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| Date: | Tuesday 30 May 2017 |
| Time: | 16:17 LT |
| Type: |  Cessna 441 Conquest II |
| Owner/operator: | Rossair Charter (Pty) Ltd |
| Registration: | VH-XMJ |
| MSN: | 441-0113 |
| Year of manufacture: | 1979 |
| Fatalities: | Fatalities: 3 / Occupants: 3 |
| Other fatalities: | 0 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | 4 km west of Renmark Airport, SA -
 Australia
|
| Phase: | Initial climb |
| Nature: | Training |
| Departure airport: | Renmark Airport, SA (RMK/YREN) |
| Adelaide Airport, SA (ADL/YPAD) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
A twin‑engine Cessna 441 Conquest II, registered VH-XMJ departed Adelaide Airport, Australia for a return flight via Renmark Airport.
On board the aircraft were an inductee pilot undergoing a proficiency check, flying from the front left control seat; the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat; and a Civil Aviation Safety Authority (CASA) flying operations inspector, observing and assessing the flight from the first passenger seat directly behind the inductee pilot. Each pilot was qualified to operate the aircraft.
The flight departed Adelaide at about 15:24 local time and flew to the Renmark area for exercises related to the check flight, followed by a landing at Renmark Airport. After a short period of time running on the ground, the aircraft departed from runway 25 at about 16:14.
A distress beacon broadcast was subsequently received and the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.
The ATSB determined that, following a simulated failure of one of the aircraft’s engines at about 400 ft above the ground during the take‑off from Renmark, the aircraft did not achieve the expected single engine climb performance or target airspeed. As there were no technical defects identified, it is likely that the reduced aircraft performance was due to the method of simulating the engine failure, pilot control inputs or a combination of both.
It was also identified that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained. That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats. Consequently, about 40 seconds after initiation of the simulated engine failure, the aircraft experienced an asymmetric loss of control.
The single engine failure after take‑off exercise was conducted at a significantly lower height above the ground than the 5,000 ft recommended in the Cessna 441 pilot’s operating handbook. This meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground.
While not necessarily contributory to the accident, the ATSB also identified that:
- The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
- The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot. Therefore, despite having significant experience in Cessna 441 operations, he had reduced ability to actively monitor the flight and communicate any identified problem.
- The inductee and chief pilot, while compliant with recency requirements, had limited recent experience in the Cessna 441 and that probably led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
- The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
- The Civil Aviation Safety Authority’s method of oversighting Rossair in the several years prior to the accident increased the risk that organisational issues would not be identified and addressed.
Finally, a lack of recorded data from this aircraft reduced the available evidence about pilot handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.
Accident investigation:
 |
|
Sources:
Preliminary report :
https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-057/
http://www.adelaidenow.com.au/news/south-australia/plane-missing-in-riverland-after-activating-emergency-beacon-near-renmark-on-tuesday-afternoon/news-story/3497257d134465746943ca4632938103
https://www.sbs.com.au/news/article/2017/05/30/plane-crash-leaves-three-dead-regional-south-australia
https://indaily.com.au/news/2017/05/31/aviation-safety-officer-board-fatal-sa-plane-crash/
http://www.abc.net.au/news/2017-05-31/rossair-chief-pilot-among-dead-in-riverland-plane-crash/8574710
Images:
Figure: ATSB
Media:
First pictures of the Renmark plane crash that killed three men. Report in 7 News at 6pm. pic.twitter.com/TfNUAYsxA1
— 7 News Adelaide (@7NewsAdelaide) May 30, 2017
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 30-May-2017 11:26 | Pineapple | Added |
| 30-May-2017 12:09 | Aerossurance | Updated [Time, Phase, Nature, Destination airport, Narrative, ] |
| 30-May-2017 12:11 | Aerossurance | Updated [Source, Embed code, ] |
| 30-May-2017 12:16 | Aerossurance | Updated [Time, Departure airport, Destination airport, Source, Embed code, Narrative, ] |
| 30-May-2017 12:19 | Aerossurance | Updated [Aircraft type, Embed code, ] |
| 31-May-2017 06:10 | Aerossurance | Updated [Time, Source, Narrative, ] |
| 31-May-2017 08:10 | Anon. | Updated [Source, ] |
| 31-May-2017 08:11 | harro | Updated [Source, ] |
| 31-May-2017 14:32 | Aerossurance | Updated [Source, Embed code, Narrative, ] |
| 30-Jun-2017 07:31 | Iceman 29 | Updated [Departure airport, Destination airport, Source, Embed code, Narrative, ] |
| 17-Nov-2017 22:05 | wf | Updated [Cn, Operator, Location, Embed code, ] |
| 30-Apr-2020 06:02 | harro | Updated [Location, Departure airport, Destination airport, Narrative, Photo, Accident report, ] |
| 30-Apr-2020 06:03 | harro | Updated [Embed code, Accident report, ] |
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