbook mode modifications could possibly be commanded by way of the bottom management station pc or a backup guide controller (see the part titled Floor management station).
In guided mode the plane was positioned based mostly on the corrected GNSS place and transited by a collection of pre‑programmed waypoints, earlier than returning to the launch location.
In stabilised mode the GNSS positioning was disabled and the plane was manually flown utilizing the hand controller. This mode was used if the plane had an error that rendered it unable to return to dwelling routinely.
In loiter mode the plane held each lateral and vertical place till an additional command was offered by the pilot, both by way of the GCS or utilizing the hand controller.
In return to launch (RTL) mode the plane routinely tracked again to a place over the launch location. Because the plane didn’t have impediment avoidance sensors, this selection was most popular just for particular person or small teams of plane as commanding RTL for the entire swarm was more likely to lead to a number of plane collisions and lack of plane.
In land mode the plane landed immediately beneath its present location.
Plane errors
The Newton V2.2 had 6 error modes that could possibly be offered on the bottom management station. These had been:
EKF (autopilot failure)
W (waypoint difficulty)
B (battery voltage was low)
F (plane had breached the geofence)
T and S (Too far and Static) each indicated that the plane was not on the deliberate place. Too far indicated that the plane was greater than 0.8 m from its goal place. The space from the goal place required to activate a static error was not recognized within the plane documentation.
These errors had been damaged into 3 classes relying on the required pilot response when they’re offered.
EKF or W errors required the pilot to return the plane to launch.
B error – the plane ought to activate RTL routinely.
F error – the plane would routinely activate RTL and re-enter the geofence. If it didn’t return throughout the geofence the motors can be routinely shut down.
T and S errors had been for data and monitoring. The pilot was solely to intervene and manually activate RTL if the space between the deliberate and precise areas continued to extend.
The show of those errors on the GCS is mentioned additional within the part Flight management software program – Warnings. The RPIC recognized that there have been as much as 10 plane presenting with EKF errors, and that that they had by no means skilled multiple EKF error concurrently.
Fleet
On the time of the prevalence the operator had a complete Damoda V2.2 fleet of 1,136 plane registered with the Civil Aviation Security Authority (CASA). The primary 515 of those had been registered with CASA on the finish of October 2022. The remaining plane had been registered in April of 2023, shortly after their buy.
Together with these further plane, the operator additionally bought further help tools for a second full GCS format. This enabled the operator to both function 2 unbiased fleets of 500 plane or to mix the two fleets for a single present of as much as 1,024 plane. When the operator bought the extra plane, it was equipped with the newest model of the plane firmware and the producer’s newest GCS software program (see the part titled Flight management software program).
Floor management station
The bottom management station (GCS) consisted of 4 components:
a laptop computer pc working Damoda’s flight management software program
a Wi-Fi community to which all of the plane had been linked, enabling communications and information switch between the plane and flight management software program earlier than and in the course of the present
a differential floor station for actual time correction of the GNSS sign
a spectrum analyser used to establish abnormalities or points within the frequency bands that the plane and the GNSS sign had been working.
These components had been delivered to the present location by the operator and had been arrange by the flight crew.
Flight management software program
Working on a laptop computer pc, the flight management software program offered all command and management actions for the swarm by the native community. Frequent to all Damoda plane varieties, the software program allowed flight crew to observe the standing of all plane earlier than and all through the present. It was used to add, manipulate and take a look at the proposed present, management the plane both by the software program itself or by tethering them to the hand controller.
The flight management software program additionally displayed errors and warnings affecting the plane or the software program. The flight management software program was not used for the event of the present flight paths or ‘drama’. This was accomplished in a unique software program bundle and a drama file containing the present flight paths for every plane was imported into the flight management software program for importing to the person plane.
When the operator obtained the primary 500 plane in October 2022 these had been supplied with model 2 of the producer’s flight management software program. Previous to the acquisition of the operator’s second 500 plane in April 2023, the producer launched an up to date model of the flight management software program (model 3), and this was offered to the operator, together with an up to date model of the plane firmware.
Wind velocity monitoring
A wind monitoring operate was launched with model 3 of the flight management software program. This operate displayed the utmost wind velocity and course encountered by plane within the swarm, within the higher proper nook of the display screen (Determine 5). To supply a studying, at the least one plane needed to be lively and linked to the GCS software program.
The wind monitoring operate remained seen and its place fixed on the display screen all through the operation of the GCS. Different performance could possibly be chosen or deselected relying on the pilot’s data choice. Wind velocity and course had been calculated and displayed in actual time by the interpretation of plane financial institution angle and motor velocity, mixed with the deliberate and precise positions of the plane.
When the wind velocity restrict was exceeded, there was no audible, visible or tactile alert offered to the pilot. As such, the flight crew wanted to actively monitor the parameter to concentrate on an exceedance of the wind velocity restrict. Determine 6 exhibits the wind velocity indicator at 3 moments in the course of the present with the wind velocity beneath, simply above and considerably exceeding the 8 m/s revealed wind velocity restrict of the plane.
Determine 5: GCS software program show with wind velocity readout highlighted
Supply: Operator, annotated by the ATSB
Determine 6: Wind velocity show beneath, simply above and considerably exceeding the wind velocity restrict
Supply: Operator, cropped and annotated by the ATSB
The flight crew suggested that on the time of the present they weren’t conscious that this performance was obtainable to them. The RPIC reported that they solely turned conscious of it after they had been reviewing the incident with one other one of many operator’s pilots who recognized the indicator to them. The RPIC acknowledged that if that they had recognized this data on the time of the present then they’d have seemingly terminated the present when the wind velocity restrict was reached.
Warnings
The GCS software program may current 2 several types of warnings relying on whether or not a person or a number of plane had been affected.
Errors associated to particular person plane offered on the GCS pc in a person field as proven in Determine 7. These containers confirmed the plane identifier, the error or errors and the mode the plane was working in. They had been then grouped by color coded class relying on the required pilot response. Errors requiring speedy motion had been coded pink, people who resulted in an computerized RTL had been coded orange and people who solely required monitoring had been coded blue.
The place an plane confirmed errors from a number of totally different classes the plane was positioned within the highest class of urgency encountered. Determine 8 exhibits all 3 of the classes showing on the GCS for this prevalence, shortly after the plane transitioned in direction of the present space.
Determine 7: GCS screenshot displaying particular person plane errors
Supply: Operator, annotated by the ATSB
Determine 8: GCS recording displaying the three error classes as they appeared on the night time of the present
Supply: Operator annotated by the ATSB
Errors that affected a number of plane had been offered as a pop‑up over different home windows on the GCS display screen (Determine 9) and required acknowledgement earlier than every other motion could possibly be taken. These warnings had been offered in situations comparable to a failure of information to efficiently add to plane or failure of a command to achieve the plane.
Determine 9: GCS screenshot displaying a multi-aircraft warning pop‑up
Supply: Operator, annotated by the ATSB
Each kinds of warnings relied on information processed by the GCS to show the related data to the pilot. The errors had been then offered in such a manner that the pilot may quickly interpret the that means and reply appropriately.
Adjusting the present
The GCS software program had the potential to regulate the place, peak and orientation of the drama file to make sure that the flight paths could possibly be executed safely. The flight crew had a number of choices for making the adjustment, which could possibly be used independently or concurrently. They might change the peak or place of the entire drama file or they may modify the launch and touchdown profiles, which modified the place and altitude that the plane moved to earlier than they transitioned into the present space.
Because of the boat mast hazard the RPIC, in session with one among firm’s different pilots, elected to regulate the place of the transition into the present space by rising the peak by 11 m and transferring all plane 2 m to the left (Determine 10). To accommodate for these modifications the whole peak of the present was additionally adjusted up by 8 m taking the utmost present peak to 126 m.
Determine 10: Drama adjustment performance as set by the RPIC
Supply: Operator, annotated by the ATSB
Setting the geofence and exclusion zone
The geofence is a polygon product of a collection of GNSS areas surrounding the present space (Determine 11). It was manually created within the flight management software program after which uploaded to the plane. As soon as in flight, if an plane handed by the geofence it routinely activated the RTL mode to deliver it again contained in the geofenced space and return to land. If the plane remained exterior the geofence then the motors had been shut down and the plane fell to the bottom or water uncontrolled.
Determine 11: Improvement and placement of Geofence
Supply: Operator, annotated by the ATSB
The flight management software program had a measurement characteristic that allowed the operator to establish and measure approximate distances over the bottom map. This allowed the willpower of the scale of each the geofence and the next dimension of the exclusion zone (see the part titled Exclusion zone).
Hand controller
Swarm operations are carried out autonomously with the plane transferring by a collection of pre‑programmed waypoints or within the related failsafe modes. Within the occasion of a system difficulty or error that prevented the automated system from successfully controlling the swarm, guide management could possibly be taken utilizing a hand controller. The controller allowed the operator to fly the swarm, command mode modifications and activate related failsafe modes on the plane. For the hand controller for use it have to be tethered to the related plane within the swarm. It could possibly be tethered to all plane within the swarm or to sure plane independently.
The guide controller employed by the operator was a VANTAC Taranis hand‑held controller, manufactured by FrSky. The VANTAC (Determine 12) was a programmable, 24 channel, 2.4 GHz transmitter that could possibly be used to regulate a variety of distant units, together with RPA. The controller had 8 programable management switches, (6 3‑place and a pair of 2‑place) that the consumer may assign to modes or operational settings. In help of the Damoda swarm operations the switches had been assigned as per Determine 12. The mode swap allowed the operator to vary the mode between land, loiter and stabilised modes. As a part of the operator’s pre-flight guidelines the throttle (vertical motion on the left management stick) on the controller was to be set to 50% in order that if the controller was required the plane would have adequate energy to hover.
The emergency kill swap was a 2‑place swap. When activated it instantly shut down the motors, inflicting the plane to fall to the bottom. This was the command that the copilot carried out as soon as the RPIC instructed them to disarm the fly‑away plane.
Determine 12: FrSky VANTAC Taranis controller
Supply: Operator
Crew data
The operator’s manuals listed the crew for a light-weight present operation in 3 distinct teams, all underneath the oversight of the RPIC, as follows:
flight crew, answerable for the protected setup and operation of the fleet of drones
floor/help crew, assisted within the set-up of the fleet and operational space and monitoring the bottom and airspace across the present for potential intruders
further safety or different personnel concerned in securing the operational space, comparable to water police for a present over water.
Flight crew
For gentle present operations involving as much as 500 plane the corporate operations guide required a flight crew of two – a mission commander (RPIC) and a copilot. The CASA permission for the operation (see the part titled Operational approval) listed particular pilots who had been accredited to function multiple RPA at a time. The CASA permission didn’t particularly require a second pilot, nevertheless the operator’s manuals contained a requirement for a 2 or 3 pilot operation relying upon the swarm dimension.
Distant pilot in command
The RPIC was authorised and certified to behave because the mission commander for the operation that was being undertaken. They held a Distant Pilot License (RePL) for multi‑copter operations as much as 25 kg. Upon becoming a member of the operator in October 2022, that they had accomplished the Damoda coaching program and subsequently been endorsed by CASA to function multiple RPA at a time.
On the time of the operation the RPIC had roughly 6 hours on kind consisting of 32 coaching or operational exhibits various in dimension from 10 to 1,050 plane carried out at a variety of areas, together with over water, and in each day and night time circumstances. The RPIC’s most up-to-date present flight was the rehearsal for the Docklands operation, which was carried out 4 days previous to the present.
The RPIC held final duty for the protected operation of the present in accordance with the related permissions and operator’s manuals. The operations guide outlined the precise obligations of the RPIC to incorporate however weren’t restricted to:
Conducting an operational security briefing on objects related to the RPA operation.
RPA crew co-ordination.
Making certain the RPA is in CASA accredited airspace.
Making certain operations are carried out in accordance with firm working procedures together with the JSA [job safety assessment] and Flight Authorisation.
Sustaining communication with the RPA crew all through the complete operation utilizing Native Comms Handheld Radios.
Confirming obligations of all flight crew members
Reviewing the present design and confirm operational space, exclusion space, and minimal drone separation distance (1.0 m) previous to flight.
Confirming correct set-up of base station.
Operation of the RPA.
Put up-flight information recording.
Verify all crew health for responsibility.
Reporting incidents to the Chief Pilot.
Copilot
The copilot for this operation was authorised and certified to function within the function of copilot. They held a RePL for multi‑copter operations as much as 25 kg and had accomplished the operator’s Damoda coaching program following the introduction of the plane kind in October 2022.
The copilot had beforehand accomplished 17 lightshow coaching flights working in both the RPIC or copilot function, the newest of which was as a copilot 3 days previous to the prevalence flight at Sydney Olympic Park. The operator’s flight logs recognized that previous to that operation that they had not accomplished a present in additional than 6 months. The copilot had not been endorsed by CASA as certified to function as mission commander (RPIC) in a single‑to‑many operations, nevertheless underneath the operator’s manuals this was not required to function within the function of copilot.
The copilot’s function as outlined within the operator’s manuals was to help the RPIC within the conduct of the present. The guide delegated particular obligations to the copilot. Whereas not particularly acknowledged within the guide, one of many goals of this was to scale back the RPIC’s workload. The obligations of the copilot included:
conducting an operational security briefing on airspace objects
administration of stakeholders
administration of present help crew
monitoring working space Airband VHF frequencies all through the complete operation
broadcasting on VHF frequency when wanted
instantly advising Mission Commander of any related airspace site visitors
present timing
co-ordinating incident response
help the Distant Pilot in Command and be co-located in the course of the present except attending to an emergency
activate emergency procedures in occasion of RPIC incapacitation
Maintain direct communication with the all crew all through the complete operation utilizing Native Comms Handheld Radios (or co-location).
Visible commentary of swarm
Alert of drone flyaway
Management of drone flyaway Drones IDs 1-500
The copilot was additionally the operator’s chief distant pilot (CRP). As such, that they had general duty for the RPAS operation, together with the approval of operations deliberate by the opposite pilots. The copilot had accomplished coaching on the V2.2 plane and GCS software program when it was launched, nevertheless they acknowledged that they usually left the planning and operation of the exhibits to the opposite pilots who had been more adept in swarm operations. This allowed them to concentrate on different areas of their function within the organisation.
Attributable to staffing modifications on the operator (see the part titled Staffing modifications) the chief distant pilot had been introduced into this operation as a copilot. As they weren’t endorsed by CASA, they may not assume the function of RPIC.
Floor crew
In help of the flight crew the operator’s guide required that one floor crew member be current for each 100 plane throughout the show. Beneath the operations guide these crew members had been answerable for a variety of duties. These included:
floor dealing with of the RPAs
pre- and post-flight checks of the RPAs
battery administration
monitoring of the bottom and airspace across the present space for potential breaches
sustaining direct communications with the flight crew all through the complete operation.
The operator sourced floor crew members from a labour rent firm. Floor crew members had been briefed by the RPIC and required to finish a consent and compliance declaration acknowledging that they understood their function. As soon as briefed by the RPIC the administration of the present help crew was the duty of the copilot.
Further personnel
As this present was to be carried out over water, the operator was required to make sure that water site visitors was maintained away from the present space exclusion zone. To implement this zone the operator had engaged vessels from Parks Victoria, Victorian water police and a personal contractor to observe the present space perimeter. Communications between these vessels and the flight crew was maintained by UHF radio.
Multi-crew operations
Cockpit gradient
A cockpit or authority gradient refers to how balanced energy and choice‑making authority is inside a group. Authority isn’t essentially outlined by expertise or competence in a job however could also be by the function that an individual holds (SKYbrary, 2025). The place a cockpit gradient is simply too steep, group members will not be prepared to problem or specific considerations over a frontrunner’s selections, and the place too shallow it might probably gradual choice‑making processes.
A unfavourable gradient is the place a group member in a subordinate function has extra energy or authority than the group chief. This may undermine the group chief’s authority and result in the chief deferring to, or inserting further weight on, that group member’s opinions or concepts.
In crewed operations, to be endorsed to fly multi‑crew, pilots should undertake multi‑crew coordination (MCC) coaching. A part of this coaching required the candidate to show efficient administration of flight deck gradient for duties that had been being carried out. Neither the CASA approval nor the operator’s documentation required this or equal coaching for swarm operations.
Operator data
Operations guide
The operator maintained an operations guide and operations library in accordance with the necessities of Half 101 of the Civil Aviation Security Laws 1998 (CASR); each had been accredited by CASA. The operations guide contained the operator’s overarching processes and procedures and outlined varied regulatory compliance necessities. The operational library contained extra particular plane data and operational processes.
For instance, the operator’s guide contained details about the conduct of RPAS show operations, nevertheless the precise course of for finishing up the pre‑present guidelines was contained within the operational library. Equally, the fundamental and overarching emergency procedures had been contained throughout the operations guide however particular responses and processes for various emergencies had been within the operational library.
The operations guide outlined that the chief distant pilot was answerable for all operational issues and distant pilot coaching affecting security. This included:
making certain that operations had been carried out in compliance with related laws
duty for purposes, permissions and approvals to facilitate operations
sustaining a reference library of operational paperwork
creating guidelines and procedures referring to flight operations.
Checklists
To help present operations utilizing Damoda plane the operator maintained and utilised a number of checklists contained throughout the operations library. The present day and flight checklists had been the first paperwork utilized by the crew in preparations for a present. There have been totally different variations of those checklists relying on whether or not kind of than 500 drones had been getting used within the present.
For a present of as much as 500 drones, the present day guidelines consisted of 10 objects, taking the crew by the set‑up of the GCS and the laying out of all drones in preparation for the present. It additionally included steerage on the set‑up of the community and RTK tools and environmental monitoring together with electromagnetic and wind circumstances.
The ultimate merchandise on this guidelines (Determine 13) was for a climate inspection. This merchandise required the pilot to examine the present climate forecast and measure the wind velocity at 5‑minute intervals for the 30 minutes earlier than the present begin ‘if the pilot has capability’. The guidelines didn’t establish a selected location the place these wind readings are to be taken. The guidelines was dated 7 March 2023, which was earlier than the introduction of the wind administration plan and climate drone (see the part titled Wind administration plan).
Determine 13: Merchandise 10 on the operator’s present day guidelines
Supply: Operator
At interview each the RPIC and copilot recognized that this guidelines was obtainable to help them within the lead‑as much as the present. The RPIC acknowledged that they and different pilots had been conversant in the content material and they didn’t at all times confer with the guidelines throughout preparations for the present.
For a present of as much as 500 drones the flight guidelines consisted of 20 objects taking the flight crew by the set‑up of the plane and GCS tools, a evaluation of the emergency procedures and closing checks. Merchandise 17 was the ultimate merchandise earlier than launch and it required the RPIC to contemplate their confidence within the fleet and assess the general threat components earlier than deciding whether or not to launch the present. The RPIC acknowledged that the flight guidelines was necessary and was at all times used within the lead‑as much as the present.
Emergency procedures
The operator’s manuals outlined the procedures within the occasion of an emergency in the course of the swarm show. It outlined procedures for a variety of non‑swarm associated emergencies together with fireplace on the bottom, crew medical occasion and non‑cooperative site visitors (plane or hen) interacting with the swarm.
The final response to any of those emergencies was to reply to the speedy menace (if required) after which place the swarm on the bottom as shortly and safely as attainable both utilizing an RTL or land command despatched to all plane or manually controlling plane to the bottom.
The operator maintained particular emergency procedures for plane producing EKF (autopilot failure) and W (waypoint difficulty) errors. These errors required an instantaneous response from the pilot to pick RTL and if the RTL command failed the plane had been to be flown again manually utilizing the hand controller.
Merchandise 2 of the operator’s flight guidelines required that the RPIC and copilot reviewed the emergency procedures previous to flight. The GCS recorded that the RPIC acknowledged that the response to those errors can be to RTL, take management of the plane manually and if neither of those had been profitable, land the plane within the water.
In response to this prevalence, the RPIC activated the emergency process for EKF errors and fly away plane. Whereas initially the RPIC activated a loiter command, at the moment neither the fly away nor the primary EKF error had occurred. When these occurred the RPIC instructed the copilot to regulate after which deactivate the plane and tried to RTL every plane displaying an EKF error on the GCS.
Coaching and checking
With the introduction of the Damoda plane all of the operator’s pilots, together with the copilot (CRP) undertook preliminary coaching with the producer’s Australian agent. The CRP recognized that there have been some gaps within the coaching so the operator’s pilots undertook additional in‑home familiarisation and testing with the present software program to grasp the related capabilities and options.
When model 3 of the GCS software program was launched, no formalised coaching was undertaken with the producer or its Australia agent. The operator and RPIC reported that the producer had offered a doc with set up steerage and a few variations between the outdated and new variations of the software program. They additional recognized that previous to beginning operations with the brand new software program the pilots undertook familiarisation with it, figuring out updates to present options and a number of the new options.
There was no documented course of for making certain that each one pilots had the identical stage of competence or had been conscious of all of the related options of the software program.
Previous to commencing present operations, the RPIC was required to finish the operator’s inside coaching program and be checked by CASA for approval to function a number of plane concurrently. The coaching syllabus for operations utilizing the Damoda plane concerned 8 classes. The primary required the pilot to show right set‑up and operation of all of the present {hardware}, together with the GCS and plane.
The next classes concerned incremental will increase within the variety of plane from a single plane by to a 1,050 plane flight. Every session required the pilot to establish the related configuration, set‑up and crewing modifications for the variety of plane being operated. The CASA examine for approval to the operational instrument was constructed into this coaching syllabus and was accomplished as a part of session 7. Session 8 was a closing demonstration flight with 1,050 RPA.
The operator’s guide required present‑certified RPICs, copilots and floor crew members to undertake proficiency checks to make sure that they had been operationally succesful. Proficiency checks lined a variety of things relevant to every of those roles. They had been required each 12 months except the candidate had carried out a minimal of 4 related gentle present operations within the final 12 months, whereby the time between the proficiency checks could possibly be prolonged to 24 months.
The RPIC had joined the operator lower than 12 months beforehand and had accomplished greater than the required 4 gentle present operations as RPIC that means {that a} proficiency examine was not required till October 2024.
Proficiency checks had been required for every plane kind and extra proficiency checks weren’t required within the occasion of great modifications to the software program.
Wind administration plan
In response to a selected request from an earlier shopper the operator had developed a wind administration plan. Launched on 21 Might 2023, the plan was ‘…to make sure the protected and profitable execution of a drone gentle present occasion in windy circumstances’. Whereas initially developed for that particular shopper the plan made no particular reference to that shopper or occasion, usually figuring out the set‑up and operational wind limits and specifying how climate could possibly be monitored. The set‑up restrict was 18 kt (9.2 m/s) measured 3 hours earlier than the flight and the operational restrict was 14 kt (7.2 m/s) measured 5 minutes earlier than the flight. The wind administration plan additionally contained increased stage statements about how the usage of sure plane, coaching of pilots, engagement with stakeholders, an emergency response plan and submit‑occasion analysis was used to realize the aim of the plan.
Regardless of containing operationally related data associated to wind administration and responses to adversarial circumstances the plan was solely included within the occasion plan for the present and was not built-in into the organisation’s operational processes and procedures.
Model 1.1 of the wind administration plan was dated 6 June 2023, roughly 5 weeks earlier than the accident flight. The up to date model elevated the operational wind restrict from 14 to 15.3 kt (7.2 to 7.9 m/sec) and launched, on the RPIC’s discretion, the usage of a climate drone to check the circumstances within the present space earlier than the present was launched. The plan didn’t element how the climate drone could possibly be used, however the CRP recognized that it could possibly be carried out with a separate plane or an plane from the swarm could possibly be tethered to the controller and flown manually for the climate examine. As with the sooner model, the up to date model of the plan was solely included within the occasion operational plan and never built-in into present processes and procedures.
The wind administration plan didn’t confer with the wind velocity readout on the GCS show.
The RPIC suggested that they had been conscious of the wind administration plan and that, to their information on the time of the prevalence, it didn’t include the choice for the launch of a climate drone. They additional acknowledged that this was solely launched submit this accident.
Staffing modifications
Within the weeks main as much as the present there have been a number of staffing modifications that impacted how the present was deliberate and carried out. Firstly, the operator’s chief govt officer (CEO) had left and this present was the primary alternative for the brand new CEO to see the corporate’s drone swarm operation in practise. Secondly, the operations supervisor, who had been the principle level of interplay between the shopper and flight crew throughout present preparations had left the corporate and had not been changed.
Because of the departure of the operations supervisor, the RPIC had taken on this function and subsequently was concerned in preparation of a number of exhibits, together with the Docklands present. This included liaising immediately with the shopper and different stakeholders. The RPIC acknowledged that having the pilot working the present concerned in shopper interplay throughout operational planning was usually prevented. This was to make sure that the RPIC on the night time may concentrate on working the present and never have to fret about partaking with the shopper.
Usually, as soon as a present had been deliberate, contact with the shopper can be handed over to the copilot for them to handle on the night time of the present. For this present that didn’t happen as a result of already established relationship between the RPIC and shopper.
The discount in group dimension led to by the operations supervisor’s departure lowered the personnel obtainable for this present. Subsequently the CRP who was copilot‑certified, however acknowledged that they weren’t ‘current’ within the operation, stepped into the function of copilot. The RPIC commented that this resulted in a unique dynamic between the RPIC and copilot than if the copilot had been extra skilled.
Operator’s evaluation
Following the accident the operator carried out a evaluation into the prevalence and recognized the next:
The flight crew didn’t take into account the circumstances within the present space at altitude.
RPIC was underneath unrealistic strain to finish the present within the allotted time.
The copilot’s restricted expertise elevated strain on the RPIC.
Requirement to maneuver the present lowered time obtainable for present preparations.
The RPIC had important confidence within the reliability and performance of the operational fleet.
Operational data
Operational approval
In Australia RPAS operations are ruled by Half 101 of the CASR. Beneath regulation 101.300 an individual could not function multiple RPA with no particular approval from CASA. On 12 Might 2023 CASA issued a 12‑month approval for the operator and specified pilots to function multiple RPA at a time and at night time, topic to a collection of circumstances. Among the circumstances listed on this approval had been that the:
operator should have an lively discover to airmen (NOTAM) advising when and the place the operation was going down
operator should function in accordance with their operations guide
operator could solely function Damoda multirotor plane as much as 750 g
RPA should have acceptable failsafe performance within the occasion the info hyperlink to it was misplaced.
operator should preserve an acceptable exclusion distance to non-essential personnel as outlined within the particular revision of their operations library.
Offered that these circumstances could possibly be met, the operator was permitted to plan exhibits at any location in Australia.
Present planning
As soon as a possible present location had been recognized, an operational self‑evaluation was to be carried out on the location utilizing the method outlined within the operations library. The evaluation was to incorporate hazards throughout the operational space, together with the present airspace, the launch and restoration space and the traversal airspace between these 2 areas. The evaluation additionally decided the exclusion zone necessities.
The self-assessment required consideration of the entry to each the bottom and airspace in these areas, clearance and obstacles, the potential for RF interference, floor topography and different potential customers. The guide particularly recognized that waterways had been a most popular operational space because the water offered a pure barrier to public entry. Waterways with out vessel entry had been most popular, nevertheless the place vessel entry was attainable then an exclusion zone wanted to be arrange and enforced by the related authorities.
Docklands
The present planning for the Docklands operation was carried out by the RPIC and one of many operator’s different pilots. A part of the planning course of was engagement with the harbour authority to organise a harbour closure and enforcement of the exclusion zone across the present. Within the days main as much as the present, the operator requested that the 15‑minute closure window for the present be moved later attributable to forecast wind circumstances. The operator suggested that the harbour authority had acknowledged that this was not attainable.
Occasion operational plan
The occasion operational plan contained all of the related data that the crew required to conduct the present, comparable to timings, location, related stakeholder contact particulars and plans for site visitors and crowd management. Listed as attachments to the operational plan had been 5 appendices (labelled A by E). Appendix A was the wind administration plan. The occasion operational plan didn’t specify which model was hooked up, nevertheless on the time v1.1 was present. Appendix D contained the operator’s threat evaluation. This doc recognized the lack of plane into the water as a hazard that required therapy. Many of the therapies had been associated to administration of batteries and inspection of plane, the ultimate therapy was the provision of divers onsite to get better any RPAS that had been misplaced into the water.
The occasion operational plan and its appendices had been obtainable to the flight crew on the day of the accident. Nevertheless, the RPIC reported that within the lead‑as much as the present the crew would usually confer with the checklists somewhat than the occasion operational plan for related processes. Within the 50 minutes main as much as the present the one reference that was recorded to the occasion operational plan was related to acquiring the frequency for the close by Essendon air site visitors management tower.
Operational space
Victoria Harbour is situated roughly 1 km south‑west of the Melbourne CBD. The world surrounding the harbour is a combined residential and business precinct with the Docklands Stadium on the northern finish and a number of other excessive‑rise buildings adjoining to the harbour, with the tallest being roughly 140 m.
South of the harbour the Bolte Bridge crosses the Yarra River with two 140 m tall help towers. The chosen launch web site had beforehand been utilized by one other operator to launch a swarm show. That show had encountered points with magnetic interference near the bottom, which was believed to be as a result of giant quantity of metal reinforcing of the concrete on the launch web site related to its earlier use as an operational dock.
The operator had recognized this as a possible hazard and anticipated that there could also be some magnetic interference with the plane, nevertheless there have been minimal impacts recognized within the GCS recording or reported by the flight crew previous to or in the course of the preliminary launch of the swarm.
As proven in Determine 1 there have been a number of jetties the place pleasure craft had been moored extending as much as 90 m into the harbour. Because the operator didn’t have entry controls in place for these jetties, to make sure security for anybody on them on the time of the present, they wanted to be exterior of the exclusion zone across the present space.
Exclusion zone
An exclusion zone ensures that, within the occasion of an plane operational difficulty, it will likely be contained and never pose a threat to non‑important personnel. The zone is calculated from the geofence, based mostly on the plane’s most operational velocity and its wind velocity restrict. Subsequently, an plane working at most operational velocity with a tail wind on the plane’s wind velocity restrict will nonetheless be contained. The exclusion zone was calculated at 50 ft working peak increments between 100 ft and 400 ft (most allowable present peak).
Desk 1, reproduced from the operations library, exhibits the calculated minimal exclusion zones for Damoda V2 plane between 100 ft and 400 ft.
Desk 1: Damoda V2 minimal exclusion zones by plane peak
Previous to setting the geofence, the pilot measured the space between the sting of the present space and a publicly-accessible jetty on the other facet of the harbour to be 62 m. The RPIC then set the geofence across the present space manually utilizing a buffer of 8–15 m, leading to an efficient exclusion zone between 47–54 m (Determine 14).
Determine 14: Exclusion zone positioning
Supply: Operator, modified and annotated by the ATSB
Primarily based on the operator’s exclusion zone calculation course of, the ATSB assessed the scale of zone required to include plane working at most present velocity and topic to a tailwind of twice the accredited restrict of the plane (16 m/s) at a peak of 126 m (the utmost deliberate peak of the present). In that situation, an exclusion zone of greater than 100 m would have been required.
Meteorological data
Operator accessed data
The flight crew suggested that, all through the afternoon and within the lead‑as much as the present, that they had accessed meteorological data from a number of sources. This included the Bureau of Meteorology (BoM), Windy and Willy Climate purposes and aviation meteorological forecasts, together with the related graphical space forecast and terminal space forecast for Essendon Airport (6 nautical miles to the north-west of Docklands). In discussing the wind circumstances the flight crew famous that they had been above the restrict of the plane, however anticipated them to ease main as much as the present time.
Floor‑based mostly monitoring
The flight crew had been monitoring the wind velocity on the bottom utilizing a handheld anemometer[6]. The flight crew reported that in the course of the set‑up for the present the wind had been recorded in extra of the aircrafts’ restrict.
Desk 2 exhibits the recorded wind readings that had been taken within the 40 minutes main as much as the present, ending at 1817.
Desk 2: Wind velocity measurements taken at launch web site recorded by GCS
Bureau of Meteorology aviation forecasts and observations
The graphical space forecast issued by the BoM, legitimate on the time of the present for the Docklands space, recognized floor visibility exceeding 10 km and extreme turbulence beneath 6,000 ft for many of south‑japanese Victoria.
At 0927 on the day of the present the BoM issued a terminal space forecast (TAF) for Essendon Airport (YMEN)[7]. The TAF was legitimate between 1000 and 2200 native time on the day of the present. It forecast winds from the north at 18 kt gusting to twenty-eight kt, strengthening to twenty kt gusting 32 kt from 1100, with extreme turbulence beneath 5,000 ft from 1000.
At 1507 the BoM issued an amended TAF legitimate from 1600 until 0400 the day after the present. From 1600 it forecast winds from the north at 18 kt gusting 28 kt and extreme turbulence beneath 5000 ft. From 2200 winds had been forecast from the north at 14 kt with the turbulence lowering to reasonable.
Corresponding observations
METAR and SPECI data for YMEN for the interval from the beginning of the amended TAF at 1600 till 1830 (the present launch time) was per the forecast circumstances. The wind course was constantly from the north and wind speeds diversified across the aircrafts’ restrict, with gusts between 25–30 kt (Determine 15).
Determine 15: YMEN wind velocity observations
Supply: ATSB utilizing BOM information
Plane
Whereas airborne and linked to the GCS the plane reported wind velocity and course data, which was displayed on the wind monitor. The wind velocity was manually extracted from the GCS recording and plotted at 5 second intervals displaying the modifications in wind velocity all through the prevalence (Determine 16).
Inside 10 seconds of the primary information being recorded, the plane had been working in extra of the wind velocity restrict. Because the plane climbed in the course of the transition to the present space the wind velocity elevated quickly progressing to greater than double the 8 m/s restrict of the plane.
Over the next 35 seconds the wind velocity decreased and remained at or near the restrict till 1833:30, roughly 2 minutes after the present was launched. On the time the wind velocity decreased many of the plane had activated their failsafe mode and had been making an attempt to land within the water. However the potential impact of wind gusts, at these decrease heights the wind speeds had been seemingly nearer to the speeds recorded on the bottom earlier than launch.
Determine 16: Wind speeds displayed on the GCS
Supply: ATSB based mostly on operator information
Recorded information
Plane
Following the prevalence the operator downloaded the flight logs from the plane that weren’t submerged and offered these, together with the display screen recording and logs from the GCS software program to the producer for additional evaluation.
The producer recognized that as much as 397 plane concurrently reported ‘T’ errors. Additional evaluation of the obtainable logs indicated that plane throttled to 100% and that the recorded pitch angle of the plane (max 53°) exceeded the traditional flight angle (Determine 17).
The producer concluded that the plane had encountered wind circumstances exceeding their functionality.
Determine 17: Plane pitch, roll and throttle parameters
Supply: Producer, annotated by the ATSB
Particularly, whereas many of the plane had been displaying the commanded loiter mode, the producer recognized that:
Because of the affect of the wind velocity, the facility of the motors was not capable of present the required carry for the drones, so that they moved up and down and slowly landed.
With out the capability to offer the required carry the plane couldn’t preserve place within the loiter because the RPIC had commanded and subsequently descended. This resulted in many of the plane ditching into the harbour. The GCS recording didn’t present proof of a mode change, with most plane nonetheless displaying the ‘L’ indicating they had been in loiter mode on the GCS when connection was misplaced.
The producer’s report additionally acknowledged that the pilot was answerable for testing the wind velocity and ought to be conscious that the winds at peak could also be larger than that on the bottom.
Floor management station
In accordance with the operator’s present day guidelines the RPIC began display screen recording on the GCS laptop computer pc at 1740, 50 minutes earlier than the present was launched. The recording captured all exercise that was displayed on the display screen, together with command inputs and alternatives, errors and performance shows by till 1920, 50 minutes after launch.
The recording solely captures what was displayed on the display screen and never the knowledge that the software program used to generate the visible show. For instance, in the course of the present an plane standing window was open over the situation map so the situation of the plane throughout and after transition into the present space was not seen.
The software program used to document the display screen additionally recorded the enter from the pc’s microphone, capturing the interactions and communications between varied crew members that had been inside vary. Appendix A summarises the recording main as much as the present.
Closed circuit tv
A collection of 6 closed circuit tv (CCTV) cameras round Victoria Harbour (Determine 18) captured the present’s launch, transition to the present space and a number of the present. The footage captured the uncommanded motion of a number of plane, plane collisions, the plane touchdown within the water and the fly away plane (Determine 2).
Digicam 1 captured the situation of the boat mast that the RPIC had recognized as presenting an impediment to the swarm (Determine 2). Digicam 4 captured a number of flags displaying full extension on the time that the present was launching within the background. Noting that wind circumstances diversified with peak, this digital camera was used to realize a common understanding of the circumstances across the present web site within the lead‑as much as, and on the time of, the present.
Determine 18: CCTV cameras round Docklands
Supply: Google Earth, annotated by the ATSB
Security evaluation
Introduction
At 1830 on 14 July 2023, the distant pilot in command (RPIC) of a swarm of 500 Damoda Newton V2.2 plane commanded the plane to launch to conduct a light-weight present. Shortly after launch, and earlier than the plane transitioned to the present space, the RPIC was offered with an rising variety of errors. The swarm continued in direction of the present space the place additional errors offered with a number of plane getting into failsafe modes and touchdown or falling into the water. A complete of 427 plane had been submerged, with solely 236 recovered.
The next evaluation will take into account the conduct of the present from the launch to the plane ditching into the water, together with the components that impacted the choice to launch. It is going to additionally evaluation a number of issues of safety that elevated the chance to the operation.
Launch choice
Obtainable data
Previous to the present the flight crew monitored wind circumstances by referencing varied climate sources and taking wind velocity measurements at floor stage. The circumstances on the bottom had been beneath the restrict of the plane with gusts exceeding the restrict. The flight crew anticipated that, based mostly on their interpretation of the obtainable forecasts, wind circumstances would ease within the lead‑as much as the present time.
Nevertheless, at 1817, 13 minutes earlier than the present launch, a wind velocity of seven m/s was recorded on the bottom, just one m/s beneath the allowable wind restrict. Right now there was a dialog between the RPIC and the copilot concerning the wind circumstances. The RPIC recognized that the circumstances on the bottom had been close to the restrict of the plane and that the wind velocity within the present space was more likely to be increased than that at floor stage. The copilot responds that it’s solely gusting and that they simply should get off the bottom. Within the following 13 minutes previous to the launch the RPIC was occupied with different duties and no additional wind velocity evaluation was undertaken.
Wind administration plan
The model of the operator’s wind administration plan present on the time of the accident offered steerage for the gathering of wind data throughout the present space utilizing a climate drone. The RPIC was conscious of the wind administration plan however not that it contained the choice to make use of a climate drone. That understanding was per the content material of the earlier model of the plan that didn’t include that choice.
Because the wind administration plan was hooked up to the occasion operational plan, which was ready by the RPIC and accredited by the copilot of their function as CRP, each flight crew ought to have been conscious of the plan’s availability to them on the night time of the present and its contents. Nevertheless, in response to the draft report, each suggested that they had been unaware of its attachment to the occasion operational plan. Additional, because the wind administration plan had not been included in any operational course of or process there was no immediate for the flight crew to evaluation or entry the plan previous to the present for steerage within the windy circumstances. Subsequently, neither the plan nor the climate drone choice it contained had been used.
If a climate drone had been launched it’s extremely seemingly that it will have encountered circumstances like these skilled by the swarm. That might then have offered the flight crew with affirmation that circumstances had been unsuitable for the sunshine present to proceed.
Management points and ditching
Present launch
Ten seconds after the RPIC commanded the swarm to launch, the wind velocity displayed on the bottom management station (GCS) was equal to the aircrafts’ restrict of 8 m/s. An additional 10 seconds later the readout was displaying a wind velocity of 9.9 m/s. Right now 85 plane had been displaying errors on the GCS. Of those, the 20 the place the error kind was seen had been all displaying ‘T’ errors indicating that they had been out of place. The producer’s evaluation of the flight information recognized that these ‘T’ errors had been offered as a result of plane motors being unable to carry place towards the prevailing wind.
Having dominated out interference with or spoofing of the GNSS sign the ATSB additionally thought of the potential of a malicious actor making an attempt to take management of the swarm. Nevertheless, the GCS pc confirmed no sudden modifications to plane mode or any instructions obtained by the plane that weren’t commanded both by the RPIC or routinely by plane logic. Moreover, if the plane had been interfered with and tasked to alternate positions then they’d seemingly not have recorded out of place errors.
Floor management station wind velocity show
There was no indication from the dialogue, feedback or actions recorded on the GCS pc that the flight crew recognized a wind restrict exceedance. They didn’t equate the 85 plane indicating ‘T’ errors to a restrict exceedance or establish the wind velocity readout. The RPIC and copilot had been each unaware of the GCS wind velocity show performance so weren’t monitoring it for restrict exceedances. They acknowledged that if that they had recognized that the wind was in exceedance of restrict that they’d have taken actions to terminate the present.
As soon as the present had launched the copilot’s obligations as outlined within the operations guide had been to observe the airspace for related site visitors, visually observe the swarm and to observe it for fly aways. These 3 duties required the copilot’s consideration to be on the swarm and the encompassing airspace somewhat than element displayed on the GCS pc. Whereas the copilot visually recognized plane out of place, they didn’t affiliate it with a wind velocity restrict exceedance.
Motion into the present space
Because the plane moved into the present space alongside the pre‑programmed flight paths, the wind velocity will increase noticeably from 8.3 m/s to 18.5 m/s 40 seconds later. CCTV footage confirmed a number of plane within the higher layers of the present drop into the decrease layers and collide with each other. The GCS displayed an rising variety of errors throughout all 3 classes. Not all errors had been proven on the display screen concurrently so it was not attainable to find out the precise variety of plane presenting every error. Nevertheless, the producer’s evaluation confirmed a most of 397 plane concurrently recorded T errors indicating that they had been out of place and the GCS recorded at the least 11 plane offered with F errors indicating that that they had breached the geofence.
The RPIC’s final command to the swarm was to loiter, the producer’s evaluation confirmed that this command was obtained by plane within the swarm. The producer’s evaluation additional recognized that, as a result of wind circumstances the motors had been unable to offer the required carry to stay airborne whereas making an attempt to take care of their place. The producer reported that they subsequently descended into the water beneath their location.
Human Components
Pilot workload
All duties require a stage of cognitive load to course of the knowledge and undertake the exercise. Workload is a measure of the quantity of psychological effort that’s wanted or expended to course of this data. People have a restricted capability to course of data, the place the knowledge processing required is near, or exceeds, the human functionality that is known as overload and may have a number of unfavourable results on efficiency. These results can embody, activity shedding, attentional focusing, discount in situational consciousness, elevated fatigue and the elevated probability of errors. (United Kingdom Civil Aviation Authority, 2016)
The extent of workload that a person activity requires varies relying on a variety of things. These embody the problem of the duty, familiarity and recency with the duty, the variety of different duties which can be being carried out concurrently and the time obtainable to finish the duty. (United Kingdom Civil Aviation Authority, 2016)
The completion of an RPAS gentle present requires flight crew to be acquainted and work together with a number of methods together with:
the plane
the assorted {hardware} and software program components of the GCS
situation monitoring tools
operational processes and procedures.
The flight crew additionally must work together with and handle help crew and stakeholders. The operator had procedures to mitigate this by the implementation of the multi‑crew operation requiring at the least 2 flight crew members for exhibits of greater than 10 plane.
Workload evaluation
A evaluation of the operational setting within the lead‑as much as and on the time the present was launched recognized 2 components that elevated the RPIC’s workload above the traditional stage for present operations. These had been the
copilot’s restricted expertise in present operations
RPIC’s lack of familiarity with adjusting the present place.
Copilot expertise
For this operation the operator’s chief distant pilot (CRP) was performing the function of copilot. On the time of the present the RPIC had accomplished nearly twice as many exhibits because the copilot, and the copilot had solely carried out a single present within the earlier 6 months, which was on the Wednesday night time earlier than this present. Whereas not required to be, the copilot was additionally not accredited by CASA to function within the RPIC function.
At interview each flight crew recognized that the copilot had much less expertise in present operations in comparison with the RPIC and the copilot themselves recognized that, whereas present, they had been ‘rusty’ when it got here to point out processes and procedures. In consequence, some duties that had been usually assigned to the copilot had been carried out by the RPIC. The GCS recording captured the RPIC:
actively managing varied stakeholders and the present help crew
making certain that the present timings had been met
alerting the copilot of an plane fly away.
All these duties had been the duty of the copilot within the operator’s procedures. The RPIC reported that if that they had been working with a extra present pilot the division of duties would have been extra equal, which might have lowered their psychological load.
The elevated duties that the RPIC carried out meant that they needed to transfer from activity to activity quickly, and work on a number of duties concurrently. Each of that are identified to extend workload. (United Kingdom Civil Aviation Authority, 2016)
RPIC lack of familiarity
On the night time of the present the presence of the boat mast hazard meant that the RPIC needed to reposition the present. Being unfamiliar with the required course of, the RPIC elected to seek the advice of, by telephone, with one other pilot who was conversant in the system.
The dialog between the RPIC and the opposite pilot had been prearranged for 1800, 30 minutes earlier than the present launch time. Nevertheless, the opposite pilot didn’t name again till 8 minutes later, leaving solely 22 minutes earlier than launch to impact the change.
Subsequently the RPIC was preoccupied with duties of transferring the present for 18 of the 30 minutes main as much as the present. Primarily based on the required actions it was assessed that, for somebody conversant in the method and web site, the transfer of the present may have been accomplished in about 5 minutes.
In abstract, the mix of activity unfamiliarity, time strain and additional duties as a result of copilot’s restricted present expertise considerably elevated the RPIC’s workload within the lead‑as much as launch. That lowered the effectiveness of the wind velocity evaluation very important for the security of the launch choice.
Operational strain
Stress refers to a sense of inside or exterior stress, which can not essentially be based mostly on precise urgency or necessity. This strain can stem from varied sources, comparable to tight schedules, stakeholder expectations or private requirements of efficiency. It could possibly result in rushed selections, chopping corners or taking of pointless dangers that may impression the security of operations. (Ramdeen, 2024)
A number of ATSB investigations and different publications have mentioned the impression that private, social or organisational pressures (perceived or precise) can have on pilot climate‑associated choice‑making. Of their security leaflet about visible flight guidelines into instrument meteorological circumstances (VFR into IMC) occurrences, (UK CAA, 2024) the UK Civil Aviation Authority (CAA) recognized that as a pilot:
‘You could really feel strain to begin or proceed a flight attributable to components comparable to time constraints, passenger expectations, disruption to your private life or the continuation bias of eager to execute the supposed plan. The impact of those pressures is typically known as ‘get-there-itis’ and may result in a disregard for climate circumstances or an excessively optimistic interpretation of the state of affairs, rising the chance of a VFR into IMC situation’
As a big public occasion an RPAS gentle present will seemingly place a stage of strain on the flight crew, and notably the RPIC, for the present to go forward. The operator’s procedures went some technique to mitigating this hazard by assigning the copilot the duty of stakeholder engagement to isolate the RPIC from the potential pressures. On this event nevertheless, the RPIC carried out this activity.
Components identified to extend strain
A evaluation of the operational setting on the night time of the present recognized plenty of the components that the CAA recognized as more likely to improve strain. These, along with 2 different components, are mentioned within the following sections.
Time constraints
To conduct the present, the harbour wanted to be closed to maintain vessel site visitors out of the exclusion space. To minimise disruption the port authority offered a 15‑minute time window, beginning at 1830, for the ten‑minute present. Within the days main as much as the present the operator recognized that the forecast circumstances on the present time had been going to be marginal and had requested that the present time be moved later. The operator suggested that the port authority wouldn’t permit them to maneuver the present later as a result of impression on the harbour’s operations. This meant that the RPIC needed to launch at 1830, or the present couldn’t go forward.
Stakeholder expectation
RPAS gentle present operations don’t contain passengers nevertheless there are different stakeholders who could have the identical want for a flight to go forward and restricted understanding of the operational necessities. On this case the shopper had expended important capital and anticipated that the present would proceed.
The RPIC suggested that that they had been in touch with the shopper’s consultant on a number of events within the lead‑as much as the present giving updates on circumstances and what that meant for the chance of the present going forward. The RPIC acknowledged that they had been conscious that the shopper had different individuals ready on the choice as as to whether the present would proceed.
Secondly, the just lately appointed CEO and COO had restricted expertise with the sunshine present operation and had travelled particularly to see this present and observe the operation in particular person. The RPIC suggested that the CEO and COO had spoken with them within the lead‑as much as the present and expressed a want to see the present function successfully.
Continuation bias
Continuation bias is ‘an unconscious cognitive bias to proceed with the unique plan regardless of altering circumstances.’ (Transportation Security Board of Canada, 2019) In a crewed operation continuation bias may seem as a pilot departing into questionable circumstances on a route they’ve accomplished efficiently plenty of occasions earlier than. It may additionally seem as a flight crew conducting a number of makes an attempt to land on the vacation spot airport somewhat than divert to a location the place the circumstances are extra appropriate. (Federal Aviation Administration, 2022)
The RPIC reported that the operator had by no means needed to cancel a present attributable to wind circumstances. Additional, the RPIC’s data indicated that that they had carried out greater than 30 exhibits with out incident. Subsequently, persevering with with the present launch was a well-known course of and based mostly on earlier expertise a unfavourable end result from this choice was not anticipated.
Further components
The sunshine present was being carried out in a populated space, had been marketed by the shopper and was supporting a nationwide sporting group’s fixture, which was anticipated to attract a big crowd. The present subsequently had the next than regular profile that offered important publicity and a possibility to show the operator’s functionality.
On the night time of the accident the copilot, because the operator’s CRP, held larger organisational authority than the RPIC. Regardless of the RPIC holding general duty for the protected conduct of the flight, that pairing created a unfavourable cockpit gradient. On a number of events in the course of the lead‑as much as the launch the copilot acknowledged to the RPIC that they believed that the circumstances are appropriate for launch. Whereas the RPIC recognized that they had been the final word authority onsite, the statements from the copilot doubtlessly influenced their choice‑making.
Abstract
The evaluation of the operational setting recognized that the RPIC was seemingly experiencing time strain, expectations from the shopper and senior employees that the present would go forward, an expectation bias as that they had carried out many exhibits with no related difficulty with these plane. As recognized by the CAA these pressures can result in a disregard or overly optimistic interpretation of the state of affairs. Additional rising strain the present had the next than regular profile and there was a unfavourable cockpit gradient between the RPIC and copilot.
The operator’s report into the accident recognized that the RPIC had been positioned underneath further strain by exterior components together with:
the shopper engagement
the time strain from the time window obtainable for the present to be carried out
confidence within the fleet as a result of variety of profitable exhibits that had been accomplished.
Additional, the RPIC recognized immediately that that they had felt that there was strain to have the present occur and for it to achieve success.
Main as much as the present the RPIC had data that the climate circumstances on the bottom had been close to, however beneath, the restrict of the plane however the circumstances throughout the present space had been unknown. An optimistic interpretation of circumstances within the present space can be that the circumstances had been higher or at the least equal to these at floor stage. Beneath this interpretation of the circumstances they’d have been acceptable for the present to go forward.
In crewed operations a poor climate‑associated choice can put the plane, crew and passengers susceptible to a deadly end result. In uncrewed operations the first dangers relate to monetary and reputational harm within the occasion of an incident or accident. Whereas current, the chance to private security of the crew was low, which can have altered the flight crew’s threat notion or tolerance.
Operational necessities
To mitigate towards the boat mast impediment the RPIC elected to carry the complete present by 8 m above the initially deliberate most peak of 118 m to a peak of 126 m. The operator’s CASA permission required the RPIC to adjust to their accredited operations guide and subsequently operations library. The operations library acknowledged that exhibits had been to not be carried out at night time above 120 m (400 ft) except a selected approval had been accredited by CASA, no such permission had been issued for this operation.
On the time that they modified the present peak the RPIC recognized that they had been in exceedance of the 400 ft restrict. The telephone dialogue with the opposite pilot who was aiding within the present transfer recognized that this was a minor breach of the restrict, and it was mitigated by the presence of buildings that exceeded the utmost present peak.
The CASA permission additionally required that the operations be carried out inside an exclusion zone, which was detailed within the operations library. The function of the exclusion zone was to make sure that within the occasion of an plane lack of management, bystanders had been maintained at a protected distance. For a most present peak of 400 ft a minimal exclusion zone of 70 m was required. The exclusion zone set by the RPIC was not capable of be exactly decided however was estimated to be between 47 and 54 m, from a publicly accessible jetty.
The exclusion zone is calculated based mostly on plane peak and wind circumstances. The RPIC’s choice to carry the present to keep away from the boat mast meant that the deliberate exclusion zone of 70 m was not relevant. The zone ought to have been recalculated based mostly on the brand new present peak. For an 8 m (26 ft) improve in present peak the exclusion zone ought to have been elevated by about 4 m. Additional, the wind speeds that the plane encountered, being greater than twice the wind restrict, elevated the required exclusion zone to greater than 100 m.
The obtainable information didn’t establish the utmost peak that plane reached or whether or not any plane exceeded the exclusion zone. Nevertheless, because the flight was automated, if it had continued as deliberate it will have been in breach of each the utmost peak and exclusion zone restrictions accredited by the regulator. By not complying with these limitations security defences constructed into the documentation and approval course of had been eliminated. Whereas this didn’t contribute to the accident, it elevated the chance of an adversarial end result.
Floor management station functionality
Model 3 of the Damoda flight management software program launched a wind velocity learn out, displaying wind velocity and course, within the high proper nook of the show. Following launch, if the wind velocity restrict was exceeded, no lively alert was proven on the GCS pc show. In its report, the producer expressed a view that the flight crew ought to be actively monitoring the wind velocity readout.
An alert, visible, audible or tactile, improves the possibility that the operator will probably be made conscious of this data, particularly when underneath excessive workload. In crewed aviation there are a number of alerts which can be offered to pilots regardless of data already being offered independently to them. For instance, plane are required to have an airspeed indicator however lively stall warnings are generally used.
The software program displayed a number of kinds of alerts, which diversified from particular person plane displaying single or a number of errors, by to pop‑up containers advising {that a} command had failed to achieve a number of plane. All had been clearly identifiable on the display screen and had been simply interpreted by somebody who was conversant in the system.
For gentle present operations wind velocity and course are crucial to the security of flight. The small tolerances between plane and their comparatively gentle weight signifies that modifications in wind velocity can considerably impression the plane place and result in an elevated threat of collisions.
The implementation of an lively alert to the wind velocity monitoring operate would enhance the pilot’s capability to each establish and reply to wind velocity exceedances.
The RPIC acknowledged that they weren’t conscious of the wind velocity readout on the time of the prevalence. Subsequently, for an alert to have been efficient on this occasion it will have needed to each establish the wind velocity readout and the exceedance to the flight crew. Because the alerting operate didn’t exist, it was not attainable to find out if it may have successfully achieved each this stuff. As such, the shortage of an alert was not thought of contributory to the accident.
Pilot coaching
Following the introduction of model 3 of the GCS software program, the operator’s pilots undertook familiarisation flights with the brand new software program, and the producer was consulted about points after they had been encountered. Nevertheless, there was no formalised coaching, as there had been for an earlier model of the software program, and there was no system of evaluation in place to make sure that all pilots had an equal understanding of the software program earlier than they began utilizing it operationally.
The operator had each preliminary coaching and proficiency necessities for pilots to make sure that they had been competent within the methods that they’d be anticipated to make use of. The continued proficiency checks had been solely required on the introduction of latest plane varieties or yearly or biennially, relying on how just lately a pilot had accomplished operational flights. As such, if a pilot had just lately been checked and a brand new software program model was then launched it could possibly be as much as 2 years of operational flying earlier than their proficiency on the brand new software program and understanding of all its options can be assessed.
The flight crew for this present weren’t conscious of the wind velocity indication operate or assured within the means of transferring the present. Nevertheless, at the least one different pilot was conscious of those methods and the right way to successfully use them.
With out a well timed verification course of in place there was no manner for the operator to know whether or not their familiarisation course of had been efficient and if the pilots understood the right way to use the related options in an operational setting. Had such a system been in place, it’s extra seemingly that the flight crew would have recognized the wind velocity restrict exceedance and that transferring the present would have been achieved extra effectively.
Operational doc modifications
The choice of utilizing climate drones to evaluate airborne circumstances was launched with model 1.1 of the wind administration plan, dated 6 June 2023. This represented a major change within the data gathering course of for the wind velocity data within the lead‑as much as the present. The wind administration plan, together with the occasion threat evaluation, the emergency administration plan and the maritime security administration plan, had been obtainable to the flight crew as attachments to the occasion operational plan. Whereas the occasion plan was obtainable, it was not a main reference throughout preparations for the present. The present day and pre‑flight checklists had been the first references.
As neither of those paperwork contained reference to both the climate drone or the wind administration plan, subsequently the flight crew had been much less seemingly to make use of a climate drone to gather related data from the present space. That elevated the chance of launching into unsafe flight circumstances.
It couldn’t be decided whether or not inclusion of the knowledge within the operator’s procedures would have altered the result of the accident because it was not identified how or the place this data would have been included within the operational procedures/paperwork. Moreover, as not all of the procedures such because the present day guidelines had been routinely used, the inclusion of the climate drone choice could not have been recognized by the members of the flight crew, notably given the excessive workload and time‑restricted setting within the lead‑as much as present launch.
Findings
From the proof obtainable, the next findings are made with respect to regulate points and ditching involving RPA swarm of 500 Damoda Newton 2.2 RPA, Victoria Harbour, Docklands, Victoria on 14 July 2023.
Contributing components
The distant pilot in command launched the present with the wind velocity near the restrict of the plane and conscious that circumstances within the present space had been more likely to be worse than these on the bottom.
Within the lead‑as much as the present, the flight crew didn’t use a climate drone to conduct a wind examine at present altitude as outlined within the operator’s wind administration plan. In consequence, the distant pilot in command didn’t have correct details about the circumstances throughout the present space on the time they launched the swarm.
Shortly after launch, earlier than transitioning to the present space, the swarm encountered wind circumstances that exceeded the aircrafts’ operational manoeuvring functionality. This resulted in a number of plane being out of place and errors presenting on the bottom management station pc.
The flight crew had been each unaware that the bottom management station had a wind velocity monitoring operate. The distant pilot in command didn’t use it to observe the wind circumstances after take-off. In consequence, they didn’t establish that the wind exceeded the aircrafts’ limits and continued with the transition to the present space.
Shortly after beginning the transition into the present space, the swarm encountered wind circumstances that had been greater than double the revealed functionality of the plane. This led to a number of plane being unable to carry place, with at the least 11 plane breaching the geofence, a number of plane collisions and most plane descending into the water.
The distant pilot in command’s workload was considerably elevated attributable to their unfamiliarity with the method to make the required present place adjustment and the copilot’s restricted information and expertise in present operations. This lowered the effectiveness of the wind velocity evaluation very important for the security of the launch choice.
It’s seemingly that the distant pilot in command perceived the next than regular stage of strain for the present to go forward. This mixed with the next than regular workload, contributed to their choice to launch the present into unknown wind circumstances.
Different components that elevated threat
The distant pilot in command programmed and launched the present with a most peak which exceeded the 120 m restrict and with an inadequate exclusion zone, each of which had been limitations in accordance with the operator’s CASA‑issued permission to conduct the exhibits. This elevated the chance of harm to bystanders within the occasion of an plane malfunction.
Model 3 of the Damoda floor management station software program included a wind velocity readout, however didn’t actively alert the pilot if the wind velocity restrict was exceeded. This elevated the chance {that a} pilot would fail to establish a restrict exceedance and proceed a present into unsafe circumstances. (Security difficulty)
The operator didn’t present formal coaching on model 3 of the bottom management station software program to its pilots. As an alternative, counting on familiarisation flights and advert hoc recommendation from the producer. This elevated the chance that show-qualified pilots would fail to establish exceedances in flight crucial parameters and expertise elevated workload. (Security difficulty)
Following the introduction of a climate drone choice to the wind administration plan in June of 2023, the operator had not up to date its operational procedures to incorporate this selection. In consequence, flight crew weren’t prompted to make use of this technique for gathering data on wind circumstances within the present space previous to launch. (Security difficulty)
Questions of safety and actions
No set off in key operational paperwork to make use of climate drone
Security difficulty quantity: AO-2023-033-SI-01
Security difficulty description: Following the introduction of a climate drone choice to the wind administration plan in June of 2023, the operator had not up to date its operational procedures to incorporate this selection. In consequence, flight crew weren’t prompted to make use of this technique for gathering data on wind circumstances within the present space previous to launch.
Floor Management Station pilot assurance
Security difficulty quantity: AO-2023-033-SI-02
Security difficulty description: The operator didn’t present formal coaching on model 3 of the bottom management station software program to its pilots. As an alternative, counting on familiarisation flights and advert hoc recommendation from the producer. This elevated the chance that show-qualified pilots would fail to establish exceedances in flight crucial parameters and expertise elevated workload.
Security advice to The Australian Site visitors Community Pty Restricted
Security advice quantity: AO-2023-033-SR-02
Security advice description: The Australian Transport Security Bureau recommends that The Australian Site visitors Community Pty Restricted develops a course of to make sure that future software program modifications are communicated and understood by all pilots earlier than commencing operations.
Plane management software program
Security difficulty quantity: AO-2023-033-SI-03
Security difficulty description: Model 3 of the Damoda floor management station software program included a wind velocity readout, however didn’t actively alert the pilot if the wind velocity restrict was exceeded. This elevated the chance {that a} pilot would fail to establish a restrict exceedance and proceed a present into unsafe circumstances.
Security advice to Damoda Clever Management Know-how Co., Ltd
Security advice quantity: AO-2023-033-SR-01
Security advice description: The Australian Transport Security Bureau recommends that Damoda Clever Management Know-how Co., Ltd implements lively wind velocity exceedance alerting within the floor management station software program.
Security motion not related to an recognized security difficulty
Further security motion by The Australian Site visitors Community Pty Restricted
The Australian Site visitors Community Pty Restricted suggested the ATSB that following this incident it carried out a number of modifications to its present planning and conduct processes. These included:
modifications to the crewing necessities to have 2 CASA-approved pilots working each present
institution of a number of go/no-go factors in the course of the launch sequence permitting for extra clearly outlined cease factors
introduction of sterile cockpit procedures to restrict exterior interactions with the flight crew in crucial phases within the lead‑as much as present launch.
Glossary
Sources and submissions
Sources of data
The sources of data in the course of the investigation included:
the distant pilot in command and copilot
The Australian Site visitors Community Pty Restricted
the plane and floor management station software program producer
Civil Aviation Security Authority
one other Australian operator of the kind
floor management station software program display screen recording
Bureau of Meteorology
video footage of the accident flight and different images and movies taken on the day of the accident
References
Federal Aviation Administration. (2022). CFIT and Plan Continuation Bias. Washington DC: United States Division of Transportation.
Ramdeen, A. (2024, 04). Performing Beneath Percieved Stress in Aviation Upkeep. Naval Security Command Aviation Security Weblog.
SKYbrary. (2025, Might). Authority Gradients. Retrieved from SKYbrary:
Transportation Security Board of Canada. (2019). AIR TRANSPORTATION SAFETY INVESTIGATION REPORT A18P0031 Lack of management and collision with terrain Island Specific Air Inc. Beechcraft King Air B100, C-GIAE Abbottsford Airport, British Columbia 23 February 2018. Quebec: Transportation Security Board of Canada.
UK CAA. (2024). VFR Flight Into IMC – CAP 2562. London: UK CAA.
United Kingdom Civil Aviation Authority. (2016). Flight crew human components handbook. West Sussex: United Kingdom Civil Aviation Authority.
Submissions
Beneath part 26 of the Transport Security Investigation Act 2003, the ATSB could present a draft report, on a confidential foundation, to any particular person whom the ATSB considers acceptable. That part permits an individual receiving a draft report back to make submissions to the ATSB concerning the draft report.
A draft of this report was offered to the next immediately concerned events:
distant pilot in command
Australian Site visitors Community Pty Ltd chief distant pilot
Plane and GCS software program producer
Civil Aviation Security Authority
Submissions had been obtained from:
distant pilot in command
Australian Site visitors Community Pty Ltd chief distant pilot
The submissions had been reviewed and, the place thought of acceptable, the textual content of the report was amended accordingly.
Appendices
Appendix A – Floor management station recording abstract
Possession of mental property rights on this publicationUnless in any other case famous, copyright (and every other mental property rights, if any) on this report publication is owned by the Commonwealth of Australia.Inventive Commons licenceWith the exception of the Commonwealth Coat of Arms, ATSB brand, and images and graphics through which a 3rd occasion holds copyright, this report is licensed underneath a Inventive Commons Attribution 4.0 Worldwide licence.The CC BY 4.0 licence lets you distribute, remix, adapt, and construct upon our materials in any medium or format, as long as attribution is given to the Australian Transport Security Bureau. Copyright in materials obtained from different companies, personal people or organisations, belongs to these companies, people or organisations. The place you want to use their materials, you will have to contact them immediately.[1] For a restricted take a look at a smaller set of 10 plane from the principle fleet are used. They’re used to check the system and placement with out the necessity for all 500 plane and the related help crew.
[2] The exclusion zone across the present was a security characteristic in case of an plane difficulty that ensured that spectators weren’t injured by falling plane. It was calculated based mostly on the peak and most velocity of the plane performing the present.
[3] Disarming the plane switched off the plane’s motors.
[4] Ingress safety code is given by a sequence of two digits following the letters IP and signifies how properly a tool is protected towards the ingress of mud and water. The primary digit signifies the extent of safety from stable particle ingress from 0 (no safety) to six (mud tight). The second digit signifies that stage of safety towards water ingress from 0 (no safety) to 9 (protected towards excessive strain water jets and immersion in water).
[5] The minimal exclusion zone was 30 m except in any other case particularly accredited by CASA.
[6] System that measures wind velocity.
[7] The terminal space forecast issued by the BOM is legitimate for areas inside 5 NM of the aerodrome. Subsequently the forecast isn’t formally legitimate for the Victoria Harbour.
Plane Particulars
Producer
DAMODA
Mannequin
Newton 2.2
Plane Operator
The Australian Site visitors Community Pty Ltd
Operation kind
Half 101 Unmanned plane and rockets
Sector
Remotely piloted plane
Departure level
Docklands, North Wharf Street, Victoria
Vacation spot
Docklands, North Wharf Street, Victoria
Harm
Destroyed
Security Points
AO-2023-033-SI-01
No set off in key operational paperwork to make use of climate drone
AO-2023-033-SI-02
Floor Management Station pilot assurance
AO-2023-033-SI-03
Plane management software program
Associated
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