Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

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 Cessna 404 Titan II in Jandakot: 2 killed

Date & Time: Aug 11, 2003 at 1537 LT
Type of aircraft:
Operator:
Registration:
VH-ANV
Flight Phase:
Survivors:
Yes
Schedule:
Jandakot - Jandakot
MSN:
404-0820
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16722
Captain / Total hours on type:
12345.00
Aircraft flight hours:
16819
Circumstances:
The aircraft took off from runway 24 right (24R) at Jandakot Airport, WA. One pilot and five passengers were on board the aircraft. The flight was being conducted in the aerial work category, under the instrument flight rules. Shortly after the aircraft became airborne, while still over the runway, the pilot recognized symptoms that he associated with a failure of the right engine and elected to continue the takeoff. The pilot retracted the landing gear, selected the wing flaps to the up position and feathered the propeller of the right engine. The pilot later reported that he was concerned about clearing a residential area and obstructions along the flight path ahead, including high-voltage powerlines crossing the aircraft’s flight path 2,400 m beyond the runway. The aircraft was approximately 450 m beyond the upwind threshold of runway 24R when the pilot initiated a series of left turns. Analysis of radar records indicated that during the turns, the airspeed of the aircraft reduced significantly below the airspeed required for optimum single-engine performance. The pilot transmitted to the aerodrome controller that he was returning for a landing and indicated an intention to land on runway 30. However, the airspeed decayed during the subsequent manoeuvring such that he was unable to safely complete the approach to that runway. The pilot was unable to maintain altitude and the aircraft descended into an area of scrub-type terrain, moderately populated with trees. During the impact sequence at about 1537, the outboard portion of the left wing collided with a tree trunk and was sheared off. A significant quantity of fuel was spilled from the wing’s fuel tank and ignited. An intense postimpact fire broke out in the vicinity of the wreckage and destroyed the aircraft. Four passengers and the pilot vacated the aircraft, but sustained serious burns in the process. One of those passengers died from those injuries 85 days after the accident. A fifth passenger did not survive the post-impact fire.
Probable cause:
Significant factors:
1. The material specification contained in the engineering order for replacing the pump bushing of the engine driven fuel pump (EDFP) fitted to the right engine was not appropriate.
2. High torsional loads between the EDFP’s spindle shaft and the sleeve bearing sheared the pump’s drive shaft during a critical phase of flight.
3. The reduction in fuel pressure was insufficient to sustain operation of the engine at the take-off power setting.
4. The loss of engine power occurred close to the decision speed with the landing gear extended while the aircraft was over the runway.
5. The pilot elected to continue the takeoff.
6. The aircraft was manoeuvred, including turns and banks, at low altitude resulting in a decrease in airspeed below that required to maximise one-engine inoperative performance.
7. The pilot was unable to maintain the aircraft’s altitude over terrain that was unsuitable for an emergency landing.
Final Report:

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 Beechcraft B200C Super King Air in Coffs Harbour

Date & Time: May 15, 2003 at 0833 LT
Operator:
Registration:
VH-AMR
Flight Type:
Survivors:
Yes
Schedule:
Sydney – Coffs Harbour
MSN:
BL-126
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18638
Captain / Total hours on type:
460.00
Circumstances:
The aircraft impacted the sea or a reef about 6 km north-east of Coffs Harbour airport. The impact occurred immediately after the pilot initiated a go-around during an instrument approach to runway 21 in Instrument Meteorological Conditions (IMC) that included heavy rain and restricted visibility. Although the aircraft sustained structural damage and the left main gear detached, the aircraft remained airborne. During the initial go-around climb, the aircraft narrowly missed a breakwater and adjacent restaurant at the Coffs Harbour boat harbour. Shortly after, the pilot noticed that the primary attitude indicator had failed, requiring him to refer to the standby instrument to recover from an inadvertent turn. The pilot positioned the aircraft over the sea and held for about 30 minutes before returning to Coffs Harbour and landing the damaged aircraft on runway 21. There were no injuries or any other damage to property and/or the environment because of the accident. The aircraft was on a routine aeromedical flight from Sydney to Coffs Harbour with the pilot, two flight nurses, and a stretcher patient on board. The flight was conducted under instrument flight rules (IFR) in predominantly instrument meteorological conditions (IMC). During the descent, the enroute air traffic controller advised the pilot to expect the runway 21 Global Positioning System (GPS) non-precision approach (NPA). The pilot reported that he reviewed the approach diagram and planned a 3-degree descent profile. He noted the appropriate altitudes, including the correct minimum descent altitude (MDA) of 580 ft, on a reference card. A copy of the approach diagram used by the pilot is at Appendix A. The aerodrome controller advised the pilot of the possibility of a holding pattern due to a preceding IFR aircraft being sequenced for an instrument approach to runway 21. The controller subsequently advised that holding would not be required if the initial approach fix (SCHNC)2 was reached not before 0825. At about 0818, the aerodrome controller advised the pilot of the preceding aircraft that the weather conditions in the area of the final approach were a visibility of 5000 m and an approximate cloud base of 1,000 ft. At 0825 the aerodrome controller cleared the pilot of the King Air to track the aircraft from the initial approach fix to the intermediate fix (SCHNI) and to descend to not below 3,500 ft. The published minimum crossing altitude was 3,600 ft. About one minute later the pilot reported that he was leaving 5,500 ft and was established inbound on the approach. At 0828 the pilot reported approaching the intermediate fix and 3,500 ft. The controller advised that further descent was not available until the preceding aircraft was visible from the tower. At 0829 the controller, having sighted the preceding aircraft, cleared the pilot of the King Air to continue descent to 2,500 ft. The pilot advised the controller that he was 2.2 NM from the final approach fix (SCHNF). At that point an aircraft on a 3-degree approach slope to the threshold would be at about 2,500 ft. The controller then cleared the pilot for the runway 21 GPS approach, effectively a clearance to descend as required. The pilot subsequently explained that he was high on his planned 3-degree descent profile because separation with the preceding aircraft resulted in a late descent clearance. He had hand flown the approach, and although he recalled setting the altitude alerter to the 3,500 ft and 2,500 ft clearance limits, he could not recall setting the 580 ft MDA. He stated that he had not intended to descend below the MDA until he was visual, and that he had started to scan outside the cockpit at about 800 ft altitude in expectation of becoming visual. The pilot recalled levelling the aircraft, but a short time later experienced a 'sinking feeling'. That prompted him to go-around by advancing the propeller and engine power levers, and establishing the aircraft in a nose-up attitude. The passenger in the right front seat reported experiencing a similar 'falling sensation' and observed the pilot's altimeter moving rapidly 'down through 200 ft' before it stopped at about 50 ft. She saw what looked like a beach and exclaimed 'land' about the same time as the pilot applied power. The pilot felt a 'thump' just after he had initiated the go-around. The passenger recalled feeling a 'jolt' as the aircraft began to climb. Witnesses on the northern breakwater of the Coffs Harbour boat harbour observed an aircraft appear out of the heavy rain and mist from the north-east. They reported that it seemed to strike the breakwater wall and then passed over an adjacent restaurant at a very low altitude before it was lost from sight. Wheels from the left landing gear were seen to ricochet into the air and one of the two wheels was seen to fall into the water. The other wheel was found lodged among the rocks of the breakwater.During the go-around the pilot unsuccessfully attempted to raise the landing gear, so he reselected the landing gear selector to the 'down' position. He was unable to retract the wing flaps. It was then that he experienced a strong g-force and realised that he was in a turn. He saw that the primary attitude indicator had 'toppled' and referred to the standby attitude indicator, which showed that the aircraft was in a 70-degree right bank. He rapidly regained control of the aircraft and turned it onto an easterly heading, away from land. The inverter fail light illuminated but the pilot did not recall any associated master warning annunciator. He then selected the number-2 inverter to restore power to the primary attitude indicator, and it commenced to operate normally. The pilot observed that the left main landing gear had separated from the aircraft. He continued to manoeuvre over water while awaiting an improvement in weather conditions that would permit a visual approach. About 4 minutes after the King Air commenced the go-around, the aerodrome controller received a telephone call advising that a person at the Coffs Harbour boat harbour had witnessed an aircraft flying low over the harbour, and that the aircraft had '…hit something and the wheel came off'. The controller contacted the pilot, who confirmed that the aircraft was damaged. The controller declared a distress phase and activated the emergency response services to position for the aircraft's landing. Witnesses reported that the landing was smooth. As the aircraft came to rest on the runway, foam was applied around the aircraft to minimise the likelihood of fire. The occupants exited the aircraft through the main cabin door.
Probable cause:
This occurrence is a CFIT accident resulting from inadvertent descent below the MDA on the final segment of a non-precision approach, fortunately without the catastrophic consequences normally associated with such events. The investigation was unable to conclusively determine why the aircraft descended below the MDA while in IMC, or why the descent continued until CFIT could no longer be avoided. However, the investigation identified a number of factors that influenced, or had the potential to influence, the development of the occurrence.
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:

Crash of a De Havilland DHC-2 Beaver off Whitsunday Island

Date & Time: Mar 6, 2003 at 1615 LT
Type of aircraft:
Operator:
Registration:
VH-AQV
Flight Type:
Survivors:
Yes
Schedule:
Hamilton Island - Whitsunday Island
MSN:
1257
YOM:
1958
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1757
Captain / Total hours on type:
50.00
Circumstances:
The pilot was conducting a charter positioning flight from Hamilton Island Marina to Whitehaven Beach, Whitsunday Island. At approximately 1615LT, pilot was landing the aircraft towards the south, about 600 metres off the beach, to avoid mechanical turbulence associated with terrain at the southern end of Whitehaven Beach. He reported that the approach and flare were normal, however, as the aircraft touched down on the right float, the aircraft swung sharply right and then sharply left. The left wing contacted the water, and the aircraft overturned. The pilot exited the upturned aircraft through the left rear passenger door and activated a 121.5 MHz distress beacon.
Probable cause:
The wind strength and sea state at the time of the occurrence were not ideal for floatplane operations, particularly given the pilot's relative lack of experience in open water operations. In comparison, it was unlikely the non-standard floats contributed significantly to the development of the accident. The loss of directional control suggests a lower than ideal pitch attitude at touchdown, a configuration which reduces a floatplane's directional stability. The pilot's use of a distress beacon for search and rescue purposes was appropriate, however the timeliness of his rescue from the upturned aircraft can be attributed to the effectiveness of the company's flight monitoring system and subsequent search and rescue actions.
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.