ATSB releases final report into Rossair plane crash, which killed three pilots near Renmark in 2017
The final report into the Rossair plane crash that killed three pilots in the Riverland in 2017 has found they were flying too low when they conducted a simulated engine failure exercise.
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Three pilots conducting an engine failure exercise were flying significantly lower than the recommended altitude, preventing them from regaining control before crashing into scrubland in South Australia’s Riverland, the nation’s aviation safety watchdog has concluded.
Rossair chief pilot Martin Scott, 48, Civil Aviation Safety Authority operations inspector Stephen Guerin, 56, and experienced pilot Paul Daw, 65, died in the crash on May 30, 2017.
Their nine-seat Cessna 441 Conquest nosedived into scrubland about 3km west of Renmark Aerodrome shortly after taking off about 4.15pm.
The trio was completing an evaluation flight for Mr Daw, who was planning to join the ranks of Rossair. The airline was subsequently placed into voluntary administration in July 2018.
In its final report released on Thursday, almost three years after the crash, the Australian Transport Safety Bureau says the pilots performed a simulated failure of one of the plane’s engines at 400ft (122m).
The report says that altitude is significantly lower than the 5000ft (1524m) recommended in the Cessna 441 pilot’s operating handbook.
It says the pilots were flying at a height insufficient to recover the loss of control before their plane crashed into the ground.
“Conducting a simulated engine failure after an actual takeoff is a high-risk exercise with little margin for error,” the report says.
“As no technical defects were identified, it is likely the reduced aircraft performance was due to the method of simulating the engine failure, pilot control inputs or a combination of both.
“It was also identified that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained.
“That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats.
“Consequently, about 40 seconds after initiation of the simulated engine failure, the aircraft experienced an asymmetric loss of control.”
The ATSB report says that, while not necessarily contributing to the crash, it also identified:
ROSSAIR’S training and checking manual procedure for simulating an engine failure in a turboprop plane was inappropriate and increased the risk of asymmetric control loss.
MR GUERIN was not in a control seat and was unable to share the headset system used by Mr Scott and Mr Daw, reducing his ability to monitor the flight and communicate problems.
MR DAW and Mr Scott, while compliant with requirements, had limited recent experience in a Cessna 441, which “probably led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise”.
MR SCOTT and other key Rossair operational managers were experiencing high levels of workload and pressure during the months leading up to the crash.
The ATSB report found the flight was only in the air for 20 seconds when the pilots began to simulate a right engine failure. A plan to conduct the simulated failure above 400ft had been discussed before the flight.
Mr Guerin was sitting in the front passenger seat behind the two pilots when the exercise started but, despite being the most experienced pilot at the controls of a Cessna 441, was unable to help control the plane.
The ATSB report found Mr Guerin’s view of the instrument readouts was likely obstructed and that, to get the attention of the two pilots, he had to tap them on the shoulder.
Mr Scott and Mr Daw were wearing headsets and unable to hear him over the noise of the plane.
There are no Cessna 441 simulators in Australia, which the ATSB says was a “factor which increased risk” in the crash.
Terri Hutchinson, the fiancee of Mr Scott, said the crash was “completely preventable” if action had been taken to resolve safety problems within Rossair.
She accused the business of putting money first with “little regard for the extreme workload, stress levels and commercial pressure which was placed upon their staff members”.
“This was another needless accident, which has left families and friends devastated by the loss of their loved ones,” she said.
“Recommendations from investigators and coroners continue to be ignored.
“Consequently, it is only a matter of time before we see yet another tragic accident because valuable lessons appear to be routinely disregarded.”
The ATSB report was initially estimated to be complete in 12 months but was further delayed when the lead investigator quit the case in April 2019 – nearly a year after it was due.
In May 2019, the ATSB revealed its investigation was being hampered by the lack of a flight data recorder or cockpit voice recorder. The plane was not legally required to have either.
The plane crash is the equal worst in South Australia since eight people were killed aboard Whyalla Airlines flight 904, which ditched into Spencer Gulf on May 31, 2000.
Less than a month after the Rossair tragedy, a mother and daughter, and their pilot, died when an Angel Flight crashed just after takeoff near Mt Gambier on June 28.