The Australian Transport Safety Bureau’s (ATSB) final report into the loss of control and collision with terrain involving a Beechcraft B200 King Air, highlights the importance of following a cockpit checklist.

During take-off from Melbourne-Essendon Airport, Australia on the morning of 21 February 2017, the aircraft diverged to the left of the runway centreline. Having reached a maximum altitude of 160 feet (49 metres) above ground level, the aircraft began to descend with an increasing left sideslip. The aircraft subsequently collided with the roof of a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport. The aircraft was destroyed by the impact. The pilot and four passengers were fatally injured. Two people on the ground received minor injuries.

The ATSB’s investigation found that 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.

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.

More info:

• Final report (PDF)

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The ATSB is advising pilots to be conservative when relying on pilot reports for runway surface conditions, in particular, when the conditions are considered damp.

The ATSB’s investigation into the reduced braking effectiveness during landing of a Boeing 737-800 at Christchurch International Airport (New Zealand), 11 May 2015, highlights the how misperceptions of runway surface conditions can lead to runway excursions.

After touch down on runway 29, the Boeing 737-800 did not decelerate as expected during the later stages of the landing roll. The crew overrode the autobrakes, applied hard manual braking and retained the use of reverse thrust until the end of the runway. The aircraft stopped about 5 metres from the end of the runway.

The ATSB found that, due to an increased workload, the crew misperceived the runway surface conditions, believing it to have a damp surface condition when in fact it was wet. This resulted in the aircraft’s expected landing performance not being achieved.

Considerable efforts have been made by organisations such as the United States Federal Aviation Administration (FAA) to address this issue with the introduction of the runway condition assessment matrix. The International Civil Aviation Organization (ICAO) will be adopting the FAA’s runway condition assessment matrix in November 2020.

The Australian Civil Aviation Safety Authority (CASA) have advised the ATSB they anticipate aligning their runway condition definitions with ICAO post 2020.

Until then, pilots are advised to apply a conservative approach when relying other pilot reports for runway surface conditions, in particular, when the conditions are considered damp, the ATSB states.

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Investigators issued a preliminary report on the Aeroméxico Embraer ERJ-190 takeoff accident at Durango, Mexico, stating a microburst (windshear) event was a factor.

On July 31, 2018, Aeroméxico Flight AM2431 operated by an Aeroméxico Connect Embraer ERJ-190 impacted airport terrain shortly after commencing takeoff from runway 03 at Guadalupe Victoria International Airport (MMDO), Durango, and a post-impact fire ensued. All 105 occupants survived.

The investigators issued a preliminary report on September 5, stating the flight encountered a microburst (windshear) phenomenon with descending and rapidly changing wind. In more detail the flight data recorder shows that the aircraft commenced the takeoff roll on runway 03 at 15:22 hours local time. During the takeoff roll there were notable variations in airspeed and wind direction. At 15:22:42 hours, the aircraft was accelerating through an airspeed of 146 knots. Wind at that time was 47 degrees (from the right-hand side) at 33 knots. Eight seconds later the aircraft had rotated and was climbing through 8 feet radio altitude at an airspeed of 145 knots. By that time the wind had shifted to a crosswind: 103 degrees at 11 knots. The aircraft reached a highest altitude of about 30 feet. At 15:22:56 hours, the aircraft had descended to 19 feet and was caught in a 22-knot tailwind of 30 degrees. The aircraft then hit the ground to the left of the runway.

The investigation is ongoing. The final results will be published in November 2018.

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