A PILOT’S failure to notice that a rudder trim was in full nose-left position caused a Bendigo-owned small plane to crash into Essendon DFO killing five people in February last year, the Australian Transport Safety Bureau found.
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The oversight caused the Beechcraft B200 Super King plane to “yaw” left on takeoff and enter into a shallow climb before starting to descend.
The plane’s operator – Corporate and Leisure Aviation – did not have an “appropriate flight check system in place” and the fault was not detected, but the ATSB did not say this contributed to the crash. An appropriate checklist would require the rudder trim to be checked five times.
A cockpit voice recorder was also not switched on, leaving investigators without potentially valuable information, and the plane was operating above its maximum take-off weight. This was also dismissed as a cause of the crash.
The report makes no reference to Bendigo-based company BB1544, which was listed as owning the plane at the time. Its directors are Andrew Hoare and MyJet’s Dr Chris Richards.
The owners cooperated with investigators at all times and no engine failure was detected.
Background:
The final report – released on Monday – highlighted the “critical importance” of flight checklists.
“Cockpit checklists are an essential tool for overcoming limitations with pilot memory, and ensuring that action items are completed in sequence and without omission,” the report states.
“The improper or non-use of checklists has been cited as a factor in some aircraft accidents.
“Research has shown that this may occur for varying reasons and that experienced pilots are not immune to checklist errors.”
Corporate and Leisure Aviation was solely operated by the pilot, Max Quartermain, 63. He intended to fly four American passengers to King Island, a 36-minute flight.
A pilot who worked with Mr Quartermain told the ATSB he was a “one-man show” and he had little “outside influence” or much checking.
The flight was booked by a golf tour company which had used Mr Quartermain’s services in the past.
A non-compliance notice was issued to Corporate and Leisure Aviation just over one year before the crash and compliance was achieved in December, 2016.
As part of the crash investigation, a pilot performed the exact same flight using a flight simulator with the full left rudder trim on.
The pilot found controlling the aircraft was “challenging” up to 140 knots before it became “uncontrollable”. They found the takeoff should have been rejected when it became apparent the plane was veering left.
Bendigo owners say report clears plane maintenance record
The Bendigo-based owners of the small plane say the ATSB’s report has cleared its maintenance record, which was found to have played no role in the fatal crash.
In a statement, co-directors of BB1544 Dr Chris Richards and Andrew Hoare hoped the report would improve safety in the future and prevent further tragedies.
“The ATSB did not identify any pre-impact faults that may have contributed to the accident. A review of the maintenance documentation by ATSB did not reveal any anomalies that may have contributed to the accident,” the statement read.
“These finding support our position that the aircraft was exceptionally maintained and that no mechanical or structural faults contributed to the accident.
“We hope that the safety messages that come from this report improve aviation safety and prevent the occurrence of similar tragic events.”
Witnesses saw left turn during flight takeoff
Witnesses with intimate knowledge of small aircraft told investigators they noticed the plane turning to the left after it took off from Essendon airport just before 9am on February 21 last year.
Its takeoff from the runway was also described as “longer than expected” and its climb was shallow. The landing gear remained down.
“The witness then observed the aircraft stop climbing and adopt an almost level attitude, which coincided with the left yaw increasing,” the report stated.
“The witness stated the aircraft was going ‘extremely slow’ and was almost ‘floating’.”
The plane maintained a role of less than 10-degrees to the left and reached a height of 160 feet.
As the left sideslip continued and the plane started to descend, the pilot repeated “mayday” seven times to the Essendon tower.
It collided with Essendon DFO 10 seconds after takeoff, and two seconds after the “mayday” message was transmitted.
Experienced pilot Max Quarterman was killed in the crash, along with American tourists Greg Reynolds De Haven, Glenn Garland, John Washburn and Russell Munsch.
It was Victoria’s worst air disaster in 30 years.
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