Fatal Cessna 441 crash blamed on high-risk training manoeuvre

written by Adam Thorn | May 1, 2020
The Cessna 441 crash site, 4km west of Renmark Airport (ATSB)

Three pilots died in a Cessna 441 crash because they were flying too low while attempting an engine failure training exercise, an ATSB investigation has concluded.

The report found Rossair’s chief pilot Martin Scott, inductee Paul Daw and CASA flying operations inspector Stephen Guerin had carried out a “high-risk exercise with little margin for error” at just 400 feet, rather than the 5,000 feet recommended by the plane manufacturer.

While there were no technical defects with the aircraft itself, experts identified a number of other factors that contributed to the incident, such as Scott’s large workload, the limited experience of Scott and Daw in a 441, and the CASA inspector not having access to the headset system.

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The investigation also established that power on both engines wasn’t restored when a safe single-engine speed was not reached. “That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats,” said ATSB executive director transport safety Nat Nagy.

“Consequently, about 40 seconds after commencing the simulated engine failure exercise, the aircraft experienced an asymmetric loss of control, and impacted the ground about four kilometres west of Renmark Airport.”

The incident happened on 30 May 2017 and involved a twin-engine Cessna 441 Conquest II, registered VH-XMJ. The aircraft was operated by Rossair and departed Adelaide Airport for a return flight via Renmark Airport, South Australia.

Onboard the aircraft were:

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  • An inductee pilot, Paul Daw, undergoing a proficiency check, flying from the front left control seat.
  • The chief pilot, Martin Scott, 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.
  • A Civil Aviation Safety Authority (CASA) flying operations inspector, Stephen Guerin, 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 3:24pm 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 4:14pm.

A distress beacon broadcast was subsequently received by the Joint Rescue Coordination Centre and passed on to air traffic services at 4:25pm.

Following an air and ground search, the aircraft was located by a ground party at 6:56pm about four kilometres west of Renmark Airport. All on board were killed and the aircraft was destroyed.

The ATSB determined that, following a simulated failure of one of the aircraft’s engines at about 400 feet above the ground during the take-off from Renmark, the aircraft did not achieve the expected single-engine climb performance or target airspeed.

Cessna 441 crash positions
Exemplar Cessna 441 in a similar configuration to the accident aircraft (ATSB)

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.

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 feet 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 CASA’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.

After the accident, Scott’s fiancée, Terri Hutchinson, told reporters, “When that plane came crashing down, my whole world crashed down with it.

“I feel quite bleak about the future. I’ve got a nine-year-old boy to raise without his daddy. And it makes me feel very sad that all our plans and dreams, just up in smoke.”

The full report can be read here.

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2 Comments

  • Ben

    says:

    Vale Paul Daw. My flight instructor when I was undergoing my commercial training at the Australian Aviation College in Adelaide back in 1999. He was an ex Kendell Airlines then KLM pilot reaching the rank of captain on their Fokker 100s. He returned to Adelaide for family reasons and became the instructor that everyone wanted to fly with. Brilliant pilot, great guy.

    My thoughts go out to his family and the others who also lost their lives.

  • Ian Jones

    says:

    Stephen Geurin
    I had the pleasure of meeting Steven many years ago when I put myself in a very risky situation on the return flight from the country.
    After that I was asked to attend counselling with Stephen at Casa in Adelaide.
    He was one of the most caring people I have ever met and went above and beyond to an exceptional degree to ensure the safety of my future flying career and work with the public.
    I can not say enough how proud I am to have met this man and how he will be missed
    A true gentleman of a caliber rarely encountered
    Dr Ian Jones

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