Crash of a Fletcher FU24-950 Fletcher in Waipukurau

Date & Time: Apr 20, 2010 at 1420 LT
Type of aircraft:
Operator:
Registration:
ZK-EGT
Flight Phase:
Survivors:
Yes
Schedule:
Waipukurau - Waipukurau
MSN:
242
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was engaged in a crop spraying mission on a plantation close to a farm located in Waipukurau. The accident occurred on takeoff in unknown circumstances. While the pilot was seriously injured, the aircraft was damaged beyond repair.

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of a PAC Cresco 08-600 in Tarata: 1 killed

Date & Time: Dec 14, 2008 at 1155 LT
Type of aircraft:
Operator:
Registration:
ZK-LTC
Flight Phase:
Survivors:
No
Schedule:
Tarata - Tarata
MSN:
20
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12100
Aircraft flight hours:
3272
Aircraft flight cycles:
33147
Circumstances:
On Sunday 14 December 2008, the aircraft departed from Stratford Aerodrome at 0630 hours for a transit flight to a farm airstrip near Tarata. Shortly after becoming airborne the pilot noticed the engine chip detector warning light on the instrument panel was illuminated. He diverted to the company maintenance base at Wanganui aerodrome for the defect to be rectified. The aircraft engineer found a light metallic fuzz on the engine magnetic (mag) plug. The fuzz was cleaned off and the mag plug refitted. The aircraft was released to service with a condition that a further inspection of the mag plug was to be performed after 10 hours flight time. The topdressing job, which involved the spreading of 450 tonnes of lime, had commenced on Thursday 11 December 2008 and continued on Friday 12 December 2008. No flying took place on Saturday 13 December 2008 due to a local horse-riding event being held on the farm property. The aircraft arrived at the farm airstrip at 0940 hours on the Sunday morning, and shortly thereafter commenced operations to complete the spreading of the lime. At the time of the accident, 423 tonnes of lime had been spread. The pilot flew a series of topdressing flights before needing to stop for the first refuel. When interviewed, the loader driver stated that the pilot informed him that he was having some difficulty with the lime product not flowing consistently from the aircraft hopper during the sowing runs. At approximately 1145 hours the pilot stopped again to refuel. On completion of the refuel, this gave the aircraft an estimated fuel load of 300 litres. The pilot completed a further two flights. On the third flight, the aircraft became airborne at the end of the airstrip and then descended 55 feet below the level of the airstrip where the aft fuselage struck a fence line. A concentration of lime along the aircraft’s take-off path indicated that the pilot had initiated an attempt to jettison his load at the end of the airstrip. Following the collision with the fence, the aircraft remained airborne for a further 450 metres before it impacted the side of a small hill in a slight nose down attitude. The aircraft then came to rest 12 metres to the left of the initial impact point. The accident occurred in daylight, at approximately 1155 hours NZDT, at Tarata, at an elevation of 410 feet amsl. Latitude: S39° 08.169', longitude: E174° 21.710'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, held the appropriate Medical Certificate, was experienced and fit to carry out aerial topdressing operations.
- The aircraft had been operating normally from the airstrip up to the time of the accident.
- The aircraft descended after take-off and struck a fence. The collision with the fence damaged the elevator control cable system which jammed the elevator control surface. This resulted in the pilot being unable to adequately control the aircraft in pitch, and the aircraft subsequently struck the ground.
- The aircraft was loaded with 1900 kg of lime product on the accident flight, this was in excess of the 1860 kg maximum structural hopper load. No variation above the maximum structural hopper load is allowed for in CAR Part 137. The aircraft’s all-up weight at the time of the accident was under the maximum allowed under the overload provisions of CAR Part 137 by 145 kg.
- The Aircraft Flight Manual does not provide take-off performance data for operation over the maximum certificated take-off weight and up to the maximum agricultural weight as allowed by CAR Part 137.
- A change in wind direction had occurred in the late morning which may have presented the pilot with a slight tail-wind or possible low level turbulence, including down draught conditions, during and after take-off.
- The windsock was not in the most suitable position to indicate the wind conditions to the pilot.
- Partial or full load jettisons had taken place on previous flights, indicating that the pilot was having difficulty achieving the required aircraft performance during or after take-off.
- On the accident flight, the aircraft was probably overloaded for the prevailing environmental conditions.
- The reported poor flowing qualities of the lime product being spread may have hampered the pilot’s efforts to jettison the load after take-off. The effectiveness of the jettison may have also been reduced by the downward flight path of the aircraft on leaving the end of the airstrip. It is unlikely that the pilot could comply with the CAR Part 137.103 requirement to jettison 80% of the load within five seconds.
- The possibility of a pre-existing airframe or engine defect that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The ELT fitted to the aircraft was no longer an approved type, therefore the aircraft was not airworthy in accordance with CARs. The ELT was incapable of being detected by satellite and therefore would not automatically alert rescue services, however, this did not hamper rescue efforts in this accident.
- The accident was not survivable.
Final Report:

Crash of a Fletcher FU-24-950 in Kaihoka

Date & Time: Apr 26, 2008 at 1115 LT
Type of aircraft:
Operator:
Registration:
ZK-DZC
Flight Phase:
Survivors:
Yes
MSN:
205
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1928.00
Circumstances:
During takeoff the topdressing aircraft collided with a low hill. The pilot lost control soon after the collision. During the ensuing crash he was seriously injured and the aircraft was destroyed.
Probable cause:
Cause factors reported by pilot were a possible tailwind component, and the aircraft may have been overloaded for the conditions.

Crash of a Fletcher FU-24-954 in Raglan

Date & Time: Jan 31, 2008 at 0630 LT
Type of aircraft:
Operator:
Registration:
ZK-JNX
Flight Phase:
Survivors:
Yes
MSN:
275
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from a remote terrain located in Te Uku, near Raglan, the pilot lost control of the aircraft that collided with a fence and crashed, bursting into flames. The pilot escaped uninjured while the aircraft was destroyed by fire.

Crash of a Fletcher FU-24-950EX in Opotiki: 1 killed

Date & Time: Nov 10, 2007 at 1320 LT
Type of aircraft:
Operator:
Registration:
ZK-EGV
Flight Phase:
Survivors:
No
Site:
MSN:
244
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5243
Captain / Total hours on type:
4889.00
Circumstances:
On the afternoon of Friday 9 November 2007, the pilot of ZK-EGV, a specialised agricultural aeroplane powered by a turbine engine, began a task to sow 80 tonnes of superphosphate over a farm situated in low hills 5 km south of Opotiki township and 4 km from the Opotiki aerodrome. The pilot was familiar with the farm’s airstrip where he loaded the product, and with the farm. After 6 or 7 loads, the wind was too strong for top-dressing, so the pilot and loader-driver flew back to their base at the Whakatane aerodrome, about 40 km away. At Whakatane, the aeroplane’s fuel tanks were filled. Later that day, the pilot replaced the display for the aeroplane’s precision sowing guidance system, which had a software fault. The next morning, 10 November 2007, the pilot bicycled about 6 km from his house to the Whakatane aerodrome. The loader-driver said that the pilot looked “pretty tired” from the effort when he arrived at the aerodrome at about 0545. After the aeroplane had been started using its internal batteries, the pilot and loader-driver flew to complete a task at a farm west of Whakatane. The pilot’s notebook recorded that he began the task at 0610 and took 45 loads to spread the remaining 68 tonnes of product, an average load of 1511 kilograms (kg). The loader-driver said that the pilot had determined about 2 months earlier that the scales on the loader used at that airstrip were “weighing light” by about 200 kg, so the loader-driver allowed for that difference. After that task, the pilot and loader-driver flew back to the farm south of Opotiki where they had been the previous afternoon. A different loader at that airstrip had accurate scales, and the loader-driver said that he loaded 1500 kg each time, as requested by the pilot. The fertiliser that remained in the farm airstrip storage bin after the accident was found to be dry and free flowing. The sowing task at this farm began at 1010 and the pilot stopped after every hour to uplift 180 litres (L) of fuel, which weighed 144 kg. During the last refuel stop, between 1226 and 1245, he had a snack and a drink. Sowing recommenced at 1245 with about 3 minutes between each load, the last load being put on at about 1316. The loader-driver said the wind at the airstrip was light and the pilot did not report any problem with the aeroplane. After the last refuel, the top-dressing had been mostly out of sight of the loader-driver. When the aeroplane did not return when expected for the next load, the loader driver tried 3 or 4 times to call the cellphone installed in the aeroplane. This was unsuccessful, so at 1338 he followed the operator’s emergency procedure and called 111 to report that the aeroplane was overdue. Telephone records showed that on 10 November 2007 the aeroplane cellphone had been connected for a total of more than 90 minutes on 14 voice calls, and had been used to send or receive 10 text messages. Correlation of the call times with the job details recorded by the pilot suggested he sent most of his messages while the aeroplane was on the ground. Nearly all of the calls and messages involved a female work colleague who was a friend. The pilot initiated most calls by sending a message, but each time that the signal was lost during a call, the friend would stop the call and immediately re-dial the aeroplane phone; so, in some cases, consecutive connections were parts of one long conversation. The longest session exceeded 35 minutes. The nature of the calls could not be determined, but the friend claimed the content of the last phone call was not acrimonious or likely to have agitated the pilot. The friend advised that the pilot had said he often made the phone calls to help himself stay alert. At 1153, in a phone call to his home, the pilot indicated that the job was going well and he might be home by about 1400. In one call to the friend, the pilot said that he was a bit tired and that he hoped the wind would increase enough that afternoon to force him to cancel the next job. At 1308:45, the friend called the aeroplane phone and talked with the pilot until the call was disconnected at 1320:14. The friend said that while the pilot had been talking, the volume of his voice decreased slightly then there was a “static” sound. Apart from the reduced volume, the pilot’s voice had sounded normal and he had not suggested anything untoward regarding the job or the aeroplane. The friend immediately called back, but got the answerphone message from the aeroplane phone. Two further attempts to contact the pilot were unsuccessful, but the friend did not consider that anything untoward might have happened. An orchardist who was working approximately 3 km from the farm being top-dressed had heard an aeroplane flying nearby for some hours before he heard a loud sound that led him to fear that there had been an accident. He noted that the time was 1320 and immediately began to search the surrounding area. After the loader-driver’s emergency call, the Police organised an aerial search, which found the wreckage of the aeroplane at 1435 on the edge of a grove of native trees, approximately 600 metres (m) northwest of the area being top-dressed. The pilot had been killed. His body was not removed until 26 hours after the accident, because of a Police concern not to disturb the wreckage until aviation accident investigators were present. The CAA began an investigation that day into the accident and the Commission sent an investigator to help determine whether there were any similarities with another Fletcher accident that the Commission was then investigating. On 19 November 2007, because of potential issues that concerned regulatory oversight, the Commission started its own inquiry.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The reason for the aeroplane colliding with trees was not conclusively determined. However, the pilot was affected by a number of fatigue-inducing factors, none of which should have been significant on its own. The combination of these factors and the added distractions of a prolonged cell phone call and a minor equipment failure were considered likely to have diverted the pilot’s attention from his primary task of monitoring the aeroplane’s flight path.
- Although pilot incapacitation could not be ruled out entirely, it was considered that the pilot’s state of health had not directly contributed to the accident.
- The potential distraction of cellphones during critical phases of flight under VFR was not specifically addressed by CARs.
- Apart from the probable failure of the GPS sowing guidance equipment, no evidence was found to suggest that the aeroplane was unserviceable at the time of the accident, but its airworthiness certificate was invalid because there was no record that the mandatory post-flight checks of the vertical tail fin had been completed in the previous 3 days.
- The installation of a powerful turbine engine without an effective means of de-rating the power created the potential for excessive power demands and possible structural overload, but this was not considered to have contributed to the accident.
- The pilot was an experienced agricultural pilot in current practice. Although he had met the operator’s continued competency requirements, the operator’s method of conducting his last 2 competency checks was likely to have made them invalid in terms of the CAR requirements.
- Although the aeroplane was grossly overloaded and the hopper load exceeded the structural limit on the take-off prior to the accident, neither exceedance contributed to the accident, and the aeroplane was not overloaded at the time of the accident.
- The emergency locator transmitter did not radiate a useful signal because of damage to the antenna socket on the unit. The installation was also not in accordance with the manufacturer’s instructions or the recommended practice.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Tauranga

Date & Time: Dec 28, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
ZK-WNZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tauranga - Hamilton
MSN:
278
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was ferrying the aircraft from Tauranga to a Hamilton maintenance facility when one of the engines failed. The pilot elected to turn back to Tauranga but, shortly after, the remaining engine failed. The pilot carried out a forced landing into a tidal estuary. The aircraft incurred substantial damage to the nose landing gear. Subsequent CAA safety investigation determined that on an earlier flight, the aircraft's electrical system incurred a defect that rendered several electrical components unserviceable, including the two tip/main fuel tank selector valves. No engineering inspection or rectification ensued and the operator ferried the aircraft from Great Barrier Island unaware that the engines were being fed from the tip tanks only. The operator departed Tauranga for Hamilton under similar circumstances, reaching the vicinity of the Kaimai Ranges when the tip tanks became empty.
Probable cause:
Fuel exhaustion.

Crash of a Fletcher FU-24-950 near Kaitaia: 1 killed

Date & Time: Mar 31, 2006 at 1345 LT
Type of aircraft:
Operator:
Registration:
ZK-EGP
Flight Phase:
Survivors:
No
Site:
Schedule:
Kaitaia - Kaitaia
MSN:
238
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1347
Captain / Total hours on type:
864.00
Aircraft flight hours:
11230
Circumstances:
On Friday 31 March 2006 the pilot intended to carry out topdressing on properties near a steep hill range nine kilometres to the south-west of Kaitaia. The day’s activities commenced at approximately 0600 hours when the pilot and loaderdriver met at Kaitaia aerodrome. The pilot and loader-driver flew in the aircraft from the aerodrome to a farm airstrip located on the back of a hill range near the Pukepoto Quarry where the fertiliser-loading truck had been parked overnight. The topdressing operation began in the morning with spreading approximately 25 tonnes of superphosphate on nearby farmland which was stored in the fertiliser bins next to the airstrip. As the last of the superphosphate was being spread, a consignment of fresh lime was delivered by a trucking contractor. The topdressing operation continued with the spreading of the lime on another property near the base of the hill range, about three kilometres from the airstrip. At around 1000 hours, while waiting on another delivery of lime by the trucking contractor, the pilot and loader-driver flew in the aircraft to another airstrip about 20 km to the south-east near Broadwood. They repositioned a fertiliser-loading truck located at this airstrip to another airstrip near Pawarenga, in anticipation of the next day’s topdressing. The pilot and loader-driver then flew back to the original farm airstrip near the Pukepoto Quarry, arriving at approximately 1100 hours. At about this time the pilot received a cell phone call from his supervising Chief Pilot. During the conversation he asked the Chief Pilot for his advice about the best direction for spreading lime on the land that he was currently working on. The pilot also commented about how the lime was ‘hanging up’ and not flowing easily from the aircraft’s hopper. The Chief Pilot cautioned the pilot about the poor flow properties of new lime and advised him to spread the lime in line with the hill range, not up the slope. The topdressing operation then resumed until all the lime in the fertiliser bin had been used. The pilot and loader-driver then stopped for lunch during which time the aircraft was refuelled and another truckload of lime was delivered. The pilot had commented to the loader-driver during lunch that the lime was still hanging up in the aircraft’s hopper. He was finding that he needed to complete about two passes to clear the entire load from the hopper. Just before starting the afternoon’s topdressing flights, the pilot had a conversation on his cell phone with a bank manager in Auckland. The conversation concerned the financial position of his topdressing business. The loader-driver reported that the pilot became very agitated during the conversation, but appeared to calm down prior to beginning the afternoon’s flying. The farm-owner observed the aircraft on its first flight of the afternoon as it completed the first two passes. He was aware that the aircraft had flown further away after these two passes and assumed the aircraft was returning to the airstrip for a second load of lime. He did not notice anything abnormal about the aircraft. Other witnesses reported that the aircraft flew parallel with a plantation of 30-40 metre high trees towards the rising hill range. The closest eye witness reported seeing what appeared to be fertiliser dropping from the aircraft as it flew along the tree line up the slope. The dropping of the fertiliser then stopped at which point the aircraft was seen entering a steep right hand turn away from the slope whilst descending towards the ground. The aircraft disappeared in to tall bush on the hillside and witnesses heard the aircraft impact the ground. A large smoke-like cloud was then seen rising up through the bush. On hearing the impact, the farm-owner and a local share-milker from a nearby farm searched the hillside for the aircraft. The aircraft was obscured by the tall bush and was initially difficult to locate. The share-milker made his way down the hillside through the bush to the aircraft. He quickly realised that the pilot was deceased. The farmer-owner went to alert the emergency services, however another property owner who had heard the aircraft strike the ground and seen the smoke had already telephoned the New Zealand Police. The accident occurred in daylight, at approximately 1345 hours NZDT, 9 km south-west of Kaitaia at an elevation of 880 feet AMSL. Latitude: S 35° 10' 26.1", longitude: E 173° 11' 29.4"; grid reference: NZMS 260 N05 283698.
Probable cause:
Conclusions:
- The pilot was appropriately licensed and was being supervised as required by Civil Aviation Rules.
- The aircraft had been maintained in accordance with the requirements of Civil Aviation Rules, and had a valid airworthiness certificate.
- There was no evidence that the aircraft had suffered any mechanical problem which may have contributed to the accident.
- The probable initiator of the accident was a hung load of lime which would have limited the climb performance of the aircraft. Factors contributing to the accident were the steep rising terrain and a high tree line which restricted the turning options for the pilot.
- The pilot flew the aircraft into a situation where he had limited recovery options. Due to his limited agricultural flying experience, he may not have appreciated his predicament until it was too late or taken recovery action early enough. The aircraft appears to have aerodynamically stalled during a right hand turn from which there was insufficient height to recover.
- In addition, the pilot’s decision making ability and concentration may have been impaired to some degree by various distractions and fatigue.
- The accident was not survivable.
- The standard sight (observation) window installed on Fletcher aircraft is an impractical method for pilots to monitor the upper level of the hopper contents during flight, particularly with a product like lime which has a higher relative density compared to other fertiliser products.
Final Report:

Crash of a De Havilland DH.104 Dove 1B at Ohakea AFB

Date & Time: Feb 3, 2006 at 1020 LT
Type of aircraft:
Operator:
Registration:
ZK-UDO
Flight Type:
Survivors:
Yes
MSN:
04412
YOM:
1953
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a private tour when enroute, the crew decided to divert to Ohakea AFB due to the deterioration of the weather conditions. On final approach, when full flaps was selected, the aircraft rolled left and right. The pilots could not control the aircraft that struck the runway surface and came to rest. While all occupants were uninjured, the aircraft was considered as damaged beyond repair.
Probable cause:
Failure of the port flap jack linkage eye-bolt which caused an asymmetrical flap condition, causing the aircraft to be out of control.

Crash of a Fletcher FU-24-950 in Whangarei: 2 killed

Date & Time: Nov 22, 2005 at 1142 LT
Type of aircraft:
Operator:
Registration:
ZK-DZG
Flight Type:
Survivors:
No
MSN:
207
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16000
Captain / Total hours on type:
2382.00
Aircraft flight hours:
10597
Circumstances:
On 21 November 2005, the day before the accident, the pilot had completed a day of aerial topdressing in ZK-DZG, a New Zealand Aerospace Industries Fletcher FU24-950, then flown the aircraft with his loader-driver as a passenger to Whangarei Aerodrome. That evening the pilot contacted his operator’s (the company’s) chief engineer in Hamilton and said that the airspeed indicator in ZK-DZG was stuck on 80 knots. The chief engineer told him the pitot-static line for the indicator was probably blocked and to have a local aircraft engineer blow out the line. Early the next morning, the day of the accident, the pilot flew ZK-DZG with his loader-driver on board to an airstrip 50 km north-west of Whangarei to spread fertiliser on a farm property. As the morning progressed, the weather conditions became unsuitable for aerial topdressing. At about 1020, the pilot used his mobile telephone to talk to another company pilot at Kerikeri, and told him that the wind was too strong for further work. The conversation included general work-related issues and ended about 1045, with the pilot saying that he was shortly going to return to Whangarei and go to his motel. Before leaving for Whangarei, the pilot spoke with a truck driver who had delivered fertiliser to the airstrip about 1100. The driver commented later that the pilot said the wind had picked up enough to preclude further topdressing. After they had covered the fertiliser, the pilot told the driver that he and the loader-driver would fly to Whangarei. The driver did not recall anything untoward, except that the pilot had casually mentioned there was some electrical fault causing an amber light in the cockpit to flicker and that it would only be a problem if a second light came on. He said the pilot did not appear to be concerned about the light. The driver then left and did not see the aircraft depart. The pilot used his mobile telephone to tell an aircraft engineer at Whangarei Aerodrome about the airspeed indicator problem and asked him if he could have a look at it and blow out the pitot-static system. The engineer believed the call was made from the ground at about 1130, but he could not be certain of the time. The engineer agreed to rectify the problem and the pilot said he would arrive at the Aerodrome about noon. The engineer said he did not know that the pilot had spent the previous night in Whangarei or that the aircraft had been parked at the Aerodrome overnight. ZK-DZG was equipped with a global positioning system (GPS) and its navigation data was downloaded for analysis. From the data it was established that the aircraft departed from the airstrip at 1131 and flew for about 39 km on a track slightly right of the direct track to Whangarei Aerodrome, before altering heading direct to the aerodrome and Pukenui Forest located 5 km west of Whangarei city. A witness who had some aeroplane pilot flying experience, and was on a property close to the track of ZK-DZG, said he saw the aircraft fly past shortly after about 1130 at an estimated height of 500 feet. He watched it fly in the direction of Pukenui Forest for about 40 seconds before turning his head away. A short time later he turned again to look at the aircraft, which by then was just above the horizon about 2 ridges away. He said there was a strong, constant wind blowing from the right (south) of the aircraft, which appeared to be drifting sideways and rocking its wings. He then saw the aircraft enter a steep descending turn that seemed to tighten before it disappeared from view. He estimated it to have turned about 270 degrees. Another witness near the aircraft track and accident site reported seeing the aircraft at about 1140 flying just above the tree line and thought it might have been “dusting” the forest. The aircraft then turned and disappeared behind some trees. Other witnesses who heard or saw the aircraft described the weather as squally throughout the morning with strong winds from the south, and said that near the time of the accident there was no rain. The witnesses noticed nothing untoward with the aircraft itself, and at the time none was concerned that the aircraft may have been involved in an accident. The local aircraft engineer said he was not concerned when ZK-DZG did not arrive at Whangarei, because from his experience it was not unusual for agricultural pilots to change their plans at the last minute and to not inform the engineers. He described his conversation with the pilot as being casual and said the pilot did not mention that he was finishing topdressing for the day because of the weather. He thought the pilot was just trying to fit in the maintenance work and that his plans had changed. The pilot had not asked him to provide any search and rescue watch, nor did the engineer expect him to because he could not recall any pilot having asked him to do so. There was no evidence that the pilot made any radio calls during the flight. The frequency to which the radio was selected and its serviceability could not be determined because of the accident damage. At about 2200 a member of the pilot’s family contacted the emergency services when she became concerned that there had been no contact from the pilot. An extensive aerial search began at first light the next morning, and at about 1120 the wreckage of ZK-DZG was located about 50 metres (m) below a ridge in a heavily wooded area of Pukenui Forest, at an elevation of 920 feet above sea level. Both occupants were fatally injured.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The pilot was correctly licensed, experienced and authorised for the flight.
- The pilot was operating the aircraft in an unserviceable condition because of a stuck airspeed indicator, which prevented him accurately assessing the aircraft airspeed. Consequently the
aircraft could have exceeded its airspeed limitations by some degree in the turbulent conditions.
- The structural integrity of the vertical fin had been reduced to such an extent by a cluster of unnoticed pre-existing fatigue cracks in its leading edge that eventual failure was inevitable. When the fin failed, it brought about an unrecoverable loss of control and the accident.
- Although the early design of the vertical fin met recognised requirements, it did not provide for any structural redundancy and the leading edge of the fin (a structural component) was not
damage-tolerant.
- The cracks in the fin leading edge went unnoticed until the failure, most likely because an approved black rubber anti-abrasion strip along that surface had prevented any detailed examination of it.
- The approved maintenance programmes did not reflect the inspection-dependent nature of the vertical fin for its ongoing airworthiness, with the inspection periods having been extended over
the years without full consideration given to the importance of frequent inspections for timely detection of fatigue damage.
- There was no evidence that the fitment of a more powerful STC-approved turbine engine, in place of a piston engine, had initiated the fatigue cracks in the fin leading edge. However, once
started, the extra engine power might have contributed to the rate of propagation of the cracks.
- The vertical fin defects and failures in the Fletcher aircraft over the years were not confined to turbine-powered aircraft.
- The CAA’s STC approval process for the turbine engine installation was generally robust and had followed recognised procedures, but the process should have been enhanced by an in-depth
evaluation of the fatigue effects on the empennage.
- Given the generally harsh operating environment and frequency of operations for the turbine powered Fletcher, the continued airworthiness requirements of the fin were not scrutinised as
robustly as they should have been during the STC approval process. Consequently the maintenance programmes had not been improved to ensure the ongoing structural integrity of the fin.
Final Report: