Finding into death of Greg Reynolds De Haven
Deceased
Maxwell Charles Quartermain; Greg De Haven; Glenn Garland; John Washburn; Russell Munsch
Demographics
67y, male
Date of death
2017-02-21
Finding date
2022-09-30
Cause of death
Multiple injuries sustained in an air crash
AI-generated summary
A Beechcraft King Air B200 aircraft crashed at Essendon Airport 10 seconds after takeoff, killing the pilot Maxwell Quartermain (age 67) and four passengers. The aircraft's rudder trim tab was in a 'full nose-left' position rather than neutral, causing uncontrollable yaw and preventing the pilot from maintaining altitude despite attempts to compensate. The aircraft collided with a shopping centre building engulfed in flames. While the precise mechanism for the rudder trim being misaligned remains uncertain, the coroner found the primary clinical/operational lesson is strict adherence to manufacturer checklists—five separate checklist items required checking the rudder trim position before takeoff. Evidence suggests either the checklist was not used effectively or the checks were not properly performed. Prior incidents showed the pilot had inconsistent checklist discipline and a concerning failed instrument proficiency check. Key preventable factors include: failure to use or comply with mandatory pre-flight checklists; possible lack of proper oversight by the aviation regulator despite prior safety concerns; and inadequate operational control systems for the operator's charter business.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Rudder trim tab in full nose-left position at takeoff
- Loss of directional control during takeoff
- Inadequate or ineffective checklist performance
- Pilot's cognitive/attentional deficits regarding pre-flight checks
- Absence of manufacturer-approved checklist in aircraft
- Inadequate oversight of operator's Air Operations Certificate compliance
- Non-compliance with non-compliance notice NCN 713808
Coroner's recommendations
- CASA consider redoubling emphasis of the essential nature of checklist discipline especially to older pilots as part of increased obligations for more frequent IPCs for pilots older than 65
- CASA consider promulgating explicit directions that if a rudder trim tab function test is undertaken as part of pre-flight check, the position of the rudder trim tab be checked on more than one occasion subsequently and prior to takeoff
- CASA consider instigating a formal audit trail for non-compliance notices and their acquittal
- CASA consider requiring pilots to have instrument proficiency checks conducted by a variety of testers with variety and time periods to be determined by CASA itself
Full text
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