Finding into death of Greg Reynolds De Haven

67y · Male·Multiple injuries sustained in an air crash

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.