Accident Beechcraft B200 King Air VH-ZCR,
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Date:Tuesday 21 February 2017
Time:08:58
Type:Silhouette image of generic BE20 model; specific model in this crash may look slightly different    
Beechcraft B200 King Air
Owner/operator:Corporate and Leisure Charters
Registration: VH-ZCR
MSN: BB-1544
Year of manufacture:1996
Total airframe hrs:6996 hours
Engine model:Pratt & Whitney Canada PT6A-42
Fatalities:Fatalities: 5 / Occupants: 5
Aircraft damage: Destroyed, written off
Category:Accident
Location:0,3 km SE of Melbourne-Essendon Airport, VIC (MEB/YMEN) -   Australia
Phase: Initial climb
Nature:Private
Departure airport:Melbourne-Essendon Airport, VIC (MEB/YMEN)
Destination airport:King Island Airport, TAS (KNS/YKII)
Investigating agency: ATSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Beechcraft B200 Super King Air, registered VH-ZCR, was destroyed after impacting terrain near Melbourne-Essendon Airport, Australia.
The aircraft was conducting a charter passenger flight from Essendon Airport to King Island, Tasmania.
The four passengers arrived at the terminal at 08:41 and were escorted by the pilot directly to the aircraft. At 08:49, the left engine was started and, shortly after, the right engine was started. At 08:53, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. He was cleared to taxi to holding point Tango for runway 17. At 08:58, ATC cleared the flight for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll.
The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline .
The aircraft’s track began diverging to the left of the runway centreline before rotation and the
Following the sustained left sideslip, the aircraft began to descend and at 08:58:48 the pilot transmitted on the Essendon Tower frequency repeating the word 'MAYDAY' seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre, coming to rest in a loading area at the rear of the building.

Contributing factors
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.
Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- 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.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Accident investigation:
cover
  
Investigating agency: ATSB
Report number: AO-2017-024
Status: Investigation completed
Duration: 1 year and 7 months
Download report: Final report

Sources:

ATSB
The Age

Location

Images:


photo (c) ATSB; Melbourne-Essendon Airport, VIC (MEB); 21 February 2017


photo (c) ATSB; Melbourne-Essendon Airport, VIC (MEB); 21 February 2017


photo (c) ATSB; Melbourne-Essendon Airport, VIC (MEB); 21 February 2017


photo (c) Alec Wilson; Melbourne-Essendon Airport, VIC (MEB); 24 November 2014; (CC:by-sa)

Revision history:

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