The Australian Transport Safety Bureau (ATSB) has determined that pilot error was behind a charter plane crash that killed five people in Melbourne last year.
The aircraft crashed into a DFO shopping centre in Essendon shortly after takeoff, killing pilot Max Quartermain and four American tourists.
The ATSB’s final report found the Beechcraft B200 King Air began to descend, turning towards the left after reaching a maximum altitude of 49 meters above ground level, causing it to collide with the roof of the shopping centre.
The investigation found 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, resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance.
According to the report, the pilot had five opportunities to notice the error.
ATSB Chief Commissioner, Greg Hood said this accident emphasised 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 said.