Aircraft Crash Essendon YMEN

[Kurt A]

Original reports of an Air Ambulance Crash after take off at Essendon Airport this morning.

Now reported as a King Island flight, 5 seater charter aircraft.

More info to come.

https://uploads.tapatalk-cdn.com/20170220/75399cda043e9961f7fdcd9f76c34146.jpg

[MarkR]

Maybe a rethink of having retail operations within an airport boundary might be in order longer term?

[Rob Fluke]

This might be the flight/acft, http://flightaware.com/live/flight/VHZCR

[Kurt A]

Seems correct Flukey.

https://uploads.tapatalk-cdn.com/20170221/07aa80bae80edbead303fd2eea81bb9d.jpg

[Philip Argy]

Reports coming in now of a Mayday call to the effect that there was left engine total failure on takeoff from runway 17 and insufficient power to clear the DFO building with a left wing down stall whilst attempting to return to Essendon for an emergency landing, the left wing slicing open the flat steel roof of the building and the a/c flipping off the roof at the back of the Focus on Furniture store loading dock.

An aircraft wheel was seen crossing the adjacent Tullamarine Freeway and the southbound lanes are to be closed pending ATSB inspection/photography of debris across the freeway.

From aerial views of the remains of the fuselage the fire seems to have completely incinerated 95% of the a/c, with only a fragment of nose and tail discernable, and the boarding stairs framework oddly poking up in the remains.

From all accounts there is no explanation for why the twin turboprop King Air with only 5 people aboard and one engine failure could not sustain flight and altitude sufficient for an emergency return to the airfield.

[MarkR]

Way too early for speculation, but there would appear to be some parallels with Advance Airlines Flight 4210 incident at YSSY, including the fact I suspect its the port engine that possibly failed, single pilot ops and aircraft was turning into the dead engine.

[Kurt A]

http://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/

[Robert S]

Ten News has published dashcam footage from a vehicle which appears to be travelling northbound on Bulla Road, just on the overpass over the Tullamarine Freeway.

https://twitter.com/channeltennews/status/833884749802254336

[Zac M]

Maybe a rethink of having retail operations within an airport boundary might be in order longer term?

It could have easily been an airport terminal.....why dont we we rethink having those within an airport boundary as well :rolleyes:

[MarkR]

Zac, the terminals are placed within ICAO and CASA guidelines with regard airport design, the DFO at Essendon and indeed the one at Canberra are not. RESA and clear ways are there for a reason.

[Rowan McKeever]

Zac, the terminals are placed within ICAO and CASA guidelines with regard airport design, the DFO at Essendon and indeed the one at Canberra are not.

Whilst you're correct, Zac is too. It's all well and good to say terminals are located in accordance with ICAO and CASA guidelines, but take a look at the FR24 track of today's accident aircraft and you would find that the same situation occurring:
* on SYD's RWY07, would have the aircraft in T2;
* on DRW's RWY11, would have the aircraft in or very close to the terminal;
* on MEL's RWY16, would have the aircraft in the international terminal;
* on ADL's RWY05, would have the aircraft in or close to the terminal, etc.

[Robert.M]

Albury Airport has quit a bit of development to its west, a couple of houses to the east appox. 2km from the end of the runway but development is slowly growing out that way. You've also got Moorabbin and Bankstown Airports that also have quite a bit of development around them

The biggest problem is the fact that Government have allowed housing and commercial developments to get so close to an airport that has been around far longer.

[Adrian B]

Talking to a colleague whom flies out of YMMB. He notices turbulence when an easterly blows across from the Costco buildings to the east. Now there is a new building to the west of the 35L/R threshold many are worried about the same when westerly winds are in play.

[Brian Wilkes]

It could have easily been an airport terminal.....why dont we we rethink having those within an airport boundary as well :rolleyes:

I would have to agree with Mark on this one Zac. The airport boundary and DFO are basically on top of each other and if you have been to the Avalon airshow on the Runway edge behind the line, it's pretty much the same. The Gable runway Markers are few meters away from the fence lines near the DFO.

[Zac M]

The government doesn't just allow building companies to do as they please though...surely to god there would have been all sorts of risk assessments done in the planning stages of the development, I dont see how a government planning authority would allow a development to go ahead if it posed a threat to the safety of the airport, so in my mind clearly this was deemed a safe design before it went ahead, otherwise why is it there?

[Brian Wilkes]

Really really don't care about arguing with you just letting you some facts and backing up what Mark posted before, as for the safety, design and rules thats the governments problem in which they said will be apart of the investigation regarding the DFO location.

Governments and people make mistakes all the time and frankly I've been waiting for an aircraft to run off the runway into the DFO since it was put there.

[MarkR]

Whilst you're correct, Zac is too. It's all well and good to say terminals are located in accordance with ICAO and CASA guidelines, but take a look at the FR24 track of today's accident aircraft and you would find that the same situation occurring:
* on SYD's RWY07, would have the aircraft in T2;
* on DRW's RWY11, would have the aircraft in or very close to the terminal;
* on MEL's RWY16, would have the aircraft in the international terminal;
* on ADL's RWY05, would have the aircraft in or close to the terminal, etc.

Actually it would have hit the DHL facility in Syd, but that's besides the point, terminals are necessary, shops are not, why increase the risk of more deaths by putting bodies in a facility that does not have to be there.

It's naive to think just because it's got government approval it's Ok, especially when you look at what planning approvals are needed post deregulation of federal airports. Not saying we need to go back to the days of the FAC, but in my books being conservative vs being greedy is a no brainer.

[Ryan Hothersall]

Having only flown in and out of Essendon once, is this the DFO outlet that was hit?.

https://c1.staticflickr.com/8/7286/16656085031_f3fa75e02f_b.jpg (https://flic.kr/p/rnQMMR)AirnostalgiaDC3-VH-TMQ-50 (https://flic.kr/p/rnQMMR) by Ryan Hothersall (https://www.flickr.com/photos/ryanhothersall/), on Flickr

[Rowan McKeever]

Yes, somewhere in the vicinity of the JB Hi-Fi sign.

[Greg Hyde]

ATSB expect a prelim report in 28days.

[Nigel C]

Way too early for speculation, but there would appear to be some parallels with Advance Airlines Flight 4210 incident at YSSY, including the fact I suspect its the port engine that possibly failed, single pilot ops and aircraft was turning into the dead engine.

Yesterday's accident was 37 years to the day since the Advance Airlines tragedy :(

[Robert Zweck]

Last year we visited the DFO and parked next to the northern car park fence. A King Air landed on RWY 27 and rolled through at high speed. We were alarmed at how close he was to the fence.

What if a loss of directional control?

[MarkR]

Interim report has been published, CVR wasn't operative unfortunately.

http://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/

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.

[Adrian B]

There is also word of allegedly contaminated fuel delivery out of a new truck.

[MarkR]

You mean a rumour, as opposed to what's been reported?

review of the approval process for the building that was struck by the aircraft

Should be interesting.

[Philip Argy]

One would hope that the fuel truck and its contents were isolated and tested immediately after the event. But if that happened, why no mention of it in the interim report?

Also, the abnormally long take-off roll could indicate that the engines were not developing full power.

Certainly a line of enquiry that needs some focus ...

[Martin Buzzell]

Also, the abnormally long take-off roll could indicate that the engines were not developing full power.

I thought about this. Not knowing the 200, wouldn't that show on the gauges?


I wonder what the take off weight was? They were on a golf trip.

[Philip Argy]

I believe the B200 is nominally a 12 seater plus luggage, so it would be surprising if pilot plus four golfers, even with lots of gear, would exceed MTOW. But that will obviously be a line of enquiry for ATSB.

The facts reported to date just leave a big puzzle which will require a lot of effort to solve, especially now that the CVR has been found to have stopped recording anything after a flight on 3 January 2017.

[MarkR]

Flap settings were wrong, which may explain the longer takeoff roll.

[Adrian B]

Also heard of a 5 knot tailwind to match

[MarkR]

Some interesting outcomes from the investigation:

https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/

1. Primary cause was the rudder trim being selected full nose left and its lack of detection via the PIC
2. Aircraft was above MTOW by 240kgs which is unlikely to have contributed
3. Two buildings on the perimeter had issues with their building approval
4. Both engines were producing high power at impact.


While the building approval issue did not have an impact, a separate investigation will be of interesting reading:

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ai-2018-010/

[Martin Buzzell]

I was quite surprised they said the 240 kilos did not contribute to the collision.

[Radi K]

I was quite surprised they said the 240 kilos did not contribute to the collision.

Because it's only about 6% above the MTOW. Within the design limits.

You'd be surprised how many commercial jets every day technically take off beyond their maximum weights. Airlines use "standard" weights for passengers. If a few of these are above the "standard" (87kg for example) then you could technically be above max weight. Same goes for "standard" hand luggage.

[Radi K]

Understand same pilot involved in this incident: https://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-108/

[Daniel M]

The old swiss cheese model in full effect here

[Martin Buzzell]

Because it's only about 6% above the MTOW. Within the design limits.

You'd be surprised how many commercial jets every day technically take off beyond their maximum weights. Airlines use "standard" weights for passengers. If a few of these are above the "standard" (87kg for example) then you could technically be above max weight. Same goes for "standard" hand luggage.

I understand the airlines because their aircraft are bigger, but there was mention of a longer take off roll.

[MarkR]

The report seems to ask more questions than it answers, with those who have actual B200 experience really questioning its assumptions.

Given the deceased relatives are now looking at pursuing legal damages, I wouldn't be surprised to hear the subsequent court case and expert cross examinations cast further doubt on the validity of the report. To me, its another Pel Air type report, and I would not be surprised if re-investigation is commenced down the track, possibly by an overseas safety organization.

[Martin Buzzell]

The report seems to ask more questions than it answers, with those who have actual B200 experience really questioning its assumptions.

Given the deceased relatives are now looking at pursuing legal damages, I wouldn't be surprised to hear the subsequent court case and expert cross examinations cast further doubt on the validity of the report. To me, its another Pel Air type report, and I would not be surprised if re-investigation is commenced down the track, possibly by an overseas safety organization.

That's good. I'm glad I'm not the only one that thinks there's something missing.

[Philip Argy]

A 29 degree slip angle reduced effective wing surface area thus fatally compromising climb performance. This resulted from the 15 degree left rudder trim which simulator testing showed rendered the aircraft uncontrollable above 140 knots, thus making it impossible for the pilot to correct the slip or the aircraft's heading. That's it in a nutshell. We may never know why the full left rudder trim was not detected but it is most likely because the pilot did not bother with checklists and thought he could do everything from memory.

There's a broader question of why the B200 design allows for a rudder trim limit which renders the aircraft uncontrollable at normal speeds. I'd have thought at least some warning signal should be generated if take off power is selected with that rudder trim set.

All other factors appear to be insignificant compared to the extreme rudder trim setting.

I'm not sure why others think the analysis is deficient. You need to read the whole report carefully.

[Rowan McKeever]

It’s important to remember ATSB reports are written so’s not to apportion blame, and I think discussion on this and other forums should follow that lead. While it may be that the actions and/or omissions of those on board contributed to the crash, all of those people are tragically deceased. Their families and friends may well be among us, and we should be sensitive to those people.

That said, I feel the analysis of the crash itself is perfectly adequate and has probably identified all the major contributing factors. The ATSB couldn’t afford not to be thorough in this instance, given the Pelair investigation and the public profile of the Essendon crash, questions about building approvals, etc. I would’ve liked, though, a little more discussion about how a similar occurrence can realistically be avoided in future.

[Martin Buzzell]

simulator testing showed rendered the aircraft uncontrollable above 140 knots, thus making it impossible for the pilot to correct the slip or the aircraft's heading.

In this instance, it never got anywhere near that airspeed.

[Philip Argy]

Not clear what maximum speed was reached - take off was at 111 kts and positive rate of climb was maintained until the full left rudder trim created a slip angle that led to a loss of lift being generated as well as an inhibited ability to change heading. Whether control was impossible or just very difficult probably doesn't matter - it seems clear enough that the condition could not be corrected unless the pilot realised what was wrong, and he plainly did not. Why he did not appears from the report to be because three pre-takeoff opportunities to check the rudder trim setting were missed or did not lead to detection of the adverse setting. :(

I don't know why that left rudder trim could not be overcome with sufficient right rudder but the simulator apparently showed that it could not be.

[MarkR]

That said, I feel the analysis of the crash itself is perfectly adequate and has probably identified all the major contributing factors. The ATSB couldn’t afford not to be thorough in this instance, given the Pelair investigation and the public profile of the Essendon crash, questions about building approvals, etc. I would’ve liked, though, a little more discussion about how a similar occurrence can realistically be avoided in future.

I dont think the report is adequate at all, ie the mentioning of the lack of a checklist when no checklist could be found, is conjecture given the impact damage. If you want to read a report that does fit the bill, on an accident that was very similar try https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20141030X24112&key=1

More detail https://www.ntsb.gov/about/employment/_layouts/ntsb.aviation/brief2.aspx?ev_id=20141030X24112&ntsbno=CEN15FA034&akey=1

[Philip Argy]

I don't think the NTSB report you cite is "better" than the ATSB report on ZCR. In fact it's scant on the critical detail of why there was so much left rudder, especially if the left engine was thought by the pilot to have failed. The NTSB also appears to more explicitly "blame" the pilot instead of taking the ATSB approach of noting that the checklist for the B200 provides three pre-takeoff opportunities for detecting full left rudder trim and then providing some plausible explanations for why those opportunities may have been missed or not detected the incorrect setting.

[MarkR]

The NTSB also appears to more explicitly "blame" the pilot instead of taking the ATSB approach of noting that the checklist for the B200 provides three pre-takeoff opportunities for detecting full left rudder trim .

Point being from a pilots perspective the trim was not the be all and end all of the incident, note the NTSB investigation covers pilot meds, fuel load, aircraft systems and weather, why didn’t the pilot at Essendon follow the engine out procedure ie go clean? Subsequent civil litigation will no doubt she’d more light on the investigations.

[Philip Argy]

He didn't have an engine out and the real cause eluded him. In the available time he couldn't solve his problem. And the ATSB covers all of the aspects you've mentioned - have you read the entire report in full?

[Mick F]

Being a few hundred kilos overweight would make zero to very minimal difference to a King Air.

The B200 can obtain an STC that permits a 1,000lbs increase in MTOW with the only requirement being the addition of a flight data recorder.

Mick

[MarkR]

Somewhat similar accident at Dallas overnight, albeit a 350

https://7news.com.au/news/disaster-and-emergency/ten-killed-in-dallas-small-plane-crash-c-192402

It comes a week after another king air loss (BE90) on takeoff in Hawaii