Report out.
https://www.atsb.gov.au/publications...r/ao-2017-057/What the ATSB found
The ATSB determined that, following a simulated failure of one of the aircraft’s engines at about 400 ft above the ground during the take‑off from Renmark, the aircraft did not achieve the expected single engine climb performance or target airspeed. As there were no technical defects identified, it is likely that the reduced aircraft performance was due to the method of simulating the engine failure, pilot control inputs or a combination of both.
It was also identified that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained. That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats. Consequently, about 40 seconds after initiation of the simulated engine failure, the aircraft experienced an asymmetric loss of control.
The single engine failure after take‑off exercise was conducted at a significantly lower height above the ground than the 5,000 ft recommended in the Cessna 441 pilot’s operating handbook. This meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground.
While not necessarily contributory to the accident, the ATSB also identified that:
- The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
- The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot. Therefore, despite having significant experience in Cessna 441 operations, he had reduced ability to actively monitor the flight and communicate any identified problem.
- The inductee and chief pilot, while compliant with recency requirements, had limited recent experience in the Cessna 441 and that probably led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
- The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
- The Civil Aviation Safety Authority’s method of oversighting Rossair in the several years prior to the accident increased the risk that organisational issues would not be identified and addressed.
Finally, a lack of recorded data from this aircraft reduced the available evidence about pilot handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.