Finding into death of Russell Langford Munsch
Deceased
Maxwell Charles Quartermain, Greg De Haven, Glenn Alan Garland, John Washburn, Russell Langford Munsch
Date of death
2017-02-21
Finding date
2022-09-30
Cause of death
Multiple injuries sustained in air crash
AI-generated summary
A Beechcraft King Air B200 crashed at Essendon Airport 10 seconds after takeoff, killing all five occupants: pilot Maxwell Quartermain and four passengers. The investigation determined the rudder trim tab was in 'full nose-left' position at takeoff, severely compromising aircraft control. The aircraft veered left on the runway and became uncontrollable after becoming airborne. Critical lessons include: the paramount importance of checklist discipline for preflight rudder trim checks, which would have identified and corrected the misalignment. While the precise timing of when the rudder trim was moved to 'full nose-left' could not be determined, the Coroner found Mr Quartermain either failed to conduct required checks or failed to properly conduct them. Issues with regulatory oversight, including incomplete follow-up of prior incidents and noncompliance notices, were identified but not found causative.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Rudder trim tab in full nose-left position at takeoff
- Failure to conduct or properly conduct preflight rudder trim checks
- Loss of aircraft control due to trim misalignment
- Possible inadequate checklist discipline
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 borne by pilots older than 65
- CASA consider promulgating explicit directions that if a rudder trim tab function test is undertaken as part of preflight check, subsequently and prior to takeoff the position of the rudder trim tab be checked on more than one occasion
- CASA consider instigating a formal audit trail for NCNs and their acquittal
- CASA consider requiring pilots to have IPCs conducted by a variety of testers
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —