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  #31  
Old 24th September 2018, 12:01 PM
MarkR MarkR is offline
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Some interesting outcomes from the investigation:

https://www.atsb.gov.au/publications...r/ao-2017-024/

1. Primary cause was the rudder trim being selected full nose left and its lack of detection via the PIC
2. Aircraft was above MTOW by 240kgs which is unlikely to have contributed
3. Two buildings on the perimeter had issues with their building approval
4. Both engines were producing high power at impact.


While the building approval issue did not have an impact, a separate investigation will be of interesting reading:

https://www.atsb.gov.au/publications...r/ai-2018-010/
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  #32  
Old 25th September 2018, 01:06 PM
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Martin Buzzell Martin Buzzell is offline
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I was quite surprised they said the 240 kilos did not contribute to the collision.
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  #33  
Old 26th September 2018, 02:17 AM
Radi K Radi K is offline
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Quote:
Originally Posted by Martin Buzzell View Post
I was quite surprised they said the 240 kilos did not contribute to the collision.
Because it's only about 6% above the MTOW. Within the design limits.

You'd be surprised how many commercial jets every day technically take off beyond their maximum weights. Airlines use "standard" weights for passengers. If a few of these are above the "standard" (87kg for example) then you could technically be above max weight. Same goes for "standard" hand luggage.
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  #34  
Old 26th September 2018, 02:18 AM
Radi K Radi K is offline
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Understand same pilot involved in this incident: https://www.atsb.gov.au/publications...r/ao-2015-108/
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  #35  
Old 26th September 2018, 06:15 AM
Daniel M Daniel M is offline
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The old swiss cheese model in full effect here
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  #36  
Old 26th September 2018, 07:26 AM
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Martin Buzzell Martin Buzzell is offline
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Quote:
Originally Posted by Radi K View Post
Because it's only about 6% above the MTOW. Within the design limits.

You'd be surprised how many commercial jets every day technically take off beyond their maximum weights. Airlines use "standard" weights for passengers. If a few of these are above the "standard" (87kg for example) then you could technically be above max weight. Same goes for "standard" hand luggage.
I understand the airlines because their aircraft are bigger, but there was mention of a longer take off roll.
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  #37  
Old 26th September 2018, 01:42 PM
MarkR MarkR is offline
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The report seems to ask more questions than it answers, with those who have actual B200 experience really questioning its assumptions.

Given the deceased relatives are now looking at pursuing legal damages, I wouldn't be surprised to hear the subsequent court case and expert cross examinations cast further doubt on the validity of the report. To me, its another Pel Air type report, and I would not be surprised if re-investigation is commenced down the track, possibly by an overseas safety organization.
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  #38  
Old 26th September 2018, 05:25 PM
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Martin Buzzell Martin Buzzell is offline
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Quote:
Originally Posted by MarkR View Post
The report seems to ask more questions than it answers, with those who have actual B200 experience really questioning its assumptions.

Given the deceased relatives are now looking at pursuing legal damages, I wouldn't be surprised to hear the subsequent court case and expert cross examinations cast further doubt on the validity of the report. To me, its another Pel Air type report, and I would not be surprised if re-investigation is commenced down the track, possibly by an overseas safety organization.
That's good. I'm glad I'm not the only one that thinks there's something missing.
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  #39  
Old 4th October 2018, 08:00 PM
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Philip Argy Philip Argy is offline
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Default Slip angle is the key

A 29 degree slip angle reduced effective wing surface area thus fatally compromising climb performance. This resulted from the 15 degree left rudder trim which simulator testing showed rendered the aircraft uncontrollable above 140 knots, thus making it impossible for the pilot to correct the slip or the aircraft's heading. That's it in a nutshell. We may never know why the full left rudder trim was not detected but it is most likely because the pilot did not bother with checklists and thought he could do everything from memory.

There's a broader question of why the B200 design allows for a rudder trim limit which renders the aircraft uncontrollable at normal speeds. I'd have thought at least some warning signal should be generated if take off power is selected with that rudder trim set.

All other factors appear to be insignificant compared to the extreme rudder trim setting.

I'm not sure why others think the analysis is deficient. You need to read the whole report carefully.
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Last edited by Philip Argy; 4th October 2018 at 08:08 PM.
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  #40  
Old 4th October 2018, 11:59 PM
Rowan McKeever Rowan McKeever is offline
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It’s important to remember ATSB reports are written so’s not to apportion blame, and I think discussion on this and other forums should follow that lead. While it may be that the actions and/or omissions of those on board contributed to the crash, all of those people are tragically deceased. Their families and friends may well be among us, and we should be sensitive to those people.

That said, I feel the analysis of the crash itself is perfectly adequate and has probably identified all the major contributing factors. The ATSB couldn’t afford not to be thorough in this instance, given the Pelair investigation and the public profile of the Essendon crash, questions about building approvals, etc. I would’ve liked, though, a little more discussion about how a similar occurrence can realistically be avoided in future.
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