Pilot blamed for fatal crash

[altocu]

Found this on the ABC website:

By New Zealand correspondent Gillian Bradford

Air safety investigators have blamed the pilot for a crash that killed eight people near Christchurch.

An inquiry has found the pilot made a mobile phone call just minutes before the plane hit the ground.

The Piper Chieftain crashed near Christchurch in June last year, killing the pilot - Michael Bannerman - and seven of the country's top scientists.

A Transport Accident Investigation Commission report has found Mr Bannerman used his mobile phone while the plane was descending.

The commission says the phone could have interfered with the aircraft's navigational equipment or led to the pilot becoming distracted.

Investigators are now calling for all small aircraft to be fitted with a terrain awareness warning system, a device that would have alerted the pilot he was getting dangerously close to the ground.

[Thread Bear]

Obviously not alot to go on in that news story but who's to say he wasn't calling someone regards a maintenance issue or comms failure and in distress.

[aerocom]

The idea that all aircraft be fitted with a GPWS is stupid. The cost of these units would ground most of GA. Why not make all aircraft 2 pilot fully IFR with TCAS while we are at it.

[prospector]

Lethalweapon
I would like to differ from your post. I agree entirely with the report as written. Before any comment can be made regarding this occurence considerable experience must be held operating as single pilot IFR. An ILS down to minimums, handflying from raw data, is not an easy exercise. It would appear that the pilot was behind the play before the approach proper even commenced. This could be due to a number of reasons. Total IFR experience was certainly not great, currency certainly left a lot to be desired. Any distraction from a cellphone call, at the logged time, would certainly have created major situational awareness problems at a time when there is no room for any loss of concentration. To bring in an argument that a GPS was being used as a primary approach aid rather than the ILS is only supposition. If it was it is inexcusable, as stated neither system was approved for IFR ops. And I agree going below MDA is inexcusable.
To my mind, the fact that one person wore so many caps in the Company is the prime cause of the occurence. One should not have to worry about the cost of a missed approach, flight to the alternate, alternate transport or accommodation for the pax whilst carrying out a difficult approach single pilot. That these factors must have been given undue weight at this time would perhaps be why the nav aids (ADF's) were not even tuned to carry out a missed approach, which, with the actual Wx must always have been a distinct possibility.

Prospector

[Thread Bear]

Here's the report for those that haven't seen it...

http://www.nzherald.co.nz/pdf/chieftanreport.pdf

[chad valiant]

In my opinion the claim of faulty nav instruments is not a runner.

One of the most basic checks you carry out while flying a ILS approach is DME distance compared to the height at that distance on the plate. eg 3 times profile, at 10 miles = 3000ft. As for wake tubulence ATC will provide safe seperation when on the ILS. Why was his phone even turned on?.

[Kaptin M]

1.7 Meteorological Information

1.7.1 A complex low covered New Zealand on 6 June 2003. An associated rain band crossed South Island during the afternoon with patches of moderate rain or drizzle in many places in Canterbury.

1.7.3 The 1700 special weather report (SPECI) for Christchurch Aerodrome…
was:
surface wind variable 3 kt, visibility 1000m in light drizzle, cloud overcast
400 feet, temperature 10 degrees…..

1.7.4 The 1900 SPECI for Christchurch Aerodrome was:
Surface wind variable 3kt, visibility 500m in light drizzle, cloud scattered
At 500 feet, temperature 10 degrees……….


1.7.5 The Christchurch ATIS, Information Whiskey issued at 1811, which the pilot was referred to at 1853, with the change to runway 20 was:
Runway-in-use 20, runway wet, expect ILS approach, surface wind 030/3
Visibility 500m in drizzle, cloud scattered at 200 feet, overcast at 700 feet,
Temperature 9 degrees…..



Moving on to Section 1.12 Wreckage and impact information

1.12.9 Significant engine instrument readings were:
Manifold pressure: number 1…..25 inches, number 2……43 inches
Fuel flow: number 1….30gph, number 2…..22 gph

1.12.10 Overhead panel switch positions were:
………..prop de-ice off, surface de-ice marked U/S.



“Significant” INDEED, in view of the fact that ICING CONDITIONS (Temp +10 to -40 degrees C, visible moisture…meaning cloud, fog, rain, drizzle) were forecast and reported!!

Why was the aircraft allowed to be dispatched into these conditions?

What is the significance of the uneven power settings?

I tend to suspect wing AND engine icing.


2.13 On the accident approach, ZK-NCA was not asked by air traffic control
to fly a fast approach; in fact when about 12 miles out, Christchurch
Control asked for its speed to be reduced below 175 knots, presumably
because ZK-NCA was closing with the Boeing 737 ahead.



For the time being I would like to leave you all with these facts as presented.

[Hudson]

There is no mention of the possibility of erroneous light signals displayed by the PAPI under the high moisture conditions described in the report. This is a well known phenomena in all types of VASIS particularly those visual systems that use colour coded displays. There is a strong suspicion in some circles that a fatal accident to a RFDS aircraft flown as single pilot, may have been caused by the pilot following erroneous fly-down light signals, during a dark night poor visibility approach into Mount Gambier. That aircraft - a Kingair 200 was flown by a 13,000 pilot highly experienced in black hole approaches.

Later, ERSA was amended to warn pilots of erroneous T-VASIS indications that could occur under certain weather conditions at Mt Gambier.

In the Christchurch case, although it appears that the pilot's flying was sloppy on the ILS glide path, there is significantly no discussion on whether he may have seen the PAPI approaching the ILS minima and attempted to follow its indications.

There is no proof - -only supposition - that the pilot did not become partially visual with the runway in the last few seconds of the flight. Conditions were ideal for erroneous VASIS light signals - there is plenty of documented evidence of this shortcoming in VASIS/PAPI design. Low fog amd mist over the VASIS can cause significant light bending resulting in erroneous signals as seen by the pilot.

The magazine Australian Aviation recently ran an excellent and thought provoking article on VASIS errors in high moisture laden air conditions. Virtually, one cannot trust what one sees just when you need to rely on the system for safe glide path guidance.

Certainly in the ATSB report of the Mount Gambier night accident where the Kingair flew into the deck in line with the runway and 3.1 miles from the threshold, there was no mention at all of the possibility of erroneous VASIS light signals in foggy conditions. Simply, the investigators didn't think of it unti lafter the report was published after local pilots described the Mt Gambier VASIS as well known unreliable in fog and mist - exactly the same as the Christchurch weather.

[Kaptin M]

From prospector:To my mind, the fact that one person wore so many caps in the Company is the prime cause of the occurence. One should not have to worry about the cost of a missed approach, flight to the alternate, alternate transport or accommodation for the pax whilst carrying out a difficult approach single pilot. That these factors must have been given undue weight at this time would perhaps be why the nav aids (ADF's) were not even tuned to carry out a missed approach, which, with the actual Wx must always have been a distinct possibility.As you stated, that was in your mind, and is pure unfounded speculation on YOUR part, and which in FACT is contradicted in 1.1.8 of the report, where it states:
During the cruise part of the flight, the passenger seated in the co-pilot seat, who was wearing a headset, had some conversation with the pilot. He subsequently recalled that the pilot had told him that the Christchurch weather was poor, and if it got worse they might end up in Woodbourne.

Why is there the supposition that the pilot of ZK-NCA did not become visual, when the preceding B737 only just over 3 minutes beforehand had made a landing off the same approach?

Irt the "erratic" flying of the ILS, this is again possible for reasons other than the pilot's handling ability eg. ice on the antennae, scalloping of the signals from the LLZ and G/S transmitter, a change in the aircraft's handling characteristics.

Strangely, there is no mention of any NOTAMs, esp. wrt serviceability of the navaids. From my experience, I know of 2 ILS's that have permanent scalloping of the LLZ - causing the autopilot to wander from side to side all the way down finals when engaged.
I would be interested to know if the LLZ at CHC exhibits this characteristic, and what the pilots of the B737 experienced during their approach.
Perhaps some of you Kiwis who fly regularly into there can comment.

Hudson also raises what may be an extremely important issue - the integrity of the PAPI. For my part, many years ago as an F/O experienced a T-vasis in Launceston simultaneously displaying full fly UP and full fly DOWN during an approach when there was shallow ground fog.
I haven't seen the same with PAPI.....yet.
As Hudson notes:Conditions were ideal for erroneous VASIS light signals - there is plenty of documented evidence of this shortcoming in VASIS/PAPI design. Low fog and mist over the VASIS can cause significant light bending resulting in erroneous signals as seen by the pilot. Add to that some light drizzle on the plexiglass windscreen, not fitted with external wipers, nor defrost, and the links of the chain join up one-by-one.

[Bevan666]

PAPI is less suseptable to the 'fly up/fly down' confusion which can occur with VASI's. Vasis are spread out over a large area (~1500 ft horizontally) while papi's are in a row, within feet of each other.

The larger the spread in the lights, the greater chance of atmospheric variations over that distance, and therefor greater chance of a variation in the amount of distortion (it is the variance in distortion which causes simulataneous flyup/down lights).

PAPI lights will still be 'bent' the same way in the same conditions, but are more likely to be bent the same for each of the four lights (due to a smaller geographic spread). Now how you detect when this is occuring would be difficult indeed.

Bevan..

[prospector]

Kaptin M,
Your first post you appear to favour ice as the cause, in fact you even state "Why was the aircraft allowed to be dispatched into these conditions"
Consider who it was that allowed the flight to be dispatched. The company CEO, Chief Pilot, Check and Training officer, under what hat should he have declined the very good revenue producing flight??.

The people that conducted the enquiry had all the information that they needed to investigate all the possibilities, no doubt if there was any fault with any of the aids this would have been promulgated by NOTAM.

The question of distortion of approach lights I am sure would have been covered, no body else had reported this as a problem on the night, not even the preceeding 737.

Your questioning of the integrity of the LLZ.
A.. It was not a coupled approach, this was pointed out in the report, although not perfect the LLZ tracking was not the problem, it was tracking the glidescope that was very poor.
B.. If he became visual why then did they fly into the ground??

As you correctly state it is speculation on my part, but the speculation is done with some 6,000 hrs of SPIFR operations, including many night approaches to Christchurch over the years. I see nothing in the statement of the Pax in the front right seat that would contradict that speculation.

As usual you would appear to be more interested in playing the man rather than the ball, this leads me to the conclusion that your non de plume is in fact close to your real name Capt Walter Mitty.

Prospector

[prospector]

Lethal Weapon,
I will try to make this as simple as I can.

The reply in that post was as addressed, to Capt M. in reply to his reference to statements made by this pax referring to the use of Woodbourne as an alternate. If you read and digest the report this statement was made long before top of descent.

The investigators are all qualified people, they have access to a lot more relevant information than any one on this forum. The reason for this thread is to surmise as to what took place in the mind of the pilot in the last few minutes of that flight. I am sure the investigators have their own thoughts on this but it could only be speculation and as such could not be published. Any other opinion, such as mine can also only be speculation.

From my experience I know that an ILS approach flown to minimums, by hand, with only raw data, is not an easy exercise and any distraction is not to be encouraged. The reason for this thread would appear to be what happened in that last few moments, it can only be speculation on anybodies part.

Where you get political bull**** and the rest of your observations from is beyond me, sorry, I thought the object of the exercise was to try and determine what does make a pilot fly into the ground 1.2 miles short of the runway, one thing we can be certain of it was not by intent, if not then it was by accident?? can flying below MDA, when obviously not in visual contact, be an accident?? My input was to put forward a possible reason, that the pilot could have had more on his mind that just the ILS approach, as I have stated previously, this possibility could have been the reason that the MDA was busted. Perhaps not intentionally, but it was certainly busted.

Prospector

[Kaptin M]

In my first post, prospector, I was suggesting that icing may have been one of several contributory factors that caused this accident - your attention span being obviously somewhat limited, you apparently didn't read through to my closing paragraph.."For the time being I would like to leave you all with these facts as presented."

From prospector...although not perfect the LLZ tracking was not the problem,And from the official report 2.33The radartrack plot showed a somewhat erratic track of ZK-NCA....The erratic and oscillatory nature of the track itself, while probably within limits, does show that the pilot was not coping easily with the approach. It was a calm night, so there would have been little turbulence or drift to complicate the task, and a steadier track should normally be more achievable...So WHY was he having difficulty maintaining a steady straight track?
Icing problems - airframe/antennae/engine? Or ALL 3? Plus a faulty LLZ signal?
Has the CHC LLZ been known to be subject to scalloping?

Again from poor old prospector, "If he became visual why then did they fly into the ground??"
Try putting ALL of the above suggestions together to try to realise that an accident is a CHAIN OF EVENTS. (Icing+erratic signals+flawed PAPI indication+++)!!
This message is driven home time and again, and which in my 15 1/2 thousand hours of flying I have come to realise makes no-one immune - even those with a lot less time :O

Again, back to the possibility of the LLZ signal and/or the PAPI being suspect, prospector states, "no body else had reported this as a problem on the night, not even the preceeding 737."
Were they ever asked, subsequently?
If not, why not?
If they were, then why wasn't that mentioned in the report?

NOTAMS - why is no mention made of any NOTAMS that were in effect that night?
As obscure as they may seem, they are a consideration for every flight.

"The reason for this thread is to surmise as to what took place in the mind of the pilot in the last few minutes of that flight." RUBBISH! And if that is what you believe, prospector, then you don't belong here, but would be more at home at some Tarot card or "mystics" meeting than on a professional pilots' forum.

[prospector]

Kaptin M(itty).

Once again you are busy making assumptions. All the points you have brought up were no doubt looked into by the investigators. Are you suggesting you, (with all your hours????) know more than these qualified, trained and on the spot investigators?? The quality of your statements would indicate not.

Prospector

[Hudson]

Prospector. You have a touching faith in the skills of the accident investigators. Believe me they are not perfect. The absence of meaningful investigation into the role played by the VASIS in the Mount Gambier fatal accident proved that.

Re PAPI limitations. Like T-VASIS and other navigation systems such as red - white VASIS. They are all likely to produce erroneous indications in fog or mist and the systems cannot necessarily be relied upon in these conditions. In the brochures for these systems you will find no mention of these limitations.

The fact that a previous crew made no comment about the Christchurch PAPI means nothing at all. When they became visual they would have been glued to the ILS glide path either on automatics or partial automatics and flight director. They would have no time to look at the PAPI and with speeds around 130 knots over the fence it is doubtful if they would have time to compare PAPI and ILS glide indications. In any case it is possible that the PAPI and ILS glide path transmitter are sited differently.

In several mysterious CFIT accidents over the years where the crew have flown into the deck at night on final approach there has been little said in the accident reports of the possibility of erroneous light signals from VASIS - if indeed the weather conditions were conducive at the time. The Mount Gambier accident revealed that local pilots operating into Mt Gambier had frequently experienced gross VASIS light signal errors in mist, but for some reason no one thought it of much consequence.

[prospector]

Hudson,
For the most part, unless there is any glaring anomolies, one must go with the findings of these investigators. They have more information to hand than the sideline experts.

If the Mt Gambier occurence is that involving VH-FMN than I fail to see where you are coming from regarding lights. Are you saying that the Investigators analysis is completely wrong???

Prospector

[Kaptin M]

prospector, if your sole message is to come into this thread and monotonously re-state that the accident report is correct in its entirety, then you've bored us enough.
Your personal conjecture that the pilot "pushed on regardless" is refuted by the report, as detailed in an earlier post.

Some of us are interested in discussing WHY this pilot may have received sufficient visual miscues causing a CFIT.
Without doubt, some pilots have "busted" minimas during instrument approaches, but on this approach the CFIT was not into rising high ground, but rather at ground level, in the landing configuration.
Whilst the report answers many questions, it also leaves many not answered eg. at what altitude did the preceding B737 become visual? Did they disconnect the auto-pilot prior to landing? And if so, at what altitude?
There is a plethora of RELEVANT information that could have been provided in this report, by the crew of that aircraft in light of the relatively stable conditions, that is NOT.
Again, to my mind, the report is INcomplete as in addition to the above, no mention of NOTAMS is made, not even to the point of the investigators stating that there were no relevant NOTAMS!
Nor does it remotely address the possibility of icing, in spite of the prevailing meteorological conditions being conducive to such.

[prospector]

Kaptin M,
Have a look at 1.5.8. in the report. See if you can see any enlightening facts that throw some light on this occurence.

Prospector

[Kaptin M]

It is a liitle difficult to draw any real conclusion from that information, I would suggest, prospector, as different pilots log I/F time in different ways ie. some pilots might log an ILS (or other instrument approach) when in fact it was flown in 8/8 blue sky with complete outside visual reference, whilst others will log then when flown solely by reference to instruments.
Similarly, the logging of Instrument Flight time is at the individual pilot's discretion (although the definition is clear).

To illustrate my point, the same paragraph (1.5.8) states in the 3rd sentence, "In the same period he had logged 3.15 hours of night flying, which was not also logged as instrument time".
By definition, some pilots DO log night flight as Instrument Flight time - obviously this guy did not.
(As an aside, it is the practice with some Americans and many Mexicans, to log ALL flight time above 10,000' as IF!!)

So I think you may be indicating that, by some standards, there may have been a lack of recency - however it is also likely that this pilot did not record in his log book, every visual ILS approach as such.

Night landings, using radio aids to assist - especially where slope guidance is provided - are not, imo, as significant for I.R. pilots, as they are for VFR only pilots, who rely solely on the MK1 eyeball.

[prospector]

Kaptin Lethalweapon,
If the standard of proficiency shown in NOT completing this approach, ie never at any time stabilized, always below the Glide Path, then yes I would say it is time CAA had a look at the recency requirements.


Prospector

[TAY 611]

Lots of good points here and a fair bit of assumptions about descending below "minimums". Last time I flew a Cat 1 ILS it had a DA (thats decision altitude there prospector not minimums as in a NPA) and without getting too deep into the make up if ILS's the only time an aircraft should end up below DA will be because a decision has been made (right or wrong), the aircraft is making a missed approach or a screw up through altimetry, disorientation ETC. I am sure that there are countless stories out there of pilots who have made a decision to continue that they (seconds later) regretted. and not all of those are here to talk about it. The Cell Phone theory seems to be a bit of a red herring as I just can't believe that a SPIFR pilot would be that stupid to make a call 1/2 way down a hand flown ILS on a foggy night.