Fatal failures in Fox plane crash
The Civil Aviation Authority (CAA) has been criticised after a plane crash that killed nine people at Fox Glacier 20 months ago.
A Transport Accident Investigations Commission (TAIC) report into the crash was released today, repeating a 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 the 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.
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 said pilots must do weight and balance calculations for 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,'' Harris said.
''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."
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.
An 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 that 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,'' he said.
''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 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.
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 because of a "flaw in the regulatory system" was able to use an internal inspector to oversee and sign off the work.
The commission said the CAA 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,'' it said.
"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 0.122 metres 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 17 kilograms over its maximum permissible weight that day, but was still 242kg lighter than the maximum all-up weight for which the plane 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, plane 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.
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.
- © Fairfax NZ News
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