Crash of a Swearingen SA227AC Metro III near Stratford: 2 killed

Date & Time: May 3, 2005 at 2214 LT
Type of aircraft:
Operator:
Registration:
ZK-POA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Auckland – Blenheim
MSN:
AC-551B
YOM:
1983
Flight number:
AWO023
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6500
Captain / Total hours on type:
2750.00
Copilot / Total flying hours:
2345
Copilot / Total hours on type:
70
Aircraft flight hours:
29010
Aircraft flight cycles:
29443
Circumstances:
The crew requested engine start at 2128 and Post 23 taxied for runway 23R at about 2132. The flight data recorder (FDR) showed that during the taxi a left turn through about 320° was made in 17 seconds. Post 23 departed at about 2136 with the first officer (FO) the pilot flying (PF). The planned cruise level was flight level (FL) 180 but the cockpit voice recorder (CVR) showed that in order to get above turbulence encountered at that level the crew requested, and were cleared by air traffic control (ATC), to cruise at FL220. The autopilot was engaged for the climb and cruise. There were 2 CVR references to the crew’s use of the de-icing system to remove trace or light icing from the wings. CVR comments also indicated that stars were visible, and that the aircraft’s weather radar was serviceable. At 2159 ATC cleared Post 23 to track from near New Plymouth very high frequency (VHF) omni-directional radio range (VOR) direct to Tory VOR at the northeast end of the Marlborough Sounds, and at 2206 ATC transferred Post 23 to Christchurch Control. The CVR recorded normal crew interaction and aircraft operation, except that climb power remained set for about 15 minutes after reaching cruise level in order to make up some of the delay caused by the late departure. At about 2212:28, after power was reduced to a cruise setting and the cruise checks had been completed, the captain said, “We’ll just open the crossflow again…sit on left ball and trim it accordingly”. The only aircraft component referred to as “crossflow”, and operable by a flight deck switch or control, was the fuel crossflow valve between the left and right wing tanks. The captain repeated the instruction 5 times in a period of 19 seconds, by telling the FO to, “Step on the left pedal, and just trim it to take the pressure off” and “Get the ball out to the right as far as you can …and just trim it”. The FO sought confirmation of the procedure and said, “I was being a bit cautious” to which the captain replied, “Don’t be cautious mate, it’ll do it good”. Nine seconds later the FO asked, “How’s that?”. The Captain replied, “That’s good – should come right – hopefully it’s coming right.” There was no other comment at any time from either pilot about the success or otherwise of the fuel transfer. During this time, the repeated aural alert of automatic horizontal stabiliser movement sounded for a period of 27 seconds, as the stabiliser re-trimmed the aircraft as it slowed from the higher speed reached during cruise at climb power. Forty-seven seconds after opening the crossflow, the captain said, “Doesn’t like that one mate… you’d better grab it.” Within one second there was the aural alert “Bank angle”, followed by a chime tone, probably the selected altitude deviation warning. Both pilots exclaimed surprise. After a further 23 seconds the captain asked the FO to confirm that the autopilot was off, but it was unclear from the CVR whether the captain had taken control of the aircraft at that point. The FO confirmed that the autopilot was off just before the recording ended at 2213:41. The bank angle alert was heard a total of 7 times on the CVR before the end of the recording. During the last 25 seconds of radar data recorded by ATC, Post 23 lost 2000 ft altitude and the track turned left through more than 180°. Radar data from Post 23 ceased at 2213:45 when the aircraft was descending through FL199 about 1700 metres (m) southeast of the accident area. Commencing at 2213:58, the ATC controller called Post 23 three times, without response. He then initiated the uncertainty phase of search and rescue for the flight. The operator had a flight-following system that displayed the same ATC radar data from Airways Corporation of New Zealand (ACNZ). The operator’s dispatcher noticed that the data for Post 23 had ceased and, after discussing this with ACNZ, he advised the operator’s management. There were many witnesses to the accident who reported noticing a very loud and unusual noise. Some, familiar with the sound of aircraft cruising overhead on the New Plymouth – Wellington air route, thought the noise was an aircraft engine but described it as “high-revving” or “roaring”. Witnesses A were located about 3 kilometres (km) south of the southernmost part of the track of Post 23 as recorded by ATC radar, and about 6 km south of the accident site. They described going outside to identify the cause of an intense noise. As they looked northeast and upwards about 45°, they saw an orange-yellow light descending through broken cloud layers at high speed. A “big burst” and 3 or 4 separate fireballs were observed “just above the horizon” about 5 km away. No explosion was heard. The biggest fireball lasted the longest time and was above the others. The night was dark and it had been drizzling. Witness B, almost 7 km to the northeast of the accident site, observed light and dark cloud patterns moving towards the northwest. She thought the moon caused the light variation; however moonrise was almost 3 hours later. This witness also first observed a fireball below the cloud at an elevation of about 6°. She described it as “a big bright circle” followed by 2 smaller fireballs that fell slowly. No explosion was heard. Witness C, who was less than 1000 m from the aircraft’s diving flight path, described seeing the nose section falling after an explosion “like a real big ball of fire”. The wings were then seen falling after a smaller fireball that was followed by a third small fireball. The witness said it was a still night, with no rain at that time, and the fireballs were observed below the lowest cloud. The fireballs illuminated falling wreckage and cargo. Witness D, also less than 1000 m from the accident site, described parts of the aircraft falling, illuminated by the fireball. Witnesses generally agreed that the first and biggest fireball was round and orange, and then shrank away. Descriptions of the smaller fireballs varied, but were usually of a more persistent, streaming flame that fell very steeply or straight down. A large number of emergency service members and onlookers converged on the accident area. Those who got within about 1000 m of the scene reported a strong smell of fuel. The first item of wreckage was located at about 2315. The main wreckage field was on hilly farmland 7 km northeast of Stratford at an elevation of approximately 700 ft.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The flight crew was appropriately licensed and rated for the aircraft, and qualified for the flight.
- The captain was experienced on the type and the operation, and approved as a line training captain, while the FO was recently trained and not very experienced on the type.
- The aircraft had a valid Certificate of Airworthiness and records indicated that it had been maintained in accordance with its airworthiness requirements. There were no relevant deferred
maintenance items prior to dispatch of the accident flight.
- Although the aircraft had been refuelled in one tank only, it probably took off with the fuel balanced within limits.
- Some fuel imbalance led the captain to decide to carry out further fuel balancing while the aircraft was in cruising flight.
- The captain’s instructions to the FO while carrying out fuel balancing resulted in the aircraft being flown at a large sideslip angle by the use of the rudder trim control while the autopilot was engaged.
- The FO’s reluctance to challenge the captain’s instruction may have been due to his inexperience and underdeveloped CRM skills.
- The autopilot probably disengaged automatically because a servo reached its torque limit, allowing the aircraft to roll and dive abruptly as a result of the applied rudder trim.
- The crew was unable to recover control from the ensuing spiral dive before airspeed and g limits were grossly exceeded, resulting in the structural failure and in-flight break-up of the aircraft.
- The in-flight fire which occurred was a result of the break-up, and not a precursor to it.
- The applied rudder trim probably contributed to the crew’s inability to recover control of the aircraft.
- The crew’s other control inputs to recover from the spiral dive were not optimal, and contributed to the structural failure of the aircraft.
- The flying conditions of a dark night with cloud cover below probably hindered the crew’s early perception of the developing upset.
- The AFM limitation on use of the autopilot above 20 000 ft should have led to the crew disconnecting it when climbing the aircraft above that altitude.
- The crew’s non-observance of this autopilot limitation probably did not affect its performance, or its automatic disengagement.
- If the aircraft had been manually flown during the fuel-balancing manoeuvre, the upset would probably have not occurred.
- The operator should detail the in-flight fuel balancing procedure as a written SOP for its Metro aircraft operation.
- The AFM for the SA 226/227 family of aircraft should include a limitation and warning that the autopilot must be disconnected while in-flight fuel balancing is done, and should include a procedure for in-flight fuel balancing.
Final Report:

Crash of a Fletcher FU-24-950M in Mairoa: 1 killed

Date & Time: Dec 19, 2003 at 1500 LT
Type of aircraft:
Operator:
Registration:
ZK-BXZ
Flight Phase:
Survivors:
No
MSN:
65
YOM:
1960
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
14335
Captain / Total hours on type:
5000.00
Circumstances:
On the morning of 19 December 2003, the pilot began work about 0630 hours, flying from Te Kuiti aerodrome to an agricultural airstrip about eight nautical miles to the west. At that strip he completed a 150 tonne lime contract that had been started by two other aircraft the day before. Refuelling of the aircraft was completed approximately every hour, and the pilot stopped for a break with about four loads remaining. At 1400 hours, with the job completed, he flew to the strip from which he operated until the time of the accident. On arrival at this strip, the pilot completed a reconnaissance flight with the pilot of ZK-EMW, discussed their sowing plan, and agreed on a 1.1 tonne load with the loader driver. Take-offs were made to the south-west, landings in the opposite direction. The loader driver reported that the job was going smoothly, and that the pilot seemed in good spirits, at one stage miming wiping his brow, which the loader driver took to be a comment on the heat of the day. During this time, a third company aircraft, ZK-JAL, arrived at the strip and shut down, as the loader driver was able to handle only two aircraft at a time. The pilot of ZK-JAL flew a briefing sortie with the pilot of ZK-BXZ prior to the planned departure of ZK-BXZ. After each take-off, ZK-BXZ would turn left on to a downwind leg and then cross over the top (loading) end of the strip on the way to the sowing area. ZK-BXZ was working inward from the eastern boundary of the property, and ZK-EMW from the western boundary. While topdressing was in progress, fresh lime was being trucked to the strip and placed in the large fertilizer bin from which the loader was replenishing the aircraft. The lime was received directly from the processing plant, and was dry and free-flowing. As each load arrived, the farmer would mix a cobalt supplement with it in the bin. One of the truck drivers, who himself held a Commercial Pilot Licence (Aeroplane), took several photographs of the aircraft landing and taking off. One photograph showed ZK-BXZ leaving the end of the strip on probably its penultimate take-off, with ZK-EMW on final approach on the reciprocal heading. On this occasion ZK-EMW passed over ZK-BXZ just after the latter became airborne. The next photograph showed ZK-BXZ approximately two thirds of the way down the strip, with 20° of flap set on its final take-off, with dirt being thrown up by the wheels as it hit the soft spots in the strip. The driver did not watch the take-off beyond this point. The pilot of ZK-EMW initially reported that on his landing approach, he flew over ZK-BXZ while it was still on its take-off run. He later disputed this and claimed that ZK-BXZ had just become airborne when it disappeared from view under his right wing. In any event, ZK-BXZ only flew approximately 170 metres, so the proximity of these two aircraft was very close if ZK-BXZ was already airborne at this point in time. The close proximity of the two aircraft is significant as it is possible that ZKBXZ, being the lower of the two aircraft, may have encountered wake turbulence from ZK-EMW. All aircraft produce wake turbulence as a by-product of generating lift from their wings, the intensity varying with the aircraft’s speed, weight and configuration. The weather conditions, as discussed in the article appended to this report, were favourable for ZK-BXZ to encounter the wake vortices from the aircraft passing above. The first indication of the accident was a loud bang heard by the farmer – he was in the bin mixing in the cobalt supplement, and initially thought he had heard a truck tailgate slamming. Looking towards the end of the strip, he saw a plume of smoke and immediately went by motorcycle to investigate. On arrival at the scene, he found the aeroplane well ablaze, and was unable to get close because of the heat. As the accident occurred, a fourth company aircraft, ZK-EGV, arrived at the strip. The pilot did not see the actual impact, but flew over the burning wreckage on approach. As soon as he landed he went by foot to the accident site, as he had arrived too late to join those that had gone on board the loading vehicle. The loader driver used his fire extinguisher to quell the flames, but could do nothing to assist the pilot. After the extinguisher ran out, the fire flared up again, and all those present could do was to await the arrival of the Fire Service. The accident occurred in daylight, at approximately 1500 hours NZDT, at Mairoa, 10 nm south-west of Te Kuiti aerodrome, at an elevation of 1150 ft. Latitude: S 38° 22.9', longitude: E 174° 57.0'; grid reference: 260-R16-806117.
Probable cause:
Conclusions:
- The pilot was properly licensed, rated, and fit for the flight undertaken.
- The aircraft had been subjected to regular maintenance and appeared to be airworthy prior to the accident.
- The engine strip found no reason why the engine would not be producing full power.
- The aircraft was operating to the limits of its performance for the given conditions.
- The accident was not survivable.
- It has not been possible to determine a conclusive cause for the accident.
Final Report:

Crash of a Convair CV-580F off Paraparaumu: 2 killed

Date & Time: Oct 3, 2003 at 2125 LT
Type of aircraft:
Operator:
Registration:
ZK-KFU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Christchurch – Palmerston North
MSN:
17
YOM:
1952
Flight number:
AFZ642
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16928
Captain / Total hours on type:
3286.00
Copilot / Total flying hours:
20148
Copilot / Total hours on type:
194
Aircraft flight hours:
66660
Aircraft flight cycles:
98774
Circumstances:
On Friday 3 October 2003, Convair 580 ZK-KFU was scheduled for 2 regular return night freight flights from Christchurch to Palmerston North. The 2-pilot crew arrived at the operatorís base on Christchurch Aerodrome at about 1915 and together they checked load details, weather and notices for the flight. The flight, using the call sign Air Freight 642 (AF642), was to follow a standard route from Christchurch to Palmerston North via Cape Campbell non-directional beacon (NDB), Titahi Bay NDB, Paraparaumu NDB and Foxton reporting point. The pilots completed a pre-flight inspection of ZK-KFU and at 2017 the co-pilot (refer paragraph 1.10.4) called Christchurch Ground requesting a start clearance. The ground controller approved engine start and cleared AF 642 to Palmerston North at flight level 210 (FL 210) and issued a transponder code of 5331. The engines were started and the aircraft taxied for take-off on runway 20. At 2032 AF 642 started its take-off on schedule and tracked initially south towards Burnham NDB before turning right for Cape Campbell NDB, climbing to FL210. The flight progressed normally until crossing Cook Strait. After crossing Cape Campbell NDB, the crew changed to the Wellington Control frequency and at 2108 advised Wellington Control that AF 642 was at FL210, and requested to fly directly to Paraparaumu NDB. The change in routing was common industry practice and offered a shorter distance and flight time with no safety penalty. The Wellington controller approved the request and AF 642 tracked directly to Paraparaumu NDB. At 2113 the Wellington controller cleared AF 642 to descend initially to FL130 (13 000 feet (ft)). The co-pilot acknowledged the clearance. At 2122 the Wellington controller cleared AF 642 for further descent to 11 000 ft, and at 2125 instructed the crew to change to the Ohakea Control frequency. At 2125:14, after crossing Paraparaumu NDB, the co-pilot reported to Ohakea Control that AF 642 was in descent to 11 000 ft. The Ohakea controller responded 'Air Freight 642 Ohakea good evening, descend to 7000 ft. Leave Foxton heading 010, vectors [to] final VOR/DME 076 circling for 25. Palmerston weather Alfa, [QNH] 987.' At 2125:34 the co-pilot replied ìRoger down to 7000 and leaving Foxton heading 010 for 07 approach circling 25 and listening for Alfa. Air Freight 642. At 2125:44 the Ohakea controller replied 'Affirm, the Ohakea QNH 987.' The crew did not respond to this transmission. A short time later the controller saw the radar signature for AF 642 turn left and disappear from the screen. At 2126:17 the Ohakea controller attempted to contact AF 642 but there was no response from the crew. The controller telephoned Police and a search for AF 642 was started. Within an hour of the aircraft disappearing from the radar, some debris, later identified as coming from AF 642, was found washed ashore along Paraparaumu Beach. Later in the evening an aerial search by a Royal New Zealand Air Force helicopter using night vision devices and a sea search by local Coastguard vessels located further debris offshore. After an extensive underwater search lasting nearly a week, aircraft wreckage identified as being from ZK-KFU was located in an area about 4 km offshore from Peka Peka Beach, or about 10 km north of Paraparaumu. Police divers recovered the bodies of the 2 pilots on 11 October and 15 October.
Probable cause:
The following findings were identified:
Findings are listed in order of development and not in order of priority.
- The crew was appropriately licensed and fit to conduct the flight.
- The captain was an experienced company line-training captain, familiar with the aircraft and route.
- The co-pilot while new to the Convair 580 was, nevertheless, an experienced pilot and had flown the route earlier in the week.
- The aircraft had a valid Certificate of Airworthiness and was recorded as being serviceable for the flight.
- The estimated aircraft weight and balance were within limits at the time of the accident.
- With a serviceable weather radar the weather was suitable for the flight to proceed.
- The captain was the flying pilot for the flight from Christchurch to Palmerston North.
- The flight proceeded normally until the aircraft levelled after passing Paraparaumu NDB.
- Why the aircraft was levelled at about 14 400 ft was not determined, but could have been because of increasing or expected turbulence.
- The weather conditions at around the time of the accident were extreme.
- The aircraft descended through an area of forecast severe icing, which was probably beyond the capabilities of the aircraft anti-icing system to prevent ice build-up on the wings and tailplane.
- The crew was probably aware of the presence of icing but might not have been aware of the likely speed and the extent of ice accretion.
- The rate of ice accretion might have left insufficient time for the crew to react and prevent the aircraft stalling.
- The transponder transmissions were impaired probably due to ice build-up on the aerials.
- The aircraft probably stalled because of a rapid build-up of ice, pitching the aircraft nose down and probably disorientating the crew. This could have resulted from a tailplane stall.
- Although the aircraft controls were probably still functional in the descent, a very steep nose down attitude, high speed and a potentially stalled tailplane, made recovery very unlikely.
- Under a combination of high airspeed and G loading, the aircraft started to break-up in midair, probably at about 7000 ft.
- Although there was no evidence to support the possibility of a mechanical failure or other catastrophic event contributing to the accident, given the level of destruction to ZK-KFU and that some sections of the aircraft were not recovered, these possibilities cannot be fully ruled out.
- The crew of AF 642 not being advised of the presence of a new SIGMET concerning severe icing should not have affected the pilotsí general awareness of the conditions being encountered.
- Had the crew been aware of the new SIGMET it might have caused them to be more alert to icing.
- Pilots awareness of the presence of potentially hazardous conditions would be increased if other pilots commonly sent AIREPs when such conditions were encountered.
- Operatorsí manuals, especially for IFR operators, might contain inadequate and misleading information for flight in adverse weather conditions.
- The search for the aircraft and pilots was competently handled in adverse conditions.
- The regular mandatory checks of the CVR failed to show that it was not recording on all channels.
- The lack of any intra cockpit voice recordings hampered and prolonged the investigation.
- The DFDR data and available CVR recordings provided limited but valuable information for the investigation.
- Had more modern and capable recorders been installed on ZK-KFU, significantly more factual information would have be available for the investigation, thus enhancing the investigation and increasing the likelihood of finding a confirmed accident cause, rather than a probable one.
- Had suitable ULB tracking equipment been available, the finding of the wreckage and recovery of the recorders would have been completed more promptly.
- The lack of tracking equipment could have resulted in the recorders not being found, and possibly even the wreckage not being found had it been in deeper water.
Final Report:

Crash of a Fletcher FU-24-950M near Matawai

Date & Time: Sep 20, 2003 at 1015 LT
Type of aircraft:
Operator:
Registration:
ZK-BDS
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Motu - Opotiki
MSN:
001
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed during bad weather. Andrew Wilde was flying and George Muir was a passenger. While enroute from Motu - Opotiki the gully became un-negotiable, so Andrew decided to return to Motu by flying a reciprocal course low level, depicted by arrows on his hand held marine GPS. During the return trip to Motahora up the Otara river valley, he found that the cloud base had lowered even further than when he entered the valley 6 minutes prior & he became fully reliant on that little GPS. The GPS became our enemy & lured Andrew into the cloud base, which ended our flight abruptly.
Testimony from George Muir, loader driver and passenger during this flight.

Crash of a Piper PA-31-350 Navajo Chieftain in Christchurch: 8 killed

Date & Time: Jun 6, 2003 at 1907 LT
Registration:
ZK-NCA
Survivors:
Yes
Schedule:
Palmerston North – Christchurch
MSN:
31-7405203
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4325
Captain / Total hours on type:
820.00
Aircraft flight hours:
13175
Circumstances:
The aircraft was on an air transport charter flight from Palmerston North to Christchurch with one pilot and 9 passengers. At 1907 it was on an instrument approach to Christchurch Aerodrome at
night in instrument meteorological conditions when it descended below minimum altitude, in a position where reduced visibility prevented runway or approach lights from being seen, to collide with trees and terrain 1.2 nm short of the runway. The pilot and 7 passengers were killed, and 2 passengers received serious injury. The aircraft was destroyed. The accident probably resulted from the pilot becoming distracted from monitoring his altitude at a critical stage of the approach. The possibility of pilot incapacitation is considered unlikely, but cannot be ruled out.
Probable cause:
Findings:
- The pilot was appropriately licensed and rated for the flight.
- The pilotís previously unknown heart disease probably would not have made him unfit to hold his class 1 medical certificate.
- The pilotís ability to control the aircraft was probably not affected by the onset of any incapacitation associated with his heart condition.
- Although the pilot was experienced on the PA 31 type on VFR operations, his experience of IFR operations was limited.
- The pilot had completed a recent IFR competency assessment, which met regulatory requirements for recent instrument flight time.
- The aircraft had a valid Certificate of Airworthiness, and the scheduled maintenance which had been recorded met its airworthiness requirements.
- The return of the cabin heater to service by the operator, after the maintenance engineer had disabled it pending a required test, was not appropriate but was not a factor in the accident.
- The cabin heater was a practical necessity for IFR operations in winter, and the required test should have been given priority to enable its safe use.
- The 3 unserviceable avionics instruments in the aircraft did not comply with Rule part 135, and indicated a less than optimum status of avionics maintenance. However there was sufficient
serviceable equipment for the IFR flight.
- The use of cellphones and computers permitted by the pilot on the flight had the potential to cause electronic interference to the aircraftís avionics, and was unsafe.
- The pilotís own cellphone was operating during the last 3 minutes of the flight, and could have interfered with his glide slope indication on the ILS approach.
- The aircraftís continued descent below the minimum altitude could not have resulted from electronic interference of any kind.
- The pilotís altimeter was correctly set and displayed correct altitude information throughout the approach.
- There was no aircraft defect to cause its continued descent to the ground.
- The aircraftís descent which began before reaching the glide slope, and continued below the glide slope, resulted either from a faulty glide slope indication or from the pilot flying a localiser approach instead of an ILS approach.
- When the aircraft descended below the minimum altitude for either approach it was too far away for the pilot to be able to see the runway and approach lights ahead in the reduced visibility at the time.
- The pilot allowed the aircraft to continue descending when he should have either commenced a missed approach or stopped the aircraftís descent.
- The pilotís actions or technique in flying a high-speed unstabilised instrument approach; reverting to hand-flying the aircraft at a late stage; not using the autopilot to fly a coupled approach and, if intentional, his cellphone call, would have caused him a high workload and possibly overload and distraction.
- The pilotís failure to stop the descent probably arose from distraction or overload, which led to his not monitoring the altimeter as the aircraft approached minimum altitude.
- The possibility that the pilot suffered some late incapacity which reduced his ability to fly the aircraft is unlikely, but cannot be ruled out.
- If TAWS equipment had been installed in this aircraft, it would have given warning in time for the pilot to avert the collision with terrain.
- While some miscommunication of geographical coordinates caused an erroneous expansion of the search area, the search for the aircraft was probably completed as expeditiously as possible in difficult circumstances.
Final Report:

Crash of a Fletcher FU-24-101 in Douglas: 2 killed

Date & Time: Apr 4, 2003 at 1830 LT
Type of aircraft:
Operator:
Registration:
ZK-LTF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stratford - Stratford
MSN:
200
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1438
Captain / Total hours on type:
340.00
Aircraft flight hours:
5332
Circumstances:
The pilot had arranged to topdress properties for three clients, one of whom had three separate blocks to be treated. He departed from Stratford Aerodrome at 0653 hours in ZK-LTF for the first airstrip, located some 7 km to the north-east. After an initial reconnaissance flight, he began topdressing at 0722, and finished this block at 1034 hours. Via brief landings at Stratford and another airstrip 11 km to the north, he positioned the aircraft to a strip near Huiroa. The remainder of the day’s work was carried out from this strip. Four blocks were treated from this location: the first was 8 km to the north-west of the strip, the second immediately to the north, the third some 3 km west and the last 4.5 km to the south, adjacent to the Strathmore Saddle. A reconnaissance of the fourth block was flown at 1518, but actual spreading on this property was not commenced until 1755 hours. Two loads of urea were spread on the fourth block between 1755 and 1812 hours, with a 12-minute pause until the final take-off at 1824. During this break, the last of the urea was loaded, the fertiliser bins secured and the loading vehicle parked. It is not known if the aircraft was refuelled at this time. The loader driver boarded the aircraft after completing his duties, the apparent intention being to accompany the pilot back to Stratford on completion of the last drop. On arrival over the property at 1825, the pilot performed one run towards the south, made a left reversal turn, spread another swath on a northerly heading, and pulled up to commence another reversal turn to the left. At some time after this pull-up, the aeroplane struck the ground heavily on a south-westerly heading, killing both occupants on impact. Later in the evening, the pilot’s wife reported the aircraft and its occupants overdue, and a ground search was commenced, initially by friends and associates. The wreckage and the bodies of the crew were found about half an hour after midnight. The accident occurred during evening civil twilight, at approximately 1830 hours NZST, adjacent to the Strathmore Saddle, at an elevation of about 530 feet.
Probable cause:
Conclusions:
- The pilot was licensed, rated and fit for the flights being undertaken.
- The aeroplane had a current Airworthiness Certificate and had been maintained in accordance with current requirements.
- No pre-accident aircraft defect was found.
- The impact was consistent with partial recovery from a dive with insufficient height to do so.
- No conclusive reason could be found for the aircraft to have been in such a situation.
- Light conditions were probably conducive to difficult height judgement.
- The pilot’s judgement may have further been eroded by fatigue and a degree of carbon monoxide absorption.
- The accident was not survivable.
Final Report:

Ground accident of a Fokker F27 Friendship 500 in Blenheim

Date & Time: Feb 27, 2003 at 1950 LT
Type of aircraft:
Operator:
Registration:
ZK-NAN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Blenheim - Blenheim
MSN:
10365
YOM:
1968
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Airwork F-27 was on a training flight, during which the crew carried out an exercise that simulated a gear problem. They extended the gear using the emergency system. However, after landing they did not select the main gear handle down and in addition did not install the gear locking pins. The crew were then distracted by other events and during this the co-pilot selected the emergency gear handle up to reset the system. The main gear then partially collapsed.

Crash of a Piper PA-31-325 Navajo in Feilding: 3 killed

Date & Time: Dec 17, 2002 at 2041 LT
Type of aircraft:
Operator:
Registration:
ZK-TZC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Feilding – Paraparaumu
MSN:
31-7812129
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1080
Captain / Total hours on type:
70.00
Aircraft flight hours:
1806
Circumstances:
The aircraft took off from Feilding Aerodrome on a visual flight rules flight to Paraparaumu. The normal flight time was about 17 minutes. The pilot and his 2 sons, aged 7 years and 5 years, were on board. Earlier that evening the pilot, his wife and 4 children had attended the pilotís farewell work function in Palmerston North. After the function they all went to Feilding Aerodrome where he prepared ZK-TZC for the flight. The pilotís wife saw him carry out a pre-flight inspection of the aeroplane, including checking the fuel. The pilot seemed to her to be his normal self and he gave her no indication that anything was amiss either with himself or ZK-TZC. She did not see the aeroplane taxi but did see it take off on runway 10 and then turn right. She thought the take-off and the departure were normal and saw nothing untoward. She then drove to Paraparaumu with her 2 younger children, the 2 older boys having left in ZK-TZC with their father. An aviation enthusiast, who lived by the aerodrome boundary, watched ZK-TZC taxi and take off, but he did not see or hear the pilot complete a ground run. He saw the aeroplane take off on runway 10 immediately after it taxied and thought the take-off and departure were normal. He did not notice anything untoward with the aeroplane. A radar data plot provided the time, track and altitude details for ZK-TZC. No radio transmissions from the pilot were heard or recorded by Palmerston North or Ohakea air traffic control. Palmerston North Control Tower was unattended from 2030 on the evening of the accident. The radar data plot showed that after take-off ZK-TZC turned right, climbed to 1000 feet above mean sea level (amsl) and headed for Paraparaumu. When the aeroplane was about 2.7 nautical miles (nm) (5 km) from Feilding Aerodrome and tracking approximately 1.3 nm (2.4 km) northwest of Palmerston North Aerodrome it turned to the left, descended and headed back to Feilding Aerodrome. The aeroplane descended at about 500 feet per minute rate of descent to 400 feet amsl. At 400 feet amsl (about 200 feet above the ground) the aeroplane passed about 0.5 nm (900 m) east of the aerodrome and threshold for runway 28, and joined left downwind for runway 10. In the downwind position the aeroplane was spaced about 0.3 nm (500 m) laterally from the runway at an initial height of 400 feet amsl, or about 200 feet above the ground. ZK-TZC departed from controlled flight when it was turning left at a low height during an apparent approach to land on runway 10, with its undercarriage and flaps extended. ZK-TZC first rotated to face away from the aerodrome before striking the ground in a nose down attitude. The 3 occupants were killed in the impact. Two witnesses, who were about 3.5 km southeast of Palmerston North Aerodrome and about 6 km from the aeroplane, saw the aeroplane at a normal height shortly before it turned back towards Feilding. They described what they thought was some darkish grey smoke behind the aeroplane shortly before it turned around. A witness near Palmerston North recalled seeing the aeroplane in level flight at about 1000 feet before it rolled quickly into a steep left turn and then headed back toward Feilding Aerodrome. After the steep turn the aeroplane descended. He thought that one or both engines were running unevenly. He did not see any smoke or anything unusual coming from the aeroplane. He lost sight of the aeroplane when it was in the vicinity of Feilding. He remembered that at the time it was getting on toward dark and that there was a high cloud base with gusty winds. Another witness travelling on a road from Feilding Aerodrome to Palmerston North saw the aeroplane fly low over his car. He saw the undercarriage extend then retract and that the left propeller was stationary. He believed the other engine sounded normal. He then saw the aeroplane continue toward Feilding Aerodrome and cross the eastern end of the runway. He thought the aeroplane was trying to turn and said it seemed to be quite low and slow. He did not see any smoke coming from the aeroplane. He was not overly concerned because he thought it was a training aeroplane. He said the weather at the time was clear with a high overcast. The aviation enthusiast saw ZK-TZC return for a landing and fly to a left downwind position for runway 10. He thought the aeroplane was quite low. He said the left propeller was feathered and was not turning and believed the right engine sounded normal. He did not see any smoke coming from the aeroplane. He could not recall the position of the undercarriage or flaps. After a while he became concerned when he had not seen the aeroplane land. He described the weather at the time as being fine with good visibility but that it was getting on toward dark. A further witness living near Feilding Aerodrome by the threshold to runway 10 heard the aeroplane coming and then fly overhead. He said the aeroplane sounded very low and very loud, as though its engine was at maximum speed (power). The engine sounded normal, except that it sounded as though it was under high power. He said there was a slight breeze, clear conditions and a high overcast at the time. A couple living by Feilding Aerodrome on the approach path to runway 10 heard the aeroplane coming from a northerly direction. They thought its engine sounded as though it was under a heavy load and said it was making a very loud noise like a topdressing aeroplane. The engine was making a steady sound and was not intermittent or running rough. The steady loud engine noise continued until they heard a loud thump, when the engine noise stopped abruptly. They said that at the time it was getting on toward dark but the weather was clear with good visibility. An eyewitness to the accident saw the aeroplane at a very low height, about the height of some nearby treetops, when it turned left to land. The aeroplane was turning left when she saw it nose up sharply and then suddenly turn back in the opposite direction, before nosing down and hitting the ground nose first. She said the aeroplane seemed to snap in half after it hit the ground.
Probable cause:
The following findings were identified:
- The aircraft records showed ZK-TZC had been properly maintained and was airworthy before the accident.
- No conclusive reason could be found to explain why the left propeller was feathered.
- The pilot chose an improper course of action and flew an improbable circuit in attempting to land ZK-TZC back at the departure aerodrome with one engine inoperative, which led to the accident.
- The pilot's handling of the emergency was unaccountable.
- There was no indication that the training the 2 instructors gave the pilot was anything other than of a proper standard and above the minimum requirements.
- Had the pilot applied the techniques that both instructors said they taught him for a one-engine-inoperative approach and landing, and chosen any of a number of safer options readily available to him, the accident would probably not have occurred.
Final Report:

Crash of a Fletcher FU-24A-950M near Thames: 1 killed

Date & Time: Jul 24, 2002 at 1450 LT
Type of aircraft:
Operator:
Registration:
ZK-EOE
Flight Phase:
Survivors:
No
Schedule:
Orongo - Orongo
MSN:
143
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2016
Captain / Total hours on type:
1522.00
Circumstances:
About 0900 hours on 24 July 2002, the pilot commenced spraying operations on flat farmland in the Orongo area, some three kilometres to the south-west of Thames Aerodrome. Loading for the operation was carried out at Thames by the pilot’s father, who as an experienced agricultural pilot, was also acting in a supervisory role. The pilot had only recently qualified for spraying, all his previous agricultural experience being topdressing. Spraying was stopped about 1210 hours because of unsuitable wind conditions, and both pilot and loader driver took a break for lunch at the loader driver’s home. Conditions improved after lunch, and spraying was restarted at 1350 hours, the pilot finishing the remaining treatment of the first property. The second property was started at 1420. The long axes of the paddocks on this property were aligned approximately north-west/south-east, and the pilot carried out his spray runs at right angles to the general alignment, progressively covering several paddocks on each run. The beginning of the runs was delineated by a row of about 30 mature trees of various species, over which the pilot had to descend on a south-westerly heading. On completion of the main part of the property, the pilot was left with one paddock on the other side of the trees. At the north-western end of this paddock was a barn and stockyards. On the first run over this paddock, the pilot approached over the barn and made the first spray run to the south-east. He was seen to make a 180-degree reversal turn and align the aircraft with the left (looking north-west) boundary of the paddock, in close proximity to the trees. On this heading, he was flying into the sun and towards the barn. Part -way into this run the left wing outer panel struck a protruding branch and part of the aileron was torn off. Further collisions occurred as the aircraft progressed along the tree line. The aircraft rolled inverted, struck the ground and slid to a halt with the engine still running. The farmer and his partner were driving separately along the nearby road, towards the barn when the accident happened. The farmer continued to the scene while his partner went to a neighbour’s house to alert emergency services. Arriving at the aircraft, the farmer quickly realised that there was nothing he could do for the pilot. The accident occurred in daylight, at approximately 1450 hours NZST, at Orongo, at an elevation of 10 feet. Grid reference: 260-T12-347440; latitude S 37° 10.7', longitude E 175° 31.6'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, rated and fit to carry out agricultural spraying operations.
- The aircraft had been operating normally up until the time of the accident.
- While operating into the sun and in close proximity to a line of trees, the left wing of the aircraft struck a substantial branch.
- The initial collision damaged the left aileron, and subsequent collisions with further branches progressively demolished the outer wing section.
- The aircraft damage resulted in a probably uncontrollable roll, followed by an inverted ground impact.
- The accident was not survivable.
- The aircraft structure did not feature any rollover protection for the cockpit occupant(s).
Final Report:

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

Date & Time: Apr 19, 2002 at 1013 LT
Type of aircraft:
Operator:
Registration:
ZK-EGO
Flight Phase:
Survivors:
No
MSN:
237
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:
10165
Captain / Total hours on type:
152.00
Circumstances:
On the morning of Friday 19 April 2002, the pilot was engaged in spreading superphosphate on a hill-country property to the south-east of Masterton. Operations had commenced at 0735 hours, after the pilot and loader driver had flown to the airstrip from Masterton. The topdressing proceeded normally for two hours, the pilot taking a refuel and “smoko” break from 0935 to 1000 hours. The left tank only was topped off, as the fuel system design permitted the fuel levels to equalise between the left and right tanks. As was his usual practice, the pilot carried out a full pre-flight inspection during the break. The loader driver noted the time of the first takeoff after the break as 1001 hours. This sortie was completed normally; but the aircraft became overdue on the second. Looking over towards the area being worked, the loader driver saw a column of black smoke; he immediately telephoned the company chief pilot, who was operating another aircraft on a property a short distance to the south-west. The chief pilot had already seen the smoke, and flew across to investigate. He saw the aircraft burning fiercely on the shoulder of a ridge and telephoned emergency services to report the accident. He briefly contemplated landing by the accident site, but decided against it and continued to the airstrip to pick up the loader driver. They flew back to the site, but could see no sign of the pilot, so returned to Masterton. They had seen that there was a person and a motorcycle on the ground by the wreckage: this was the farmer whose property was being topdressed, and who had been working on the eastern side of the valley being sown. While the aeroplane was on its last run, the farmer saw an object fall from it and “flutter” to the ground. He was unable to tell what the object was, but thought at first that it may have been a superphosphate bag by the way it fell. Two fencing contractors were working near the farmer’s position; they also saw an object fall from the aeroplane, and shortly afterwards one remarked to the other that the aeroplane “had no tail”. They watched the aeroplane climb and “veer to the left” before striking the ground near the top of the ridge at the southern end of the valley. It caught fire on impact. The farmer, although he did not see the impact because of intervening terrain, realised something was amiss and quickly moved to a position where he could see the accident site. He then drove his four-wheel motorcycle to the site; he estimated that this took about three minutes. On arrival, he found the centre section of the aircraft well ablaze; he could see no sign of the pilot at this stage, despite being able to get as close as the left wingtip. He reported that there were a number of explosions while the fire was burning, and that once the fire had subsided, he saw the pilot’s body in the wreckage. The impact (but not the falling object) was also witnessed by another farmer on the ridge to the western side of the valley. He estimated that some 10 seconds elapsed between impact and the first sign of fire, and had expected to see the pilot jump clear. The falling object was later found to be the tail fin (vertical stabiliser); it had landed in a clearing in a small patch of bush near where the fencers had been working, 870 m from the point where the aircraft struck the ground. The accident occurred in daylight, at 1013 hours NZST, 12 km south-south-east of Masterton, at an elevation of 1240 feet. Grid reference 260-T26-370116, latitude S 41° 04.36', longitude E 175° 42.05'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, experienced and fit to carry out the series of flights.
- The aeroplane had been operating normally up to the time of the accident.
- An undetected fatigue crack, or series of cracks, had been propagating in the forward area of the tail fin for some time.
- The cracks developed to a point where the remaining structure was unable to accommodate normal flight loads, and the fin separated from the aircraft.
- The departure of the fin probably resulted in some uncommanded yawing and pitching effects, with accompanying control feedback and unusual sounds.
- The rudder became lodged in the tailplane upper surface as the fin departed, with the potential to restrict elevator control.
- The extent and duration of any elevator control restriction could not be determined.
- The resultant impact with terrain may have been an attempt by the pilot to carry out an immediate forced landing, or may have been a result of limited control available to the pilot.
- The impact and subsequent fire were not survivable.
- The fatigue cracking in the fin originated from cuts in the skin, made when the leading-edge abrasion strip was being trimmed in situ.
- It was not determined when and by whom the cuts were made, however, measures have been taken to prevent a recurrence.
Final Report: