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air crashes

Mar 29, 2017

No Mayday explanation from cockpit of Essendon crash plane

The causes of the Essendon disaster remain unresolved and the investigation has no cockpit voice or sound recordings to work on

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Essendon disaster as seen by dash cam

The pilot of the Beechcraft King Air B200 that crashed at Essendon Airport last month was unable to explain the cause of his Mayday call before it struck the roof of the adjacent DFO retail centre killing all five people on board.

The aircraft was airborne for about 14 seconds before being destroyed on impact after taking off as a charter flight to King Island according to the preliminary accident report released by the ATSB this morning.

No evidence of engine or equipment malfunction (other than a problem with the cockpit voice recorder) has been as yet identified in the wreckage of the small high performance twin engined turbo-prop.

However the ATSB report cautions that its investigations into the clues that may be provided by the wreckage are incomplete. It provides the first detailed and unambiguous map of the flight path from takeoff to impact, as shown below.

While the ATSB has been able to read the flight data recorder, the cockpit voice recorder only contained voice and sounds from the aircraft’s previous flight. The crash investigator said it was trying to determine the reason why no sounds were recorded during the short interval between takeoff and impact.

In its brief preliminary report that ATSB says:

Witnesses familiar with the aircraft type reported that the take-off roll along runway 17 was longer than normal. After becoming airborne, the aircraft was observed to yaw left. The aircraft performed a shallow climbing left turn while maintaining a relatively level pitch and roll attitude. Airservices Australia Automatic Dependent Surveillance Broadcast (ADS-B) data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline (Figure 1). The aircraft subsequently collided with a building in the Essendon Airport retail precinct.

The report said that he aircraft collided with the roof of the building and associated concrete parapet before coming to rest in the building’s rear car park. Examination of the significantly fire- and impact‑damaged wreckage determined that, at impact the:

  • aircraft was configured with 10° of flap
  • landing gear was in the extended and locked position.

Examination of the building roof showed evidence of propeller slash marks and nose and main gear tyre marks. Those marks were consistent with the aircraft having significant left yaw and a slight left roll at initial impact.

The ATSB said that on-site examination of the wreckage did not identify any pre-existing faults with the aircraft that could have contributed to the accident.

The left and right engines separated from their mounts during the impact sequence. Both engines had varying degrees of fire and impact damage. The engines were removed from the accident site to a secure facility where they were disassembled and inspected by the ATSB with assistance from the engine manufacturer. That examination found that the cores of both engines were rotating and that there was no evidence of pre-impact failure of either engine’s internal components. However, a number of engine components were retained for further examination and testing.

The pilot Max Quartermain called Mayday seven times before the aircraft struck the DFO centre, but did not say anything else as recorded by tower audio.

The ATSB has outlined further aspects of the crash for full and intensive investigation, and would in the normal course of events, issue a final report by February next year.

Summary The causes of the disaster haven’t been determined, and may take considerable time and effort to resolve.

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38 comments

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38 thoughts on “No Mayday explanation from cockpit of Essendon crash plane

  1. Tango

    That seems to rule out fuel starvation.

    The pictures did not look like the gear was down but obviously I was wrong on that count.

    Brain is madly chewing on what could create the circumstances and not coming up with anything.

    I can’t think of a crash like that ever.

  2. Dan Dair

    It seems very strange to me that the landing gear was down & locked.?
    I’d have thought that the pilot would pushed the gear retract lever ASAP, to make the aircraft as smooth as possible once an airborne problem was detected & possibly give it the ‘best’ configuration for a crash-landing.?

    On the basis that the pilot had chance to call Mayday, I wouldn’t rule-out fuel starvation or mechanical/electronic failure of the throttle linkages.? (though since it wasn’t mentioned in the report, I assume we can rule-out fuel contamination.?)
    I imagine that a King Air would have a V1 point.? If something occurred which affected one or more engines beyond that point, the pilot may have been ‘obliged’ to take-off but unable to maintain height.?

    Just because the engines were turning upon impact, doesn’t mean that they were actually performing normally.?
    The graphic shows a significant change in rate of climb & a noticeable loss of airspeed between 8.58-47 & 50 seconds. At that point the aircraft appears to stall, as the airspeed is slightly reduced but the negative rate of climb is huge.

    As Mick Gilbert is fond of saying….. We’ll see.?

    1. Tango

      Dan: I missed that last negative.

      Still when he went over the building he was descending under control.

      It has no stall signature to it so that last data bit could be the fall off the building and a data point extrapolated to FPM that was not reached.

      Fuel contamination certainly possible and another one that crossed my mind. That does have some correlation to the Heathrow 777 with engine not outputting much but still turning.

      Frankly that’s my highest suspicion but there should be associated airport issues. Wrong fuel? Usually Kerosene is well filtered as opposed to av gas which is but does not go in larger aircraft and not as tightly delivered (at least in the US)

      Depends on what condition the engine are in as to evidence and I don’t know of the Turboprop has a fuel trap or if they are intact.

      The rest is hugely impossible with the burning as awfull as it was.

      1. Dan Dair

        Tango,
        I would have thought that it would be the easiest thing for the ATSB to do, to swab the tanks & fuel lines to extract trace-material (assuming every drop of the fuel was burned in the fire) which would enable a lab to identify any discrepancies in the fuel.? Be that wrong fuel or contaminants.?
        Water in the system I assume would show-up as inappropriate wear-marks in certain parts of the fuel or combustion systems during later, detailed examination.?

        I might easily be wrong about the aircraft stalling, but it was essential ‘wings-level’ until the impact, but quite clearly beyond 8.58-49 it had ceased to maintain it’s rate of climb & it’s airspeed.
        It doesn’t take a big leap of faith to imagine the pilot trying to level-out to keep the thing above stall-speed.?
        Additionally, stowing the gear & going to full-flaps would have significantly improved the slow-speed stall characteristics, but the pilot may not have had time to complete all these actions
        or may have been overwhelmed by the onset of an unexpected & undefined loss of engine power.?

        1. Tango

          Dan: There seems to have not been anything left to swab.

          I am not familiar with what aspects fuel contamination would have on a turbine other than inhibit it dramatically or snuff it out.

          As it all burned to one degree or another simply do not know what they got other than the brief internals looks ok and obviously some rotation from props.

          What we can determine was he did not stall it. There is a signature to that and you can see he had forward speed and the wreck spread out over a couple hundred feet. Stall it is smack all in one spot and I have seen far too many of those.

          As was noted previously by several, it has indications of simply not developing full power and it would appear on both engines.

          The aircraft is generally well handled, you don’t see a severe yaw or veer,

          The general attitude looked good but down in the dash cam.

          Frankly it looks like most power gone and he was pointing the nose down to maintain air speed. That is speculative but it is what we are taught for that type of incident.

          I don’t know what the fuel tanks are like on that aircraft so no idea if it could have been pulling off an empty tank with getting a bit of fuel but not full needed.

          Obviously there was enough power to get up to flying speed but would appear to be inhibited with the long takeoff.

          That is where the PNF comes in if you have one, he can scan the engine indicators for problems while the pilot takes off. Otherwise the pilot is going to be very focused on airspeed and attitude.

          Back to indications and indication only of a London 777 like power inhibition for unknown reasons.

      2. Tango

        Dan,
        Gear comes up when you have positive rate of climb.

        160 feet max would not be it.

        It does seem there was something inhibiting the climb, what is wild.

        I would expect a gear up as it was going off runway as no chance of a good landing and often better with gear up for a crash.

        Not much time either.

    2. James Nixon

      Only RPT aircraft have V1, Vr and V2 and guaranteed performance. General aviation aircraft have Blue Line Speed (best s/e rate of climb). For this aircaft it is 121 kts (quick google search).

    3. James Nixon

      No engine failure? Seven Mayday calls? (Three is normal) No gear retraction. The voice recorder kept the previous flight but didn’t work for this one. Only slight tailwind component. The ADS-B plot showed climb rate of 570 feet per minute off the deck and speed of 116 kts. VMCA is 86 kts, and blue line is 121 kts. Track shows left drift started immediately … left engine may have working but not been delivering full power.

      Talk about confusing. Not even heart attack makes sense. Overloading or incorrect loading? Was he shot? Just about the only thing we can’t disregard is UFO activity. Will have to wait for comprehensive analysis of the props to see how much power was being delivered.
      As always in this business, this is gonna take some time.
      — James Nixon

  3. Paul

    What is the stall speed with ten degrees of flaps?

    1. Dan Dair

      Paul,
      Having looked, I can’t find it,
      but Full flap stall is apparently 75 knots.
      Since the aircraft had just 10 degree of flaps & was climbing, I would expect that the stall speed would be a noticeably higher figure.?

      1. Tango

        Depends on heavy the load is as well.

        One reasons how much fuel on board and the weight aspect, that should be available on preliminary.

        Does not seem to be an aft weighted CG, usually those are up and stall out.

  4. Mick Gilbert

    If the airplane was “healthy” maybe the pilot wasn’t. Early days yet but it’s worth noting that the preliminary report found that “… shortly after take-off, the pilot broadcast a MAYDAY call. The pilot repeated the word ‘MAYDAY’ seven times within that transmission. No additional information regarding the nature of the emergency was broadcast.” That is decidedly odd.
    That the PIC suffered a heart attack or stroke has probably now moved up the list of possible causes.

    1. Dan Dair

      Mick Gilbert,
      With the greatest respect to my betters (ie. You),
      surely the fact that the airspeed dropped is an indication that the pilot was not incapacitated.?
      I presume that the King Air requires active input from the pilot to change throttle settings.? Assuming that is the case, an incapacitated pilot probably wouldn’t be able to change the throttle settings.?
      (of course, if the King Air requires active input to maintain throttle settings, then I’m totally wrong.!)

      1. comet

        It won’t be pilot stroke or heart attack.

        The exceptionally long takeoff roll will be a clue.

        1. Mick Gilbert

          Nobody has said that the take-off roll was “exceptionally long”; it was observed to have been “longer than normal”. And on that count it is worth noting that the airplane was operating from RWY 17 with a recorded wind speed of 5 kt from the north-north-west (ie a slight tailwind) so you’d expect a longer than normal take-off roll.

        2. Tango

          Mick:

          It all looks to slow, I would not call it sideways as much as a drift off to the left and aircraft alignment on crash was not crabbed to direction of flight.

          Wings were level, all really bizarre as that just is not the case in 99.99% of accidents.

      2. Mick Gilbert

        Dan,
        A few observations;
        From rotation to impact was 9 seconds.
        I estimate that the mayday call took about 4 seconds; it consisted of the same word repeated seven times.
        The drop in airspeed from highest recorded at 0858:46 to impact at 0848:52 was 8 kts.
        King Airs have been involved in a number of incidents and accidents that have been attributed to a phenomenon called “power lever slide back”; if the friction control setting for the throttles hasn’t been properly adjusted the levers retard abruptly when not physically held in place (eg when you remove your hand).
        The first two checklist items after establishing a positive rate of climb are LANDING GEAR … UP and FLAPS … UP; neither action was accomplished or apparently even started.
        The dash cam footage seems to show the airplane yaw very quickly through about 90° to the left, at which point the rate of climb appears to be abruptly arrested.
        The wheel marks on the roof of the roof of the DFO suggest that the airplane was oriented obliquely to the direction of travel on impact; its nose gear and left main gear were roughly aligned along the direction of flight (that’s about 30° of yaw).
        I suspect that in a high-drag configuration (gear down, flaps 10) a high rate of yaw will adversely impact both airspeed and rate of climb.
        Heart attacks and strokes often do not incapacitate immediately.
        The onset of a heart attack or stroke is sometimes accompanied by involuntary actions; arm or leg spasms, fist clenching, chest clutching, etc
        The observed behaviour of the airplane and its orientation at impact may have been the result of the application of full left rudder possibly in combination with the thrust coming back from take-off power.
        There have been cases of involuntary leg movement before in motor vehicle accidents where the driver suffers a heart attack and jams his foot on the accelerator.
        I’m not saying that any of this did happen but the fact that there doesn’t appear to be anything wrong with the airplane together with the apparent rapid yaw left, the pilot’s age and the very odd mayday call from an experienced pilot suggest that it may have.
        You know what the Zen Master says, “We’ll see.”

        1. Dan Dair

          That was my point about ‘active input’ on the throttles.

          Since active input does appear to be be necessary
          and as you say, gear up should be the first order of business once airborne, I will concede to your superior judgement……..
          the Zen master has taught you well.!!

          1. Mick Gilbert

            Dan,
            I’m not saying it must have been a heart attack or stroke (at this point of an investigation only fools and media “experts” make unconditionally declarative statements). I’m just saying that when you look at ALL the available evidence there’s nothing that would eliminate the onset of medical incapacitation as a causal factor and there’s plenty to support it.
            Good (superior) judgement comes from experience and experience often includes a lot of bad judgement.
            I believe the Zen Master is seeking out the architect of the Comments debacle for a little one-on-one about simplicity and the foolishness of trying to fix that which is not broken.

      3. Tango

        Once set the throttles stay where they are.

        Small aircraft have a friction lock, not sure on that type.

    2. Tango

      Mick:

      Certainly one that is crossing my mind. Seems a bit off as a hearty mayday possible. That would indicate at least an arm and vocal cords working, not characteristic of a heart attack or stroke.

      We have an awful lot of aircraft crashes in Alaska, you can virtually pinpoint the cause as soon as any information is released (high suspicion if you will).

      This one has no signature of any kind associated with it. I don’t use the term weird too often but this just about has me there.

      No stall, not loss of control, fuel issue look ruled out, just drifted off and gradual (relatively) down.

      Fate is the Hunter and the Hunter never rests.

      Control lock seems mildly possible but those are usually straight off the end.

      1. Mick Gilbert

        Tango, I have witnessed the onset of at least 6 heart attacks and one stroke, thankfully none in the first person. Two of the heart attack victims went down like a sack of spuds and did not get back up despite some very prompt medical attention. Pretty much all the others had bad to severe chest or upper back pain and left arm pain/weakness but were otherwise conscious and capable of speech. In two cases they became quickly disoriented. In the case of the stroke they were conscious and communicative throughout, suffered progressive right side weakness and gradually increasing disorientation accompanied by a tendency to repeat themselves.
        Now, I’m not saying that that is a statistically valid sample but if you check with a doctor you’ll find that in most cases neither heart attacks nor strokes immediately incapacitate the patient, they remain communicative but may suffer increasing levels of disorientation with left or right side weakness or spasms.
        The ATSB published “Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents 1 January 1975 to 31 March 2006” in January 2007 – it is available online. They looked at 98 occurrences relating to inflight medical events of which 10 were fatal accidents. The most common inflight medical event leading to an incident or accident was gastrointestinal illness, almost always due to food poisoning (cue Airplane! scene where Leslie Nielson describes the symptoms of food poisoning as Peter Graves experiences them). Of the 10 fatal accidents, 50% were due to the sole pilot suffering a heart attack.
        I wouldn’t be ruling it out just yet.

  5. ghostwhowalksnz

    Is this another MH370 situation , but with the carpark of DFS instead of the bottom of the Indian Ocean ?
    is there a PC simulator of a B200 ?

  6. Mick Gilbert

    Ben, somewhat off topic but a short message for your IT people;
    “Stop effing around with systems that actually work such as the Comments section. You have managed to turn a simple-to-use and easy-to-follow system into a recursive rambling shambles that combines the accessibility of the Dead Sea Scrolls with Rube Goldberg/Heath Robinson design thinking. Please roll-back to the previous version.”

    1. Dan Dair

      Thank God for that,
      I thought it must be just me that can’t make sense of it.?????

      1. Dan Dair

        IT people,
        It would be nice if, after posting a comment, the page returned to the configuration it was in BEFORE I placed the comment.
        It would also be nice if each thread had an expand button & told you how many replies were in it.

        What you have presented us with is amateurish at best.
        The last ‘upgrade’ took away the ‘trending’ list of last-5-comments on the page.
        This new ‘upgrade’ has evidently been created for the benefit of the IT team or to save on computing power & clearly not to make the site more user-friendly.?

      2. Mick Gilbert

        You’ve got to hit “Load More” to reveal replies to Comments and then hit “Load more” again to reveal the next level of replies to replies. However, I note that unless you already knew that you wouldn’t find this repky.
        Clearly whoever put this debacle into the production environment did so without any basic user acceptance testing and almost certainly without any statement of requirements/work from the customer. Someone needs a boot up the quoit for this.

        1. comet

          Pressing the Load More button (on mobile) just makes it keep repeating the same posts over and over. Posts then appear 10 or more times in the thread.

          Obviously the Crikey owners don’t care much for their readers who post comments.

      3. Dan Dair

        ……and stuff is all out of posting-sequence.?
        What a shambles

      4. comet

        The new format seems to ruin it for people using mobile. The desktop version is cumbersome but not totally ruined.

    2. comet

      Some comments are disappearing. Others are repeated 10 times. It is now unreadable. Unusable.

  7. Tango

    I will add in there should have been a lot more on the pre flight information.

    Fueling, amount loaded, when etc.

    I know of one case where we had all the Schools aircraft with water in the fuel, not from delivery but it was loaded hot, then a rainstorm hit, fuel caps had a sunken recess around them, the suction as the fuel cooled pulled in water.

    1.5 gallons came out of one wing tank on the first aircraft off the ground that morning (long runway, instructor took the aircraft and landed just fine)

    You can add in that the fule check valves are not on the bottom of the tank of a Cessna 150 (and what good is that?) when its level.

    We had to chain the tails down to get the water to roll back to the fuel check valve on the wings.

    The engine fuel sump check would show nothing as they had not run yet.

    FAA never issued a twixt on that issue. true story.

  8. Tango

    Ben: You may be on it, just using this to be sure.

    This is really mucked up with MORE key added and it not all showing up.

    Guys: If you answer on the top box it gets added to the top, at least a way to keep going.

    Each time you hit the more button, you get another layers.

    Not good but we can continue.

  9. Giant Bird

    I give up on the comments. Too hard to find them all. Tell us when it will be fixed and I will stay away until then.

  10. Ben Sandilands

    I apologise to all of those who have been so grievously inconvenienced by the problems with our comments and discussions.
    This happened right at the start of a what might be six months of surgery, and treatments for cancer, as happens to often in the older population. I will continue to post here, but there will be days when this isn’t possible, and I hope thus weekend to do some catch up work.
    I have been assured the problems that arose will be reversed.

  11. nightflyer

    Good luck with the treatment Ben. Not your fault, the ‘improved’ version of almost every website is less user friendly than the one before although I suspect the reason these days is incompatibility of more and more platforms. I’m missing your usual April Fool’s con

  12. Tango

    Ben: Best wishes and hopes from myself as well.

    Agree on all items or not, yours is one of the only two good posting sites for Aviation on ALL the web. You have done a magnificent service.

  13. Mick Gilbert

    In keeping with The Australian’s propensity for dishing up largely confected pap on its Aviation pages, today we’re treated to Ean Higgins’ article “ATSB report ‘may have prevented Essendon plane tragedy’”. Higgins reports that;

    “Dick Smith, a former chairman of the Civil Aviation Safety Authority, said it was “completely inexcusable” that the ATSB had still not completed the report of its investigation of the September 2015 incident at Mount Hotham.
    “He told The Australian that had the ATSB completed its investigation and report within a reasonable timeframe, and concluded that pilot Quartermain had engaged in poor airmanship endangering lives, he might have been grounded.
    “In that case, Mr Smith said, Quartermain would not have piloted February’s flight in which he and four American passengers died when the Beechcraft King Air crashed into a shopping centre nine seconds after it took off from Essendon airport.”
    Essentially, Dick Smith contends that;
    IF the ATSB had have promptly finalised their investigation into the near-collision and operational event involving Beech Aircraft Corp. B200, VH-OWN and Beech Aircraft Corp. B200, VH-LQR, near Mount Hotham on 3 September 2015, and
    IF they had found that Max Quartermaine was at fault, and
    IF they had subsequently revoked or suspended Quartermaine’s licence, and
    IF the cause of the recent crash of VH-ZCR was due to pilot error
    THEN everyone would have lived happily ever after.
    IF he has been accurately reported (on the basis we’re talking about The Australian, that’s another big IF) then that is a simply astounding chain of reasoning from the former head of CASA.

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