Takeoff (climb)

On 30 May 2017, a Cessna 441 Conquest II (Cessna 441), registered VH-XMJ (XMJ) and operated by AE Charter, trading as Rossair, departed Adelaide Airport, South Australia for a return flight via Renmark Airport, South Australia. On board the aircraft were:
• 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.
Each pilot was qualified to operate the aircraft. There were two purposes for the flight. The primary purpose was for the FOI to observe the chief pilot conducting an operational proficiency check (OPC), for the purposes of issuing him with a check pilot approval on the company’s Cessna 441 aircraft. The second purpose was for the inductee pilot, who had worked for Rossair previously, to complete an OPC as part of his return to line operations for the company. The three pilots reportedly started their pre-flight briefing at around 1300 Central Standard Time. There were two parts of the briefing – the FOI’s briefing to the chief pilot, and the chief pilot’s briefing to the inductee pilot. As the FOI was not occupying a control seat, he was monitoring and assessing the performance of the chief pilot in the conduct of the OPC. There were two distinct exercises listed for the flight (see the section titled Check flight sequences). Flight exercise 1 detailed that the inductee pilot was to conduct an instrument departure from Adelaide Airport, holding pattern and single engine RNAV2 approach, go around and landing at Renmark Airport. Flight exercise 2 included a normal take-off from Renmark Airport, simulated engine failure after take-off, and a two engine instrument approach on return to Adelaide. The aircraft departed from Adelaide at 1524, climbed to an altitude about 17,000 ft above mean sea level, and was cleared by air traffic control (ATC) to track to waypoint RENWB, which was the commencement of the Renmark runway 073 RNAV-Z GNSS approach. The pilot of XMJ was then cleared to descend, and notified ATC that they intended to carry out airwork in the Renmark area. The pilot further advised that they would call ATC again on the completion of the airwork, or at the latest by 1615. No further transmissions from XMJ were recorded on the area frequency and the aircraft left surveillance coverage as it descended towards waypoint RENWB. The common traffic advisory frequency used for air-to-air communications in the vicinity of Renmark Airport recorded several further transmissions from XMJ as the crew conducted practice holding patterns, and a practice runway 07 RNAV GNSS approach. Voice analysis confirmed that the inductee pilot made the radio transmissions, as expected for the check flight. At the completion of the approach, the aircraft circled for the opposite runway and landed on runway 25, before backtracking and lining up for departure. That sequence varied from the planned exercise in that no single-engine go-around was conducted prior to landing at Renmark. At 1614, the common traffic advisory frequency recorded a transmission from the pilot of XMJ stating that they would shortly depart Renmark using runway 25 to conduct further airwork in the circuit area of the runway. A witness at the airport reported that, prior to the take-off roll, the aircraft was briefly held stationary in the lined-up position with the engines operating at significant power. The take-off roll was described as normal however, and the witness looked away before the aircraft became airborne. The aircraft maintained the runway heading until reaching a height of between 300-400 ft above the ground (see the section titled Recorded flight data). At that point the aircraft began veering to the right of the extended runway centreline (Figures 1 and 15). The aircraft continued to climb to about 600 ft above the ground (700 ft altitude), and held this height for about 30 seconds, followed by a descent to about 500 ft (Figures 2 and 13). The information ceased 5 seconds later, which was about 60 seconds after take-off. A distress beacon broadcast was received by the Joint Rescue Coordination Centre and passed on to ATC at 1625. Following an air and ground search the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.

During the takeoff roll on runway 15 at Toluca-Licendiado Adolfo López Mateos, after the airplane passed the V1 speed, the warning light came on in the cockpit panel, informing the crew about the deployment of the reverse on the left engine. According to published procedures, the crew continued the takeoff and shortly after rotation, during initiale climb, the aircraft rolled to the left and crashed in an open field, bursting into flames. The wreckage was found about 200 metres past the runway end. The aircraft was destroyed and both pilots were killed.

The pilot and two medical crew members departed on an air ambulance flight in night instrument meteorological conditions to pick up a patient. After departure, the local air traffic controller observed the airplane's primary radar target with an incorrect transponder code in a right turn and climbing through 4,400 ft mean sea level (msl), which was 800 ft above ground level (agl). The controller instructed the pilot to reset the transponder to the correct code, and the airplane leveled off between 4,400 ft and 4,600 ft msl for about 30 seconds. The controller then confirmed that the airplane was being tracked on radar with the correct transponder code; the airplane resumed its climb at a rate of about 6,000 ft per minute (fpm) to 6,000 ft msl. The pilot changed frequencies as instructed, then contacted departure control and reported "with you at 6,000 [ft msl]" and the departure controller radar-identified the airplane. About 1 minute later, the departure controller advised the pilot that he was no longer receiving the airplane's transponder; the pilot did not respond, and there were no further recorded transmissions from the pilot. Radar data showed the airplane descending rapidly at a rate that reached 17,000 fpm. Surveillance video from a nearby truck stop recorded lights from the airplane descending at an angle of about 45° followed by an explosion. The airplane impacted a pasture about 1.5 nautical miles south of the airport, and a post impact fire ensued. All major components of the airplane were located within the debris field. Ground scars at the accident site and damage to the airplane indicated that the airplane was in a steep, nose-low and wings-level attitude at the time of impact. The airplane's steep descent and its impact attitude are consistent with a loss of control. An airplane performance study based on radar data and simulations determined that, during the climb to 6,000 ft and about 37 seconds before impact, the airplane achieved a peak pitch angle of about 23°, after which the pitch angle decreased steadily to an estimated -42° at impact. As the pitch angle decreased, the roll angle increased steadily to the left, reaching an estimated -76° at impact. The performance study revealed that the airplane could fly the accident flight trajectory without experiencing an aerodynamic stall. The apparent pitch and roll angles, which represent the attitude a pilot would "feel" the airplane to be in based on his vestibular and kinesthetic perception of the components of the load factor vector in his own body coordinate system, were calculated. The apparent pitch angle ranged from 0° to 15° as the real pitch angle steadily decreased to -42°, and the apparent roll angle ranged from 0° to -4° as the real roll angle increased to -78°. This suggests that even when the airplane was in a steeply banked descent, conditions were present that could have produced a somatogravic illusion of level flight and resulted in spatial disorientation of the pilot. Analysis of the performance study and the airplane's flight track revealed that the pilot executed several non-standard actions during the departure to include: excessive pitch and roll angles, rapid climb, unexpected level-offs, and non-standard ATC communications. In addition to the non-standard actions, the pilot's limited recent flight experience in night IFR conditions, and moderate turbulence would have been conducive to the onset of spatial disorientation. The pilot's failure to set the correct transponder code before departure, his non-standard departure maneuvering, and his apparent confusion regarding his altitude indicate a mental state not at peak acuity, further increasing the chances of spatial disorientation. A post accident examination of the flight control system did not reveal evidence of any preimpact anomalies that would have prevented normal operation. The engine exhibited rotational signatures indicative of engine operation during impact, and an examination did not reveal any preimpact anomalies that would have precluded normal engine operation. The damage to the propeller hub and blades indicated that the propeller was operating under high power in the normal range of operation at time of impact. Review of recorded data recovered from airplane's attitude and heading reference unit did not reveal any faults with the airplane's attitude and heading reference system (AHRS) during the accident flight, and there were no maintenance logbook entries indicating any previous electronic attitude director indicator (EADI) or AHRS malfunctions. Therefore, it is unlikely that erroneous attitude information was displayed on the EADI that could have misled the pilot concerning the actual attitude of the airplane. A light bulb filament analysis of the airplane's central advisory display unit (CADU) revealed that the "autopilot disengage" caution indicator was likely illuminated at impact, and the "autopilot trim" warning indicator was likely not illuminated. A filament analysis of the autopilot mode controller revealed that the "autopilot," "yaw damper," and "altitude hold" indicators were likely not illuminated at impact. The status of the "trim" warning indicator on the autopilot mode controller could not be determined because the filaments of the indicator's bulbs were missing. However, since the CADU's "autopilot trim" warning indicator was likely not illuminated, the mode controller's "trim" warning indicator was also likely not illuminated at impact. Exemplar airplane testing revealed that the "autopilot disengage" caution indicator would only illuminate if the autopilot had been engaged and then disconnected. It would not illuminate if the autopilot was off without being previously engaged nor would it illuminate if the pilot attempted and failed to engage the autopilot by pressing the "autopilot" push button on the mode controller. Since the "autopilot disengage" caution indicator would remain illuminated for 30 seconds after the autopilot was disengaged and was likely illuminated at impact, it is likely that the autopilot had been engaged at some point during the flight and disengaged within 30 seconds of the impact; the pilot was reporting to ATC at 6,000 ft about 30 seconds before impact and then the rapid descent began. The airplane was not equipped with a recording device that would have recorded the operational status of the autopilot, and the investigation could not determine the precise times at which autopilot engagement and disengagement occurred. However, these times can be estimated as follows:
- The pilot likely engaged the autopilot after the airplane climbed through 1,000 ft agl about 46 seconds after takeoff, because this was the recommended minimum autopilot engagement altitude that he was taught.
- According to the airplane performance study, the airplane's acceleration exceeded the autopilot's limit load factor of +1.6 g about 9 seconds before impact. If it was engaged at this time, the autopilot would have automatically disengaged.
- The roll angle data from the performance study were consistent with engagement of the autopilot between two points:
1) about 31 seconds before impact, during climb, when the bank angle, which had stabilized for a few seconds, started to increase again and
2) about 9 seconds before impact, during descent, at which time the autopilot would have automatically disengaged. Since the autopilot would have reduced the bank angle as soon as it was engaged and there is no evidence of the bank angle reducing significantly between these two points, it is likely that the autopilot was engaged closer to the latter point than the former. Engagement of the autopilot shortly before the latter point would have left little time for the autopilot to reduce the bank angle before it would have disengaged automatically due to exceedance of the normal load factor limit. Therefore, it is likely that the pilot engaged the autopilot a few seconds before it automatically disconnected about 9 seconds before impact. The operator reported that the airplane had experienced repeated, unexpected, in-flight autopilot disconnects, and, two days before the accident, the chief pilot recorded a video of the autopilot disconnecting during a flight. Exemplar airplane testing and maintenance information revealed that, during the flight in which the video was recorded, the autopilot's pitch trim adapter likely experienced a momentary loss of power for undetermined reasons, which resulted in the sequence of events observed in the video. It is possible that the autopilot disconnected during the accident flight due to the pitch trim adapter experiencing a loss of power, which would have to have occurred between 30 and 9 seconds before impact. A post accident weather analysis revealed that the airplane was operating in an environment requiring instruments to navigate, but it could not be determined if the airplane was in cloud when the loss of control occurred. The sustained surface wind was from the north at 21 knots with gusts up to 28 knots, and moderate turbulence existed. The presence of the moderate turbulence could have contributed to the controllability of the airplane and the pilot's inability to recognize the airplane's attitude and the autopilot's operational status.

On April 17th, at 11:04 UTC, the aircraft turboprop Piper PA-31 Cheyenne II, registration HBLTI, private property, took off from runway 17 of the Cascais aerodrome (LPCS) bound to Marseille airport (LFML), IFR private flight, with 1 pilot and 3 passengers on board. According to several eyewitness testimonies, after takeoff, the Swiss twin-engine started to put the left wing down and consequently to turn left while climbing slowly to about 300’ feet of altitude. The left bank1 increased and the speed decreased leading the aircraft to stall. The aircraft entered a steep dive and impacted the ground next to a logistics dock of a local supermarket, located southeast of the airfield. The crash occurred 700 m from the end of the departure runway. Following the impact, the aircraft exploded and caught fire affecting a logistic dock, a house and a truck. The aircraft was destroyed by impact force and the post-collision fire, all the four occupants were killed. The driver of the truck affected by the explosion of the plane was also killed. The fuselage, wings, the engines and propellers were severely damaged by the impact force and post-impact fuel-fed fire. The structural damage to the aircraft was consistent with the application of extensive structural loads during the impact sequence, and the effects of the subsequent fire. No pre-crash structural defects were found. All aircraft parts and control surfaces were located at the site. The flaps and the landing gear were found retracted at the time of impact.

During the takeoff roll, at a relative high speed, the pilot-in-command rejected takeoff and initiated an emergency braking procedure, apparently following an engine problem. The twin engine aircraft deviated to the left and veered off runway. While contacting soft ground, the nose gear collapsed and the airplane came to rest in the bush. All 20 occupants were rescued, among them both pilots were slightly injured.

Shortly after takeoff from Moretecocha Airfield, while climbing in poor weather conditions, the single engine airplane impacted trees and crashed in a river bed. All seven occupants were injured and the aircraft was destroyed.

A McDonnell Douglas MD-83, registration N786TW, suffered a runway excursion following an aborted takeoff from runway 23L at Detroit-Willow Run Airport, Michigan, USA. The aircraft had been chartered by the University of Michigan Basketball team for a flight to a game in Washington, DC. The flight crew prepared for take-off and calculated V-speeds (V1, VR, V2) using "Normal Thrust Takeoff", a 10 kts headwind, and a take-off weight of 146,600 lbs. The V-speeds for this configuration were 139 kts, 142 kts, and 150 kts, respectively. However, the flight crew chose to increase VR to 150 kts to allow for more control during take-off in the presence of windshear. During takeoff roll, at 14:51:56 (about 3,000 ft down the runway) and about 138 kts of airspeed, the control column was pulled back slightly from a non-dimensional value of -7 to -5.52. The airplane’s left elevator followed the control input and moved from a position of -15° trailing edge down to -13° trailing edge down. The right elevator did not change and stayed at approximately -16° trailing edge down. At 14:52:01 a large control column input was made (151 kts and 4100 ft down the runway) to a non-dimensional 18.5 and the left elevator moves to a position near 15° trailing edge up. After 14:52:05 the right elevator moves to -13° trailing edge down, but no more. The airplane does not respond in pitch and does not rotate. The captain decided to abort the takeoff. The maximum ground speed was 163 kts (173 kts airspeed) and the airplane began to decelerate as soon as the brakes were applied at 14:52:08. Spoilers were deployed at 14:52:10 and thrust reversers were deployed between 14:52:13 and 14:52:15. The aircraft could not be stopped on the runway. The airplane’s ground speed was 100 kts when it left the paved surface. The aircraft overran the end of the runway, damaged approach lights, went through the perimeter fence and crossed Tyler Road. It came to rest on grassy terrain, 345 meters past the end of the runway, with the rear fuselage across a ditch. The nose landing gear had collapsed. Runway 23L is a 7543 ft long runway.

The pilot reported that, during the preflight, it was snowing, and he wiped the snow that had accumulated on the wings off "as best as [he] could." He added that, while taxiing to the runway, "snow was falling heavily," and he observed "light accumulation of wet snow" on the wings. During the takeoff roll, he observed the snow "sloughing off" the wings as the airspeed increased. Subsequently, during the climb to about 150 ft above the ground, the airplane yawed to the left, and he attempted to recover using right aileron. He reported that he "could see a stall forming," so he lowered the nose and reduced power to idle. The airplane impacted the general aviation ramp in a left-wing-down attitude and slid 500 to 600 ft. The pilot reported on the National Transportation Safety Board Aircraft Accident/ Incident Report 6120.1 form that the airplane stalled, and he recommended "better deicing" before takeoff. The airplane sustained substantial damage to the fuselage and left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. A review of recorded data from the automated weather observation station located on the airport revealed that, about 27 minutes before the accident, the wind was 010° at 8 knots, 1/2-mile visibility, moderate snow, freezing fog, and sky condition broken at 500 ft above ground level (agl) and overcast at 1,500 ft agl. The airplane departed from runway 16. The Federal Aviation Administration (FAA) Aeronautical Information Manual stated, in part: "The presence of aircraft airframe icing during takeoff, typically caused by improper or no deicing of the aircraft being accomplished prior to flight has contributed to many recent accidents in turbine aircraft." The manual further stated, "Ensure that your aircraft's lift-generating surfaces are COMPLETELY free of contamination before flight through a tactile (hands on) check of the critical surfaces when feasible. Even when otherwise permitted, operators should avoid smooth or polished frost on lift-generating surfaces as an acceptable preflight condition." FAA Advisory Circular, AC 135-17, stated in part: "Test data indicate that ice, snow, or frost formations having thickness and surface roughness similar to medium or course sandpaper on the leading edge and upper surfaces of a wing can reduce wing lift by as much as 30 percent and increase drag by 40 percent." Included in the public docket for this report is a copy of a service bulletin from the airplane manufacturer, which describes deicing and anti-icing ground procedures. It stated, in part: During conditions conducive to aeroplane icing during ground operations, take-off shall not be attempted when ice, snow, slush or frost is present or adhering to the wings, propellers, control surfaces, engine inlets or other critical surfaces. This is known as the "Clean Aircraft Concept". Any deposit of ice, snow or frost on the external surfaces may drastically affect its performance due to reduced aerodynamic lift and increased drag resulting from the disturbed airflow.

On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.

Shortly after takeoff from Thebephatshwa AFB, en route to Gaborone, the twin engine aircraft went out of control and crashed 4 km from the airport. All three crew members were killed.