Wind caused 427 drones to plummet into Yarra River

The incident saw divers dispatched to try and rescue the drowned devices, though 191 eventually remained sunk to the bottom of the water.

In a final report, investigators concluded the pilot in command was not aware that the wind speed affecting the drones could be viewed on the computer software.

“As the errors cascaded, drones were observed to be out of position and colliding with one another,” Angus Mitchell, chief commissioner of the ATSB, said.

The drone light show was due to take place on 14 July 2023, immediately before the Matildas’ friendly game against France at Docklands Stadium in Melbourne.

The swarm consisted of 500 Damoda Newton V2.2 drones, operated by Australian Traffic Network.

Shortly after launching the swarm, the remote pilot in command (RPIC) identified both visually and from errors displayed on their ground control station (GCS) computer that multiple drones were out of position.

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Despite the errors, the drones automatically began to move from the launch location to the show area, over the water. During this transition, further errors appeared on the GCS computer, with increasing severity.

As the drones began crashing into each other, the RPIC commanded the swarm to loiter and hold position, and attempted to return those with the most significant errors to the launch site individually.

While multiple drones were in the loiter, the GCS computer lost connection to almost 400, with the majority descending into the harbour below. Of the 500 drones, 427 were lost.

The ATSB’s investigation found the drones had encountered wind conditions exceeding their published capability shortly after launch, triggering collisions and a variety of technical errors.

“The wind limit exceedance was not identified by the RPIC as they were unaware that the wind speed affecting the aircraft was displayed on the GCS computer screen,” Mitchell said.

The investigation noted the operator did not have a system to ensure all of its pilots could use all of the GCS software’s features, increasing the risk of show-qualified pilots failing to identify exceedances and increasing workload in the lead‑up to the show.

The operator has implemented several safety actions, including training improvements, the addition of a requirement for two CASA-approved pilots to operate every show, and wind speed test flights using individual aircraft to take place before flights.

The ATSB’s final report also notes that the GCS computer software did not have the functionality to actively alert a pilot to wind speed exceedances.

The manufacturer, Damoda, said it is considering an update to enable such alerts.

“This incident demonstrates the importance of drone pilots being familiar with all functionality and data provided by relevant ground control software,” Mitchell said. “It also shows the impact human factors can have on drone operations, and how they should be actively considered and managed.”

While the risk profile may differ from that of crewed operations, Mitchell noted that factors such as workload and operational pressure can equally impact drone operations.

“Operators should have systems in place to ensure that pilots are familiar with system functionality, and they should ensure operational documentation, including checklists, carry the relevant prompts for flight crews to gather all necessary information to assist their decision-making process.”

“Compliance with operational guidelines and limitations set or approved by the regulator are critically important to minimise risk to both the operation and the public.”