Crash of a Cessna 207 Skywagon in Milford Sound: 6 killed

Date & Time: Jan 19, 2002 at 1000 LT
Operator:
Registration:
ZK-SEV
Flight Phase:
Survivors:
No
Site:
Schedule:
Te Anau - Milford Sound
MSN:
207-0204
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
635
Captain / Total hours on type:
13.00
Circumstances:
On Saturday, 19 January 2002, at 0931, ZK-SEV, a Cessna 207, took off from Te Anau Aerodrome for Milford Sound Aerodrome. At about 1000 the aircraft collided with the side of a mountainous valley, approximately 4400 feet above sea level and 500 metres southeast of Gertrude Saddle, some 11 kilometres from Milford Sound. The pilot and 5 passengers on board died in the collision. The aircraft probably had not reached a suitable altitude to safely cross over Gertrude Saddle, and the pilot probably left his decision too late to turn back in the valley in order to gain more height.
Probable cause:
Findings:
Findings and safety recommendations are listed in order of development and not in order of priority.
- The pilot was appropriately qualified, fit and authorised to conduct the flight.
- The aircraft records indicated the aircraft was properly maintained and airworthy. The aircraft was appropriate for the purpose and was approved for air transport operations.
- The weather conditions were suitable for the flight.
- The aircraft was probably too low to safely cross Gertrude Saddle, and the pilot probably elected to use his escape option of a left reverse turn after recognising that he would be unable to safely cross the saddle. This was left too late to safely complete the manoeuvre.
- Had the aircraft reached a suitable height to safely cross Gertrude Saddle prior to entering Gertrude Valley, the accident may have been averted.
- The pilot may have misjudged the strength of the tailwind and thus the aircraft ground speed, and the strength of any downdraughts, as he approached Gertrude Saddle. Consequently, the
closing speed with the saddle and the low height of the aircraft may have caught the pilot by surprise.
- The pilot’s delayed action in initiating a reverse turn away from Gertrude Saddle was probably a prime contributing factor to the accident.
- Pilot inexperience may have contributed to the accident.
- The current aeroplane pilot training requirements are not sufficient to ensure pilots are suitably equipped to handle the demanding flying challenges that mountainous environments can present.
Final Report:

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

Date & Time: Dec 23, 2001 at 1430 LT
Type of aircraft:
Operator:
Registration:
ZK-MAT
Flight Phase:
Survivors:
No
Site:
Schedule:
Paiaka - Paiaka
MSN:
236
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1516
Captain / Total hours on type:
1262.00
Circumstances:
On the morning of Sunday 23 December 2001, the pilot was engaged in spreading superphosphate on a property near Otonga. When this job was completed the operation moved to a property to the east of Whangarei where urea was sown on a maize crop. This job finished at about 1130 hours when the pilot and loader driver decided to have a cup of tea and determine which job they would do next. There were two options available; it was found that the wind was unsuitable for operations from one airstrip, so it was decided to complete the job at Paiaka, which involved spreading some 112 tonnes of lime. This particular job was to have commenced on 13 December 2001 but was delayed because of wind. The loader driver arrived at Paiaka at about 1300 hours to find that the pilot had already landed and was removing the cover from the fertiliser bin that held the lime. The loader driver noticed that water had come under the edges of the cover making the lime damp around the walls of the bin. The truck driver who had delivered lime earlier in the week had also noted the presence of moisture in the lime around the edges of the bin. The work commenced at about 1320 hours and the loader driver expected the pilot to stop for fuel between 1445 and 1500 hours. After approximately 13 loads the loader driver was using the lime that had been affected by moisture. As a result he took bucket loads from the sides of the bin and mixed it with the lime in the middle of the bin in an effort to make the lime flow more freely. At approximately 1425 the pilot gave the signal to the loader driver for a refuel on the next landing. As this was earlier than the expected refuel time the loader driver assumed this was also to check if any lime was building up around the bottom of the hopper. During the 10 weeks that they had been operating the aircraft they had to clean fertiliser away from the hopper door area. This had happened several times, especially if the fertiliser was damp, and on one occasion they had to clean out part of a previous fertiliser load that had “hung up” inside the hopper. As the loader driver was preparing for the refuel he could hear the aeroplane operating under what sounded like full power, and saw the pilot manoeuvre the aircraft in an apparent attempt to dislodge the load. He saw a small “puff” of lime discharge from the aircraft as it was “bunted”. The aircraft then disappeared behind intervening terrain into a valley, some 1,500 metres from the sowing area. The loader driver did not see the aeroplane again, but heard a muffled explosion and saw smoke on the skyline. He then phoned for emergency assistance. The accident occurred in daylight, at approximately 1430 hours NZDT, at Paiaka, at an elevation of 720 feet. Grid reference 260-Q06-142267, latitude S 35° 33 2', longitude E 174° 08.3'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, rated and fit for the flights undertaken.
- The aircraft had a valid Airworthiness Certificate and had been maintained in accordance with current requirements.
- The possibility of a pre-existing defect with the aircraft or engine that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The pilot was aware that water had affected the lime that he was using.
- The pilot encountered a “hung load” of lime, probably resulting from the damp product bridging over the hopper doors, and despite bunting manoeuvres, he was unable to discharge the hopper contents.
- The aircraft entered a valley system from which there was no means of escape, either by climbing or by carrying out a reversal turn.
Final Report:

Crash of a Fletcher FU-24-950M in Waiotira

Date & Time: Sep 8, 2001 at 0710 LT
Type of aircraft:
Operator:
Registration:
ZK-CMN
Flight Phase:
Survivors:
Yes
Schedule:
Waiotira - Waiotira
MSN:
118
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15131
Captain / Total hours on type:
14935.00
Circumstances:
The aircraft was flown to a farm airstrip then loaded with a small load of agricultural product. A combination of extremely soft airstrip conditions, a quartering tailwind, and underslung spreader equipment, degraded performance to the extent that the aircraft was unable to become airborne within the available length of the strip. The load was jettisoned, but the aircraft struck a fence and scraped the ground with the left wing tip and aileron. The aircraft did become airborne, but was unable to be effectively controlled and subsequently struck the ground. The aircraft was destroyed and the pilot was seriously injured.
Probable cause:
A combination of extremely soft airstrip conditions, a quartering tailwind, and underslung spreader equipment, degraded performance to the extent that the aircraft was unable to become airborne within the available length of the strip.

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 PAC Cresco 08-600 near Gisborne: 1 killed

Date & Time: Jun 14, 2001 at 1145 LT
Type of aircraft:
Operator:
Registration:
ZK-TMO
Flight Phase:
Survivors:
No
MSN:
012
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7300
Captain / Total hours on type:
261.00
Aircraft flight hours:
5466
Aircraft flight cycles:
65887
Circumstances:
On 13 June 2001, Cresco ZK-TMO arrived at Te Aroha Station, 25 km west of Gisborne, to carry out topdressing of that property. Before operations started, the property owner briefed the pilot, and two observation flights over the areas to be sown were made. The owner also cautioned the pilot against turning left after take-off from the airstrip. Spreading commenced at 1600 hours, and 14 flights with 1800 kg loads were completed that day. The loader driver reported that no difficulties were experienced during those operations. Spreading recommenced at 0720 hours on 14 June 2001, again with 1800 kg loads, in an area to the left (east) of the airstrip. On the third flight after a refuel later in the morning, the loader driver noticed that the pilot made a partial load jettison after take-off; this resulted in a reduced duration of that sortie. However, on return, the pilot did not indicate to the loader driver that he required a reduced load. About 1145 hours, the aircraft was reloaded and commenced take-off. The loader driver watched about half the take-off roll, then continued preparing for the next load. He did not sight the aircraft again before a pall of black smoke attracted his attention. After making a radio call to the aircraft and hearing no response, the loader driver ran towards the smoke, which was to the left of and below the elevated strip. On reaching the site he found the aircraft inverted in a small stream and burning fiercely. The loader driver could see the pilot inside the aircraft but he and the property owner were unable to reach him because of the intense heat of the fire. The accident occurred in daylight, at approximately 1145 hours NZST, at Te Aroha Station; latitude S 38° 38.0' longitude E 177° 41.8', at an elevation of approximately 770 feet.
Probable cause:
The following findings were identified:
- The pilot was appropriately licensed, rated and fit for the flights being undertaken.
- The aircraft had a valid airworthiness certificate and had been maintained in accordance with current requirements.
- No pre-accident defect was found with the aircraft.
- The pilot had turned left after take-off from the strip, against the advice of the property owner.
- The advice was given in light of a previous accident in virtually identical circumstances.
- There was insufficient space available after take-off for the aeroplane to accelerate to a speed at which the bank angle necessary to clear the terrain could be sustained in level flight or a climb.
- The accident was not survivable.
Final Report:

Crash of a Fletcher FU-24-950M in Raglan

Date & Time: Dec 15, 2000 at 0640 LT
Type of aircraft:
Operator:
Registration:
ZK-BHL
Flight Phase:
Survivors:
Yes
Schedule:
Raglan - Raglan
MSN:
14
YOM:
1955
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in a local crop spraying mission. During the takeoff roll, the aircraft encountered difficulties to gain speed. The pilot suspected problems with the parking brake and after liftoff, the aircraft lost height and crashed to the left of the departure area. The pilot escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Fletcher FU-24-950 in Raetihi

Date & Time: Sep 28, 1999 at 1750 LT
Type of aircraft:
Operator:
Registration:
ZK-DLS
Flight Phase:
Survivors:
Yes
MSN:
182
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was taking off on the final sowing sortie, after which the pilot was to return to home base. The pilot reported that, on the takeoff roll, the engine appeared to overspeed and that the aircraft failed to get airborne. It subsequently sank into a shallow gully off the end of the strip. After the accident, one propeller blade was found to be free to rotate about its feathering axis. Metallurgical analysis indicated that the pitch change knob on the subject blade failed as the result of ductile overload. A second pitch change knob was also bent and cracked but had not separated from the blade. The overload sustained by the pitch change knobs was determined to have occurred at impact, not in flight. No reason was established for the failure to become airborne.

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

Date & Time: Mar 27, 1999 at 1435 LT
Type of aircraft:
Operator:
Registration:
ZK-EMV
Flight Phase:
Survivors:
No
Schedule:
Riversdale - Riversdale
MSN:
276
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8175
Captain / Total hours on type:
4500.00
Aircraft flight hours:
8837
Circumstances:
After completing the first run at the heavier weight, the pilot of ZK-EMV indicated to the loader driver that the load be increased by an additional hundredweight after the next run. The pilot of the second aircraft remained at 22 hundredweight, though he had moved his loading point back a short distance to provide additional take-off distance. The second pilot was still encountering “some sink” after take off, coinciding with the raising of flap. On completion of the second run at 22 hundredweight, the pilot of ZK-EMV positioned the aircraft for loading about 25 m to the east of his previous loading point. ZK-EMV was regarded by some personnel in the company to have had slightly better performance than other similar model aircraft. Consequently the increase to 23 hundredweight, while of interest, did not raise any concerns by the loader driver. Despite being unable to observe the departure of ZK-EMV, the loader driver was still able to hear the aircraft’s engine noise and recalled nothing unusual as the aircraft departed after loading. On returning from his run, the pilot of the second aircraft saw ZK-EMV to his lower right, in a steep climb, estimated to be about 45 to 50°. As it continued to climb the aircraft rolled slowly to the left, peaking at a height equivalent to “3 times power pole height”. Objects were seen falling from the aircraft during this time. Once inverted the aircraft descended rapidly, striking the ground. The aircraft hit the ground approximately 350 m from the strip, near where the power lines crossed a bend in the road and a small intersection. The pilot of the second aircraft landed and informed the two loader drivers. Together the group headed for the accident site in the loader truck. While en route a member of the group alerted emergency services by the use of a cellular telephone. The accident was also observed by the driver of a truck who had recently deposited a load of fertiliser in the bin at the airstrip. The driver had stopped the truck on a narrow gravel road below the airstrip to check the tailgate of the trailer. He then heard an aircraft begin its take-off run and decided to stay and watch the departure as the aircraft would fly over the road close to where the truck was parked. The driver saw ZK-EMV leave the end of the strip and “sag down a long way”, appearing to “drop like a stone”. The aircraft was observed to be in a high nose or climbing attitude as it continued to descend in a slight left turn towards a fence next to the road. The aircraft was then seen to strike the fence and balloon up, dropping fertiliser as it climbed. The aircraft then rolled left and descended in the direction of the truck driver, who quickly sought cover underneath the trailer. The aircraft struck the ground in a paddock next to the road, stopping about 5 m from the truck. With 15 years of working near agricultural aircraft, the truck driver considered himself to be familiar with their operations. The driver observed no items falling from the aircraft before it struck the fence, or anything hit the aircraft. He considered the engine to be at “full song” or maximum power the whole time and heard no change in pitch or beat. After the accident the truck driver went quickly to the upturned aircraft and attempted unsuccessfully to locate the pilot. The driver then headed for the airstrip in the truck, meeting the loader drivers and second pilot on their way to the aircraft. On reaching ZK-EMV the bucket on the loader was used to lift the aircraft to gain access to the cockpit. However, no assistance could be given to the pilot who had died on impact.
Probable cause:
The following findings were identified:
- The pilot was appropriately licensed, rated and experienced for the agricultural operation.
- The aircraft had a valid Certificate of Airworthiness and its records indicated that it had been maintained correctly.
- There was no evidence of any malfunction with the aircraft.
- The topography of the area should have presented no unusual problems for the pilot.
- The weather conditions at the time were suitable for sowing.
- A light tailwind component degraded the take-off and departure performance of the aircraft.
- Any ground effect benefits would have been lost immediately after take-off.
- The pilot was unable to establish a positive climb gradient after take-off.
- The aircraft was probably overweight for the prevailing variable weather conditions at the time of the last take-off.
- The pilot’s jettisoning of the load was too late to prevent the aircraft from striking the fence.
- As a result of striking the fence, the aircraft became uncontrollable.
Final Report:

Crash of a Cessna 402C off Halfmoon Bay: 5 killed

Date & Time: Aug 19, 1998 at 1643 LT
Type of aircraft:
Operator:
Registration:
ZK-VAC
Flight Phase:
Survivors:
Yes
Schedule:
Halfmoon Bay - Invercargill
MSN:
402C-0512
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
14564
Captain / Total hours on type:
27.00
Aircraft flight hours:
13472
Circumstances:
Surviving passengers reported that en route from Stewart Island to Invercargill there were symptoms of a righthand engine failure, which was corrected by the pilot's manipulation of floor-mounted fuel tank selectors. Shortly afterwards, both engines stopped. The pilot broadcast a Mayday and advised the passengers that they would be ditching. A successful ditching was carried out approximately 12 NM south of Invercargill. All occupants escaped from the aircraft, however, four persons exited without life jackets. The pilot entered the cabin but was unable to locate more before the aircraft sank. Rescuers reached the scene about an hour after the ditching only to find that all those without life jackets had perished, as had a young boy who was wearing one.
Probable cause:
A TAIC investigation found that there was no evidence of any component malfunction that could cause a double engine failure, although due to seawater damage the pre-impact condition of most fuel quantity system components could not be verified. Both fuel tank selectors were positioned to the lefthand tank, and it is probable that fuel starvation was the cause of the double engine failure. Company procedures for the Cessna 402 lacked a fuel quantity monitoring system to supplement fuel gauge indications. Dipping of the tanks was not a feasible option. Company pilots believed that the aircraft was fitted with low-fuel quantity warning lights, which was not the case. As three pilots believed the gauges indicated sufficient fuel was on board before the preceding round trip to the island, exhaustion may have followed an undetermined fuel indicating system malfunction. The failure of the company to require the use of operational flight logs, and other deficiencies in record keeping, were identified in the TAIC report. The much-publicised misunderstanding about the ditching location was not considered by the TAIC report to have affected the outcome of the rescue, but provides an example of the continued importance of using the phonetic alphabet in radiotelephony. A safety recommendation that operators use a fuel-quantity monitoring system to supplement fuel gauge indications was also made by the TAIC report.
Final Report:

Crash of a Fletcher FU-24-950 in Fairlie

Date & Time: Aug 30, 1997 at 0730 LT
Type of aircraft:
Registration:
ZK-DIL
Flight Phase:
Survivors:
Yes
MSN:
175
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While turning onto the sowing run, at about 300 feet agl, a significant downdraught was encountered, together with a loss of at least 5 knots airspeed. The pilot responded by pushing the control column aggressively forward and turning towards the lower ground. At the same time, he operated the jettison lever. The rate of dump and the recovery from the downdraught were far less than anticipated, and the pilot found himself about to collide with rocks in a paddock. He pulled hard back, but was unable to avoid hitting the ground with the left wing. The aircraft flipped and slid backwards to a halt. The pilot's instructor was operating a second Fletcher on the same job, saw that there had been a crash, and, after jettisoning his own load, landed nearby and went to the pilot's assistance. Meteorological conditions were favourable for topdressing, but katabatic winds were likely to have been present in the valley, after a clear, cool night. By the time of these flights, a light northwesterly was in place, which could have added to a katabatic flow. There was very light turbulence. Shortly after the accident, light wind gusts were noted; a steady, stronger wind down the valley was established by mid morning. The accident pilot's training had been completed only the day before, and foremost in his mind was the need to avoid a stall. The combination of pushing forward more than necessary, and a turning flight-path, made the jettison ineffective. In the pull-up to avoid hitting the ground the jettison rate increased, but about one third of the load remained aboard after the accident. It was recommended, and accepted, that the pilot receive more dual training on the stall characteristics of the aircraft, with an emphasis on the speed margins available when manoeuvring at low speed. The agricultural operators association was to be asked to remind members of the effect of manoeuvring on jettison characteristics.