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Inquiry 10-009 Final Report
Inquiry 10-009 Final Report
10-009 Executive summary
General
General
On 4 September 2010 the pilot of a Walter Fletcher aeroplane with 8
parachutists on board lost control during take-off from Fox Glacier
aerodrome. The aeroplane crashed in a paddock adjacent to the runway,
killing all 9 occupants.
The Walter Fletcher had been modified from an agricultural aeroplane
into a parachute-drop aeroplane some 3 months before the accident. The
modification to the aircraft had been poorly managed, and discrepancies
in the aeroplane’s documentation had not been detected by the New
Zealand Civil Aviation Authority (CAA), which had approved the change in
category.
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.
Recommendations
The Commission made 6 recommendations to the Director of Civil
Aviation. Three related to the operation of parachute-drop aircraft, 2
related to the process for converting aircraft for another purpose and
one related to seat restraints. A recommendation was made to the
Secretary for Transport regarding the need for a drug and alcohol
detection and deterrence regime for the various transport modes.
Key lessons
The investigation findings and recommendations provided reminders of the following practices that contribute to aviation safety:
- no 2 aircraft of the same model are exactly the same, even if they look that way; therefore pilots must do weight and balance calculations for every individual aircraft
- modifying aircraft is a safety-critical process that must be done in strict accordance with rules and guidelines and with appropriate regulatory oversight
- good rules, regulations and recommended practices are key to ensuring safe commercial aviation operations
- operators need to ensure that aircraft are being operated in accordance with prescribed rules and guidelines, and flown within their operating limitations
- aircraft operations need to be accompanied by relevant and robust procedures
- maintaining flight safety requires active participation and a co-ordinated approach by all sectors of the industry.
A Transport Accident Investigations Commission (TAIC) report into the crash was released today, repeating an earlier finding that the plane was out of balance and saying modifications made to it were poorly managed.
The Skydive New Zealand plane crashed soon after takeoff from Fox Glacier airstrip on September 4, 2010, killing four tourists, four skydive masters and a Queenstown pilot.
The report said the CAA allowed parachuting operators to flourish, despite knowing the industry was booming with 100,000 tandem jumps annually at the time of the accident, and should have ensured firms were operating in a safe manner.
CAA Director of Civil Aviation Graeme Harris said the report provided lessons for all pilots, and for the CAA.
TAIC found that the pilot had wrongly used weight and balance calculations for another Fletcher aircraft, he said.
It also said pilots must do weight and balance calculations for every individual aircraft, reminding pilots-in-command they were responsible for aircraft weight and balance, whether flying an airliner, private two-seater or microlight, he said.
"This is basic airmanship, taught to every student pilot. It is very sad that a critical element of pre-flight planning, which should be second nature to any pilot, appears to have been done so poorly. This is an accident that no pilot should ever forget," Harris said.
Since the accident the CAA had made significant changes. Soon after, it limited the number of skydivers who could be carried in Fletcher aircraft to six, and required that these passengers be individually weighed to ensure calculations were accurate.
The CAA now had much better tools with which to regulate the commercial skydiving sector. A new adventure aviation rule was introduced in November 2011, which set higher standards and allowed the authority to maintain significantly closer oversight of those activities.
Just before the accident, the CAA had also taken steps to more tightly control the kinds of modifications that could be made to an aircraft without direct CAA inspection.
Harris said although the pilot did not meet a basic element of good airmanship, the CAA at that time did not regulate the parachuting sector closely enough.
"In the intervening year and a half the regulatory landscape controlling these operations has been transformed. A great deal of work has been done to improve safety in this sector, and I am certain that it will."
PLANE OUT OF BALANCE
The September crash was blamed on the plane being out of balance, making the nose "pitch up".
The report said the aircraft had been modified from an agriculture plane into a parachute-drop plane three months before the accident, and the owner had not completed any weight and balance calculations before it entered service.
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As a result, the plane was being flown outside its loading limits every time it carried a full load of eight parachutists.
TAIC found the engineering company that modified the plane did not follow proper processes required by civil aviation rules, but due to a "flaw in the regulatory system" were able to use an internal inspector to oversee and sign off the work.
The commission said the Civil Aviation Authority adhered to normal practice when approving the changes, but should have had greater participation in the process to help ensure there were no safety implications.
"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."
TAIC said the Fletcher FU24 aircraft was 0.122m off balance, becoming airborne at too low a speed to be controllable, which was a significant factor contributing to the crash.
The pilot was unable to regain control and the plane continued to pitch up, then rolled left before striking the ground nearly vertically.
TAIC said the owner and the pilots did not comply with "civil aviation rules and did not follow good, sound aviation practice" by failing to conduct weight and balance checks.
They also used the incorrect amount of fuel reserves, removed the flight manual from the plane, and did not draft their own standard operating procedures before using the plane.
The plane was 17kg over its maximum permissible weight that day, but was still 242kg lighter than the maximum all-up weight for which the aeroplane was certified in its previous agriculture role.
TAIC found the engineering company that worked on the aircraft had used two modifications that 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 was then not updated to reflect the changes.
TAIC made six recommendations to the director of Civil Aviation - three relating to the operation of parachute-drop aircraft, two relating to the process for converting aircraft for another purpose and one relating to seat restraints.
Key recommendations focused on weight and balance, airplane modification, introduction into service, and regulator oversight.
Safety restraints were needed to prevent parachutists from going too far to the plane's rear.
Two of the tandem masters had smoked cannabis, though TAIC said it did not contribute to the crash as they were not crew members of the plane.
The commission said an alcohol and drug testing regime needed to be implemented for people performing activities critical to flight safety.
The crash claimed the lives of Skydive New Zealand director Rod Miller, 55, of Greymouth, pilot Chaminda Senadhira, 33, of Queenstown, dive masters Adam Bennett, 47, from Australia but living in Motueka, Michael Suter, 32, from New Plymouth and Christopher McDonald, 62, of Mapua.
The four tourists, who had been touring the West Coast on a Kiwi Experience bus trip, were Patrick Byrne, 26, of Ireland, Glenn Bourke, 18, of Australia, Annita Kirsten, 23, of Germany, and Brad Coker, 24, of England.
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