Aviation safety investigations & reports

Loss of control and collision with terrain involving Cessna 441, VH-XMJ, 4 km west of Renmark Airport, South Australia on 30 May 2017

Investigation number:
AO-2017-057
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 30 May 2017, a twin‑engine Cessna 441 Conquest II (Cessna 441), registered VH-XMJ and operated by AE Charter (trading as Rossair) departed Adelaide Airport, South Australia for a return flight via Renmark Airport, South Australia.

On board the aircraft were:

  • an inductee pilot undergoing a proficiency check, flying from the front left control seat
  • the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
  • a Civil Aviation Safety Authority (CASA) flying operations inspector, observing and assessing the flight from the first passenger seat directly behind the inductee pilot.

Each pilot was qualified to operate the aircraft.

The flight departed Adelaide at about 1524 local time and flew to the Renmark area for exercises related to the check flight, followed by a landing at Renmark Airport. After a short period of time running on the ground, the aircraft departed from runway 25 at about 1614.

A distress beacon broadcast was subsequently received by the Joint Rescue Coordination Centre and passed on to air traffic services at 1625. Following an air and ground search the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.

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.

What's been done as a result

Following the accident, CASA issued a temporary management instruction to provide higher risk protection around operations involving CASA flying operations inspectors. However, at the time of writing these instructions had not been permanently incorporated into regulation.

Safety message

Conducting a simulated engine failure after an actual take-off is a high risk exercise with little margin for error. For that reason, Cessna recommended practicing this sequence in the 441 aircraft at a height of 5,000 ft above ground level to allow the opportunity for recovery in the event that control is lost.

A review of past accidents indicates that, while accidents associated with engine malfunctions are rare, training to manage one engine inoperative flight (OEI) after take‑off is important. The ATSB recommends that such training should follow the manufacturer’s guidance and, if possible, be conducted in an aircraft simulator. If the sequence is conducted in the aircraft close to the ground then effective risk controls need to be in place to prevent a loss of control as recovery at low height will probably not be possible. Such defences include:

  • defined OEI performance criteria that, if not met, require immediate restoration of normal power
  • use of the appropriate handling techniques to correctly simulate the engine failure and ensure that aircraft drag is minimised/OEI performance is maximised
  • ensuring that the involved pilots have the appropriate recency and skill to conduct the exercise and that any detrimental external factors, such as high workload or pressure, are minimised.
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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Pilot details

Sources and submissions

Preliminary report

Preliminary report published: 30 June 2017

At about 1503 CST[1] on 30 May 2017, Cessna 441 Conquest aircraft, registered VH-XMJ (XMJ), and operated by Rossair Charter, departed Adelaide International Airport, for Renmark Airport, South Australia.

On-board were:

  • an inductee pilot undergoing a proficiency check, flying from the front left control seat
  • the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
  • a flying operations inspector from the Civil Aviation Safety Authority, observing and assessing the flight from the first passenger seat directly behind the two control seats.

Each occupant was qualified to operate the Cessna 441.

On departure, XMJ climbed to about 17,000 ft above mean sea level, and was cleared by air traffic control (ATC) to a tracking waypoint RENWB, which was the commencement of the Renmark runway 07[2] RNAV-Z GNSS[3] approach. The pilot of XMJ was then cleared to descend, and notified ATC that they intended to carry out airwork in the Renmark area. The pilot further advised that they would call ATC again on the completion of the airwork, or at the latest by 1615. No further transmissions from XMJ were recorded on the area frequency and the aircraft left radar coverage as it descended towards waypoint RENWB.

The common traffic advisory frequency used for air to air communications in the vicinity of Renmark Airport recorded several further transmissions from XMJ as the crew conducted practice holding patterns, and a practice runway 07 RNAV GNSS approach. At the completion of the approach, the aircraft circled for the opposite runway and landed on runway 25, before backtracking the runway and lining up ready for departure. Although outside radar coverage, position and altitude information continued to be transmitted via OzRunways[4], operating on an iPad in the aircraft. The weather information recorded at Renmark around this time was clear skies, south-to-south westerly winds of about 9 kt, and a temperature of 13°C.

At 1614, the common traffic advisory frequency recorded a transmission from the pilot of XMJ stating that they would shortly depart Renmark using runway 25 to conduct further airwork in the circuit area of the runway. A witness at the airport reported that, prior to the take‑off roll, the aircraft was briefly held stationary in the lined‑up position with the engines operating at significant power. The take-off roll was described as normal however, the witness looked away before the aircraft became airborne.

Figure 1: Position information of VH-XMJ as the aircraft circled and landed on runway 25 (depicted in red), before backtracking and departing (depicted in green).

Figure 1: Position information of VH-XMJ as the aircraft circled and landed on runway 25 (depicted in red), before backtracking and departing (depicted in green).

Source: OzRunways

Position and altitude information obtained from OzRunways showed the aircraft maintained runway heading until reaching about 400 ft, before veering to the right of the extended runway centreline. The aircraft continued to climb to about 700 ft prior to levelling off for about 30 seconds, and then descending to about 600 ft. The information ceased 5 seconds later, about 60 seconds after take-off. The last recorded information had the aircraft at an altitude of 600 ft, and 22 degrees to the right of the runway extended centreline. The aircraft wreckage was located 228 m to the north-west of the last recorded position, about 3 km from the take-off point.

Figure 2: Altitude information of VH-XMJ – (each vertical line represents 5 seconds)

Figure 2: Altitude information of VH-XMJ – (each vertical line represents 5 seconds)

Source: OzRunways

On-site examination of the wreckage and surrounding ground markings indicated that the aircraft impacted terrain in a very steep (almost vertical) nose‑down attitude, and came to rest facing back towards the departure runway. The horizontal and vertical tail surfaces and empennage separated from the main cabin directly behind the rear pressure bulkhead, and the cockpit and instrument panel were extensively damaged. The remaining aircraft cabin had separated from the wing. The left hand propeller blades separated at the propeller hub. The right hand propeller blade tips separated, however the blades remained attached to the hub. A strong smell and presence of jet fuel was evident at the accident site, however there was no evidence of fire. The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to be.

Both engine, gearbox and propeller assemblies, along with several other components and documentation, were removed from the accident site for further examination by the ATSB.

The investigation is continuing and will include examination of:

  • recovered components and available electronic data
  • aircraft, operator, and maintenance documentation and procedures
  • flight crew information
  • flight manoeuvres being carried out during the check flight and flight characteristics of the aircraft
  • aircraft weight and balance
  • risk assessments carried out when planning the flight
  • previous research, and similar occurrences.

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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.

 

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  1. Central Standard Time (CST) was Universal Calibrated Time (UTC) +9.5 hours
  2. Runway number: the number represents the magnetic heading of the runway.
  3. An RNAV approach is a method of navigation utilising GPS that enables a pilot to guide his aircraft to a landing in low visibility situations. It is often practiced during check flights to ensure proficiency.
  4. OzRunways is an electronic flight bag application that provides navigation, weather, area briefings, and other flight planning information.
General details
Date: 30 May 2017   Investigation status: Completed  
Time: 1615 CST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): 4 km west of Renmark Airport   Investigation phase: Final report: Dissemination  
State: South Australia   Occurrence type: Collision with terrain  
Release date: 30 April 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 441  
Aircraft registration VH-XMJ  
Serial number 441-0113  
Operator AE Charter, trading as Rossair  
Type of operation Charter  
Sector Turboprop  
Damage to aircraft Destroyed  
Departure point Renmark Airport, South Australia  
Destination Adelaide Airport, South Australia  
Last update 30 April 2020