Investigation Summary
On the morning of February 21, 2017, the pilot prepared for a charter flight to King Island with four American passengers. CCTV footage showed the pilot conducting a pre-flight walkaround, though specific cockpit actions could not be verified. The aircraft taxied to runway 17, bypassing the designated engine run-up bay. During the takeoff roll, the aircraft took longer than normal to rotate and immediately began to yaw and diverge to the left of the runway centerline. After reaching a maximum height of approximately 160 feet, the aircraft entered a sustained left sideslip and began to descend. At this point, the pilot made seven rapid 'MAYDAY' calls. The aircraft, with the landing gear still extended, clipped the roof of the DFO Essendon building and came to rest in a loading area. The subsequent fire destroyed the airframe. Investigators found the rudder trim tab was likely in the full nose-left position, a setting that would require significant physical effort to counteract if not corrected before flight.
Final Conclusions
The Australian Transport Safety Bureau (ATSB) concluded that the accident was caused by the pilot's failure to ensure the rudder trim was in the neutral position before takeoff. The checklist used by the pilot did not include a specific, standalone check for trim tab positions. Additionally, the investigation was hampered by an unserviceable Cockpit Voice Recorder (CVR), which had stopped functioning during a flight in January 2017 after an impact switch was triggered during landing. Although the aircraft was found to be over its maximum takeoff weight, this was not considered a contributing factor to the loss of control.
Video Analysis
Final report released into King Air accident at Essendon Airport — The ATSB releases its final findings on the 2017 Essendon King Air crash, highlighting the role of the rudder trim and the failure of the cockpit voice recorder.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Max Quartermain. Reported to have failed a proficiency test two years prior to the accident.
Systems & Failure Modes
Rudder Trim Tab
A small adjustable surface on the rudder used to offset aerodynamic forces. It was found in a near full nose-left position, causing the aircraft to yaw uncontrollably after takeoff.
Cockpit Voice Recorder (CVR)
A Fairchild A100S solid-state recorder that failed to record the accident flight because its impact switch had been triggered on a previous landing and was never reset.
Landing Gear
The landing gear remained in the extended and locked position throughout the short flight, increasing drag.
Interesting Facts
- 01The aircraft was approximately 240 kg over its maximum takeoff weight, though this did not cause the crash.
- 02The Cockpit Voice Recorder (CVR) had been inoperative since January 3, 2017.
- 03The pilot had failed a proficiency test two years prior to the accident.
- 04The DFO shopping complex was located on airport grounds but had not yet opened for trading at the time of the crash.
- 05Two people on the ground received minor injuries from the impact and fire.
Safety Actions & Advisories
Checklist Revision
The ATSB highlighted the need for pilots to use checklists that include specific, individual checks for all trim tab positions rather than a general 'trim set' item.
CVR Serviceability
The investigation emphasized the importance of conducting CVR self-tests before the first flight of the day to ensure the system is operational.
Known Controversies & Unanswered Questions
Airport Land Use
Reference ↗Aviation groups and local residents criticized the approval of large retail developments like the DFO complex within airport boundaries, arguing they reduce emergency landing options for pilots.
Location
ACCIDENT SITE · Coordinates taken from the official investigation report.