King Air down at Essendon?

[Airbubba]

Synopsis of the ATSB report:

What happened

On the morning of 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania with four passengers on board.

The aircraft’s take-off roll was longer than expected and a yaw to the left was observed after rotation. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. The aircraft entered a shallow climb followed by a substantial left sideslip with minimal roll. The aircraft then began to descend and the pilot transmitted a Mayday call. The aircraft subsequently collided with a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport.

The aircraft was destroyed by the impact and post-impact fire, and all on board were fatally injured. The building was severely damaged and two people on the ground received minor injuries.

What the ATSB found

The ATSB found that the pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to take-off. The position of the rudder trim resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance in the latter part of the flight.

At the time of the accident, the operator did not have an appropriate flight check system in place for VH-ZCR. Although this did not contribute to this accident, it increased the risk of incorrect checklists being used, incorrect application of the aircraft's checklists, and checks related to supplemental equipment not being performed.

The aircraft’s cockpit voice recorder did not record the accident flight due to a tripped ‘impact switch’, which was not reset prior to the accident flight. This deprived the investigation of potentially valuable recorded information.

The ATSB determined that the aircraft was operated above its maximum take-off weight on the accident flight. This was not considered to have influenced the accident.

The ATSB also found that the presence of the building struck by the aircraft did not increase the severity of the consequences of this accident. In the absence of that building, the aircraft’s flight path would probably have resulted in an uncontrolled collision with a busy freeway, with the potential for increased ground casualties.

Although not contributing to this accident, the ATSB identified that two other buildings within the retail precinct exceeded the airport’s obstacle limitation surfaces. While those exeedances had been approved by the Civil Aviation Safety Authority, the ATSB identified several issues relating to the building approval process for the precinct.

What's been done as a result

It is beyond the scope of this investigation to consider in detail the issues identified with the Bulla Road Precinct building approval processes. These issues will be addressed in the current ATSB Safety Issues investigation The approval process for the Bulla Road Precinct Retail Outlet Centre AI-2018-010.

Safety message

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 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. This accident highlights the critical importance of appropriately actioning and completing checklists.

This accident also emphasises the importance of having flight check systems in place that are applicable to specific aircraft in their current modification status. In addition, it emphasises:

• the value of cockpit voice recorders
• the significance of ensuring aircraft weight and balance limitations are not exceeded
• the challenges associated with decision-making in critical stages of a flight such as the take-off ground roll.

https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/