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 Partenavia P.68B in North Shore

Date & Time: Jul 20, 2001 at 0459 LT
Type of aircraft:
Operator:
Registration:
ZK-DMA
Flight Type:
Survivors:
Yes
Schedule:
Auckland-Whangarei
MSN:
68
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
706
Captain / Total hours on type:
200.00
Aircraft flight hours:
4773
Circumstances:
On Friday 20 July 2001, at around 0450, Partenavia P68B ZK-DMA was abeam North Shore Aerodrome at 5000 feet in darkness and enroute to Whangarei, when it suffered a double engine power loss. The pilot made an emergency landing on runway 21 at North Shore Aerodrome, but the aircraft overran the end of the runway, went through a fence, crossed a road and stopped in another fence. The pilot was the only person on board the aircraft and received face and ankle injuries. The aircraft encountered meteorological conditions conducive to engine intake icing, and ice, hail or sleet probably blocked the engine air intakes. The pilot had probably developed a mindset that dismissed icing as a cause, and consequently omitted to use alternate engine intake air, which should have restored engine power.
Probable cause:
The following findings were identified:
- The pilot was suitably qualified and authorised to conduct the flight.
- The aircraft was airworthy and its records indicated it had been maintained correctly.
- The aircraft encountered weather conditions conducive to the formation of engine intake icing.
- The engine air intakes probably became blocked by sleet, ice or hail, which caused both engines to lose power.
- The pilot probably developed a mindset that dismissed engine intake icing as a cause of the double engine power loss and omitted to apply the necessary corrective action.
- Had the pilot selected each engine’s alternate engine intake air on, engine power should have been restored.
- The Partenavia P68B flight manual warning concerning the use of alternate engine intake air should be amended to require the in-flight use of alternate air at ambient temperatures above freezing, in a high-humidity environment.
Final Report:

Crash of a De Havilland DHC-8-102 in Palmerston North: 4 killed

Date & Time: Jun 9, 1995 at 0925 LT
Operator:
Registration:
ZK-NEY
Survivors:
Yes
Schedule:
Auckland - Palmerston North
MSN:
055
YOM:
1986
Flight number:
AN703
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7765
Captain / Total hours on type:
273.00
Copilot / Total flying hours:
6460
Copilot / Total hours on type:
341
Aircraft flight hours:
22154
Aircraft flight cycles:
24976
Circumstances:
At 08:17 Ansett New Zealand Flight 703 departed Auckland (AKL) as scheduled bound for Palmerston North (PMR). To the north of Palmerston North the pilots briefed themselves for a VOR/DME approach to runway 07 which was the approach they preferred. Subsequently Air Traffic Control specified the VOR/DME approach for runway 25, due to departing traffic, and the pilots re-briefed for that instrument approach. The IMC involved flying in and out of stratiform cloud, but continuous cloud prevailed during most of the approach. The aircraft was flown accurately to join the 14 nm DME arc and thence turned right and intercepted the final approach track of 250° M to the Palmerston North VOR. During the right turn, to intercept the inbound approach track, the aircraft’s power levers were retarded to 'flight idle' and shortly afterwards the first officer advised the captain ".... 12 DME looking for 4000 (feet)". The final approach track was intercepted at approximately 13 DME and 4700 feet, and the first officer advised Ohakea Control "Ansett 703" was "established inbound". Just prior to 12 miles DME the captain called "Gear down". The first officer asked him to repeat what he had said and then responded "OK selected and on profile, ten - sorry hang on 10 DME we’re looking for four thousand aren’t we so - a fraction low". The captain responded, "Check, and Flap 15". This was not acknowledged but the first officer said, "Actually no, we’re not, ten DME we’re..... (The captain whistled at this point) look at that". The captain had noticed that the right hand main gear had not locked down: "I don’t want that." and the first officer responded, "No, that’s not good is it, so she’s not locked, so Alternate Landing Gear...?" The captain acknowledged, "Alternate extension, you want to grab the QRH?" After the First Officer’s "Yes", the captain continued, "You want to whip through that one, see if we can get it out of the way before it’s too late." The captain then stated, "I’ll keep an eye on the airplane while you’re doing that." The first officer located the appropriate "Landing Gear Malfunction Alternate Gear Extension" checklist in Ansett New Zealand’s Quick Reference Handbook (QRH) and began reading it. He started with the first check on the list but the captain told him to skip through some checks. The first officer responded to this instruction and resumed reading and carrying out the necessary actions. It was the operator’s policy that all items on the QRH checklists be actioned, or proceeded through, as directed by the captain. The first officer started carrying out the checklist. The captain in between advised him to pull the Main Gear Release Handle. Then the GPWS’s audio alarm sounded. Almost five seconds later the aircraft collided with terrain. The Dash 8 collided with the upper slope of a low range of hills.
Probable cause:
The captain not ensuring the aircraft intercepted and maintained the approach profile during the conduct of the non-precision instrument approach, the captain's perseverance with his decision to get the undercarriage lowered without discontinuing the instrument approach, the captain's distraction from the primary task of flying the aircraft safely during the first officer's endeavours to correct an undercarriage malfunction, the first officer not executing a Quick Reference Handbook procedure in the correct sequence, and the shortness of the ground proximity warning system warning.
Final Report:

Crash of a Convair CV-580 in Auckland: 3 killed

Date & Time: Jul 31, 1989 at 2200 LT
Type of aircraft:
Operator:
Registration:
ZK-FTB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Palmerston North – Auckland – Christchurch
MSN:
180
YOM:
1968
Flight number:
AFZ001
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3760
Captain / Total hours on type:
140.00
Copilot / Total flying hours:
1086
Copilot / Total hours on type:
6
Aircraft flight hours:
29999
Circumstances:
Flight Air Freight 1 was a scheduled night freight flight between Palmerston North, Auckland and Christchurch. The crew consisted of a training captain and two new co-pilots who were to fly alternate legs as co-pilot and observer. The co-pilot’s ADI of the Convair CV-580 in question had a known intermittent defect, but had been retained in service. The aircraft’s MEL however did not permit this flight to be undertaken with an unserviceable ADI. The aircraft nevertheless departed Palmerston North and arrived at Auckland at about 20:30. It was unloaded and reloaded with 11 pallets of cargo. On the next leg, to Christchurch, the handling pilot was to be the other co-pilot. Although she had completed her type rating on the Convair 580 this was her first line flight as a crew member. The flight was cleared to taxi to runway 23 for departure. Takeoff was commenced at 21:59. The aircraft climbed to a height of approx. 400 feet when it pitched down. It entered a gradual descent until it contacted the ground 387 m beyond the end of runway 23 and 91 m left of the extended centreline. The aircraft then crashed and broke up in the tidal waters of Manukau Harbour. The aircraft disintegrated on impact and all three crew members were killed.
Probable cause:
The probable cause of this accident was the training captain’s failure to monitor the aircraft’s climb flightpath during the critical stage of the climb after take-off.
Final Report:

Crash of a Grumman G-44 Widgeon in Kaipara Harbour: 2 killed

Date & Time: Jan 21, 1980
Type of aircraft:
Operator:
Registration:
ZK-BGQ
Flight Type:
Survivors:
No
Schedule:
Auckland - Kaipara Harbour
MSN:
1391
YOM:
1944
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Crashed in unknown circumstances in Kaipara Harbour while on a flight from Mechanics Bay. Both pilots were killed.

Crash of a Douglas DC-10-30 on Ross Island: 257 killed

Date & Time: Nov 28, 1979 at 1250 LT
Type of aircraft:
Operator:
Registration:
ZK-NZP
Flight Phase:
Survivors:
No
Site:
Schedule:
Auckland - Christchurch
MSN:
46910/182
YOM:
1974
Flight number:
NZ901
Country:
Region:
Crew on board:
20
Crew fatalities:
Pax on board:
237
Pax fatalities:
Other fatalities:
Total fatalities:
257
Captain / Total flying hours:
11151
Captain / Total hours on type:
2872.00
Copilot / Total flying hours:
7934
Copilot / Total hours on type:
1361
Aircraft flight hours:
20763
Circumstances:
In preparation for Flight TE901 two of the pilots attended a route qualification briefing. This briefing consisted of an audio visual presentation, a review of a printed briefing sheet and a subsequent 45 minute flight in a DC 10 flight simulator for each pilot to familiarise him with the grid navigation procedures applicable to the portion of the flight south of 60o south latitude and the visual meteorological conditions (VMC) letdown procedure at McMurdo. This briefing was completed 19 days prior to the scheduled departure date. The briefing gave details of the instrument flight rules (IFR) route to McMurdo which passed almost directly over Mt Erebus, a 12450 ft high active volcano, some 20 nm prior to the most southerly turning point, Williams Field. It also stated that the minimum instrument meteorological conditions (IMC) altitude was 16000 ft and the minimum altitude after passing overhead McMurdo was 6000 ft providing conditions were better than certain specified minima well in excess of the standard VMC in New Zealand. On the day of the flight the crew participated in a normal pre-flight dispatch planning. At 1917 hours (Z) on 27 November 1979 Air New Zealand Flight TE 901, a DC10-30 (ZKNZP) departed from Auckland Airport on a non-scheduled domestic scenic flight which was planned to proceed via South Island New Zealand, Auckland Islands, Baleny Island, and Cape Hallett to McMurdo, Antarctica then returning via Cape Hallett and Campbell Island to Christchurch its first intended landing point. The flight was dispatched on an IFR computer stored flight plan route. The flight deck crew consisted of the captain, two first officers and two flight engineers. Beside the fifteen cabin crew there was an official flight commentator on the flight who was experienced in Antarctic exploration. The passenger load was reduced by 21 from the normal passenger seating capacity as a deliberate policy to facilitate movement about the cabin to allow passengers to view the Antarctic scenery. In a discussion with the McMurdo meteorological office at 0018 hours (Z) the aircraft crew was advised that Ross Island was under a low overcast with a base of 2000 ft and with some light snow and a visibility of 40 miles and clear areas approximately 75 to 100 nm northwest of McMurdo. At approximately 0043 hours (Z) Scott Base advised the aircraft that the dry valley area was clear and that area would be a better prospect for sightseeing than Ross Island. In response to the message that the area over the Wright and Taylor Valleys was clear the captain asked the commentator if he could guide them over that way. The commentator said that would be no trouble and asked if the captain wished to head for that area at the time. The captain replied he “would prefer here first”. The US Navy Air Traffic Control Centre (ATCC) “Mac Centre” suggested that the aircraft crew take advantage of the surveillance radar to let down to 1500 feet during the aircraft’s approach to McMurdo and the crew indicated their acceptance of this offer. In the event however the aircraft was not located by the radar equipment prior to initiating its descent (or at any other time). The aircraft crew also experienced difficulty in their attempts to make contact on the very high frequency (VHF) radio telephone (R/T)and the distance measuring equipment (DME) did not lock onto the McMurdo Tactical Air Navigation System (TACAN) for any useful period. The aircraft was relying primarily on high frequency (HF) R/T during the latter part of its flight for communication with the ATCC. The area which was approved by the operator for VMC descents below 16000 feet was obscured by cloud while ZK-NZP was approaching the area, and the crew elected to descend in a clear area to the north of Ross Island in two descending orbits the first to the right and the second to the left. Although they requested and were granted a clearance from “Mac Centre” to descend from 10000 to 2000 feet VMC, on a heading of 180 grid (013oT) and proceed “visually” to McMurdo, the aircraft only descended to 8600 feet before it completed a 180° left turn to 375°G (190°T) during which it descended to 5,700 feet. The aircraft’s descent was then continued to 1500 feet on the flight planned track back toward Ross Island. Shortly after the completion of the final descent the aircraft collided with Ross Island. The aircraft’s ground proximity warning system (GWPS) operated correctly prior to impact and the crew responded to this equipment’s warning by the engineer calling off two heights above ground level, 500 and 400 feet, and the captain calling for “go round power”. The aircraft’s engines were at a high power setting and the aircraft had rotated upwards in pitch immediately prior to impact. The aircraft collided with an ice slope on Ross Island and immediately started to break up. A fire was initiated on impact and a persistent fire raged in the fuselage cabin area after that section came to rest. The accident occurred in daylight at 0050 hours (Z) at a position of 77° 25’30” S and 167° 27’30” E and at an elevation of 1467 feet AMSL. The cockpit voice recorder (CVR) and digital flight data recorder (DFDR) established that the aircraft was operating satisfactorily and the crew were not incapacitated prior to the accident.
Probable cause:
The probable cause of this accident was the decision of the captain to continue the flight at low level toward an area of poor surface and horizon definition when the crew was not certain of their position and the subsequent inability to detect the rising terrain which intercepted the aircraft’s flight path. The following findings were reported:
- The flight planned route entered in the company’s base computer was varied after the crew’s briefing in that the position for McMurdo on the computer printout used at the briefing was incorrect by over 2 degrees of longitude and was subsequently corrected prior to this flight.
- The system of checking the detailed flight plan entries into the base computer was inadequate in that an error of 2° of longitude persisted in a flight plan for some 14 months,
- Some diagrams and maps issued at the route qualification briefing could have been misleading in that they depicted a track which passed to the true west of Ross Island over a sea level ice shelf, whereas the flight planned track passed to the east over high ground reaching to 12,450 feet AMSL,
- The briefing conducted by Air New Zealand Limited contained omissions and inaccuracies which had not been detected by either earlier participating aircrews or the supervising Airline Inspectors,
- The crew were not aware of the VHF R/T callsigns in use in the area and these are not published in the briefing notes, the NZAIP, or the US Department of Defence documents which were available to the crew. They were however specified in US Navy instruction CNSFA INST 3722.1, a copy of which was held by Operation Deep Freeze Headquarters,
- The question of making a landing near McMurdo on either the ice runway or the skiways at Williams Field and the type of emergencies which might require such a diversion was not discussed at the company’s briefing,
- The Civil Aviation Division Airline Inspectors had formally approved the audio visual stage of the route qualification briefing for the flight and one had witnessed a typical audio visual segment of the briefing for an Antarctic flight, twice, without requiring any amendments or detecting the errors contained in the briefing. They had also confirmed that it was no longer necessary for captains to carry out a supervised flight as required in the Operations Specifications in view of these briefings and the flight simulator detail,
- Civil Aviation Regulation 77 1(a) had not been complied with,
- The operator departed from the stated undertaking to carry two captains on each flight and substituted an additional first officer in lieu of the second captain,
- Of the flight deck crew only one engineer had flown to the Antarctic previously,
- The crew were not monitoring their actual position in relation to the topography adequately even though a continuous readout of the aircraft’s latitude and longitude and distance to run to the next waypoint was continuously available to them from the AINS,
-The crew did not observe the transition level in use in the McMurdo air traffic control area for resetting this aircraft’s altimeters and this procedure was not published in either the briefing notes or the US Department of Defence documents which were made available to the crew. The procedure used was that prescribed in US Federal Aviation Regulation 91.81 which required the QNH to be set basically at FL 180 during descent but this was modified in low pressure areas,
- The captain’s altimeter was not set to the correct QNH until the aircraft reached 3,500 feet,
- The captain initiated a descent to an altitude below both the IMC (16000 feet) and VMC (6000 feet) minima for the area in a cloud free area but in contravention of the operator’s briefing and outside the sector approved for the descent to 6000 feet by the DCA and the Company,
- The co-pilot was devoting a significant proportion of his time in an endeavour to establish VHF contact with the McMurdo ground stations and did not monitor the decisions of the pilot in command adequately in that he did not offer any criticism of the intention to descend below MSA in contravention of company restrictions and basic good airmanship,
- The descent was intentionally continued below the VMC limit specified by CAD and Air New Zealand Limited, of 6000 feet to an indicated 1500 feet,
- The crew were distracted but not preoccupied by their failure to raise the Ice Tower or any local ground station on VHF, the failure of the DME to lock on to the TACAN and the lack of any identification of the aircraft on radar,
- The company deleted an earlier requirement for VMC descents to be monitored by radar and substituted the alternative procedure of contacting the radar controller for co-ordination of the descent,
- The failure of the aircraft’s systems to establish satisfactory VHF contactor to “lock on” to the McMurdo TACAN was probably due to the aircraft’s low altitude in conjunction with significant high ground between the aircraft and the ground equipment,
- The flight engineers endeavoured to monitor the progress of the flight and expressed their dissatisfaction with the descent toward a cloud covered area,
- Although the route selected by Air New Zealand for the approach to McMurdo crossed almost directly over a 12450 ft active volcano just 20 miles from destination in preference to the normal approach path of military aircraft which was across the sea level ice shelf the Air New Zealand route was safe provided the crew observed the minimum altitudes stipulated for the flight and no extraordinary activity occurred in the volcano,
- Despite the shortcomings of some aspects of the route qualification briefing, this flight and Antarctic flights in general were not unacceptably hazardous, if they had been conducted strictly in accordance with the route qualification briefing as presented,
- The CAD procedure of reapproving Antarctic flights each season on the condition that they complied with the constraints of the previous season’s flights led to some items being discontinued without formal notification or agreement, e.g. the carriage of 2 captains on each flight, and the requirement for a briefing by ODF Headquarters,
- The on board navigation and flight guidance system operated normally during the latter stages of the flight,
- The aircraft’s GPWS operated in accordance with its design specifications,
- CAD had not implemented effectively the section of the ICAO standard detailed in Annex 6 of the convention which requires appropriate life-sustaining equipment to be carried on flights across land areas which have been designated by the State concerned as areas in which search and rescue would be especially difficult. Although the Commander of the USN Antarctic Support Force stated that “limited SAR capability existed over land and very little over water”, this may not constitute “designation of the area” as being especially difficult for search and rescue activities by the State concerned,
- Although some notes on Antarctic survival were given to the Chief Purser immediately before this flight no additional life-sustaining equipment was carried or training given to the crew members to facilitate survival following an emergency landing on the ice or in the polar waters of Antarctica,
- Neither the passengers nor the crew were expecting the collision and all received fatal injuries on impact with the ice,
- The search and rescue organisation was mobilised and co-ordinated in a competent manner despite the difficult environment and the aircraft was located as soon as practicable, (11 hours) after the collision occurred,
- The aircraft was not fitted with a self activated ELT but such equipment is not at present required,
- The aircraft’s CVR and DFDR operated as intended and provided an excellent record for the investigators of this accident. The CVR system however could be significantly improved as discussed in recommendation 8.
- The aircraft’s radar would have depicted the mountainous terrain ahead.
Final Report:

Crash of a Fokker F27 Friendship 500 off Auckland: 2 killed

Date & Time: Feb 17, 1979 at 1435 LT
Type of aircraft:
Operator:
Registration:
ZK-NFC
Survivors:
Yes
Schedule:
Gisborne - Auckland
MSN:
10456
YOM:
1971
Flight number:
NZ4374
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
18718
Aircraft flight cycles:
25704
Circumstances:
On final approach to Auckland-Ardmore Airport, the aircraft's speed increased from 165 to 211 knots. The pilot-in-command (first officer) completed a last turn to join the runway 05 but was unable to locate it due to heavy showers. Too low, the airplane struck water surface and crashed in shallow water 1,025 meters short of runway 05 threshold. A pilot and a passenger were killed while two other occupants were injured.
Probable cause:
The accident was probably caused by the crew being misled, by a visual illusion in conditions of reduced visibility, into believing they were at a safe height and consequently failing to monitor the flight instruments sufficiently to confirm their aircraft maintained a safe approach path. The accident was the consequence of a controlled flight into terrain.

Crash of a Piper PA-31-350 Navajo Chieftain in Whitianga: 2 killed

Date & Time: Sep 2, 1974
Registration:
N54357
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Whitianga - Auckland
MSN:
31-7405248
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Whitianga Aerodrome, while in initial climb, the twin engine airplane went out of control, stalled and crashed near the Whitianga beach. The aircraft was destroyed and both occupants were killed. They were completing a delivery flight to Auckland when the accident occurred.
Probable cause:
The pilot was unable to cope with an in-flight emergency initiated by a power plant malfunction and compounded by poor weather conditions, as a consequence of which the aircraft stalled and the pilot lost control at too low an altitude to effect recovery. Autopsy of the pilot revealed acute interstitial myocarditis conducive toward destruction of the cardiac muscle fibers. It is a silent disease prone to cause irregularities in cardiac rhythm, fainting, and occasionally sudden death. The possibility that the pilot had become physically incapacitated to some degree could not be entirely discounted.

Crash of a Boeing 707-321B in Pago Pago: 97 killed

Date & Time: Jan 30, 1974 at 2341 LT
Type of aircraft:
Operator:
Registration:
N454PA
Survivors:
Yes
Schedule:
Auckland - Pago Pago - Honolulu - Los Angeles
MSN:
19376/661
YOM:
1967
Flight number:
PA806
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
91
Pax fatalities:
Other fatalities:
Total fatalities:
97
Captain / Total flying hours:
17414
Captain / Total hours on type:
7416.00
Copilot / Total flying hours:
5107
Copilot / Total hours on type:
5107
Aircraft flight hours:
21625
Circumstances:
On January 30, 1974, Pan Am Flight 806, Boeing 707-321B 'Clipper Radiant' operated as a scheduled flight from Auckland, New Zealand, to Los Angeles, California. En route stops included Pago Pago, American Samoa, and Honolulu, Hawaii. Flight 806 departed Auckland at 2014. It was cleared to Pago Pago on an IFR flight plan. At 2311, Flight 806 contacted Pago Pago Approach Control and reported its position 160 miles south of the Pago Pago airport. Approach control responded, "Clipper eight zero six, roger, and Pago weather, estimated ceiling one thousand six hundred broken, four thousand broken, the visibility - correction, one thousand overcast. The visibility one zero, light rain shower, temperature seven eight, wind three five zero degrees, one five, and altimeter's two nine eight five." At 2313, Pago Pago Approach Control cleared the flight to the Pago Pago VORTAC. Flight 806 reported leaving FL330 three minutes later and leaving FL200 at 2324. Pago Pago Approach Control cleared the flight at 2324: "Clipper eight zero six, you're cleared-for the ILS DME runway five approach - via the two zero mile arc south-southwest. Report the arc, and leaving five thousand." At 2333, the flight requested the direction and velocity of the Pago Pago winds and was told that they were 360 degrees variable from 020 degrees at 10 to 15 knots. At 2334, the flight reported out of 5,500 feet and that they had intercepted the 226 degree radial of the Pago Pago VOR. The approach controller responded, "Eight oh six, right. Understand inbound on the localizer. Report about three out. No other reported traffic. Winds zero one zero degrees at one five gusting two zero." At 2338, approach control said, "Clipper eight oh six, appears that we've had power failure at the airport. " The first officer replied, "Eight oh six, we're still getting your VOR, the ILS and the lights are showing." Approach control then asked, "See the runway lights?" The flight responded, "That's Charlie." The approach controller then said, " ...we have a bad rain shower here. I can't see them from my position here." "We're five DME now and they still look bright," the first officer responded. Approach Control replied, "´kay, no other reported traffic. The wind is zero three zero degrees at two zero, gusting two five. Advise clear of the runway." At 23:39:41, the flight replied, "Eight zero six, wilco." This was the last radio transmission from the flight. On the flight deck the windshield wipers were turned on and the flaps were set at the 50° position, which completed the checklists for landing. At 23:40:22, the first officer stated, "You're a little high." The radio altimeter warning tone then sounded twice and the first officer said "You're at minimums." He reported the field in sight and said that they were at 140 kts. At 23:40:42, the aircraft crashed into trees at an elevation of 113 feet, and about 3,865 feet short of the runway threshold. The first impact with the ground was about 236 feet farther along the crash path. The aircraft continued through the jungle vegetation, struck a 3-foot-high lava rock wall, and stopped about 3,090 feet from the runway threshold. Of the 101 occupants of the aircraft, 9 passengers and 1 crew member survived the crash and fire. One passenger died the next day; the crew member and three passengers died 3 days after the accident. One passenger died of his injuries 9 days after the accident. Thus only four passengers survived the crash.
Probable cause:
The flight crew's late recognition, and failure to correct in a timely manner, an excessive descent rate which developed as a result of the aircraft's penetration through destabilizing wind changes. The winds consisted of horizontal and vertical components produced by a heavy rainstorm and influenced by uneven terrain close to the aircraft's approach path. The captain's recognition was hampered by restricted visibility, the illusory effects of a "black hole" approach, inadequate monitoring of flight instruments, and the failure of the crew to call out descent rate during the last 15 seconds of flight.
Final Report:

Crash of a Fletcher FU-24 in Orakei

Date & Time: Oct 29, 1973
Type of aircraft:
Operator:
Registration:
ZK-CDW
Flight Phase:
Survivors:
Yes
Schedule:
Auckland - Auckland
MSN:
90
YOM:
1962
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 Orakei, in the suburb of Auckland, while engaged in a spraying mission.