ATSB finds trim setting led to Essendon crash


A misset rudder trim was behind the crash of a B200 King Air in Essendon in February 2017, the Australian Transport Safety Bureau has found.

The charter flight crashed shortly after take-off into a shopping centre near Essendon Airport, on 21 February 2017, killing the pilot and four passengers.

‘The pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to take-off,’ the ATSB said this morning. ‘The position of the rudder trim resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance in the latter part of the flight.’

From its inspection of the wreckage, the ATSB discovered the rudder trim set to maximum nose left deflection.

‘The rudder trim actuator screw jack was extended 43 mm when measured from the actuator body to the center of the rod end, which equated to the rudder trim being in the full nose-left position,’ the accident report says.

The ATSB found the aircraft’s checklists required the position of the rudder trim be checked five times and the weight and balance of the aircraft be checked once before take-off. It was not clear which of the available checklists for the B200 King Air the pilot used but all require rudder trim to be checked.

The ATSB also found the aircraft was overweight by 240 kg, but this had not had a significant effect on the outcome of the flight. The aircraft’s cockpit voice recorder had been inoperative after a previous flight incident tripped an impact switch on the unit. No pre-existing engine problems were found.

The ATSB said the crash highlighted the importance of having, using and completing checklists.

‘Cockpit checklists are an essential tool for overcoming limitations with pilot memory and ensuring that action items are completed in sequence and without omission. The improper or non-use of checklists has been cited as a factor in some aircraft accidents. Research has shown that this may occur for varying reasons and that experienced pilots are not immune to checklist errors.’

As always, the ATSB emphasised that its findings should not be read as apportioning blame or liability to any particular organisation or individual.

Flight Safety Australia has run several stories on take-off, checklist use, and the factors that can induce errors among experienced and skilled pilots, which would be worth rereading in conjunction with the ATSB’s report on this tragic crash.

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  1. Bullshit! I don’t believe their finding for one second! They are looking for a scape goat! I knew Max & I too have 1000’s of hrs on the B200, even with full rudder trim set the machine would be controllable otherwise it would not have gotten certification! ATSB ought to be ashamed of themselves!!

  2. I understand your extreme disfaction on this report as I’ve been in the same situation more than once in my flying career. However what else do you suggest could be the likely cause?

    • I don’t have the answer Peter W but I refuse to accept their version of events! Max had a zillion Hrs on type & sure that doesn’t absolve him from making mistakes deliberate or otherwise (there wouldn’t be a pilot out there who hasn’t ticked every box so to speak before every flight) but the incorrect setting of a rudder trim or not picking it up as not set for T/off is more a rooky mistake than a highly experienced person on type. In all the years on type I never moved any of the trims to the full travel (cause that alone is lining up a swiss cheese hole) so unless there was some maint action prior to that flight involving the trim movement to that extreme & left there then something doesn’t add up here & the ATSB found an easy out ! Again disgraceful!

  3. How about some correcting rudder input …the tab is fine control ..not primary control. The report sounds very sus unless the pilot had health issues and was unable to correct the tab drift..

  4. I agree the finding on rudder trim only is highly unlikely and I couldn’t make sense of it until I read another extract of the report where it stated: “The ATSB also noted that the aircraft did not have flaps set at the time of impact. It was normal practice to use approach flaps for take-off, and the ATSB thought that although it was possible they were retracted after take-off, it was considered highly unlikely due to the short time between rotation and the crash.”

    240kg over MTOW and no flaps would explain the long TO roll and poor performance once airborne. The rudder trim would then be a contributor to the factors that brought this aircraft down.

    • Brian, it is good to see that there are experienced aviators still able to ‘critically analyse the factual information’. Biased and emotive terms such as ‘They are looking for a scape goat! and ‘I don’t have the answer Peter W but I refuse to accept their version of events! will do very to advance aviation safety. Remember more experienced swimmers drown each year in Australia, than inexperienced swimmers. The number of hours in a cockpit will never negate the need for checklist as each of us (regardless of experience) still have human limitations, that’s the reason why we need and use checklists isn’t it?

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