The Australian Transport Safety Bureau’s (ATSB) final report into the loss of control and collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR, highlights the importance of following a cockpit checklist.
During take-off from Essendon Airport, Victoria, on the morning of 21 February 2017, the aircraft diverged to the left of the runway centreline.
Having reached a maximum altitude of 160 feet (49 metres) above ground level, the aircraft began to descend with an increasing left sideslip. The aircraft subsequently collided with the roof of a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport.
The aircraft was destroyed by the impact. The pilot and four passengers were fatally injured. Two people on the ground received minor injuries.
The ATSB’s investigation 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, which assists a pilot with controlling an aircraft’s movement around the vertical axis, resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance.
ATSB Chief Commissioner, Mr Greg Hood said this accident emphasised the importance of having a cockpit checklist in place applicable to an aircraft’s specific and current modification status.
“Checklists are a part of every pilot’s pre-flight risk management plan and are an essential tool for overcoming limitations of the human memory,” Chief Commissioner Hood said.
“Checklists ensure action items are completed in sequence and without omission. In this particular tragic accident there were opportunities in the checklist that existed for the pilot to ensure the rudder trim was set to neutral prior to take-off.”
In addition to the importance of using a checklist, this accident also emphasises the challenges associated with decision-making during critical stages of a flight.
“Pilots need to carefully consider their decision-making, particularly during critical phases of flight, such as take-off,” Chief Commissioner Hood said.
Last update 16 November 2018