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Safety watchdog works out what caused fatal crash

September 25, 2018 Headline News No Comments Email Email

The Australian Transport Safety Bureau (ATSB) has worked out what led to Victoria’s worst civil aviation accident in 30 years, a crash which killed four American tourists and their pilot when their plane crashed into a shopping centre in Melbourne.

The tragedy coincided with last year’s Asia-Pacific Incentives & Meetings expo (AIME) in Melbourne. Essentially, the cause was pilot error. In a report released yesterday, the ATSB says the pilot took off with a vital control in the wrong position; a mistake which the ATSB says highlights the importance of pilot checklists.


  • The aircraft’s cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
  • The aircraft’s maximum take-off weight was likely exceeded by about 240 kilograms.

Last photo of plane

The ATSB is tasked with investigating such accidents. It’s currently also investigating the seemingly inexplicable crash in Sydney last New Year’s Eve of a Sydney Seaplanes de Havilland Canada DHC-2 Beaver, which killed all six aboard: five British tourists and the pilot. That investigation is still active.

Back to the Melbourne crash, the ATSB found that the pilot failed to notice the aircraft’s rudder trim was in the full nose-left position. As a result, during take-off from Essendon Airport, Victoria, on the morning of 21 February 2017, the twin-engine Beechcraft B200 King Air 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 plane continued curving around to the left and subsequently slammed into the roof of a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport.

The impact destroyed the aircraft and killed the pilot and his four passengers. Two people on the ground received minor injuries.

Television footage from 9News showed the damage

The four American tourists were travelling to Tasmania’s King Island on a golfing trip-of-a-lifetime. The crash occurred under cloudless skies in good conditions.

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, caused a loss of directional control and impaired the aircraft’s climb performance.

ATSB Chief Commissioner, Greg Hood, said the accident highlighted 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,” 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,” Hood stressed.

Written by Peter Needham

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