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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 exceedances 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.

Beechcraft B200 King Air aircraft, registered VH-ZCR immediately prior to collision with a building in the Bulla Road Precinct

VH-ZCR immediately prior to collision with a building in the Bulla Road Precinct
Source:  Supplied

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The occurrence

Context

Safety analysis

Findings

General details

Sources and submissions

Appendices

Australian Transport Safety Bureau

 

Preliminary report: 29 March 2017

The occurrence

On 21 February 2017, the pilot of a Beechcraft King Air B200, registered VH-ZCR, was conducting a flight from Essendon Airport, Victoria to King Island, Tasmania. On board were the pilot and four passengers. The weather was fine with a recorded wind speed of 5 kt (9 km/h) from the north‑north‑west and a temperature of 12 °C.

Witnesses familiar with the aircraft type reported that the take-off roll along runway 17[1] was longer than normal. After becoming airborne, the aircraft was observed to yaw[2] left. The aircraft performed a shallow climbing left turn while maintaining a relatively level pitch[3] and roll[4] attitude. Airservices Australia Automatic Dependent Surveillance Broadcast (ADS-B) data[5] indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline (Figure 1). The aircraft subsequently collided with a building in the Essendon Airport retail precinct.

The pilot and passengers were fatally injured and the aircraft destroyed. Additionally, a number of people on the ground received minor injuries.

Figure 1: Aircraft track from Airservices Australia ADS-B data. All heights above ground level

Figure 1: Aircraft track from Airservices Australia ADS-B data. All heights above ground level 

Source: Google earth, modified by the ATSB

Wreckage and impact information

The aircraft collided with the roof of the building and associated concrete parapet before coming to rest in the building’s rear car park (Figures 2 and 3). Examination of the significantly fire- and impact‑damaged wreckage determined that, at impact the:

  • aircraft was configured with 10° of flap
  • landing gear was in the extended and locked position.

Examination of the building roof showed evidence of propeller slash marks and nose and main gear tyre marks (Figure 3). Those marks were consistent with the aircraft having significant left yaw and a slight left roll at initial impact.

Figure 2: Accident site overview

Figure 2: Accident site overview

Source: Metropolitan Fire Brigade (Melbourne), modified by the ATSB

On-site examination of the wreckage did not identify any pre-existing faults with the aircraft that could have contributed to the accident.

The left and right engines separated from their mounts during the impact sequence. Both engines had varying degrees of fire and impact damage. The engines were removed from the accident site to a secure facility where they were disassembled and inspected by the ATSB with assistance from the engine manufacturer. 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. However, a number of engine components were retained for further examination and testing.

The propellers separated from the engines during the impact sequence. Both propellers exhibited evidence of rotation and have been retained by the ATSB for detailed examination. The ATSB also retained several airframe components, documents and electronic devices for further examination.

Figure 3: Accident site building roof overview
Figure 3: Accident site building roof overview

Source: Metropolitan Fire Brigade (Melbourne), modified by the ATSB

Recorded information

Cockpit voice recorder

A Fairchild model A100S cockpit voice recorder (CVR), part number S100-0080-00 and serial number 01211, was fitted to the aircraft. This model of recorder uses solid-state memory to record cockpit audio and has a recording duration of 30 minutes. CVRs are designed on an ‘endless loop’ principle, where the oldest audio is continuously overwritten by the most recent audio. Apart from pilot speech and radio transmissions, CVRs can record control movements (for example flap and gear levers), switch activations, aural warnings and background sounds such as propeller and engine noise.

The aircraft’s fire‑damaged CVR was recovered from the accident site and transported to the ATSB’s technical facility in Canberra, Australian Capital Territory on 23 February 2017 for examination and download (Figure 4).

Figure 4: Comparison of an undamaged Fairchild model A100S CVR (top) with the CVR from VH-ZCR (bottom)

Figure 4: Comparison of an undamaged Fairchild model A100S CVR (top) with the CVR from VH-ZCR (bottom)
Source: ATSB

The CVR from VH-ZCR was disassembled and the memory board was removed from inside the crash-protected memory module. The memory board was undamaged (Figure 5).

Figure 5: Memory board (removed from inside the crash-protected module)

Figure 5: Memory board (removed from inside the crash-protected module)

Source: ATSB

The CVR was successfully downloaded however, no audio from the accident flight was recorded. All the recovered audio was from a previous flight on 3 January 2017. The ATSB is examining the reasons for the failure of the CVR to operate on the accident flight.

Air traffic control audio

Examination of the recorded air traffic control radio calls for Essendon Tower on 21 February 2017 revealed that, shortly after take-off, the pilot broadcast a MAYDAY call.[6] The pilot repeated the word ‘MAYDAY’ seven times within that transmission. No additional information regarding the nature of the emergency was broadcast.

Further investigation

The investigation is continuing and will include:

  • examination of both propellers to determine the blade angles at impact, their pre-impact condition and to assess the impact damage
  • further examination of a number of retained engine and airframe components
  • further interviews with a number of witnesses and involved parties
  • further analysis of numerous witness reports
  • review of the aircraft’s maintenance and operational records
  • review of the meteorological conditions at the time
  • review of the approval process for the building that was struck by the aircraft
  • analysis of aircraft performance and other operational factors
  • review of the pilot’s medical and flying history
  • review of the operating processes and approvals
  • determining the reasons for the failure of the CVR to record during the accident flight
  • further analysis of recorded information, including:
    - Automatic Dependent Surveillance Broadcast data
    - dash camera and other video footage provided by witnesses
    - closed-circuit television video footage
    - air traffic control audio recordings.

Identification of safety issues

Should any significant safety issues be identified during the course of the investigation, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations. This will allow those parties to develop safety action to address the safety issues. Details of such safety issues, and any safety action in response, will be published on the ATSB website at www.atsb.gov.au.

 

_________
The information contained in this update is released in accordance with section 25 of the
Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this update.

 

__________

  1. Runway number: the number represents the magnetic heading of the runway. The runway identification may include L, R or C as required for left, right or centre.
  2. The motion of an aircraft about its vertical or normal axis.
  3. The movement of an aircraft about its lateral axis.
  4. The movement of an aircraft about its longitudinal axis.
  5. ADS-B data is transmitted from the aircraft multiple times a second and includes Global Positioning System latitude, longitude, groundspeed, track angle, vertical speed and pressure altitude. Estimated heights have been derived from the pressure altitude data, after barometric correction, and terrain elevation data. The resolution of pressure altitude data was 25 ft.
  6. MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.
 
 

Download Download: Video animation AO-2017-024 [MP4: 62MB] Credit: ATSB

Download Essendon King Air report_Greg Hood ATSB.mp4 [MP4: 270.07MB]

Download Essendon report_Greg Hood_ATSB-1.mp3 [MP3: 97KB]

Download Essendon report_Greg Hood_ATSB-2.mp3 [MP3: 158KB]

Download Essendon report_Greg Hood_ATSB-3.mp3 [MP3: 173KB]

Download Essendon report_Greg Hood_ATSB-4.mp3 [MP3: 420KB]

 

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Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

 

Updated: 9 February 2018

The investigation into this accident has been completed and a draft report is in the final stages of completion. The report will soon undergo a review by the ATSB’s Commission and by Directly Involved Parties (DIPs), which is a process that enables checking of factual accuracy and ensures natural justice. It has been necessary to extend the completion date for this investigation due to a number of factors, including accommodating the involvement of international DIPs, who have up to sixty days to comment under international conventions.

As with any ATSB investigation, if a critical safety issue is identified during the course of an investigation, it is immediately brought to the attention of the relevant parties so that appropriate safety action can be taken

 

Updated: 17 March 2017

After spending an extended period on-site, the ATSB investigation team is now preparing a preliminary investigation report into the tragic accident at Essendon Airport. The time on-site has allowed the team to collect a large volume of evidence from a number of closed-circuit television sites and many witness statements.

The team has also extensively examined the aircraft wreckage. Importantly, with assistance from our colleagues at the United States National Transportation Safety Board, the Federal Aviation Administration, and the engine manufacturer, the ATSB was able to disassemble and examine both of the aircraft’s engines.

While the ATSB’s standard practice is to publicly release a preliminary factual report within 30 days of any major accident, the preliminary report release will be slightly delayed due to the extensive on-site activities required for this investigation. It is anticipated that the preliminary report will be released to the public in the week commencing 27 March 2017.

 

Updated: 24 February 2017

The ATSB investigation team is expected to complete the examination of the accident site today (Friday, 24 February).

A number of components including the aircraft’s engines and propellers have been recovered for detailed examination at Essendon Airport. This will take place into next week.

The team has conducted a number of interviews with witnesses and recovered CCTV footage for further review.

The aircraft’s cockpit voice recorder has been delivered to the ATSB’s technical facilities in Canberra for download and analysis.

During the next week, the investigation team will review the weather conditions at the time of the accident and process the large amount of witness statements sent in to the ATSB. The ATSB thanks all the witnesses who have submitted their accounts of this tragic accident.

Further updates will be posted as significant information comes to hand.

 

21 February 2017

The ATSB is investigating the collision with terrain involving B200 King Air registered VH-ZCR at Essendon Airport, Melbourne, Victoria, on 21 February 2017.

The ATSB has deployed a team of four investigators to the accident site and are expected to arrive on site this afternoon. 

The investigators will assume responsibility for the secured site, once it has been made safe.

The ATSB team consists of four investigators (one from Brisbane, three from ATSB headquarters in Canberra) to work on-site with specialties in:

  • Aircraft mechanical engineering,
  • Operations, and
  • Engineering.

The onsite investigation will involve:

  • examining the site and wreckage
  • gathering recorded data including radio and radar
  • interviewing witnesses.

Witnesses are requested to contact the ATSB on 1800 020 616 or email ATSBinfo@atsb.gov.au.

 

 
General details
Date: 21 February 2017 Investigation status: Completed 
Time: 0858 EDT Investigation phase: Final report: Dissemination 
Location   (show map):Essendon Airport Investigation type: Occurrence Investigation 
State: Victoria Occurrence type: Collision with terrain 
Release date: 24 September 2018 Occurrence class: Operational 
Report status: Final Occurrence category: Accident 
 Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Raytheon Aircraft Company 
Aircraft model: Beechcraft King Air B200  
Aircraft registration: VH-ZCR 
Serial number: BB-1544 
Type of operation: Charter 
Sector: Turboprop 
Damage to aircraft: Destroyed 
Departure point:Essendon, Vic.
Destination:King Island, Tas.

Related link

Statement final report released 24 September 2018
 
 
 
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Last update 26 September 2018