What happened
- an inductee pilot undergoing a proficiency check, flying from the front left control seat
- the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
- a Civil Aviation Safety Authority flying operations inspector (FOI), observing and assessing the flight from the first passenger seat directly behind the left hand pilot seat.
Probable cause
Findings
Contributing factors
- Following a planned simulated engine failure after take-off, the aircraft did not achieve the expected single engine climb performance, or target airspeed, over the final 30 seconds of the flight.
- The exercise was not discontinued when the aircraft’s single engine performance and airspeed were not attained. That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats.
- It is likely that the method of simulating the engine failure and pilot control inputs, together or in isolation, led to reduced single engine aircraft performance and asymmetric loss of control.
- Not following the recommended procedure for simulating an engine failure in the Cessna 441 pilot’s operating handbook meant that there was insufficient height to recover following the loss of control.
Other factors that increased risk
- The Rossair training and checking manual procedure for a simulated engine failure in a turboprop aircraft was inappropriate and, if followed, increased the risk of asymmetric control loss.
- The flying operations inspector was not in a control seat and did not share a communication systems with the crew. Consequently, he had reduced ability to actively monitor the flight and communicate any identified performance degradation.
- The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
- The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
- In the 5 years leading up to the accident, the Civil Aviation Safety Authority had conducted numerous regulatory service tasks for the air transport operator and had regular communication with the operator’s chief pilots and other personnel. However, it had not conducted a systemic or detailed audit during that period, and its focus on a largely informal and often undocumented approach to oversight increased the risk that organisational or systemic issues associated with the operator would not be effectively identified and addressed.
Other findings
- A lack of recorded data from this aircraft reduced the available evidence about handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.