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Source: MIL-OSI Submissions

Source: New Zealand Civil Aviation Authority

Published date: 17 December 2021 – Safety investigators from the Civil Aviation Authority (CAA) have made seven safety recommendations following an extensive investigation into a fatal accident that occurred in September 2019. The accident involved an Italian-designed single engine aircraft with two people on board. It crashed into the Tararua range, near Eketahuna in the lower North Island, claiming the lives of the occupants.

The flight, with a student pilot and instructor on board were completing the student’s training requirements to achieve a Microlight Intermediate Certificate.

The CAA determined that the aircraft encountered an area of strong downdraught conditions that exceeded the aircraft’s performance capabilities and led to a collision with terrain.

CAA’s Deputy Chief Executive – Aviation Safety, David Harrison said “The two main actions arising from this investigation are the importance of thorough flight planning and the accurate understanding of weather information.

“In the course of CAA’s safety investigation, we have identified seven areas where we can make the aviation system safer for both current and future pilots.  Some seem obvious, like taking full account of prevailing and potential weather conditions. Nothing should be left to chance when you are in the air.” Mr Harrison said.

He continued “I would also acknowledge the collaboration that has resulted from this accident. We have worked with the Recreational Aircraft Association of New Zealand (RAANZ) and Flying New Zealand (FNZ) to increase their understanding and awareness of the safety actions that were needed here, and they have risen to the challenge.”

Background

The aircraft departed Paraparaumu aerodrome (NZPP) on Sunday 29 September 2019 at approximately 1336 hours on a dual training flight to Foxpine aerodrome (NZFP).

The Civil Aviation Authority (CAA) was notified of the missing aircraft that evening.

The aircraft wreckage was located at approximately 0730 hours on the morning of 27 September 2019, on the eastern side of the Tararua Range. Rescue personnel were winched into the accident site and confirmed the aircraft was ZK-SGO and that both occupants were deceased.

A CAA field investigation was commenced and ultimately determined that the aircraft encountered an area of strong downdraught conditions that exceeded the aircraft’s performance capabilities and led to a collision with terrain.

As a result of this tragic accident, the CAA has issued the following safety actions:

CAR 91.217: Pre-flight action should be re-applied if a pilot decides to change to a new destination at any time. This is the responsibility of the pilot in command. 

A CAA safety action has been raised to encourage the Recreational Aircraft Association of New Zealand (RAANZ) and Flying New Zealand (FNZ) to promote to their memberships the importance of CAR 91.217 (CAA Action 22A259).

The CAA reminds all pilots of CAR 91.311 Minimum heights for VFR. Non-compliance with this CAR has been identified in many other fatal accidents.
A CAA safety action has been raised to encourage the RAANZ and FNZ to promote to their memberships the importance of CAR 91.311 (CAA Action 22A265).

An article titled “Flight planning not a quick once-over” [PDF 386 KB] was published in CAA’s Vector magazine in the Spring 2020 issue. The article aimed to raise awareness of the importance of proper preflight preparation to minimise the risks of the flight going awry (CAA Action 22A260).

The CAA reminds all pilots of the need to carefully interpret and fit all the ‘pieces’ of available weather information together when prefight planning. Having all this information will help pilots ‘see and understand’ the broader weather picture.

A CAA safety action has been raised to encourage the RAANZ and FNZ to promote to their membership all the available weather information tools (CAA Action 22A261).

While there was no evidence to suggest the flight in the Tararua Range was a ‘pseudo’ mountain flying training flight, the CAA would recommend that microlight pilots obtain and read all the GAP booklets that relate to mountain flying. These publications collectively describe many of the potential hazards of flying in and around mountainous terrain. These can be obtained from a local flying club or aero club, downloaded directly from CAA here or requested as hard copies by emailing publications@caa.govt.nz.
A CAA safety action has been raised to encourage the RAANZ and FNZ to promote to their memberships the availability of these publications (CAA Action 22A262).

Given the mountainous topography of New Zealand, the CAA encourages microlight pilots who choose to operate frequently in these environments, to improve their knowledge by completing the ‘Aeroplane terrain and weather awareness syllabus’ for private pilots. Pilots can contact an approved training organisation to conduct this training.

A CAA safety action has been raised to encourage the RAANZ and FNZ to promote awareness of this training opportunity to their respective members (CAA Action 22A266).

The safety messages in this report are similar to the safety messages from many other fatal accident reports over time. The CAA will therefore produce an Online Vector article detailing the observation and commonalities found in many fatal and non-fatal accident since 2000.

A CAA safety action has been raised within CAA to help facilitate the publication of this article prior to the 2022 summer flying season (CAA Action 22A264).

Key lessons for aviators

Rules

Flight Planning – All flights need flight planning to some degree. Ensure you get everything you need to complete that flight safely and ensure you understand the information you get.
If you need to, or decide to change plans in-flight, do that new planning ‘by any means available’ e.g. radio flight information service communication (FISCOM) or call them.
Minimum heights. The rules are there for a reason. They are carefully considered and designed. If an action you might take will break a rule, tell yourself no, and find a safer way to conduct your flight. That might mean turning back, landing elsewhere or making a diversion.

Weather

Get all the weather information you can and review it carefully.
Weather forecasting is not an exact science.
Learn how to interpret the weather so you can be prepared for what forecasting cannot prepare you for.
Pilots must use their collective knowledge to complete the weather picture on a given day.

Mountain Flying

Get formal mountain flying training if you plan to operate in or near mountainous terrain.

MIL OSI