Crash of a PAC 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 on this FU-24-954. The single engine aircraft hit the terrain in Mount Linton, near Ohai. The aircraft was damaged beyond repair and the pilot, sole aboard, was seriously injured.

Crash of a PAC Fletcher FU-24-950 in North Rawajitu: 1 killed

Date & Time: May 11, 2013 at 1100 LT
Type of aircraft:
Operator:
Registration:
PK-PNC
Flight Phase:
Survivors:
No
Schedule:
North Rawajitu - North Rawajitu
MSN:
243
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Pilot was engaged in a spraying mission on an oil palm plantation in the region of North Rawajitu, Lampung Province. Less than three minutes after take off, single engine aircraft stalled and crashed in flames in a wooded area. Pilot was killed and aircraft was destroyed by impact forces and post impact fire.

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

Date & Time: Dec 8, 2012 at 1324 LT
Type of aircraft:
Operator:
Registration:
ZK-EMX
Flight Phase:
Flight Type:
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
Circumstances:
Ages 27, the young pilot just accomplished his transition on this type of aircraft and decided to perform a solo training mission. During flight, while cruising at low altitude, aircraft pitched up, banked to the right and crashed into the ground. The pilot was killed and the aircraft was destroyed.

Crash of a Pacific Aerospace FU-24A-954 Fletcher in Wynella Station: 1 killed

Date & Time: Dec 20, 2010 at 1700 LT
Type of aircraft:
Registration:
VH-FNM
Survivors:
No
Schedule:
Wynella Station - Wynella Station
MSN:
263
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5815
Circumstances:
On 20 December 2010, the owner/pilot of a Pacific Aerospace Corporation FU-24-954 Fletcher aircraft, registered VH-FNM, was conducting aerial spreading of urea fertilizer at Wynella Station; a property 40 km south-south-west of Dirranbandi, Queensland. At about 1650 Eastern Standard Time, the pilot was returning to the landing strip after the completion of an application run. The aircraft impacted the terrain, and the pilot was fatally injured.
Probable cause:
Examination of the accident site indicated that the aircraft’s engine was delivering power at the time of impact. Wreckage examination did not reveal evidence of any defect or mechanical failure that would have contributed to the event. Although the post-mortem report on the pilot noted that he had significant coronary atherosclerosis, there was insufficient information available to determine whether pilot incapacitation was involved in the accident. The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation
operations.
Final Report:

Crash of a PAC Fletcher FU-24 in Fox Glacier: 9 killed

Date & Time: Sep 4, 2010 at 1327 LT
Type of aircraft:
Registration:
ZK-EUF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fox Glacier - Fox Glacier
MSN:
281
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
4554
Captain / Total hours on type:
41.00
Circumstances:
Shortly after take off from Fox Glacier aerodrome, while climbing, aircraft stalled and crashed in flames in a paddock near the airfield. All nine occupants, the pilot and 8 skydivers, were killed.
The new owner and operator of the aeroplane had not completed any weight and balance calculations on the aeroplane before it entered service, nor at any time before the accident. As a result the aeroplane was being flown outside its loading limits every time it carried a full load of 8 parachutists. On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable. The pilot was unable to regain control and the aeroplane continued to pitch up, then rolled left before striking the ground nearly vertically.
Probable cause:
Findings:
- There were no technical defects identified that may have contributed to the accident and the aeroplane was considered controllable during the take-off roll, with the engine able to deliver power during the short flight.
- The aeroplane’s centre of gravity was at least 0.122m rear of the maximum permissible limit, which created a tendency for the nose to pitch up. The most likely reason for the crash was the aeroplane being excessively out of balance. In addition, the aeroplane probably became airborne early and at too low an airspeed to prevent uncontrollable nose-up pitch.
- The aeroplane reached a pitch angle that would have made it highly improbable for the unrestrained parachutists to prevent themselves sliding back towards the tail. Any shift in weight rearward would have made the aeroplane more unstable.
- The engineering company that modified ZK-EUF for parachuting operations did not follow proper processes required by civil aviation rules and guidance. Two of the modifications had been approved for a different aircraft type, one modification belonged to another design holder and a fourth was not referred to in the aircraft maintenance logbook.
- The flight manual for ZK-EUF had not been updated to reflect the new role of the aeroplane and was limited in its usefulness to the aeroplane owner for calculating weight and balance.
- Regardless of the procedural issues with the project to modify ZK-EUF, the engineering work conducted on ZK-EUF to convert it from agricultural to parachuting operations in the standard category was by all accounts appropriately carried out.
- The weight and balance of the aeroplane, with its centre of gravity at least 0.122m outside the maximum aft limit, would have caused serious handling issues for the pilot and was the most significant factor contributing to the accident.
- ZK-EUF was 17 kg over its maximum permissible weight on the accident flight, but was still 242 kg lighter than the maximum all-up weight for which the aeroplane was certified in its previous agricultural role. Had the aeroplane not been out of balance it is considered the excess weight in itself would have been unlikely to cause the accident. Nevertheless, the pilots should have made a full weight and balance calculation before each flight.
- The aeroplane owner and their pilots did not comply with civil aviation rules and did not follow good, sound aviation practice by failing to conduct weight and balance calculations on the aeroplane. This resulted in the aeroplane being routinely flown overweight and outside the aft centre of gravity allowable limit whenever it carried 8 parachutists.
- The empty weight and balance for ZK-EUF was properly recorded in the flight manual, but the stability information in that manual had not been appropriately amended to reflect its new role of a parachute aeroplane. Nevertheless, it was still possible for the aeroplane operator to initially have calculated the weight and balance of the aeroplane for the predicted operational loads before entering the aeroplane into service.
- The aeroplane owner did not comply with civil aviation rules and did not follow good, sound aviation practice when they: used the incorrect amount of fuel reserves; removed the flight manual from the aeroplane; and did not formulate their own standard operating procedures before using the aeroplane for commercial parachuting operations.
- The Director of Civil Aviation delegated the task of assessing and overseeing major modifications to Rule Part 146 design organisations and individual holders of “inspection authorisations”. The delegations did not absolve the Director of his responsibility to monitor compliance with civil aviation rules and guidance.
Page 38 | Report 10-009
- The delegations increased the risk that unless properly managed the CAA could lose control of 2 safety-critical functions: design and inspection. The Director had not appropriately managed that risk with the current oversight programme.
- The CAA had adhered strictly to its normal practice and was acting in accordance with civil aviation rules when approving the change in airworthiness category from special to standard. However, knowing the scope, size and complexity of the modifications required to change ZK-EUF from an agricultural to a parachuting aeroplane, it should have had greater participation in the process to help ensure there were no safety implications.
- There was a flaw in the regulatory system that allowed an engineering company undertaking major modification work on an aircraft to have little or no CAA involvement by using an internal or contracted design delegation holder and a person with the inspection authorisation to oversee and sign off the work.
- The level of parachuting activity in New Zealand warranted a stronger level of regulatory oversight than had been applied in recent years.
- The CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner.
- The CAA had mechanisms through the Director’s powers under the Civil Aviation Act and his designated powers under the HSE Act to effectively regulate the parachuting industry pending the introduction of Rule Part 115.
- An alcohol and drug testing regime needs to be initiated for persons performing activities critical to flight safety, to detect and deter the use of performance-impairing substances.
- In this case the impact was not survivable and the passengers wearing safety restraints would not have prevented their deaths, but in other circumstances the wearing of safety restraints might reduce injuries and save lives.
- Safety harnesses or restraints would help to prevent passengers sliding rearward and altering the centre of gravity of the aircraft. It could not be established if this was a factor in this accident.
Final Report:

Crash of a PAC FU24-950 Fletcher in Waipukurau

Date & Time: Apr 20, 2010 at 1420 LT
Type of aircraft:
Operator:
Registration:
ZK-EGT
Flight Phase:
Survivors:
Yes
Schedule:
Waipukurau - Waipukurau
MSN:
242
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Pilot was engaged in a spreading mission on a plantation close to a farm located in Waipukurau. Accident occurred on take off in unknown circumstances. While the pilot was seriously injured, aircraft was damaged beyond repair.

Crash of a PAC Fletcher FU-24 in Ketapang: 2 killed

Date & Time: Dec 31, 2009 at 0826 LT
Type of aircraft:
Operator:
Registration:
PK-PNX
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ujung Tanjung - Jambi - Pangkal Pinang - Ketapang - Tangar
MSN:
187
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2892
Captain / Total hours on type:
641.00
Circumstances:
The pilot and one engineer were performing a ferry flight from Ujung Tanjung to Tangar with intermediate stop in Jambi, Pangkal Pinang and Ketapang. One minute after take off from runway 17 at Ketapang-Rahadi Oesman Airport, aircraft hit the roof of the local hospital and crashed in a parking lot. Both occupants were killed.
Probable cause:
Causes:
The investigation concluded that the aircraft engine was not in power during impact with the hospital roof. There was a corroded fuel pump, that indicated of contaminated fuel.
Findings:
• The aircraft was airworthy prior departure.
• The pilot was fit for flight.
• The booster pump was found of an evident of surface corrosion on the spring, plate and van pump indicated that contaminated fuel.
• Referred to the Fletcher Flight Manual and Pilot Operating Handbook chapter 3.10. Fuel System Failure, the booster pump must have been operated prior to flight.
• The propeller blades were on fine pitch and no sign of rotating impact. The engine was not in powered when hit the ground.
• No evidence damage related to the engine prior to the occurrence.
Final Report:

Crash of a PAC Fletcher FU-24 in Nelson

Date & Time: Apr 20, 2008 at 1030 LT
Type of aircraft:
Operator:
Registration:
ZK-DZC
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
205
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:

After takeoff from a remote terrain, aircraft stalled and hit fences before coming to rest in flames. Aircraft was destroyed while the pilot was uninjured. It is believed that the accident was caused by a sudden change of wind direction and speed after takeoff.

Crash of a PAC Fletcher FU-24 in Raglan

Date & Time: Jan 31, 2008 at 0630 LT
Type of aircraft:
Operator:
Registration:
ZK-JNX
Flight Phase:
Survivors:
Yes
MSN:
275
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:

Shortly ater takeoff from a remote terrain near Ragland, pilot lost control of his aircraft which hit a fence and came to rest in flames. Pilot was rescued while the aircraft was destroyed by fire.

Crash of a PAC Fletcher FU-24 in Indonesia: 1 killed

Date & Time: Dec 11, 2007 at 0930 LT
Type of aircraft:
Operator:
Registration:
PK-PNB
Flight Phase:
Survivors:
No
MSN:
248
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:

While performing a spraying flight, aircraft crashed in a palm grove. Pilot killed.