What Happened
On the morning of April 6, 2023, a chartered GippsAero GA8 Airvan, registered VH‑TBU and operated by Shine Aviation Services, departed from Geraldton Airport for the Rat Island aircraft landing area in the Houtman Abrolhos Islands, Western Australia. The aircraft carried a pilot and six passengers. During the landing on runway 18, the aircraft failed to stop before the edge of the island and tipped into shallow seawater. All occupants were uninjured. The aircraft was substantially damaged.
ATSB Findings
The Australian Transport Safety Bureau (ATSB) determined that the aircraft was unstable during the approach due to excessive height and airspeed. The aircraft floated for a significant time during the landing and touched down approximately halfway down the runway, leaving insufficient remaining distance to stop. The pilot recognized opportunities to conduct a go-around when they noticed they were not on the correct approach profile but did not execute one.
The approach was steeper than normal. Although the pilot identified this and took corrective action, flight analysis showed the aircraft arrived at the threshold both high and fast. The ATSB considered whether the pilot's seating position affected their approach perspective but deemed any significant effect unlikely because the pilot had identified the steep profile.
The aircraft touched down well into the runway at a recorded groundspeed of 77 knots. The pilot recalled that the aircraft's airspeed was slightly below the reference speed (Vref) of 70 knots, indicating a tailwind component. Skid marks on the runway showed that the brakes had been applied and the wheels had locked, which reduced stopping effectiveness compared to modulated braking and flap retraction. The ATSB considered it unlikely that braking capacity was affected by the seating configuration or low hydraulic fluid in the brake master cylinder.
Opportunities to go-around existed before landing and during touchdown. The pilot recalled considering a go-around when pushing the nose down to intercept the profile, but expected to regain the correct profile and airspeed prior to landing. After wheel contact, the pilot again considered a go-around but assessed the airspeed as below the take-off speed of 70 knots, raising concern about stalling over the water.
The ATSB also found that the pilot was possibly experiencing mild to moderate acute fatigue due to restricted sleep in the previous 24 and 48 hours and a lack of sustenance that morning. Fatigue can impair decision-making and reaction time. However, the ATSB could not definitively conclude whether fatigue affected the pilot's decision not to conduct a go-around. The operator's procedures for sleep arrangements during split-shift duty periods were reviewed; sign-on and sign-off times accounted for commuting and aircraft preparation.
Safety Actions Taken
Shine Aviation Services implemented safety actions to improve pilot training on landing and late-stage go-around procedures for their single- and multi-engine piston aircraft. An increased oversight program was also introduced to provide more regular mentoring for junior flight crew.
Safety Message
The ATSB noted that this incident highlights how an unstable approach can increase the risk of a runway excursion. They emphasized that pilots should be prepared to conduct a go-around if stabilised approach criteria are not met. The later the decision to go-around is made, the more likely additional hazards will need to be managed.