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 Falcon 3000XL near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0900 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Survivors:
No
Site:
MSN:
117
YOM:
2004
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While flying at low height northwest of Tiniroto, the single engine airplane hit power cables and crashed in a wooded area. Both occupants were killed. Power between Wairoa and Gisborne was cut. The aircraft was a PAC750XL model built in 2004, modified in 2011 and renamed Pacific Aerospace Falcon 3000XL.

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1215 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While cruising at a height of some 5,000 feet, the pilot encountered problems with the engine. The 12 skydivers and the pilot abandoned the aircraft and bailed out. All 13 occupants were safe while the aircraft crashed into the Taupo Lake and was destroyed.

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 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:
0
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 involved in a top dressing mission in the region of Otane, south of Hastings, New Zealand. On final approach, aircraft seemed to be too low and hit tree tops before crashing nose down in a prairie. Both occupants were seriously injured while the aircraft was partially 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:
Crew was performing a training mission. In flight, in unknown circumstances, aircraft went out of control and crashed inverted in a prairie located near Mount Nicholas, between Queenstown and Te Anau, Otago. Both occupants were seriously injured while the aircraft was destroyed.

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 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 Fletcher 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:
The pilot was engaged in a crop spraying mission on a plantation close to a farm located in Waipukurau. The accident occurred on takeoff in unknown circumstances. While the pilot was seriously injured, the aircraft was damaged beyond repair.

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report: