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Taranaki Regional Council

Crash of a PAC Cresco 08-600 in Tarata: 1 killed

Date & Time: Dec 14, 2008 at 1155 LT
Type of aircraft:
Operator:
Registration:
ZK-LTC
Flight Phase:
Survivors:
No
Schedule:
Tarata - Tarata
MSN:
20
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12100
Aircraft flight hours:
3272
Aircraft flight cycles:
33147
Circumstances:
On Sunday 14 December 2008, the aircraft departed from Stratford Aerodrome at 0630 hours for a transit flight to a farm airstrip near Tarata. Shortly after becoming airborne the pilot noticed the engine chip detector warning light on the instrument panel was illuminated. He diverted to the company maintenance base at Wanganui aerodrome for the defect to be rectified. The aircraft engineer found a light metallic fuzz on the engine magnetic (mag) plug. The fuzz was cleaned off and the mag plug refitted. The aircraft was released to service with a condition that a further inspection of the mag plug was to be performed after 10 hours flight time. The topdressing job, which involved the spreading of 450 tonnes of lime, had commenced on Thursday 11 December 2008 and continued on Friday 12 December 2008. No flying took place on Saturday 13 December 2008 due to a local horse-riding event being held on the farm property. The aircraft arrived at the farm airstrip at 0940 hours on the Sunday morning, and shortly thereafter commenced operations to complete the spreading of the lime. At the time of the accident, 423 tonnes of lime had been spread. The pilot flew a series of topdressing flights before needing to stop for the first refuel. When interviewed, the loader driver stated that the pilot informed him that he was having some difficulty with the lime product not flowing consistently from the aircraft hopper during the sowing runs. At approximately 1145 hours the pilot stopped again to refuel. On completion of the refuel, this gave the aircraft an estimated fuel load of 300 litres. The pilot completed a further two flights. On the third flight, the aircraft became airborne at the end of the airstrip and then descended 55 feet below the level of the airstrip where the aft fuselage struck a fence line. A concentration of lime along the aircraft’s take-off path indicated that the pilot had initiated an attempt to jettison his load at the end of the airstrip. Following the collision with the fence, the aircraft remained airborne for a further 450 metres before it impacted the side of a small hill in a slight nose down attitude. The aircraft then came to rest 12 metres to the left of the initial impact point. The accident occurred in daylight, at approximately 1155 hours NZDT, at Tarata, at an elevation of 410 feet amsl. Latitude: S39° 08.169', longitude: E174° 21.710'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, held the appropriate Medical Certificate, was experienced and fit to carry out aerial topdressing operations.
- The aircraft had been operating normally from the airstrip up to the time of the accident.
- The aircraft descended after take-off and struck a fence. The collision with the fence damaged the elevator control cable system which jammed the elevator control surface. This resulted in the pilot being unable to adequately control the aircraft in pitch, and the aircraft subsequently struck the ground.
- The aircraft was loaded with 1900 kg of lime product on the accident flight, this was in excess of the 1860 kg maximum structural hopper load. No variation above the maximum structural hopper load is allowed for in CAR Part 137. The aircraft’s all-up weight at the time of the accident was under the maximum allowed under the overload provisions of CAR Part 137 by 145 kg.
- The Aircraft Flight Manual does not provide take-off performance data for operation over the maximum certificated take-off weight and up to the maximum agricultural weight as allowed by CAR Part 137.
- A change in wind direction had occurred in the late morning which may have presented the pilot with a slight tail-wind or possible low level turbulence, including down draught conditions, during and after take-off.
- The windsock was not in the most suitable position to indicate the wind conditions to the pilot.
- Partial or full load jettisons had taken place on previous flights, indicating that the pilot was having difficulty achieving the required aircraft performance during or after take-off.
- On the accident flight, the aircraft was probably overloaded for the prevailing environmental conditions.
- The reported poor flowing qualities of the lime product being spread may have hampered the pilot’s efforts to jettison the load after take-off. The effectiveness of the jettison may have also been reduced by the downward flight path of the aircraft on leaving the end of the airstrip. It is unlikely that the pilot could comply with the CAR Part 137.103 requirement to jettison 80% of the load within five seconds.
- The possibility of a pre-existing airframe or engine defect that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The ELT fitted to the aircraft was no longer an approved type, therefore the aircraft was not airworthy in accordance with CARs. The ELT was incapable of being detected by satellite and therefore would not automatically alert rescue services, however, this did not hamper rescue efforts in this accident.
- The accident was not survivable.
Final Report:

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

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

Crash of a Fletcher FU-24-101 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 Fletcher FU-24-950M near Mangamingi: 1 killed

Date & Time: Mar 1, 1983 at 0848 LT
Type of aircraft:
Operator:
Registration:
ZK-CLI
Flight Phase:
Survivors:
No
Schedule:
Mangamingi - Mangamingi
MSN:
001
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot and loader driver arrived in the morning in ZK-CLI, flying over from Stratford. They had been working at the same farm the previous day. At about 08:35 a break in the operation was taken for refueling. The Fletcher was airborne again at about 08:45 carrying 16 hundredweight ( 815 kgs ) of fertilizer, and the pilot flew towards an area of river flat enclosed in a horseshoe bend in the Patea River, surrounded by higher ground. The loader driver reversed his vehicle to the superphosphate bin and began filling the bucket in preparation for the next sortie. As he did so he heard the sound of an impact and, hurrying back to the airstrip, saw the Fletcher crashed nose down on a hillside above the opposite bank of the Patea River, and about 1,200 metres to the northeast of the strip. The driver estimated that about a minute and a half had elapsed between the take off and the sound of the crash. The aircraft was wrecked. There was no fire. The pilot was found dead. The weather was fine with a light breeze. Flying conditions were not considered to be a factor in the accident. The condition of the propeller showed that the engine was producing power at the time of impact. The gross weight and C of G were within the permitted limits. There was evidence of about 250 kg of fertilizer at the crash site. It is believed that the pilot had carried out two sowing runs on the river flat area and was climbing away steeply to clear an adjacent ridge when control was lost during a turn and the plane dived into the ground.

Crash of a Fletcher FU-24 in Brooklands

Date & Time: May 7, 1964
Type of aircraft:
Operator:
Registration:
ZK-BWC
Flight Phase:
Survivors:
Yes
MSN:
7
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in Brooklands, in the suburb of New Plymouth. The pilot was injured.

Crash of a Fletcher FU-24 in Waverley: 1 killed

Date & Time: Feb 27, 1957 at 1700 LT
Type of aircraft:
Operator:
Registration:
ZK-BHT
Flight Phase:
Survivors:
No
Schedule:
Waverley - Waverley
MSN:
21
YOM:
1955
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
ZK-BHT had been fitted with a 6.6 hp Kohler 4-stroke, fan cooled, Auxiliary Power Unit. The purpose of this unit was to drive the aircraft's spray system. This arrangement was used with only moderate success in the application of non-inflammable liquids from the air. After trials final approval for the use of the system was granted by the Airworthiness Division of the CAA. At some point of time after the 15th of January 1957 the aircraft operator began to use the aircraft for the application, for burning-off purposes, of diesel fuel. At no point, it seems, did they inform or seek the approval of the Airworthiness Division of their intention to use the aircraft to spray an inflammable liquid. At 1345 on the day of the accident diesel oil was loaded into the plane in order to disperse the oil on a scrub-covered ravine on a farm in the Omahina Valley near Waverley. After the fifth sortie the pilot told his loader driver that during the flight he had operated the hopper jettison control briefly in order to put a heaver deposit of diesel on an area of thick scrub. The cockpit, he said, had immediately filled with dense, black smoke making him think the aircraft had caught fire. An inspection of the interior of the fuselage aft of the hopper showed that it was coated in a film of diesel oil extending back to the tail cone. There was an oil film also on the underside of the fuselage.The two mopped up the oil as best they could, tightened up a leaking connection in the supply pipe to one of the spray booms, and the operation was continued. Two further sorties were carried out uneventfully but on the eighth sortie as the Fletcher was climbing out of the ravine in order to land on the strip, which was located some 300 to 400 feet above the level of the ravine, two witnesses who had been observing the operation for some time saw a plume of flame being emitted from the underside of the fuselage about midway between the nose and the tail. At this point the aircraft was only seconds away from landing. The plane leveled out and turning 90 degrees to the right disappeared behind a ridge. After turning away from the approach to the airstrip the aircraft plowed through trees on steep tree-covered slope, then dived almost vertically to the ground before subsiding to a more level position. The right wing was detached and a small fire broke out in the engine bay. This ignited fuel flowing out of the broken fuel line from the right wing tank which in turn was augmented by diesel released from the hopper when the jettison system was sheared off. Also adding to the blaze was a quantity of petrol from the tank of the Kohler APU when the vent pipe from the small tank was broken off.
Probable cause:
The accident inspector concluded that a fire had broken out in the air causing an emergency that affected the ability of the pilot to fully control the aircraft. This fire was most probably caused by the ignition of oil fumes and residue in the interior of the fuselage, the source of the ignition being the exhaust pipe of the APU which had been seen to become red hot at times.

Crash of a De Havilland DH.83C Fox Moth near Patea: 2 killed

Date & Time: Sep 27, 1953
Operator:
Registration:
ZK-AQM
Flight Type:
Survivors:
Yes
MSN:
FM.50
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After landing at Otautu farm field, the single engine aircraft failed stop and crashed in a river. The pilot was seriously injured and both passengers were killed.

Crash of a Lockheed PV-1 Ventura in Mt Egmont: 5 killed

Date & Time: Oct 3, 1944 at 1100 LT
Type of aircraft:
Operator:
Registration:
NZ4544
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ohakea - Ohakea
MSN:
5744
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
En route, while flying in marginal weather conditions, the twin engine aircraft hit the base of Mt Egmont (Mt Taranaki) located south of New Plymouth. All five crew members were killed.
Crew (1st OTU):
F/O Jack Martin,
F/Sgt Arnold Hill,
Sgt Harold Day,
Sgt James McKay,
Sgt Frank Webb.
Probable cause:
According to the investigations, the aircraft was off course at the time of the accident, most probably due to a navigation error caused by an insufficient visibility.

Crash of an Avro 652 Anson in Mt Taranaki: 2 killed

Date & Time: Sep 4, 1944 at 1515 LT
Type of aircraft:
Operator:
Registration:
NZ414
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
New Plymouth - New Plymouth
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
237
Copilot / Total flying hours:
887
Circumstances:
The crew departed New Plymouth Airport at 1419LT on a navigation exercise. While cruising at an altitude of 1,200 feet, the twin engine aircraft went through a cloudy area over Mt Egmont (Mt Taranaki). Familiar with the area, the second pilot saw trees 200 feet below and took over the control to turn to the right to avoid any collision with the mountain. Unfortunately, the aircraft stalled, hit tree tops and crashed in a wooded area. F/Sgt Peterson was able to leave the crash site and walked for about seven miles to find help. On site, the rescuers were able to evacuate a second crew member alive while both other occupants were killed.
Crew (SNR):
F/Sgt John Paterson Cummins, pilot, †
F/Sgt Maurice Roy Haycock, pilot, †
Sgt B. F. A. Rough, navigator,
F/Sgt A. F. Peterson, radio operator.

Crash of an Avro 652 Anson I off New Plymouth

Date & Time: Aug 14, 1944
Type of aircraft:
Operator:
Registration:
NZ405
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
New Plymouth - New Plymouth
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a training exercise around New Plymouth. En route, in unknown circumstances, the twin engine aircraft crashed into the sea off New Plymouth and was lost. All four crew members were rescued.