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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 overviewFigure 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 web 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 web 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.
 

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.

 

 

 
 
 

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General details
Date: 21 February 2017 Investigation status: Active 
Time: 8:59 ESuT Investigation type: Occurrence Investigation 
Location   (show map):Essendon Airport Occurrence type:Collision with terrain 
State: Victoria Occurrence class: Operational 
 Occurrence category: Accident 
Report status: Pending Highest injury level: Fatal 
Expected completion: April 2018  
 
Aircraft details
Aircraft manufacturer: Raytheon Aircraft Company 
Aircraft model: B200 
Aircraft registration: VH-ZCR 
Serial number: BB-1544 
Sector: Turboprop 
Damage to aircraft: Destroyed 
Departure point:Essendon, Vic.
Destination:King Island, Tas.

Statement

on Preliminary Report released 29 March 2017
 
 
 
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Last update 02 November 2017