Finding into death of Maxwell Charles Quartermain

Contributing factors

• rudder trim control positioned to full nose-left
• failure to properly perform or adequately check pre-flight checklist items for rudder trim position
• lack of approved flight check system documentation and checklists in aircraft
• pilot's variable checklist discipline noted in prior Mount Hotham incident investigation and subsequent assessments
• possible pilot fatigue from checking weather overnight
• possible functional test of rudder trim left uncorrected

Coroner's recommendations

1. CASA consider redoubling emphasis of the essential nature of check-list discipline especially to older pilots perhaps as a part of the increased obligations for more frequent IPCs borne by pilots older than 65
2. CASA consider promulgating explicit directions to the effect that if a rudder trim tab function test is undertaken as a part of pre-flight check that subsequently and prior to take-off the position of the rudder trim tab be checked on more than one occasion
3. CASA consider instigating a formal 'audit trail' for NCNs and their acquittal
4. CASA consider requiring pilots to have IPCs conducted by a variety of testers. The extent of variety of testers and time periods within which such variety is required may be best determined by CASA itself