Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1216 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
588
Captain / Total hours on type:
14.00
Circumstances:
On 7 January 2015 a Pacific Aerospace Limited 750XL aeroplane was being used for tandem parachuting (or ‘skydiving’) operations at Taupō aerodrome. During the climb on the fourth flight of the day, the Pratt & Whitney Canada PT6A-34 engine failed suddenly. The 12 parachutists and the pilot baled out of the aeroplane and landed without serious injury. The aeroplane crashed into Lake Taupō and was destroyed.
Probable cause:
The following findings were identified:
- The first compressor turbine blade failed after a fatigue crack, which had begun at the trailing edge, propagated towards the leading edge. The blade finally fractured in tensile overload. The separated blade fragment caused other blades to fracture and the engine to stop.
- The fatigue crack in the trailing edge of the blade was likely initiated by the trailing edge radius having been below the specification for a new blade.
- The P&WC Repair Requirement Document 725009-SRR-001, at the time the blades were overhauled, had generic requirements for trailing edge thickness inspections but did not specify a minimum measurement for the trailing edge radius.
- The higher engine power settings used by the operator since August 2014 were within the flight manual limits. Therefore it was unlikely that the operator’s engine handling policy contributed to the engine failure.
- The operator had maintained the engine in accordance with an approved, alternative maintenance programme, but the registration of the engine into that programme had not been completed. The administrative oversight did not affect the reliability of the engine or contribute to the blade failure.
- It was likely that the maintenance provider had not followed fully the engine manufacturer’s recommended procedure for inspecting the compressor turbine blades. It could not be determined whether the crack might have been present, and potentially detectable, at the most recent borescope inspection.
- The operator had not equipped its pilots with flotation devices to cover the possibility of a ditching or an emergency bale-out over or near water.
- The pilot had demonstrated that he was competent and he had the required ratings. However, it was likely that the operator’s training of the pilot in emergency procedures was inadequate. This contributed to the pilot making a hasty exit from the aeroplane that jeopardized others.
Final Report:

Crash of a Fletcher FU-24-954 in Mount Linton

Date & Time: Nov 14, 2014 at 1300 LT
Type of aircraft:
Operator:
Registration:
ZK-EMN
Flight Phase:
Survivors:
Yes
MSN:
265
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was engaged in an agricultural spraying mission. In unknown circumstances, the single engine aircraft impacted terrain and came to rest against a small hill in Mount Linton. The aircraft was damaged beyond repair and the pilot, sole aboard, was seriously injured.

Crash of a De Havilland DHC-6 Twin Otter 300 near Port Moresby: 4 killed

Date & Time: Sep 20, 2014 at 0935 LT
Operator:
Registration:
P2-KSF
Survivors:
Yes
Site:
Schedule:
Woitape - Port Moresby
MSN:
528
YOM:
1977
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
19290
Captain / Total hours on type:
5980.00
Copilot / Total flying hours:
432
Copilot / Total hours on type:
172
Aircraft flight hours:
34327
Aircraft flight cycles:
46302
Circumstances:
A DHC-6 Twin Otter aircraft was returning from Woitape, Central Province, to Jacksons Airport, Port Moresby on the morning of 20 September 2014 on a charter flight under the instrument flight rules (IFR). The weather at Woitape was reported to have been clear, but at Port Moresby the reported weather was low cloud and rain. Witnesses reported that the summit of Mt Lawes (1,700 ft above mean sea level (AMSL)) was in cloud all morning on the day of the accident. When the aircraft was 36 nm (67 km) from Port Moresby, air traffic control gave the flight crew a clearance to descend maintaining visual separation from terrain and to track to a left base position for runway 14 right (14R) at Jacksons Airport, Port Moresby. The clearance was accepted by the crew. When the aircraft was within 9.5 nm (17.5 km) of the airport, the pilot in command (PIC) contacted the control tower and said that they were “running into a bit of cloud” and that they “might as well pick up the ILS [instrument landing system] if it’s OK”. The flight crew could not have conducted an ILS approach from that position. They could have discontinued their visual approach and requested radar vectoring for an ILS approach. However, they did not do so. The Port Moresby Aerodrome Terminal Information Service (ATIS), current while the aircraft was approaching Port Moresby had been received by the flight crew. It required aircraft arriving at Port Moresby to conduct an ILS approach. The PIC’s last ILS proficiency check was almost 11 months before the accident flight. A 3-monthly currency on a particular instrument approach is required under PNG Civil Aviation Rule 61.807. It is likely the reason the PIC did not request a clearance to intercept the ILS from 30 nm (55.5 km) was that he did not meet the currency requirements and therefore was not authorized to fly an ILS approach. During the descent, although the PIC said to the copilot ‘we know where we are, keep it coming down’, it was evident from the recorded information that his assessment of their position was incorrect and that the descent should not have been continued. The PIC and copilot appeared to have lost situational awareness. The aircraft impacted terrain near the summit of Mt Lawes and was substantially damaged by impact forces. Both pilots and one passenger were fatally injured in the impact, and one passenger died on the day after the accident from injuries sustained during the accident. Of the five passengers who survived the accident, three were seriously injured and two received minor injuries. One of the fatally injured passengers was not wearing a seat belt.
Probable cause:
The following contributing factors were identified:
- The flight crew continued the descent in instrument meteorological conditions without confirming their position.
- The flight crew’s assessment of their position was incorrect and they had lost situational awareness
- The flight crew deprived themselves of the “Caution” and “Warning” alerts that would have sounded about 20 sec and about 10 sec respectively before the collision, by not deactivating the EGPWS Terrain Inhibit prior to departure from Woitape.
Final Report:

Crash of a Beechcraft 200C Super King Air in Nouméa

Date & Time: Sep 9, 2014 at 1150 LT
Operator:
Registration:
F-GRSO
Flight Type:
Survivors:
Yes
Schedule:
Lifou – Nouméa
MSN:
BL-11
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Lifou Airport on an ambulance flight to Nouméa-Magenta Airport, carrying two passengers and two pilots. On approach to Magenta Airport, the crew followed the checklist and lower the landing gears. As all three green light failed to came on the cockpit panel, the crew elected to lower the gears manually without success. The crew completed two low passes in front of the control tower and it was confirmed that the left main gear seems to be down but not locked. After a 45-minute flight to burn fuel, the crew completed the landing. Upon touchdown, both main landing gear collapsed while the nose gear remained extended. The aircraft slid for few dozen metres before coming to rest. All four occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The rupture of two teeth of the sprocket of the control cylinder of the left main landing gear caused the cylinder to be locked and thus caused the mechanical system to extend the landing gear. This blockage prevented the complete extension and locking of the landing gear. This rupture and other damage to the two main landing gear actuators was probably the result of improper installation of the toothed gear and / or improper adjustment of the assembly.
Final Report:

Crash of a PAC-750XTOL in Golgubip

Date & Time: Jul 19, 2014 at 1143 LT
Operator:
Registration:
P2-RNB
Survivors:
Yes
Schedule:
Kiunga – Golgubip
MSN:
190
YOM:
2013
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2930
Captain / Total hours on type:
1900.00
Aircraft flight hours:
143
Circumstances:
A Pacific Aerospace PAC P-750 XTOL single engine aircraft was chartered to transport store goods and six passengers from Kiunga to Golgubip. Although Golgubip is in mountainous terrain and the weather in the area is often poor, the pilot was tasked to fly there without ever having been to Golgubip before. The terrain to the north north east of Golgubip rises gradually behind the airstrip. Visual illusions which may affect the pilot’s perception of height and distance can be associated with airstrips situated in terrain of this kind. On arrival at Golgubip, the pilot orbited and positioned the aircraft for landing. During the final approach he decided to discontinue the approach and to initiate a go-around procedure. The aircraft impacted terrain approximately 500 metres northwest of the airstrip and was substantially damaged. The six passengers were unhurt while the pilot sustained serious injuries. The pilot was treated in Golgubip following the accident, and was airlifted the next day to Tabubil, where he was admitted to hospital. It was later reported that the GPWS alarm sounded on approach until the final impact.
Probable cause:
Loss of control on final approach, maybe following visual illusions.
Final Report:

Crash of a Piper PA-46-310P Malibu near Narrabri

Date & Time: Jun 12, 2014 at 1630 LT
Operator:
Registration:
VH-TSV
Flight Phase:
Survivors:
Yes
Schedule:
Dubbo – Sunshine Coast
MSN:
46-8408022
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 12 June 2014, at about 1530 Eastern Standard Time (EST), a Piper PA-46 aircraft, registered VH-TSV, departed Dubbo, New South Wales for a private flight to the Sunshine Coast, Queensland with a pilot and one passenger on board. The planned route was to track via Moree and Toowoomba at 13,500 ft above mean sea level (AMSL). The pilot had operated the aircraft from Sunshine Coast to Lightning Ridge, Brewarrina and Dubbo earlier that day and reported that all engine indications were normal on those flights. About 1 hour after departing Dubbo, when about 26 NM south of Narrabri, at about 13,500 ft AMSL, the pilot observed the engine manifold pressure gauge indicating 25 inches Hg, when the throttle position selected would normally have produced about 28 inches Hg. The pilot selected the alternate air1 which did not result in any increase in power. He then elected to descend to 10,000 ft, and at that power setting when normally the engine would have produced about 29 inches Hg, the gauge still indicated only about 25 inches Hg. He turned the aircraft towards Narrabri in an attempt to fly clear of the Pilliga State Forest. The pilot assessed that the aircraft had a partial engine failure and performed troubleshooting checks. As the aircraft descended through about 8,000 ft, he observed the oil pressure gauge indicating decreasing pressure. When passing about 6,500 ft, the oil pressure gauge indicated zero and the pilot heard two loud bangs and observed the cowling lift momentarily from above the engine. The passenger observed a puff of smoke emanating from the engine and momentarily a small amount of smoke in the cockpit. The pilot established the aircraft in a glide at about 90 kt, secured the engine and completed the emergency checklist. He broadcast a ‘Mayday’ 2 call on Brisbane Centre radio frequency advising of an engine failure and forced landing. The pilot looked for a clear area below in which to conduct a forced landing and also requested the passenger to assist in identifying any cleared areas suitable to land. Both only identified heavily treed areas. The pilot extended the landing gear and selected 10º of flap and, when at about 1,000 ft, the pilot shut the fuel off, deployed the emergency beacon then switched off the electrical system. As the aircraft entered the tree tops, he flared to stall3 the aircraft. On impact, the pilot was seriously injured and lost consciousness. The passenger reported the wings impacted with trees and the aircraft slid about 10 m before coming to rest. The passenger checked for any evidence of fuel leak or fire and administered basic first aid to the pilot. The aircraft sustained substantial damage.
Final Report:

Crash of a PAC Cresco 08-600 in Otane

Date & Time: Feb 4, 2014 at 0600 LT
Type of aircraft:
Operator:
Registration:
ZK-LTE
Survivors:
Yes
Schedule:
Otane - Otane
MSN:
029
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot and the passenger were completing a top dressing mission in the region of Otane, south of Hastings, New Zealand. On final approach, the single engine aircraft seemed to be too low and hit tree tops before crashing nose down in a prairie. Both occupants were seriously injured and the aircraft was destroyed. It was dark at the time of the accident as the sunrise was computed at 0639LT.

Crash of a Piper PA-31-310 Navajo C in Aldinga

Date & Time: Jan 29, 2014 at 1132 LT
Type of aircraft:
Operator:
Registration:
VH-OFF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aldinga - Kangaroo Island
MSN:
31-7812064
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 29 January 2014, at about 1100 Central Daylight-savings Time, the pilot prepared a Piper PA-31 aircraft, registered VHOFF, for a private flight from Aldinga aeroplane landing area (ALA) to Kangaroo Island, South Australia. To check fuel quantities, the pilot entered the cockpit, turned on the master switch and placed the left and right fuel selectors onto the main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight. Once refuelling was completed, the pilot conducted a pre-flight inspection, and finished loading the aircraft. The pilot and passenger then boarded. The pilot was familiar with Aldinga ALA, which is a non-controlled airport. At uncontrolled airports, unless a restriction or preference is listed for a certain runway in either the Airservices en route supplement Australia (ERSA), or other relevant publications, selection of the runway is the responsibility of the pilot. Operational considerations such as wind direction, other traffic, runway surface and length, performance requirements for the aircraft on that day, and suitable emergency landing areas in the event of an aircraft malfunction are all taken into consideration. On this day, the pilot assessed the wind to be favoring runway 14, which already had an aircraft in the circuit intending to land. However, he decided to use runway 03 due to the availability of a landing area in case of an emergency. He then completed a full run-up check of the engines, propellers and magnetos prior to lining up for departure. The pilot reported that all of the pre-take-off checks were normal. Once the aircraft landing on runway 14 was clear of the runway, the pilot went through his usual memory checklist prior to take-off. He scanned and crosschecked the flight and panel instruments, power quadrant settings and trims, but did not complete his usual final check, which was to reach down with his right hand and confirm that the fuel selector levers were on the main tanks. After broadcasting on the common traffic advisory frequency (CTAF) he commenced the take-off. At the appropriate speed, he rotated the aircraft as it passed the intersection of the 14 and 03 runways. Almost immediately both engines began surging, there was a loss of power, the power gauges fluctuated and the aircraft yawed from side to side. Due to the surging, fluctuating gauges and aircraft yaw, the pilot found it difficult to identify what he thought was a non-performing engine. He reported there were no warning lights so he retracted the landing gear, with the intent of getting the aircraft to attain a positive rate of climb, so he could trouble shoot further at a safe altitude. When a little over 50 ft above ground level (AGL), he realized the aircraft was not performing sufficiently, so he selected a suitable landing area. He focused on maintaining a safe airspeed and landed straight ahead. The aircraft touched down and slid about another 75-100 metres before coming to rest. The impact marks of the propellers suggest the aircraft touched the ground facing north-easterly and rotated to the north-west prior to stopping. The pilot turned off the master switch and both he and the passenger exited the aircraft. After a few minutes he re-entered the cockpit and completed the shutdown. Police and fire service attended shortly after the accident.
Probable cause:
Engine malfunction due to fuel starvation.
Final Report:

Crash of a Boeing 737-3B7(SF) in Honiara

Date & Time: Jan 26, 2014 at 1259 LT
Type of aircraft:
Operator:
Registration:
ZK-TLC
Flight Type:
Survivors:
Yes
Schedule:
Brisbane – Honiara
MSN:
23705/1497
YOM:
1988
Flight number:
PAQ523
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Brisbane, the crew completed the approach and landing at Honiara-Henderson Airport. After touchdown on runway 24, the right main gear collapsed and punctured the right wing. The aircraft veered slightly to the right and came to a halt on the runway. All three occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The failure of the right main gear was the consequence of an inappropriate rework (ie, machining and re-threading) of the tee-bolt fitting and the associated installation of a reduced size nut and washer, during the last overhaul in 2004.

Crash of a Cessna 208B Grand Caravan in Kibeni: 3 killed

Date & Time: Nov 25, 2013 at 1340 LT
Type of aircraft:
Operator:
Registration:
P2-SAH
Survivors:
Yes
Schedule:
Kamusi – Purari – Vailala – Port Moresby
MSN:
208B-1263
YOM:
2007
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2200
Captain / Total hours on type:
800.00
Circumstances:
On 25 November 2013, a Cessna Aircraft Company C208B Grand Caravan, registered P2-SAH and operated by Tropicair, departed Kamusi, Western Province, for Purari River, Gulf Province, at 0312 UTC on a charter flight under the instrument flight rules (IFR). There were 10 persons on board; one pilot and nine passengers . Earlier in the day, the aircraft had departed Port Moresby for Kamusi from where it flew to Hivaro and back to Kamusi before the accident flight. SAH was due to continue from Purari River to Vailala and Port Moresby. The pilot reported that the takeoff and climb from Kamusi were normal and he levelled off at 9,000 ft and completed the top-of-climb checklist. Between Kamusi and Purari River the terrain is mostly flat and forest covered, with areas of swampland and slow-moving tidal rivers. Habitation is very sparse with occasional small villages along the rivers. The pilot recalled that the weather was generally good in the area with a cloud base of 3,000 ft and good visibility between build-ups. The pilot reported that approximately 2 minutes into the cruise there was a loud ‘pop’ sound followed by a complete loss of engine power. After configuring the aircraft for best glide speed at 95 kts, the pilot turned the aircraft right towards the coast and rivers to the south, and completed the Phase-1 memory recall items for engine failure in flight. He was assisted by the passenger in the right pilot seat who switched on the Emergency Locator Transmitter (ELT) and at 0332 broadcast MAYDAY due engine failure on the area frequency. Checking the database in the on-board Global Positioning System (GPS), the pilot found the airstrip at Kibeni on the eastern side of the Palbuna River. The pilot, assisted by the passenger next to him, tried unsuccessfully to restart the engine using the procedure in the aircraft’s Quick Reference Handbook (QRH). The passenger continued to give position reports and to communicate with other aircraft. At about 3,000 ft AMSL the pilot asked for radio silence on the area frequency so he could concentrate on the approach to Kibeni airstrip, flying a left hand circuit to land in a south westerly direction. He selected full flaps during the final stages of the approach, which arrested the aircraft’s rate of descent, but the higher than normal speed of the aircraft during the approach and landing flare caused it to float and touch down half way along the airstrip. The disused 430 metre long Kibeni airstrip was overgrown with grass and weeds. It was about 60 ft above the river and 120 ft above mean sea level, with trees and other vegetation on the slope down to the river. The aircraft bounced three times and, because the aircraft’s speed had not decayed sufficiently to stop in the available length, the pilot elected to pull back on the control column in order to clear the trees that were growing on the slope between the airstrip and the river. The aircraft became airborne, impacting the crown of a coconut palm (that was almost level with the airstrip) as it passed over the trees. The pilot banked the aircraft hard left in an attempt to land/ditch along the river and avoid trees on the opposite bank. He then pushed forward on the control column to avoid stalling the aircraft and levelled the wings before the aircraft impacted the water. The aircraft came to rest inverted with the cockpit and forward cabin submerged and immediately filled with water. After a short delay while he gained his bearings under water, the pilot was able to undo his harness and open the left cockpit door. He swam to the rear of the aircraft, opened the right rear cabin door, and helped the surviving passengers to safety on the river bank. He made several attempts to reach those still inside the aircraft. When he had determined there was nothing further he could do to reach them, he administered first aid to the survivors with materials from the aircraft’s first aid kit. After approximately 20 minutes, villagers arrived in a canoe and transported the pilot and surviving passengers to Kibeni village across the river. About 90 minutes after the accident, rescuers airlifted the survivors by helicopter to Kopi, located 44 km north east of Kibeni.
Probable cause:
The engine power loss was caused by the fracture of one CT blade in fatigue, which resulted in secondary damage to the remainder of the CT blades and downstream components. The fatigue originated from multiple origins on the pressure side of the blade trailing edge. The root cause for the fatigue initiation could not be determined with certainty. All other damages to the engine are considered secondary to the primary CT blades fracture.
Final Report: