Crash of a Britten-Norman BN-2A-21 off Tiraora Lodge

Date & Time: Mar 19, 1989 at 1635 LT
Type of aircraft:
Operator:
Registration:
ZK-SFE
Survivors:
Yes
Schedule:
Picton - Tiraora Lodge - Wellington
MSN:
406
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2345
Captain / Total hours on type:
28.00
Aircraft flight hours:
3166
Circumstances:
The flight was from Koromiko via Tiraora Lodge airstrip to Wellington. ZK-SFE took off from Koromiko with one pilot and five passengers at about 1620 hours. Three of the passengers were members of the pilot’s family. It was intended to make a stop at Tiraora Lodge airstrip to pick up additional passengers before proceeding to Wellington. Enroute to Tiraora Lodge, the aircraft encountered some turbulence from the westerly wind which was established aloft. The pilot flew the aircraft on a straight-in approach to Tiraora Lodge airstrip vector 26. Out on the bay wind gusts were disturbing the water but inshore the water was calm. There was no white water in the bay and the pilot assessed the surface wind speed as ten to fifteen knots. The sun was shining across the top of the ridge of hills which lay beyond the airstrip. As its azimuth was virtually the same as the runway direction the associated glare meant the pilot was unable to see the runway. However, the shadow of the ridge appeared to lie where the runway should have been so the pilot continued the landing approach expecting the aircraft would be in shadow when it was closer to the runway threshold and thus he would be able to see to make the landing. During the approach the aircraft encountered a downdraught which required the pilot to apply power to maintain the glidepath. The company’s missed approach procedure at Tiraora Lodge was to commence a level turn to the left 200 m from the threshold, the turn being sufficiently steep to be completed over the water. Thus the aircraft would not have to clear the trees, about 130 feet high, which surrounded the Lodge. The position from which the missed approach was to be commenced was not defined in terms of landmarks. The pilot elected to maintain a height of 200 feet on the approach reasoning that if he was unable to complete the landing, he would be able to turn above the trees which would therefore not be the limiting obstacle. By this stage, the aircraft’s indicated airspeed had been reduced to less than 88 knots and the pilot “toggled” the selector switch with the intention of setting landing flap (56°). When the pilot was able to see the airstrip he was abeam its lower end, to the right of the runway. The terrain ahead of him was uneven and divided by drainage ditches and deer fences. The overrun area beyond the runway precluded a safe arrival if the aircraft could not be stopped on the runway. A climb straight ahead was not possible due to the steep rise to a ridge at 2500 feet immediately beyond the end of the runway and high ground also prevented a turn to the right. However, a left turn seemed to offer an escape route as the ground in that direction rose less steeply. The pilot therefore commenced a missed approach to the left. He applied full power, selected flap towards “TAKE-OFF” and commenced a level turn. He had to descend the aircraft to keep it flying. Although the engines were delivering full power the performance of the aircraft was much less than he expected. Because he had been having problems with the flap actuation and indication system the pilot thought the flaps might not have retracted from the “LANDING” flap position to the “TAKE-OFF’’ position properly. On recollection, after the accident, he thought he may not have selected “LANDING” flap correctly during the approach and when he selected “TAKE-OFF” on the go-around the flaps travelled from “TAKE-OFF” to the 6° down position. Although he believed the flap position indicator to be unserviceable he did not check the position of the flaps themselves visually after either selection. Witnesses on the ground commented that the aircraft seemed to be affected by turbulence on the approach, was flying very slowly as it came level with the runway threshold and that it banked steeply when it commenced its turn. Although the pilot could not recollect hearing the stall warning horn, the passengers said that it came on and sounded continuously. During the missed approach the aircraft collided with a telephone line. When the pilot felt the drag of the telephone wire, he closed the throttles. Then, when he found the aircraft was still flying, he applied full power but the aircraft pitched nose up so he reduced the power again. The aircraft descended into the water at an angle of about 25° and then floated briefly on the surface of the bay. Although the pilot had attempted to flare the aircraft it was in a nose-down attitude on impact. All of the passengers escaped or were assisted from the aircraft and taken ashore to the Lodge for first aid and dry clothes. The accident took place in daylight at about 1635 hours NZST. The accident site was Northwest Bay, Pelorus Sound.
Probable cause:
The probable cause of this accident was the pilot’s decision to continue to fly the aircraft, at 200 feet amsl, past the point from which a missed approach could be successfully achieved, when he was unable to see the position of the runway, its threshold or the windsock.
Other contributory factors were:
- The pilot’s unfamiliarity with the Tiraora Lodge Airstrip,
- The pilot’s inadequate training in strip operation and on the aircraft type,
- The pilot’s failure to check the position of the aircraft’s flaps, visually, during the missed approach procedure when he believed the flap position indicator to be unreliable,
- The pilot’s unfamiliarity with the aircraft’s flap operating system,
- The lack of a suitable wind measuring device or other information on the local winds in the area and the presence of a substantial downflow in the area of the attempted missed approach,
- Obstructions within the obstruction free area prescribed for approved landing grounds,
- The absence of supervision of the airline by the regulatory authority.
Final Report:

Crash of a Fletcher FU24-954 in Rangitata: 1 killed

Date & Time: Dec 28, 1988 at 1005 LT
Type of aircraft:
Registration:
ZK-EMZ
Flight Phase:
Survivors:
No
Schedule:
Rangitata - Rangitata
MSN:
280
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft took off at about 0950 to spray chemicals on a 10-hectare potato crop. The flight was expected to take about 25 minutes. At 1020 when the plane had not returned to the airstrip the loader driver attempted to contact the pilot using a portable VHF transceiver. There was no response. The aircraft was found to have crashed in a level stony paddock. Physical evidence showed that the ground impact had occurred with the plane in a descending left turn and a nose down attitude. The angle of bank was 20 to 30 degrees. The outer panel of the left wing was damaged at the tip and was separated from the airframe, lying about 20 metres away. After this initial impact the plane had cartwheeled, breaking up. There was no fire. This was not a survivable accident.
Probable cause:
There was evidence that the pilot had almost completed his task at this location and was probably making a reversal turn in order to carry out a " cleaning up " run down one of the boundaries when the crash occurred. No evidence of structural or mechanical failure could be found. There was no sign of collision with any obstacle, or of bird strike. The all-up weight and C of G were within the permitted limits. Witnesses agreed that the engine was running normally right up to the the moment of the crash. The sky conditions were partly cloudy with normal horizontal visibility. There had been drizzle earlier in the day but there was no precipitation at the time of the crash. The surface wind was light and variable. The weather was not considered to be a factor. An autopsy showed that the 47-year-old pilot had some slight arterial narrowing but not sufficient to cause sudden incapacitation. Tests for chemical poisoning proved negative. The crash investigator concluded that no probable cause for the accident could be established.

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

Date & Time: Dec 12, 1987
Type of aircraft:
Operator:
Registration:
ZK-CWQ
Flight Phase:
Survivors:
No
MSN:
64
YOM:
1960
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft crashed in unknown circumstances in Wairakei. The pilot, sole on board, was killed.

Crash of a Cessna 208 Caravan I off Kaikoura: 2 killed

Date & Time: Nov 27, 1987 at 2355 LT
Type of aircraft:
Registration:
ZK-SFB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Christchurch - Wellington
MSN:
208-0059
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While cruising by night at an altitude of 11,000 feet on a cargo flight from Christchurch to Wellington, the pilot encountered icing conditions. The airplane went out of control, entered a dive and crashed in the sea off Kaikoura. Both occupants were killed.
Probable cause:
The following findings were reported:
- Icing conditions,
- The aircraft was not equipped with deicing systems,
- The pilot was tired due to a duty period more than 18 hours,
- The pilot loaded and unloaded more than 10 tons of cargo during the day,
- The pilot was soaked by rain while doing so because no foul weather gear was provided,
- The pilot did not have sufficient rest time,
- The pilot did not have a proper brake time and meal,
- The pilot was not properly trained concerning indoctrination course and suffered hypoxia in flight.

Crash of a GAF Nomad N.24A in Lake Tekapo

Date & Time: Jul 20, 1987 at 1900 LT
Type of aircraft:
Operator:
Registration:
ZK-NMD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lake Tekapo - Hamilton
MSN:
36
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Lake Tekapo, the aircraft encountered difficulties to gain height the stalled and crashed past the runway end. The pilot, sole on board, was seriously injured.
Probable cause:
It was determined that the stall during initial climb was the consequence of an excessive accumulation of frost on fuselage and wings. The aircraft was not deiced prior to takeoff.

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

Date & Time: May 6, 1987 at 1453 LT
Type of aircraft:
Operator:
Registration:
ZK-CBI
Flight Phase:
Survivors:
No
MSN:
88
YOM:
1962
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
An aerial topdressing operation was being undertaken from a sloping airstrip located on a headland near Matakana. The fertilizer to be applied was granulated superphosphate totaling 60 tonnes. The aircraft arrived at the airstrip and while waiting for the loader to arrive the pilot walked the length of the runway, then requested that the farmer cut down some saplings at the end of the strip that might obstruct his climb out path. Upon arrival of the loader the pilot instructed the driver to place 18 hundredweight (cwt) or 915 kgs of fertilizer in the aircraft. This was done, along with the addition of some fuel, and the first flight of the operation commenced. The driver did not observe the take off but while reloading his vehicle at the bin noticed a cloud of fertilizer dust off the end of the strip, indicating that the pilot had jettisoned the load. A few minutes later the driver sighted the aircraft briefly through a gap in the trees. It was flying, apparently normally, at about sowing height and on a reciprocal course to the take off direction. A faint trail of fertilizer was coming from the hopper. The plane then disappeared behind some trees and the driver did not see it again. Just after losing sight of the aircraft he saw what seemed to be a piece of red paper fluttering to the ground. When the aircraft failed to land a search was made and the wreckage of ZK-CBI was found in dense scrub about 350 metres to the left of the departure end of the airstrip. The pilot, sole on board, was killed. The investigator found that the pilot had initiated jettisoning the load 36 metres before the boundary fence. It was not clear whether the plane was still on the ground or was airborne at a low speed when a collision with the concrete post and wire fence occurred. Two posts had almost completely severed both halves of the " all flying " tailplane or stabilator. The outboard left hand section was retained by the trim tab only. The outboard part of the right hand side of the stabilator later detached and was found 150 metres from the crash site. With this degree of damage to the tailplane horizontal control must have been difficult, but the pilot was able to clear a low ridge ahead and fly out over a large basin where a 180 degree turn was completed in order to land back on the airstrip. Before the approach could be completed however, the outer part of the RH side of the stabilator separated and the aircraft dived steeply to the ground. The aircraft was destroyed by the severe impact. Fire did not break out. This was not a survivable crash.
Probable cause:
The probable cause of this accident was that the pilot did not initiate the jettisoning of the load in time to restore the take off performance which had been degraded by the kikuyu grass on the airstrip. The following findings were reported:
- The aircraft was loaded within approved limits.
- Kikuyu grass growing on the airstrip caused a significant deterioration in the acceleration of the plane on take off.
- The aircraft was capable of normal operation before the collision with the fence.
- The collision caused critical damage.
- Some minutes after the collision about 1/4 of the total horizontal stabilizer area separated from the aircraft causing it to become uncontrollable in pitch and dive to the ground.

Crash of a Fletcher FU-24A-950 in Orari Gorge: 1 killed

Date & Time: Apr 13, 1987 at 1700 LT
Type of aircraft:
Operator:
Registration:
ZK-DZA
Flight Phase:
Survivors:
No
MSN:
201
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
ZK-DZA was engaged in an aerial topdressing operation at Orari Gorge Station, situated about 16 km north-northwest of the small town of Geraldine in Canterbury. The day's work had commenced at 08:12 and by 16:30 100 tonnes of superphosphate fertilizer had been distributed over the farm in about 100 sorties. These operations had been uneventful apart from two instances of the engine stopping while idling on the ground. One of these events occurred at the start up after the lunch break and the other was after the halt taken at about 16:30 to enable the attachment of a Transland spreader unit to the plane. The pilot was unconcerned at these unwanted stoppages as the engine had a tendency to do this in warm ambient temperatures, and he attributed it to " vapour lock ". At about 16:55 the pilot took off again to spread a mixture of 575 kg of selenium pellets and between 100 and 150 kg of superphosphate over a higher area of the farm. The aircraft weight and CG were within the permitted limits. About five minutes later the loader driver heard " a thump " and on looking around sighted the plane on the side of a hill about one kilometer northwest of his location. The driver immediately radioed base to get them to inform the station manager that a crash had occurred. There was one eyewitness to the accident. A farmer working about 4 km away saw the Fletcher flying away from him and dropping a short trail of fertilizer before making " a funny move sideways " and then coming to a stop on the ground. He immediately returned to his house and telephoned Orari Gorge Station to raise the alarm. Station personnel arrived at the crash scene by 4WD vehicle within ten or fifteen minutes. They found the aircraft wrecked and the pilot dead. Fire had not occurred. The crash site was on a steep grassy slope 1,700 feet amsl. The aircraft had contacted the ground in roughly a landing attitude, at high rate of sink, and drifting to the left. It was severely damaged, with the main undercarriage legs separated and the nose leg folded back under the fuselage. The engine was displaced and the spreader torn off. Of the rest of the airframe only the tail section remained intact. Deceleration was rapid.The ground slide covered a distance of sixteen metres. This was not a survivable accident.
Probable cause:
The weather was calm with only high cloud. Examination of the engine revealed no evidence that it may have lost power in flight. An autopsy carried out on the pilot showed that he had received a broken neck and a ruptured heart in the impact. He was suffering from a moderately severe coronary heart disease at the time of death. The crash investigator concluded that this very experienced pilot may have had a heart attack and been seriously incapacitated in flight, prompting him to attempt an immediate emergency landing on the hillside.

Crash of a Fletcher FU-24-950M in Ihuraua

Date & Time: Jul 31, 1986
Type of aircraft:
Operator:
Registration:
ZK-EMD
Flight Phase:
Survivors:
Yes
MSN:
1978
YOM:
1
Flight number:
255
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while completing a spraying mission. The pilot, sole on board, was injured. The accident occurred during July, exact date unknown.

Crash of a Cessna 207 Stationair 7 in Picton: 7 killed

Date & Time: Jan 2, 1986
Registration:
ZK-WED
Flight Phase:
Survivors:
No
MSN:
207-0009
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
After takeoff from Picton-Koromiko Airport, while climbing, the engine lost power. The pilot elected to return and initiated a downwind circuit when the engine failed completely. The aircraft stalled and crashed in a field, bursting into flames. All seven occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Cessna 402 in New Zealand: 8 killed

Date & Time: Oct 4, 1985 at 1223 LT
Type of aircraft:
Operator:
Registration:
ZK-EHT
Flight Phase:
Survivors:
Yes
Schedule:
Nelson - Wellington
MSN:
402B-0340
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
While cruising in good weather conditions on a flight from Nelson to Wellington, the pilot failed to realize his altitude was insufficient when the twin engine airplane struck power cables and crashed in the Tory Channel. A passenger was rescued while eight other occupants were killed.