The Transport
Accident Investigation Commission (TAIC) has released its final report
into the crash of the Fletcher FU24, which killed four Skydive New
Zealand instructors, four tourists on a skydiving trip and a pilot on
September 4, 2010.
The
report found two of the tandem skydiving instructors tested positive to
taking cannabis – with tests revealing one instructor smoked marijuana
within three hours of the flight.
TAIC says
the presence of the drug, albeit at low levels, did not contribute to
the accident but it was a concern as the Civil Aviation Authority (CAA)
rules prohibited them from taking performance-impairing drugs.
As
a result, the Commission has recommended an alcohol and drug testing
regime for those undertaking tasks that are critical to flight safety.
The
report states the main reason for the crash was the aircraft being
overloaded and exceeding maximum take-off weight. The passengers and
crew were distributed unevenly towards the rear and the plane’s centre
of gravity was out of its allowable limit by around 30 percent.
This
may have caught the pilot unaware and the plane probably became
airborne early and at too low a speed to control it from pitching
‘nose-up’.
The plane then reached a pitch angle
at which the unrestrained parachutists were unable to stop themselves
sliding backwards and this shift in weight toward the back of the plane
would have made it even more unstable.
It
continued to pitch upward until it was almost vertical, before the left
wing dropped and the plane tilted vertically downward and crashed.
It was also revealed the owners of the aircraft used the incorrect amount of fuel reserves, removed the flight manual from the plane and did not devise their own operating procedures before using the plane for skydiving.
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It was also revealed the owners of the aircraft used the incorrect amount of fuel reserves, removed the flight manual from the plane and did not devise their own operating procedures before using the plane for skydiving.
.
The report finds:
.
.
•
The engineering company that modified the plane from its original
agricultural role to a parachuting aircraft did not follow CAA rules.
.
agricultural role to a parachuting aircraft did not follow CAA rules.
.
•
Two modifications were for a different aircraft, one belonged to a
different design holder and a fourth was not referred to in the aircraft
maintenance logbook, however TAIC said the engineering work was
appropriately carried out.
.
.
• A flaw in the CAA
regulatory system allowed the engineering company that modified the
aircraft to have little or no CAA involvement.
.
.
•
The CAA’s oversight and surveillance of commercial parachuting were not
adequate to ensure that operators were functioning in a safe manner.
.
.
• The aeroplane owner and their pilots did not comply with CAA rules and did not follow good, sound aviation practice
.
.
•
The CAA’s oversight and surveillance of commercial parachuting were not
adequate to ensure that operators were functioning in a safe manner
.
.
•
An alcohol and drug testing regime needs to be initiated for persons
performing activities critical to flight safety; and that
.
.
•
Safety harnesses or restraints would help to prevent passengers sliding
rearward and altering the centre of gravity of the aircraft”.
.
.
The
report calls for active participation and a co-ordinated approach by
all sectors of the aviation industry to address the concerns.
http://www.3news.co.nz
Download full report .pdf
http://www.3news.co.nz
Download full report .pdf
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