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Bay of Plenty Regional Council

Crash of a Fletcher FU-24A-954 near Rotorua: 1 killed

Date & Time: Dec 8, 2012 at 1315 LT
Type of aircraft:
Operator:
Registration:
ZK-EMX
Flight Phase:
Survivors:
No
MSN:
278
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
430
Captain / Total hours on type:
95.00
Aircraft flight hours:
11300
Circumstances:
The pilot, who was undertaking training toward a Grade 2 Agricultural Pilot Rating, began work at approximately 0625 hours on the day of the accident. The pilot and his instructor, who was in another topdressing aircraft, flew to a block of land to the south east of Rotorua where the pilot completed 15 sowing runs, while his instructor worked in the local vicinity in the second aircraft. The pilot and instructor completed the work on this block, had a break and then transited to the Waikite Valley, arriving at approximately 0945 hours. At 1045 hours, after refuelling his aircraft, the pilot commenced sowing a ‘special mix’ fertiliser, in an alternating pattern between the instructor and pilot, with two aircraft operating from the airstrip. The alternating pattern allowed the instructor to observe and supervise the pilot during the take off and landing phases, while allowing the operation to proceed efficiently. The pilot and instructor stopped for lunch after an hour of flying, refuelled once more and then continued with their work. The amount of fertiliser that was loaded into the pilot’s aircraft was progressively increased as the work proceeded. The initial load of product was 900 kg, gradually increasing by 50 kg increments, when the instructor was satisfied that the pilot’s performance allowed this increase. The last five loads carried prior to the accident were each 1100 kg. Nothing untoward was noticed during the sowing runs, apart from the pilot aborting one landing attempt, due to the wake turbulence from the instructor’s aircraft during take off. At the time of the accident the pilot was performing ‘clearing runs’, sowing on remaining areas of land not already covered by previous sowing runs. Immediately prior to the accident, the pilot called the instructor on the radio to enquire of his location. The instructor responded with “directly behind you on the other side of the woolshed”. A few seconds later, as the instructor approached to land at the airstrip, he observed the pilot’s aircraft flying in a westerly direction at approximately 400 ft AGL. He then saw the pilot’s aircraft make a slight turn to the left. Describing what he had seen as: “he started to climb and turn slightly to the left, then the plane was in a left hand spin”. The instructor thought at the time that the aircraft spun for one and a half rotations to the left, prior to being obscured by the ridge adjacent to the airstrip. The accident occurred in daylight, at approximately 1315 hours, at Waikite Valley, Rotorua, at an elevation of 1460 ft. Latitude S 38° 18.5', longitude E 176° 17.42'.
Probable cause:
Conclusions
- The pilot was appropriately licensed and held a valid medical certificate.
- The aircraft had been appropriately maintained and no technical discrepancy was discovered that could have contributed to the accident.
- It is likely that, during a climbing turn, the pilot inadvertently allowed an aerodynamic stall to occur at which point the aircraft suddenly departed controlled flight.
- No emergency jettison of the hopper contents was attempted.
- The height above the ground, was insufficient for the pilot to perform a successful recovery once the departure from controlled flight had fully developed.
- The pilot’s lack of experience with agricultural operations and relative unfamiliarity with the aircraft type could not be eliminated as having a bearing on the accident.
Final Report:

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

Date & Time: Nov 10, 2007 at 1320 LT
Type of aircraft:
Operator:
Registration:
ZK-EGV
Flight Phase:
Survivors:
No
Site:
MSN:
244
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:
5243
Captain / Total hours on type:
4889.00
Circumstances:
On the afternoon of Friday 9 November 2007, the pilot of ZK-EGV, a specialised agricultural aeroplane powered by a turbine engine, began a task to sow 80 tonnes of superphosphate over a farm situated in low hills 5 km south of Opotiki township and 4 km from the Opotiki aerodrome. The pilot was familiar with the farm’s airstrip where he loaded the product, and with the farm. After 6 or 7 loads, the wind was too strong for top-dressing, so the pilot and loader-driver flew back to their base at the Whakatane aerodrome, about 40 km away. At Whakatane, the aeroplane’s fuel tanks were filled. Later that day, the pilot replaced the display for the aeroplane’s precision sowing guidance system, which had a software fault. The next morning, 10 November 2007, the pilot bicycled about 6 km from his house to the Whakatane aerodrome. The loader-driver said that the pilot looked “pretty tired” from the effort when he arrived at the aerodrome at about 0545. After the aeroplane had been started using its internal batteries, the pilot and loader-driver flew to complete a task at a farm west of Whakatane. The pilot’s notebook recorded that he began the task at 0610 and took 45 loads to spread the remaining 68 tonnes of product, an average load of 1511 kilograms (kg). The loader-driver said that the pilot had determined about 2 months earlier that the scales on the loader used at that airstrip were “weighing light” by about 200 kg, so the loader-driver allowed for that difference. After that task, the pilot and loader-driver flew back to the farm south of Opotiki where they had been the previous afternoon. A different loader at that airstrip had accurate scales, and the loader-driver said that he loaded 1500 kg each time, as requested by the pilot. The fertiliser that remained in the farm airstrip storage bin after the accident was found to be dry and free flowing. The sowing task at this farm began at 1010 and the pilot stopped after every hour to uplift 180 litres (L) of fuel, which weighed 144 kg. During the last refuel stop, between 1226 and 1245, he had a snack and a drink. Sowing recommenced at 1245 with about 3 minutes between each load, the last load being put on at about 1316. The loader-driver said the wind at the airstrip was light and the pilot did not report any problem with the aeroplane. After the last refuel, the top-dressing had been mostly out of sight of the loader-driver. When the aeroplane did not return when expected for the next load, the loader driver tried 3 or 4 times to call the cellphone installed in the aeroplane. This was unsuccessful, so at 1338 he followed the operator’s emergency procedure and called 111 to report that the aeroplane was overdue. Telephone records showed that on 10 November 2007 the aeroplane cellphone had been connected for a total of more than 90 minutes on 14 voice calls, and had been used to send or receive 10 text messages. Correlation of the call times with the job details recorded by the pilot suggested he sent most of his messages while the aeroplane was on the ground. Nearly all of the calls and messages involved a female work colleague who was a friend. The pilot initiated most calls by sending a message, but each time that the signal was lost during a call, the friend would stop the call and immediately re-dial the aeroplane phone; so, in some cases, consecutive connections were parts of one long conversation. The longest session exceeded 35 minutes. The nature of the calls could not be determined, but the friend claimed the content of the last phone call was not acrimonious or likely to have agitated the pilot. The friend advised that the pilot had said he often made the phone calls to help himself stay alert. At 1153, in a phone call to his home, the pilot indicated that the job was going well and he might be home by about 1400. In one call to the friend, the pilot said that he was a bit tired and that he hoped the wind would increase enough that afternoon to force him to cancel the next job. At 1308:45, the friend called the aeroplane phone and talked with the pilot until the call was disconnected at 1320:14. The friend said that while the pilot had been talking, the volume of his voice decreased slightly then there was a “static” sound. Apart from the reduced volume, the pilot’s voice had sounded normal and he had not suggested anything untoward regarding the job or the aeroplane. The friend immediately called back, but got the answerphone message from the aeroplane phone. Two further attempts to contact the pilot were unsuccessful, but the friend did not consider that anything untoward might have happened. An orchardist who was working approximately 3 km from the farm being top-dressed had heard an aeroplane flying nearby for some hours before he heard a loud sound that led him to fear that there had been an accident. He noted that the time was 1320 and immediately began to search the surrounding area. After the loader-driver’s emergency call, the Police organised an aerial search, which found the wreckage of the aeroplane at 1435 on the edge of a grove of native trees, approximately 600 metres (m) northwest of the area being top-dressed. The pilot had been killed. His body was not removed until 26 hours after the accident, because of a Police concern not to disturb the wreckage until aviation accident investigators were present. The CAA began an investigation that day into the accident and the Commission sent an investigator to help determine whether there were any similarities with another Fletcher accident that the Commission was then investigating. On 19 November 2007, because of potential issues that concerned regulatory oversight, the Commission started its own inquiry.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The reason for the aeroplane colliding with trees was not conclusively determined. However, the pilot was affected by a number of fatigue-inducing factors, none of which should have been significant on its own. The combination of these factors and the added distractions of a prolonged cell phone call and a minor equipment failure were considered likely to have diverted the pilot’s attention from his primary task of monitoring the aeroplane’s flight path.
- Although pilot incapacitation could not be ruled out entirely, it was considered that the pilot’s state of health had not directly contributed to the accident.
- The potential distraction of cellphones during critical phases of flight under VFR was not specifically addressed by CARs.
- Apart from the probable failure of the GPS sowing guidance equipment, no evidence was found to suggest that the aeroplane was unserviceable at the time of the accident, but its airworthiness certificate was invalid because there was no record that the mandatory post-flight checks of the vertical tail fin had been completed in the previous 3 days.
- The installation of a powerful turbine engine without an effective means of de-rating the power created the potential for excessive power demands and possible structural overload, but this was not considered to have contributed to the accident.
- The pilot was an experienced agricultural pilot in current practice. Although he had met the operator’s continued competency requirements, the operator’s method of conducting his last 2 competency checks was likely to have made them invalid in terms of the CAR requirements.
- Although the aeroplane was grossly overloaded and the hopper load exceeded the structural limit on the take-off prior to the accident, neither exceedance contributed to the accident, and the aeroplane was not overloaded at the time of the accident.
- The emergency locator transmitter did not radiate a useful signal because of damage to the antenna socket on the unit. The installation was also not in accordance with the manufacturer’s instructions or the recommended practice.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Tauranga

Date & Time: Dec 28, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
ZK-WNZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tauranga - Hamilton
MSN:
278
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was ferrying the aircraft from Tauranga to a Hamilton maintenance facility when one of the engines failed. The pilot elected to turn back to Tauranga but, shortly after, the remaining engine failed. The pilot carried out a forced landing into a tidal estuary. The aircraft incurred substantial damage to the nose landing gear. Subsequent CAA safety investigation determined that on an earlier flight, the aircraft's electrical system incurred a defect that rendered several electrical components unserviceable, including the two tip/main fuel tank selector valves. No engineering inspection or rectification ensued and the operator ferried the aircraft from Great Barrier Island unaware that the engines were being fed from the tip tanks only. The operator departed Tauranga for Hamilton under similar circumstances, reaching the vicinity of the Kaimai Ranges when the tip tanks became empty.
Probable cause:
Fuel exhaustion.

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

Date & Time: Dec 11, 1990 at 0835 LT
Type of aircraft:
Operator:
Registration:
ZK-BIX
Flight Phase:
Survivors:
No
Schedule:
Waimangu - Waimangu
MSN:
50
YOM:
1957
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12173
Captain / Total hours on type:
1171.00
Circumstances:
The pilot, sole on board, was engaged in a local topdressing flight in Waimangu. Shortly after takeoff, the engine lost power. The aircraft lost height then the right wing struck a hedge and it crashed. The pilot was killed.
Probable cause:
An injector was completely blocked by a grain of sand which caused a significant power loss just after takeoff.
Final Report:

Crash of a Fletcher FU-24-950M near Lake Rotomahana

Date & Time: Mar 29, 1973 at 1630 LT
Type of aircraft:
Operator:
Registration:
ZK-CKJ
Flight Phase:
Survivors:
Yes
MSN:
104
YOM:
1964
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following a power loss the pilot attempted a forced landing on a relatively level hilltop, but during the roll the nosewheel entered a deep depression and was forced rearward and upward into the cockpit floor. Fire broke out in the engine bay immediately thereafter and flashed back into the cockpit as the pilot opened the canopy to escape. The pilot evacuated safely while the aircraft was written off.
Probable cause:
Engine failure and fire for undetermined reason.

Crash of a Fletcher FU-24-2 in Mourea: 1 killed

Date & Time: Nov 28, 1966 at 1500 LT
Type of aircraft:
Operator:
Registration:
ZK-CMJ
Flight Phase:
Survivors:
No
Schedule:
Waerenga - Waerenga
MSN:
114
YOM:
1965
Country:
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 local topdressing sowing flight in the region of Mourea, north of Rotorua. While cruising at low height, facing the sun, the airplane struck a tree (27,5 meters high), causing the left wing to be torn off. Out of control, the airplane dove into the ground and crashed in flames about 100 meters further on. The pilot was killed and the airplane was destroyed.
Probable cause:
Investigations failed to reveal any mechanical failure and the airplane was properly maintained. It is believed that the pilot failed to see the tree due to the fact that he was flying face to the sun.

Crash of a Fletcher FU-24 in Tarawera

Date & Time: Nov 4, 1964
Type of aircraft:
Operator:
Registration:
ZK-BIC
Flight Phase:
Survivors:
Yes
MSN:
30
YOM:
1956
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 the vicinity of the Tarawera volcano while completing a spraying mission. The aircraft was destroyed and the pilot was injured.

Crash of a Fletcher FU-24 in Rotorua

Date & Time: Apr 28, 1964
Type of aircraft:
Operator:
Registration:
ZK-BXP
Flight Phase:
Survivors:
Yes
Schedule:
Roptorua - Rotorua
MSN:
73
YOM:
1961
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while performing a local spraying mission. The pilot was injured and the aircraft was written off.

Crash of a Fletcher FU-24 near Taneatua: 1 killed

Date & Time: Oct 21, 1963 at 0915 LT
Type of aircraft:
Operator:
Registration:
ZK-BIN
Flight Phase:
Survivors:
No
Schedule:
Owhakatoro - Owhakatoro
MSN:
41
YOM:
1957
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft took off normally at about 0912 on approximately the twenty-sixth sortie of the morning. It was seen by the loader driver to commence a sowing run, but after a few seconds the flow of mixture from the hopper ceased, and the plane entered a right-hand turn which quickly developed into a steep diving turn before the plane went out of view behind a ridge. The loader driver then heard the sound of an impact. The Fletcher had crashed about 1.75 miles from the Owhakatoro Station airstrip. It was destroyed by impact forces. Fire did not occur. The pilot must have died instantly. Inspection of the crash site indicated that the the plane had first struck the face of the steep slope, at the base of which it came to rest. The right wing tip fitted neatly into the scar mark on the slope and showed that the aircraft had been in a steep bank to the right of 78 degrees. The plane had then pivoted with force into the bed of a swampy gully about 40 feet below. The weather at the time was CAVU with smooth, calm air.
Probable cause:
Examination of the airframe and engine revealed no pre-impact defects or failures. The loader driver testified that the engine was developing normal power at the time of the diving turn. The investigators concluded that sudden physical incapacitation of the pilot was the most likely cause of this accident.

Crash of a Fletcher FU-24 in Rotorua

Date & Time: Feb 18, 1960
Type of aircraft:
Operator:
Registration:
ZK-BOI
Flight Phase:
Survivors:
Yes
MSN:
61
YOM:
1959
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while performing a crop spraying mission. The pilot, sole on board, was injured.