A pilot who ploughed his plane into a Melbourne shopping centre, killing himself and four American tourists in a fiery crash, failed a proficiency test so badly that a flight inspector readied himself to take control of the aircraft.
The revelation was aired today before Victoria’s Coroner, who is investigating the deaths of the four US citizens — Greg De Haven, Russell Munsch, Glenn Garland and John Washburn — and pilot Max Quartermain in February 2017.
The men were bound for King Island when the Beechcraft B200 Super King plane they were travelling in crashed into the DFO shopping centre at Essendon, shortly after take-off.
The Australian Transport Safety Bureau previously found that pilot error led to the fatal incident, with the plane’s rudder trim left in the wrong position, causing the aircraft to turn sharply to the left after take-off.
The plane’s rudder position will be an issue investigated by the inquest.
Today, Coroner Darren Bracken was told that two years before the Essendon crash, aviation authorities were investigating Mr Quartermain over a near-miss on Mount Hotham.
The court heard that concerns had been expressed about Mr Quartermain’s abilities, prompting authorities to test his skills in what is known as an Instrument Proficiency Check (IPC) which happens mid-air.
It was conducted by Naomichi Nishizawa, a senior inspector in flying operations from the Civil Aviation Safety Authority, who today described Mr Quartermain’s performance as a “major failure”.
“Mr Nishizawa, this was a very serious incident. So serious in fact … you said you were ready to take over control of the aircraft,” Coroner Bracken said.
“Yes, that is correct,” Mr Nishizawa said.
“Had you found yourself in such or similar circumstances,” the coroner asked.
“Nowhere near this state,” said Mr Nishizawa, who had previously conducted 21 tests.
The test had been prompted by Mr Quartermain’s “apparent lack of geographical situation awareness”, according to Liam Magowan, the lawyer assisting the coroner.
The court heard that Mr Quartermain explained away the incident by blaming it on a GPS data card, which he asked to be replaced.
“My impression was that GPS data card could have been a contributing factor, but that is not the entire cause of the event,” Mr Nishizawa said.
“Were you sceptical of the explanation being offered by Mr Quartermain,” Mr Magowan asked.
“No, I was not,” Mr Nishizawa said.
A few weeks after the incident, Mr Nishizawa tested Mr Quartermain’s skills while in the air.
He told the coroner that while Mr Quartermain adjusted the rudder trim, “his attention seemed to have deviated from the flight path management”.
“A short time later … his flight path aircraft started flying above the normal approach path, and the aircraft was now side slipping onto the opposite direction, which suggests that he … overcompensated,” he said.
He said the plane began side-slipping and things became “unstable”.
Mr Nishizawa said that he then stopped the test.
“His approach itself was out of the tolerance as specified for the purpose of instrument proficiency check. So I exercised my discretion to discontinue the assessment,” he said.
“I have to say it would be highly unusual to suspend or cancel [a pilot’s licence] after one failure of the proficiency check.
“When we conduct the flight test, we are dealing with human performance. And in quite simple language, everyone would have a good day, a bad day.”
He failed Mr Quartermain, but today told the coroner it was “too premature” to suspend, vary or cancel Mr Quartermain’s licence at the time.
The Coroner heard that Mr Quartermain was appropriately qualified when he crashed into the DFO shopping centre in 2017.
The hearing continues.Internet Explorer Channel Network