What happened
Shortly after departing Renmark Airport, a Cessna 441, registration VH-XMJ, entered a sequence of maneuvers intended to simulate an engine failure after takeoff. During this check flight, the crew initiated a one-engine inoperative (OEI) flight sequence by reducing power on the right engine. While the initial yaw was managed, the aircraft failed to maintain the target airspeed or achieve a positive rate of climb during the final 30 seconds of the flight. The crew did not terminate the exercise despite these performance issues, which ultimately resulted in a loss of control and a fatal collision with the ground. The impact resulted in 3 fatalities.
The investigation
The ATSB examined the aircraft and found no evidence of pre-existing mechanical defects or engine malfunctions that would have caused the accident. While propeller damage was noted, the investigators determined that the power settings were consistent with a pilot's expected recovery actions. The investigation focused on the operational and organizational factors surrounding the simulated failure.
Investigators found that the operator's specific procedure for simulating an engine failure—reducing power to flight idle—differed from the manufacturer's Pilot's Operating Handbook (POH). This method created more drag than a real engine failure would, as it did not account for the effects of auto-feathering systems. Furthermore, the flying operations inspector was not in a control seat and lacked a headset connection to the crew, which likely hindered his ability to communicate concerns regarding performance degradation.
Findings
- The crew failed to discontinue the simulated engine failure despite the aircraft failing to meet target airspeed or climb performance.
- The method used to simulate the engine failure significantly increased the risk of asymmetric loss of control.
- The pilot's training and checking manual contained an inappropriate procedure for turboprop engine failure simulation.
- Personnel involved had varying levels of recent experience or currency on the specific aircraft type.
- High workloads and pressures within the company's operational management were noted.
- A lack of recorded flight data limited the ability to fully analyze cockpit communications and specific handling inputs.