3 fatalities

2017-05-30: Cessna 441 Conquest (VH-XMJ) — Rossair Charter — Renmark, Australia

Renmark, AustraliaTakeoff (climb)

On May 30, 2017, a Cessna 441 Conquest (registration VH-XMJ) operated by Rossair Charter was involved in an aviation accident near Renmark, Australia during takeoff. 3 people were killed. Investigators recorded the probable cause as: Contributing factors: Following a planned simulated engine failure after take-off, the aircraft did not achieve the expected single engine climb performance, or target airspeed, over the final 30 seconds of the flight. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781191844Data APIEditorial standards

On 30 May 2017, a Cessna 441 Conquest II, registered VH-XMJ, operated by AE Charter (Rossair), crashed near Renmark Airport, South Australia during a training flight, resulting in fatal injuries to all three occupants and destruction of the aircraft.

Accident Overview

On 30 May 2017, a Cessna 441 Conquest II (Cessna 441), registered VH-XMJ, operated by AE Charter (trading as Rossair), sustained an accident near Renmark Airport, South Australia. The aircraft was destroyed and all three occupants sustained fatal injuries. The flight was a proficiency check and inspector assessment.

Flight Sequence

The aircraft departed Adelaide Airport at 1524 Central Standard Time, climbed to about 17,000 ft, and tracked to waypoint RENWB for the Renmark runway 073 RNAV-Z GNSS approach. After a descent, the crew conducted airwork in the Renmark area, including practice holding patterns and a runway 07 RNAV GNSS approach. They landed on runway 25, backtracked, and lined up for departure. At 1614, the pilot announced departure on runway 25 for further airwork. A witness reported a brief stationary hold with significant engine power before take-off. The take-off roll appeared normal.

The aircraft maintained runway heading until reaching 300-400 ft above ground, then veered right of the extended centerline. It climbed to about 600 ft, held for 30 seconds, then descended to about 500 ft. Data ceased 5 seconds later, about 60 seconds after take-off. A distress beacon was received at 1625, and the aircraft was found at 1856 about 4 km west of Renmark Airport.

Investigation Findings

The investigation identified contributing factors. Following a planned simulated engine failure after take-off, the aircraft did not achieve expected single engine climb performance or target airspeed over the final 30 seconds. The exercise was not discontinued when performance was not attained, likely because the degraded performance or risk were not recognized by the pilots. The method of simulating the engine failure and pilot control inputs probably led to reduced performance and asymmetric loss of control. Not following the recommended procedure in the Cessna 441 pilot’s operating handbook left insufficient height to recover.

Other risk factors included an inappropriate procedure in the Rossair training manual, the flying operations inspector not being in a control seat with limited monitoring capability, the inductee pilot's limited recent experience, the chief pilot's extended period since being tested, high workload on operational managers, and a lack of systemic audit by the Civil Aviation Safety Authority. A lack of recorded data limited analysis of handling and communications.

Probable cause

Contributing factors: Following a planned simulated engine failure after take-off, the aircraft did not achieve the expected single engine climb performance, or target airspeed, over the final 30 seconds of the flight. The exercise was not discontinued when the aircraft’s single engine performance and airspeed were not attained, probably because the degraded aircraft performance or associated risk were not recognised by the pilots. It is likely that the method of simulating the engine failure and pilot control inputs, together or in isolation, led to reduced single engine aircraft performance and asymmetric loss of control. Not following the recommended procedure for simulating an engine failure in the Cessna 441 pilot’s operating handbook meant that there was insufficient height to recover following the loss of control.