Region

Crash of a PAC Cresco 08-600 near Carterton: 1 killed

Date & Time: Apr 24, 2020 at 0730 LT
Type of aircraft:
Operator:
Registration:
ZK-LTK
Flight Phase:
Survivors:
No
MSN:
30
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed shortly after takeoff from a private field located about 20 km southeast of Carterton. The pilot, sole on board, was killed.

Crash of a Pacific Aerospace 750XL Falcon 3000 near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0857 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
117
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8518
Captain / Total hours on type:
3210.00
Aircraft flight hours:
8028
Circumstances:
At approximately 0500 hrs, 12 December 2016, the pilot of ZK-JPU, arrived at Gisborne Aerodrome. The pilot was accompanied by the operator’s recently employed (trainee) loader driver and already at the hangar was a senior loader driver. The pilot conducted the preflight checks of the aircraft for the day’s agricultural aircraft operations. Earlier that morning the Managing Director of the operator had called the pilot of ZK-JPU. The Managing Director requested that after finishing the first aerial topdressing task at Tauwharetoi Station and prior to the next planned task at Waimaha Station, the pilot complete a task at Pembroke Station. This was because the Managing Director was unwell and unable to undertake the Pembroke Station task as planned. The pilot of ZK-JPU agreed to the additional task. The original work plan for the day was for both loader drivers to attend the first task at Tauwharetoi Station, with the senior loader driver providing oversight for the trainee loader driver. The pilot and the senior loader driver were then to proceed to the second task of the day, while the trainee loader driver was scheduled to return to the aerodrome with the loader truck from the first task. The expectation was for the pilot to go straight from the Tauwharetoi Station task to the Pembroke Station task and then proceed to Waimaha Station. ZK-JPU departed Gisborne Aerodrome at approximately 0515 hrs with the pilot and both loader drivers on board. The aircraft was to operate from a nearby private airstrip where the loader truck was already located, as the task had been commenced the previous week. The aircraft landed at the airstrip at approximately 0530 hrs and the pilot assisted the senior loader driver to get the truck ready, double-checking the calibration of the weigh scales and fuel drain, before commencing the task at approximately 0600 hrs. On the day of the accident another pilot from the same operator, who was operating a similar Pacific Aerospace Ltd 750XL, ZK-XLA, was aerial topdressing an area of Bushy Knoll Station, operating off the Tongataha airstrip. Bushy Knoll Station is to the north of Tauwharetoi Station, alongside the route to the next two tasks scheduled for ZK-JPU at Pembroke and Waimaha Stations. The pilot of ZK-XLA commenced operating at approximately 0555 hrs and completed two to three loads before hearing the pilot of ZK-JPU over the radio at approximately 0615 hrs. The brief conversation that followed consisted of an exchange of greetings and description of locations and intentions. Both pilots then continued with their tasks without further direct communication. On completion of the first task the pilot of ZK-JPU landed at the private airstrip and instructed the senior loader driver to pack up the gear and head back to base. The senior loader driver refuelled the aircraft with 100 litres of fuel, packed up the gear and gave the trainee loader driver the radio which had been used to communicate with the pilot. After a 15 minute break the pilot of ZK-JPU was observed by the senior loader driver getting into the left seat of the aircraft and the trainee loader driver into the right seat. The senior loader driver observed ZK-JPU take off, and then departed the airstrip in the loader truck, to return to the aerodrome. At approximately 0850 the pilot of ZK-XLA received a radio call from the pilot of ZKJPU asking “are you breaking left or right?” followed by the pilot of ZK-JPU stating “I am to your left”. ZK-JPU was then observed by the pilot of ZK-XLA flying behind and to the left of ZK-XLA. The pilot of ZK-XLA advised the pilot of ZK-JPU that he was “sowing the boundary of Bushy Knoll Station […] finishing my run and […] turning right to head back to the airstrip”. Spanning the valley near the boundary of Bushy Knoll Station, near to where the pilot of ZK-XLA was operating were a set of 110 kV high voltage power lines (consisting of six wires termed ‘conductors’, supported by towers). These conductors comprised the two circuits supplying electricity to Gisborne and the East Coast region. The span traverses the valley approximately east-west and the height above terrain at the mid-span of the bottom two conductors (the lowest point of the span) was approximately 200 ft. At 0857 hrs the power supply to Gisborne and the East Coast was interrupted. Finishing the topdressing run, the pilot of ZK-XLA commenced a right climbing turn in order to return to the airstrip and sighted ZK-JPU over his right shoulder. At this point the pilot of ZK-XLA noted that something was trailing from the left wing of ZKJPU. Realising that the item trailing from ZK-JPU’s wing was a wire, the pilot of ZKXLA transmitted “you are trailing wire’’, however no response was received from ZK-JPU. The pilot of ZK-XLA witnessed ZK-JPU continue down the valley, slowly rolling to the left before impacting terrain, approximately 700 m further to the south. A postimpact fire ensued with the pilot of ZK-XLA observing “a lot of black smoke”. The pilot of ZK-XLA immediately commenced circling the accident site and attempted to call the operator via cellphone. Unable to make contact the pilot activated the emergency communications facility on the flight following equipment installed in the aircraft and reported the accident to Gisborne Tower. The accident occurred in daylight at 0857 hrs, approximately 24 NM W of Gisborne Aerodrome, at Latitude: S 38° 44' 30.85" Longitude: E 177° 28' 37.41".
Probable cause:
Conclusions
3.1 The aircraft struck six 110 kV high voltage power lines.
3.2 The pilot likely experienced inattentional blindness, in that the pilot’s attention was likely engaged on the other aircraft and thus the pilot failed to perceive the visual stimuli.
3.3 The pilot was appropriately rated and licensed to conduct the flight.
3.4 Research has shown that striking a wire that the pilot was aware of usually occurred because something changed, such as a last minute change of plan.
3.5 The pilot elected to change the plan at the last minute and detour during the positioning flight to an area where a pilot from the same operator was also conducting aerial topdressing.
3.6 The pilot did not conduct a hazard briefing for the area about to be flown and thus did not afford himself the most accurate and well informed mental model of the area the pilot elected to operate in.
3.7 Several human factors likely influenced the pilot’s decision-making and risk perception leading to the decision to change the original plan and deviate from the minimum heights as stipulated by CAR 91.311 and operators SOPs.
3.8 The safety investigation did not identify any mechanical defects which may have contributed to the accident.
3.9 The accident was not survivable.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

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

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

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

Crash of a PAC Cresco 08-600 in Otane

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

Crash of a Cessna 207A Stationair 8 II in Mount Nicholas

Date & Time: Aug 2, 2013 at 0915 LT
Operator:
Registration:
ZK-LAW
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
207-0723
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a training mission. In unknown circumstances, the single engine aircraft crashed in a prairie located near Mount Nicholas, between Queenstown and Te Anau, coming to rest upside down. Both pilots were seriously injured and the aircraft was destroyed.

Crash of a Britten Norman BN-2B-26 Islander at Okiwi Station

Date & Time: Jan 25, 2013 at 0827 LT
Type of aircraft:
Operator:
Registration:
ZK-DLA
Survivors:
Yes
Schedule:
Auckland – Okiwi Station
MSN:
2131
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3170
Captain / Total hours on type:
296.00
Circumstances:
On approach to runway 18 at Okiwi, New Zealand, the aircraft encountered windshear on short final as the pilot reduced power to land. The pilot was unable to arrest the descent rate and the aircraft landed heavily. Damage was caused to both landing gear oleos and one brake unit, with rippling found on the upper and lower skin of each wing. One passenger sustained a back injury, which was later identified as a fractured vertebra. The pilot was aware of fluctuating wind conditions at Okiwi and had increased the approach speed to 70 knots as per company standard operating procedures. The pilot reported that despite this, the airspeed reduced rapidly and significantly at 10 to 15 feet agl, leaving little time to react to the situation.
Probable cause:
Loss of height and hard landing due to windshear on short final.

Crash of a PAC Cresco 08-600 in Waitaanga

Date & Time: Dec 11, 2012 at 1738 LT
Type of aircraft:
Operator:
Registration:
ZK-LTR
Flight Phase:
Survivors:
Yes
Schedule:
Taumatunui - Mount Messenger
MSN:
003
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft crashed in unknown circumstances in Waitaanga while completing a spraying mission between Taumatunui and Mount Messenger. The aircraft was destroyed and the pilot, sole on board, was seriously injured.

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-24-954 in Fox Glacier: 9 killed

Date & Time: Sep 4, 2010 at 1327 LT
Type of aircraft:
Registration:
ZK-EUF
Flight Phase:
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: