Crash of a Piper PA-46-310P Malibu near Narrabri

Date & Time: Jun 12, 2014 at 1630 LT
Operator:
Registration:
VH-TSV
Flight Phase:
Survivors:
Yes
Schedule:
Dubbo – Sunshine Coast
MSN:
46-8408022
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 12 June 2014, at about 1530 Eastern Standard Time (EST), a Piper PA-46 aircraft, registered VH-TSV, departed Dubbo, New South Wales for a private flight to the Sunshine Coast, Queensland with a pilot and one passenger on board. The planned route was to track via Moree and Toowoomba at 13,500 ft above mean sea level (AMSL). The pilot had operated the aircraft from Sunshine Coast to Lightning Ridge, Brewarrina and Dubbo earlier that day and reported that all engine indications were normal on those flights. About 1 hour after departing Dubbo, when about 26 NM south of Narrabri, at about 13,500 ft AMSL, the pilot observed the engine manifold pressure gauge indicating 25 inches Hg, when the throttle position selected would normally have produced about 28 inches Hg. The pilot selected the alternate air1 which did not result in any increase in power. He then elected to descend to 10,000 ft, and at that power setting when normally the engine would have produced about 29 inches Hg, the gauge still indicated only about 25 inches Hg. He turned the aircraft towards Narrabri in an attempt to fly clear of the Pilliga State Forest. The pilot assessed that the aircraft had a partial engine failure and performed troubleshooting checks. As the aircraft descended through about 8,000 ft, he observed the oil pressure gauge indicating decreasing pressure. When passing about 6,500 ft, the oil pressure gauge indicated zero and the pilot heard two loud bangs and observed the cowling lift momentarily from above the engine. The passenger observed a puff of smoke emanating from the engine and momentarily a small amount of smoke in the cockpit. The pilot established the aircraft in a glide at about 90 kt, secured the engine and completed the emergency checklist. He broadcast a ‘Mayday’ 2 call on Brisbane Centre radio frequency advising of an engine failure and forced landing. The pilot looked for a clear area below in which to conduct a forced landing and also requested the passenger to assist in identifying any cleared areas suitable to land. Both only identified heavily treed areas. The pilot extended the landing gear and selected 10º of flap and, when at about 1,000 ft, the pilot shut the fuel off, deployed the emergency beacon then switched off the electrical system. As the aircraft entered the tree tops, he flared to stall3 the aircraft. On impact, the pilot was seriously injured and lost consciousness. The passenger reported the wings impacted with trees and the aircraft slid about 10 m before coming to rest. The passenger checked for any evidence of fuel leak or fire and administered basic first aid to the pilot. The aircraft sustained substantial damage.
Final Report:

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 Piper PA-31-310 Navajo C in Aldinga

Date & Time: Jan 29, 2014 at 1132 LT
Type of aircraft:
Operator:
Registration:
VH-OFF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aldinga - Kangaroo Island
MSN:
31-7812064
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 29 January 2014, at about 1100 Central Daylight-savings Time, the pilot prepared a Piper PA-31 aircraft, registered VHOFF, for a private flight from Aldinga aeroplane landing area (ALA) to Kangaroo Island, South Australia. To check fuel quantities, the pilot entered the cockpit, turned on the master switch and placed the left and right fuel selectors onto the main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight. Once refuelling was completed, the pilot conducted a pre-flight inspection, and finished loading the aircraft. The pilot and passenger then boarded. The pilot was familiar with Aldinga ALA, which is a non-controlled airport. At uncontrolled airports, unless a restriction or preference is listed for a certain runway in either the Airservices en route supplement Australia (ERSA), or other relevant publications, selection of the runway is the responsibility of the pilot. Operational considerations such as wind direction, other traffic, runway surface and length, performance requirements for the aircraft on that day, and suitable emergency landing areas in the event of an aircraft malfunction are all taken into consideration. On this day, the pilot assessed the wind to be favoring runway 14, which already had an aircraft in the circuit intending to land. However, he decided to use runway 03 due to the availability of a landing area in case of an emergency. He then completed a full run-up check of the engines, propellers and magnetos prior to lining up for departure. The pilot reported that all of the pre-take-off checks were normal. Once the aircraft landing on runway 14 was clear of the runway, the pilot went through his usual memory checklist prior to take-off. He scanned and crosschecked the flight and panel instruments, power quadrant settings and trims, but did not complete his usual final check, which was to reach down with his right hand and confirm that the fuel selector levers were on the main tanks. After broadcasting on the common traffic advisory frequency (CTAF) he commenced the take-off. At the appropriate speed, he rotated the aircraft as it passed the intersection of the 14 and 03 runways. Almost immediately both engines began surging, there was a loss of power, the power gauges fluctuated and the aircraft yawed from side to side. Due to the surging, fluctuating gauges and aircraft yaw, the pilot found it difficult to identify what he thought was a non-performing engine. He reported there were no warning lights so he retracted the landing gear, with the intent of getting the aircraft to attain a positive rate of climb, so he could trouble shoot further at a safe altitude. When a little over 50 ft above ground level (AGL), he realized the aircraft was not performing sufficiently, so he selected a suitable landing area. He focused on maintaining a safe airspeed and landed straight ahead. The aircraft touched down and slid about another 75-100 metres before coming to rest. The impact marks of the propellers suggest the aircraft touched the ground facing north-easterly and rotated to the north-west prior to stopping. The pilot turned off the master switch and both he and the passenger exited the aircraft. After a few minutes he re-entered the cockpit and completed the shutdown. Police and fire service attended shortly after the accident.
Probable cause:
Engine malfunction due to fuel starvation.
Final Report:

Crash of a Boeing 737-3B7(SF) in Honiara

Date & Time: Jan 26, 2014 at 1259 LT
Type of aircraft:
Operator:
Registration:
ZK-TLC
Flight Type:
Survivors:
Yes
Schedule:
Brisbane – Honiara
MSN:
23705/1497
YOM:
1988
Flight number:
PAQ523
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Brisbane, the crew completed the approach and landing at Honiara-Henderson Airport. After touchdown on runway 24, the right main gear collapsed and punctured the right wing. The aircraft veered slightly to the right and came to a halt on the runway. All three occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The failure of the right main gear was the consequence of an inappropriate rework (ie, machining and re-threading) of the tee-bolt fitting and the associated installation of a reduced size nut and washer, during the last overhaul in 2004.

Crash of a Cessna 208B Grand Caravan in Kibeni: 3 killed

Date & Time: Nov 25, 2013 at 1340 LT
Type of aircraft:
Operator:
Registration:
P2-SAH
Survivors:
Yes
Schedule:
Kamusi – Purari – Vailala – Port Moresby
MSN:
208B-1263
YOM:
2007
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2200
Captain / Total hours on type:
800.00
Circumstances:
On 25 November 2013, a Cessna Aircraft Company C208B Grand Caravan, registered P2-SAH and operated by Tropicair, departed Kamusi, Western Province, for Purari River, Gulf Province, at 0312 UTC on a charter flight under the instrument flight rules (IFR). There were 10 persons on board; one pilot and nine passengers . Earlier in the day, the aircraft had departed Port Moresby for Kamusi from where it flew to Hivaro and back to Kamusi before the accident flight. SAH was due to continue from Purari River to Vailala and Port Moresby. The pilot reported that the takeoff and climb from Kamusi were normal and he levelled off at 9,000 ft and completed the top-of-climb checklist. Between Kamusi and Purari River the terrain is mostly flat and forest covered, with areas of swampland and slow-moving tidal rivers. Habitation is very sparse with occasional small villages along the rivers. The pilot recalled that the weather was generally good in the area with a cloud base of 3,000 ft and good visibility between build-ups. The pilot reported that approximately 2 minutes into the cruise there was a loud ‘pop’ sound followed by a complete loss of engine power. After configuring the aircraft for best glide speed at 95 kts, the pilot turned the aircraft right towards the coast and rivers to the south, and completed the Phase-1 memory recall items for engine failure in flight. He was assisted by the passenger in the right pilot seat who switched on the Emergency Locator Transmitter (ELT) and at 0332 broadcast MAYDAY due engine failure on the area frequency. Checking the database in the on-board Global Positioning System (GPS), the pilot found the airstrip at Kibeni on the eastern side of the Palbuna River. The pilot, assisted by the passenger next to him, tried unsuccessfully to restart the engine using the procedure in the aircraft’s Quick Reference Handbook (QRH). The passenger continued to give position reports and to communicate with other aircraft. At about 3,000 ft AMSL the pilot asked for radio silence on the area frequency so he could concentrate on the approach to Kibeni airstrip, flying a left hand circuit to land in a south westerly direction. He selected full flaps during the final stages of the approach, which arrested the aircraft’s rate of descent, but the higher than normal speed of the aircraft during the approach and landing flare caused it to float and touch down half way along the airstrip. The disused 430 metre long Kibeni airstrip was overgrown with grass and weeds. It was about 60 ft above the river and 120 ft above mean sea level, with trees and other vegetation on the slope down to the river. The aircraft bounced three times and, because the aircraft’s speed had not decayed sufficiently to stop in the available length, the pilot elected to pull back on the control column in order to clear the trees that were growing on the slope between the airstrip and the river. The aircraft became airborne, impacting the crown of a coconut palm (that was almost level with the airstrip) as it passed over the trees. The pilot banked the aircraft hard left in an attempt to land/ditch along the river and avoid trees on the opposite bank. He then pushed forward on the control column to avoid stalling the aircraft and levelled the wings before the aircraft impacted the water. The aircraft came to rest inverted with the cockpit and forward cabin submerged and immediately filled with water. After a short delay while he gained his bearings under water, the pilot was able to undo his harness and open the left cockpit door. He swam to the rear of the aircraft, opened the right rear cabin door, and helped the surviving passengers to safety on the river bank. He made several attempts to reach those still inside the aircraft. When he had determined there was nothing further he could do to reach them, he administered first aid to the survivors with materials from the aircraft’s first aid kit. After approximately 20 minutes, villagers arrived in a canoe and transported the pilot and surviving passengers to Kibeni village across the river. About 90 minutes after the accident, rescuers airlifted the survivors by helicopter to Kopi, located 44 km north east of Kibeni.
Probable cause:
The engine power loss was caused by the fracture of one CT blade in fatigue, which resulted in secondary damage to the remainder of the CT blades and downstream components. The fatigue originated from multiple origins on the pressure side of the blade trailing edge. The root cause for the fatigue initiation could not be determined with certainty. All other damages to the engine are considered secondary to the primary CT blades fracture.
Final Report:

Crash of an ATR42-320F in Madang

Date & Time: Oct 19, 2013 at 0915 LT
Type of aircraft:
Operator:
Registration:
P2-PXY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Madang – Tabubil – Kiunga
MSN:
87
YOM:
1988
Flight number:
PX2900
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7110
Captain / Total hours on type:
3433.00
Copilot / Total flying hours:
3020
Copilot / Total hours on type:
2420
Aircraft flight hours:
24375
Circumstances:
On 19 October 2013, an Avions de Transport Régional ATR42-320 freighter, registered P2-PXY (PXY) and operated by Air Niugini, was scheduled to fly from Madang to Tabubil, Western Province, as flight PX2900 carrying a load tobacco for a client company. There were three persons on board; the pilot in command (PIC), a copilot, and a PNG experienced DHC-8 captain whose function was to provide guidance during the approach into Tabubil. The PIC was the handling pilot and the copilot was the support monitoring pilot. The flight crew taxied to the threshold end of runway 25 intending to use the full length of the runway. The take-off roll was normal until the PIC tried to rotate at VR (speed for rotation, which the flight crew had calculated to be 102 knots). He subsequently reported that the controls felt very heavy in pitch and he could not pull the control column back in the normal manner. Flight data recorder (FDR) information indicated that approximately 2 sec later the PIC aborted the takeoff and selected full reverse thrust. He reported later that he had applied full braking. It was not possible to stop the aircraft before the end of the runway and it continued over the embankment at the end of the runway and the right wing struck the perimeter fence. The aircraft was substantially damaged during the accident by the impact, the post-impact fire and partial immersion in salt water. The right outboard wing section was completely burned, and the extensively damaged and burnt right engine fell off the wing into the water. Both propellers were torn from the engine shafts and destroyed by the impact forces.
Probable cause:
The following findings were identified:
- The investigation found that Air Niugini’s lack of robust loading procedures and supervision for the ATR 42/72 aircraft, and the inaccurate weights provided by the consignor/client company likely contributed to the overload.
- The mass and the centre of gravity of the aircraft were not within the prescribed limits.
- The aircraft total load exceeded the maximum permissible load and the load limit in the forward cargo zone ‘A’ exceeded the zone ‘A’ structural limit.
- There was no evidence of any defect or malfunction in the aircraft that could have contributed to the accident.
Final Report:

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: