King Air down at Essendon?
I’ve heard the Giant Flying Spaghetti Monster’s Noodly Appendage was responsible for causing a loss of power in one engine. (Which kinda shows why a timely report by an expert investigatory body can be useful.)
It would explain why the aircraft ended up taking out runway lights before even making it airborne. Doesn't explain why there wasn't an abort.
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Some pilots are want to wind in a lot of rudder trim in the event of an asymmetric event..so what if the trim was fully applied?
" That examination found that the cores of both engines were rotating and that there was no evidence of pre-impact failure of either engine’s internal components."
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" That examination found that the cores of both engines were rotating and that there was no evidence of pre-impact failure of either engine’s internal components."
I have heard that the rudder trim was found set hard left, FWIW.
It took the ATSB a while to work that out.
Date of Report: 21 June 2007.
Over 2 years seems about par for the ATSB course.
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Lookleft, the Tamworth accident has stayed with me. I knew the pilot and was one of the witnesses interviewed by the ATSB in that report.
While it is a great report I have always had lingering doubts about the findings which have not always sat well with me. There is an element to accidents where we may not always conclusively know everything after the event.
For example: "During the on-site examination of the wreckage, investigators located a number of tools including a damaged hand tool (Figure 6) that would not normally be expected to be carried on the aircraft."
...and: "The location of the bent hand tool in the wreckage raised the possibility that it may have contributed to the flight control difficulty. Despite the tool being found in the wreckage, it was not possible to establish whether it was in an internal section of the aircraft that contained part of a primary flight control system or when it had been introduced.
The bending damage to the tool was found to be consistent with severe impact and breakup forces and there was no evidence that the tool had interfered pre-impact with a control system. Such evidence, however, may not have been detectable post-accident."
The report investigates a number of possible probable causes, control interference, trim runaway, autopilot problem, and trim settings. In this case they concluded the report with what they believed to be a 'most probable' cause although other factors certainly cannot be ruled out:
"The limited evidence did not allow the investigation to be certain about the existence of abnormal rudder and/or aileron trim settings during the flight. However, in the absence of any other likely factor and with supporting evidence, the investigation considered that the pilot probably took off with abnormal rudder and/or aileron trim settings and with increasing airspeed, was unable to maintain control."
Flying over the smoking hole in the ground, attending the funeral of a talented young man with his devastated young bride dressed in black, grieving with the family over a life cut all too short (he wasn't even supposed to have been flying that day) stays in ones memory... RIP Jason C.
Be ever vigilant out there folks...
While it is a great report I have always had lingering doubts about the findings which have not always sat well with me. There is an element to accidents where we may not always conclusively know everything after the event.
For example: "During the on-site examination of the wreckage, investigators located a number of tools including a damaged hand tool (Figure 6) that would not normally be expected to be carried on the aircraft."
...and: "The location of the bent hand tool in the wreckage raised the possibility that it may have contributed to the flight control difficulty. Despite the tool being found in the wreckage, it was not possible to establish whether it was in an internal section of the aircraft that contained part of a primary flight control system or when it had been introduced.
The bending damage to the tool was found to be consistent with severe impact and breakup forces and there was no evidence that the tool had interfered pre-impact with a control system. Such evidence, however, may not have been detectable post-accident."
The report investigates a number of possible probable causes, control interference, trim runaway, autopilot problem, and trim settings. In this case they concluded the report with what they believed to be a 'most probable' cause although other factors certainly cannot be ruled out:
"The limited evidence did not allow the investigation to be certain about the existence of abnormal rudder and/or aileron trim settings during the flight. However, in the absence of any other likely factor and with supporting evidence, the investigation considered that the pilot probably took off with abnormal rudder and/or aileron trim settings and with increasing airspeed, was unable to maintain control."
Flying over the smoking hole in the ground, attending the funeral of a talented young man with his devastated young bride dressed in black, grieving with the family over a life cut all too short (he wasn't even supposed to have been flying that day) stays in ones memory... RIP Jason C.
Be ever vigilant out there folks...
I know what you felt and continue to feel about losing a colleague and friend CN. My first attendance at a pilot's funeral was at age 24 and that is a long time ago. There were quite a few after that. Never gets easy. No report is easy to read when it involves someone you know.
... I have always had lingering doubts about the findings which have not always sat well with me.
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I have also heard the rumours that the rudder trim was found fully hard over to the left. It may have been but who knows if it was that way prior to impact. I very much doubt the rudder trim theory. From my experience I would suspect that the aircraft is almost impossible to keep straight and would very quickly veer off the runway resulting in an abort. I have experienced the friction nut scenario in the aircraft during an early morning take off and it definitely gets your attention. I have run the Essendon loose friction nut scenario in the Sim and ended up very close to the same spot as old mate.
Groggy
Groggy
I owe ATSB an apology. They brought this one in before the two year mark.
ATSB is handing down its report...not good for pic. Rudder trim and takeoff weight.
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Synopsis of the ATSB report:
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.
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.
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:
https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/
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/
