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 Britten-Norman BN-2A-26 Islander in Tep Tep: 8 killed

Date & Time: Dec 13, 2002
Type of aircraft:
Operator:
Registration:
P2-CBB
Flight Phase:
Survivors:
No
Site:
Schedule:
Tep Tep – Madang
MSN:
140
YOM:
1969
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
After takeoff from Tep Tep Airstrip, the twin engine aircraft collided with a cliff located in the Finisterre Mountain Range. The aircraft was destroyed and all eight occupants were killed. This was the inaugural flight from the newly constructed Tep Tep Airstrip.

Crash of a Cessna 207 Skywagon in Cradle Mountain

Date & Time: Nov 7, 2002 at 1404 LT
Registration:
VH-EHL
Flight Type:
Survivors:
Yes
Schedule:
Cradle Mountain - Cradle Mountain
MSN:
207-0141
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
730
Captain / Total hours on type:
180.00
Circumstances:
The Cessna 207 aircraft (C207) was engaged on a sightseeing flight from Cradle Mountain, to Lake St. Clair and return. On board were the pilot and 4 passengers. The flight departed Cradle Mountain at approximately 1310 ESuT and tracked direct to Lake St Clair at 7000 ft due to turbulence. The aircraft then returned to Cradle Mountain. At approximately 1404, as the aircraft was approaching the airfield, the pilot configured the aircraft for a straight in approach to strip 02. The pilot had selected two stages of flap, and had reduced power to approximately 19 inches of manifold pressure. He reported that at approximately half a mile from the airfield the engine stopped without any prior warning. After completing trouble checks, the pilot became aware that the aircraft would not reach the airfield. He then manoeuvred the aircraft towards an open area on his right while broadcasting a MAYDAY call. Melbourne air traffic control acknowledged this call. The pilot then completed additional trouble checks and changed the fuel tank selection, but the engine failed to respond. The aircraft touched down heavily on the main wheels and slid approximately 40 metres before coming to a stop. During the touchdown and subsequent ground slide, the nose wheel detached from the aircraft, the propeller was damaged and the right wing was partially separated from the airframe. After the aircraft stopped the pilot checked the passengers and discovered that two of them had suffered serious injuries.
Probable cause:
The pilot reported that he had completed a daily inspection of the aircraft earlier in the morning. That inspection included assessing the fuel quantity on board the aircraft and completing a fuel drain and water check. Both of these checks did not reveal any problem with the fuel. The pilot estimated that there was approximately 185 litres of fuel on board the aircraft, 90 litres in the right tank and 95 litres in the left tank. The aircraft had last been refuelled the day previously from drum stock. The aircraft had completed two flights since that refuelling with no problems being reported. The engineers that recovered the aircraft reported that there was approximately 30 litres of fuel in the left tank and approximately 100 litres of fuel in the right tank. The C207 aircraft has a fuel selector in the cockpit that allows the pilot to supply fuel to the engine from either the right tank or the left tank, but not from both tanks simultaneously. The pilot reported that he conducted the flight with the fuel selector switched to the left tank. He also reported that he did not move the selector during the flight and only moved it to the right tank as part of his trouble checks when the engine failed. The pilot reported that he did not complete flight or fuel plans for the flight, but operated on previous knowledge from other flights. A post occurrence analysis of the weather indicated that the winds at 7000 feet were as forecast. Post flight analysis of the flight revealed that the aircraft would have required 57 litres of fuel to complete the flight, which included allowances for taxi and climb. The engine was sent by the owner to an engine overhaul facility for testing. The ATSB did not attend the testing of the engine. The engine was fitted to the test cell in the condition as removed from the aircraft. The engine was started and test run in accordance with the engine manufacturer's overhaul manual. The engine ran normally and all temperature and pressure limits were within normal ranges. The investigation was unable to determine why the engine failed to operate normally in the latter stages of the flight.
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-24-950M near Goroka: 1 killed

Date & Time: May 3, 2002 at 1525 LT
Type of aircraft:
Operator:
Registration:
P2-SDG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Karimui – Goroka
MSN:
18
YOM:
1955
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, was completing a cargo flight from Karimui to Goroka. While approaching Goroka, the single engine aircraft crashed in unknown circumstances in Kaw Kaw Gap, about 30 km south of Goroka. The pilot was killed.

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:

Crash of a Cessna 340A in Cairns

Date & Time: Mar 9, 2002 at 1729 LT
Type of aircraft:
Registration:
N79GW
Flight Type:
Survivors:
Yes
Schedule:
Bankstown – Cairns
MSN:
340A-0680
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot of a Cessna 340 departed Bankstown, NSW at 1223 ESuT, for Townsville, Qld via Walgett, St George, Roma, Emerald and Clermont. He reported that he climbed the aircraft to 16,000 ft and adopted a long range power setting of about 49% which equated to a true air speed (TAS) of 168 kts and a fuel burn of 141 lbs per hour. As the pilot approached the ‘OLDER’ waypoint north of Clermont, he reviewed his fuel situation and, because of a strong tailwind decided to continue on to Cairns. He informed an enroute controller of his decision and requested, for fuel planning purposes, a clearance to allow him to track in the opposite direction on a one-way air route. The controller was unable to approve his request but offered the pilot a direct track to Biboohra, a navigation aid 20 NM west of Cairns. The pilot accepted the amended track with the intention of later requesting a more direct route to Cairns. About 15 minutes later, the pilot requested a more direct track, but was told to call the approach controller for a possible clearance. He contacted the approach controller and told the controller that he had minimum fuel. The controller asked the pilot if he was declaring an emergency, to which he replied affirmative. The pilot later commented that he did this in the hope of expediting his arrival. He was instructed to descend to 6,500 ft and track direct to Cairns. The controller asked the pilot if he preferred to join the runway 15 circuit via a left downwind or right downwind, to which the pilot requested to join a left downwind. The pilot later commented that the aircraft fuel flow gauges were indicating a total flow of 140 lbs per hour and the fuel quantity gauges for the selected main tanks, although wandering somewhat, were ‘displaying a healthy amount’ considering that he was about 12 NM from his destination. As the pilot approached 6,500 ft, he requested a clearance for further descent, to which the controller instructed the pilot to descend to 4,000 ft. As the aircraft descended to 4,000 ft, the pilot saw Cairns City, but could not see the runway at Cairns airport. The aircraft's distance measuring equipment (DME) indicated 9 NM to the DME navigation aid at Cairns Airport. The pilot reported that at about this time, he observed one of the fuel flow gauges indicating zero, while at the same time, one or both engines began to surge and run roughly. He immediately informed the controller of the situation. The controller asked the pilot if he was familiar with a local airstrip (Greenhill which is 10 NM to the southeast of Cairns airport), to which the pilot replied that he wasn't. The controller indicated to the pilot that the strip was situated in his two o'clock position at a range of about two miles and to be aware of power lines and the sugar cane. The pilot was unsure of what to look for and was unable to see the strip, but after conducting a number of steep turns, saw a cleared strip in a field. He decided that he had to land. He extended the landing gear, but realised that the aircraft was too high and attempted a 360-degree steep turn onto final to reposition the aircraft. However, the airspeed was rapidly decreasing and there was insufficient height to complete the approach. At 1729 EST, the aircraft impacted the ground short of the strip and slid for about 20 metres. The pilot was seriously injured and the passengers received minor injuries.
Probable cause:
The reason for the initial fuel flow fluctuations was not identified by the pilot. It is likely that the pilot assumed the zero reading indicated impending fuel exhaustion and concentrated on conducting a landing in unfamiliar terrain. During the landing approach the pilot lost control of the aircraft and it descended rapidly to the ground.
Final Report:

Crash of a Cessna 207 Skywagon in Milford Sound: 6 killed

Date & Time: Jan 19, 2002 at 1000 LT
Operator:
Registration:
ZK-SEV
Flight Phase:
Survivors:
No
Site:
Schedule:
Te Anau - Milford Sound
MSN:
207-0204
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
635
Captain / Total hours on type:
13.00
Circumstances:
On Saturday, 19 January 2002, at 0931, ZK-SEV, a Cessna 207, took off from Te Anau Aerodrome for Milford Sound Aerodrome. At about 1000 the aircraft collided with the side of a mountainous valley, approximately 4400 feet above sea level and 500 metres southeast of Gertrude Saddle, some 11 kilometres from Milford Sound. The pilot and 5 passengers on board died in the collision. The aircraft probably had not reached a suitable altitude to safely cross over Gertrude Saddle, and the pilot probably left his decision too late to turn back in the valley in order to gain more height.
Probable cause:
Findings:
Findings and safety recommendations are listed in order of development and not in order of priority.
- The pilot was appropriately qualified, fit and authorised to conduct the flight.
- The aircraft records indicated the aircraft was properly maintained and airworthy. The aircraft was appropriate for the purpose and was approved for air transport operations.
- The weather conditions were suitable for the flight.
- The aircraft was probably too low to safely cross Gertrude Saddle, and the pilot probably elected to use his escape option of a left reverse turn after recognising that he would be unable to safely cross the saddle. This was left too late to safely complete the manoeuvre.
- Had the aircraft reached a suitable height to safely cross Gertrude Saddle prior to entering Gertrude Valley, the accident may have been averted.
- The pilot may have misjudged the strength of the tailwind and thus the aircraft ground speed, and the strength of any downdraughts, as he approached Gertrude Saddle. Consequently, the
closing speed with the saddle and the low height of the aircraft may have caught the pilot by surprise.
- The pilot’s delayed action in initiating a reverse turn away from Gertrude Saddle was probably a prime contributing factor to the accident.
- Pilot inexperience may have contributed to the accident.
- The current aeroplane pilot training requirements are not sufficient to ensure pilots are suitably equipped to handle the demanding flying challenges that mountainous environments can present.
Final Report:

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

Date & Time: Dec 23, 2001 at 1430 LT
Type of aircraft:
Operator:
Registration:
ZK-MAT
Flight Phase:
Survivors:
No
Site:
Schedule:
Paiaka - Paiaka
MSN:
236
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:
1516
Captain / Total hours on type:
1262.00
Circumstances:
On the morning of Sunday 23 December 2001, the pilot was engaged in spreading superphosphate on a property near Otonga. When this job was completed the operation moved to a property to the east of Whangarei where urea was sown on a maize crop. This job finished at about 1130 hours when the pilot and loader driver decided to have a cup of tea and determine which job they would do next. There were two options available; it was found that the wind was unsuitable for operations from one airstrip, so it was decided to complete the job at Paiaka, which involved spreading some 112 tonnes of lime. This particular job was to have commenced on 13 December 2001 but was delayed because of wind. The loader driver arrived at Paiaka at about 1300 hours to find that the pilot had already landed and was removing the cover from the fertiliser bin that held the lime. The loader driver noticed that water had come under the edges of the cover making the lime damp around the walls of the bin. The truck driver who had delivered lime earlier in the week had also noted the presence of moisture in the lime around the edges of the bin. The work commenced at about 1320 hours and the loader driver expected the pilot to stop for fuel between 1445 and 1500 hours. After approximately 13 loads the loader driver was using the lime that had been affected by moisture. As a result he took bucket loads from the sides of the bin and mixed it with the lime in the middle of the bin in an effort to make the lime flow more freely. At approximately 1425 the pilot gave the signal to the loader driver for a refuel on the next landing. As this was earlier than the expected refuel time the loader driver assumed this was also to check if any lime was building up around the bottom of the hopper. During the 10 weeks that they had been operating the aircraft they had to clean fertiliser away from the hopper door area. This had happened several times, especially if the fertiliser was damp, and on one occasion they had to clean out part of a previous fertiliser load that had “hung up” inside the hopper. As the loader driver was preparing for the refuel he could hear the aeroplane operating under what sounded like full power, and saw the pilot manoeuvre the aircraft in an apparent attempt to dislodge the load. He saw a small “puff” of lime discharge from the aircraft as it was “bunted”. The aircraft then disappeared behind intervening terrain into a valley, some 1,500 metres from the sowing area. The loader driver did not see the aeroplane again, but heard a muffled explosion and saw smoke on the skyline. He then phoned for emergency assistance. The accident occurred in daylight, at approximately 1430 hours NZDT, at Paiaka, at an elevation of 720 feet. Grid reference 260-Q06-142267, latitude S 35° 33 2', longitude E 174° 08.3'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, rated and fit for the flights undertaken.
- The aircraft had a valid Airworthiness Certificate and had been maintained in accordance with current requirements.
- The possibility of a pre-existing defect with the aircraft or engine that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The pilot was aware that water had affected the lime that he was using.
- The pilot encountered a “hung load” of lime, probably resulting from the damp product bridging over the hopper doors, and despite bunting manoeuvres, he was unable to discharge the hopper contents.
- The aircraft entered a valley system from which there was no means of escape, either by climbing or by carrying out a reversal turn.
Final Report:

Crash of a Beechcraft 200C Super King Air in Mount Gambier: 1 killed

Date & Time: Dec 10, 2001 at 2336 LT
Operator:
Registration:
VH-FMN
Flight Type:
Survivors:
Yes
Schedule:
Adelaide - Mount Gambier - Adelaide
MSN:
BL-47
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13730
Captain / Total hours on type:
372.00
Aircraft flight hours:
10907
Circumstances:
The Raytheon Beech 200C Super King Air, registered VH-FMN, departed Adelaide at 2240 hours Central Summer Time (CSuT) under the Instrument Flight Rules for Mount Gambier, South Australia. The ambulance aircraft was being positioned from Adelaide to Mount Gambier to transport a patient from Mount Gambier to Sydney for a medical procedure, for which time constraints applied. The pilot intended to refuel the aircraft at Mount Gambier. The planned flight time to Mount Gambier was 52 minutes. On board were the pilot and one medical crewmember. The medical crewmember was seated in a rear-facing seat behind the pilot. On departure from Adelaide, the pilot climbed the aircraft to an altitude of 21,000 ft above mean sea level for the flight to Mount Gambier. At approximately 2308, the pilot requested and received from Air Traffic Services (ATS) the latest weather report for Mount Gambier aerodrome, including the altimeter sub-scale pressure reading of 1012 millibars. At approximately 2312, the pilot commenced descent to Mount Gambier. At approximately 2324, the aircraft descended through about 8,200 ft and below ATS radar coverage. At approximately 2326, the pilot made a radio transmission on the Mount Gambier Mandatory Broadcast Zone (MBZ) frequency advising that the aircraft was 26 NM north, inbound, had left 5,000 ft on descent and was estimating the Mount Gambier circuit at 2335. At about 2327, the pilot started a series of radio transmissions to activate the Mount Gambier aerodrome pilot activated lighting (PAL).2 At approximately 2329, the pilot made a radio transmission advising that the aircraft was 19 NM north and maintaining 4,000 ft. About 3 minutes later, he made another series of transmissions to activate the Mount Gambier PAL. At approximately 2333, the pilot reported to ATS that he was in the circuit at Mount Gambier and would report after landing. Witnesses located in the vicinity of the aircraft’s flight path reported that the aircraft was flying lower than normal for aircraft arriving from the northwest. At approximately 2336 (56 minutes after departure), the aircraft impacted the ground at a position 3.1 NM from the threshold of runway (RWY) 18. The pilot sustained fatal injuries and the medical crewmember sustained serious injuries, but egressed unaided.
Probable cause:
The following factors were identified:
- Dark night conditions existed in the area surrounding the approach path of the aircraft.
- For reasons which could not be ascertained, the pilot did not comply with the requirements of the published instrument approach procedures.
- The aircraft was flown at an altitude insufficient to ensure terrain clearance.
Final Report: