Air Adventures Pa31 Crash Coroners Inquiry

[Six Lima]

Saw an article on TV3's Nightline News last night refering to the coroner's inquiry into the Air Adventures crash last June. Had some expert giving evidence. He basically blamed the pilot but the two points that were highlighted by the clip was the fact the pilot only had 24 hrs night experience and that the plane was carrying too much fuel ?

Is this more average reporting taking something out of context because it seems very strange to criticise anybody for carrying too much fuel, unless it's put the aircraft over-weight. I did read the accident report but don't remember anything about overloading, nor anything about the fuel loaded.

Can anyone shed any light?

[Cloud Cutter]

From the TAIC report

The accident probably resulted from the pilot becoming distracted from monitoring his altitude at a critical stage of the approach. The possibility of pilot incapacitation is considered unlikely, but cannot be ruled out.


Safety issues identified included:


· the desirability of adoption of TAWS equipment for smaller IFR air transport aircraft

· the need for VFR/IFR operators to have practical procedures for observing cellphone rules during flight

· the need for pilots on single-pilot IFR operations to use optimum procedures during instrument approaches

ZK-NCA Accident Report - TAIC



Sounds as though the pilot may have been using a cell phone in the final stages of the ILS. There was fog at CH but a preceeding 737 had landed a few minutes earlier. Not sure TAWS would have helped, the pilot didn't seem to be responding to visual glideslope info, would an aural warning have made much difference?

As for carrying too much fuel, haven't heard that one. Maybe they're saying the aircraft was above MLW, of course that has no bearing on the accident. To me, one of the most interesting parts of the report is the radar plot of the ILS approach. For some reason it was flown rather inaccurately and consistantly below GS.

[romansandal]

I heard a theory not so long ago that was intriguing. The aircraft may have been flying a non-precision approach monitoring GPS distance as opposed to DME distance, as per normal. Consequently this would have put him roughly 1mile back from the DME profile, explaining the consistently low approach.

Unfortuanately this doesn't explain why the a/c went through DA/MDA, which is the real issue.

[Cloud Cutter]

That would explain the consistantly low profile. It's interesting to note that a call was made from the pilots cell phone to his home commencing 1904:36 and terminating 1907:45. The last radar return from NCA was at 1907:29. It is reasonable to conclude that the phone was in use at the time of impact.

If you've ever used (or even turned on) a cell phone while monitoring an ILS you may have seen the instrument deviations it can cause (of course you can only do this VFR).

[gaunty]

for smaller IFR air transport aircraft

They still just don't get it.

A Chieftain or anything =<5700 kg is NOT an "air transport" aircraft.

They are NORMAL category, private, business and recreational types. .

And RPT single pilot ops?

And if I've got he "right" accident they took the cream of their scientific community with em, doesn't matter, 7 it is still too many.

[A4 gunnie]

Was this aircraft GPS equipped? I think it had a pretty basic IF panel.

[romansandal]

Handheld GPS mounted on the dash.

[piontyendforward]

Dear Gaunty

It is "air transport operations" in New Zealand, USA, UK etc in fact in any country other than Aussie.

Nobody else in the world has "RPT" operation what ever the hell that is.

135 ops yes
121
125
etc all Air Transport operation

Cheers

[chicken6]

Just saw this on the TelstraClear site

http://www.telstraclear.co.nz/newsfe...m.cfm?id=64204

Makes you wonder either what it takes to be an expert, or what it takes to be a journalist.

If the expert says you are, "...forced to fly visually" when the rad alt fails, then why are aircraft allowed to take off IFR without them installed? And how many rad alts actually have a flashing RED light? I've seen yellow, I've seen the letters DH but not red. Romansandal got it right IMHO, you're never FORCED to go visual unless you're out of fuel.

If the journalist can report this (and it's hopefully a misquote) on a very popular website and homepage for a lot of people, how do they not get sued for whatever the appropriate thing is (slander? misquoting? being a jerk?)

Hopefully just another case of bad listening from the media.

[Dale Harris]

Just a small correction Gaunty, our old Queenair was transport category. Last i flew it, it was under 5700 kg.

[AIRCAB]

On the Phone??

This maybe a stupid question or i might have missed something, but why the hell was he on the phone while doing an ILS?

Did he have a radio failure

[gaunty]

SUBCHAPTER C--AIRCRAFT

=< 5700kg
PART 23—AIRWORTHINESS STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES
>= 5700kg
PART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANES


and what Airworthiness Standard is required and with what you you must comply to operate them.

SUBCHAPTER G--AIR CARRIERS AND OPERATORS FOR COMPENSATION OR HIRE: CERTIFICATION AND OPERATIONS


PART 119—CERTIFICATION: AIR CARRIERS AND COMMERCIAL OPERATORS

PART 121—OPERATING REQUIREMENTS: DOMESTIC, FLAG, AND SUPPLEMENTAL OPERATIONS

PART 125—CERTIFICATION AND OPERATIONS: AIRPLANES HAVING A SEATING CAPACITY OF 20 OR MORE PASSENGERS OR A MAXIMUM PAYLOAD CAPACITY OF 6,000 POUNDS OR MORE; AND RULES GOVERNING PERSONS ON BOARD SUCH AIRCRAFT

PART 135—OPERATING REQUIREMENTS: COMMUTER AND ON DEMAND OPERATIONS AND RULES GOVERNING PERSONS ON BOARD SUCH AIRCRAFT

for the full monty

Go here

You also need to have more than a passing familiarity with the history and post colonial development of aviaton in OZ and the fundamental and pivotal effect the two airline policy had in distorting the development of NON airline travel and on the tortured and terminally mangled evolution of the regulatory regime in this country.

[Cloud Cutter]

gaunty

Nobody is saying that a PA31 is a 'transport category aircraft' IAW FAR Part 23/25, however the report refers to 'smaller IFR air transport aircraft' which it most certainly is when conducting an IFR ATO IAW NZCAR Part 135 (as is a C172 on an IFR freight run for that matter).

As for RPT, doesn't apply in this case Regular Pubic Trasport = Scheduled ATOs. This was an Unscheduled A to B ATO (Charter). And there's no problem with single pilot scheduled IFR ATOs under 135.


AIRCAB

Not a stupid question at all - I can't figure it out, certainly no coms failure. Perhaps complacency?


As for the dodgy reporting, what an absolute load of crap. The fact that the Radar Altimeter was U/S was mentioned in the report amongst various other arbitrary instrument info. You can just tell they're fishing for a conspiracy theory 'unpluged instrument leads to death of controversial scientists'

[gaunty]

Cloud Cutter

I don't doubt that we may find ourselves in heated agreement in most aspects, the problem is the perception created in the public mind by the use of the words "air transport", "RPT" and perhaps even the word "airline" for a charter company in what is actually an "air taxi" environment.

I was able to get the West Aussie Coroner over here to undestand the "perception" issue in relation to use of FAR 23 v FAR25 types for Fly in Fly out operations.
Basically in the public perception if its got more than one engine (turboprop even) and maybe even more than one pilot it's the same as an "airline" operation, just a whole lot cheaper. By definition it is not possible for it to be a whole lot cheaper and get within coooee of airline standards.
Several of his major recomendations out of the case in question was that companies or organisations that required their staff to travel by air as part of their work commitments should either use "transport category" equipment and/or if that was not possible to inform their staff of the safety and performance differences between Normal and Transport category aircraft before travel.
That the aircraft in question was properly maintained, crewed, licensed and operated correctly in accordance with the operators AOC was found not to be the point in regard to the duty of care incumbent on the staffs employer.
The employer was under the impression, neither were they aware nor advised by their "consultant" that there was another and higher level of safety available to them.
Neither was whether they or their staff would or should have chosen the alternative argued in this instance.
The perception that the "regulator" had signed them off was all that was "seen" and to be OK in the absence of the other "knowledge"

Now that "knowledge" has been thoroughly and comprehensively revealed in WA at least, it will be very hard to defend the continued use of FAR23 types in this context if a company has to defend a "duty of care" case is brought against them.

The world has moved on.

[Obiwan]

"The only time an airplane has too much fuel on board is when it is on fire" - Sir Charles Kingsford Smith

[Cloud Cutter]

gaunty

Thanks, I see your point.

[Sqwark2000]

From the NZ Herald, Tues 28/9/04

Weather OK on air crash night

28.09.2004


A Qantas airline pilot says the weather should not have prevented an Air Adventures plane from making a safe, visual approach to Christchurch Airport on June 6 last year.

Mark Watson, at the time a trainee captain with Qantas, landed at the airport just after 7pm that Friday.

About three minutes later, an Air Adventures plane, which was due to land just moments after his, ploughed into farmland 2km short of the runway.

The crash killed pilot Michael Bannerman, 52, and Crop & Food Research employees Howard Bezar, 55, Katherine Carman, 35, Alistair Clough, 37, Richard Finch, 41, Desma Hogg, 41, Andrew Rosanowski, 37, and Margaret Viles, 53.

The Christchurch Coroner yesterday reconvened a hearing into the deaths, hearing evidence from police, an aviation expert and the Qantas pilot.

In a statement, Mr Watson said the weather was "okay" as he approached the airport on a domestic flight from Auckland.

There were "holes in the fog" that hung over the outskirts of Christchurch, meaning the crash was unlikely to be due to bad weather, Mr Watson said.

"I wouldn't have thought the crash would have been weather-related. He shouldn't have had problems with gaining a visual."

Instead, Mr Watson cited pilot workload, and the possible mixing of visual and instrumental landing approaches as reasons for the crash.

Mr Watson said the pilot, Mr Bannerman, may also have made a "commercial decision" not to switch to his alternative landing plan and take the plane to Blenheim.

Aviation expert Keith Mitchell told the court he had assessed details of the flight and found the plane was overweight at take-off and Mr Bannerman had probably tried to mix an instrumental and visual landing. Mr Bannerman only had 24 hours night-flying experience and may have fallen victim to a trap known as the "black-hole approach".

This happened when a pilot relied on a visual approach at night while flying over flat, featureless land, causing them to misjudge the approach and touch down short of the landing strip.

Detective Ashley Millen, who headed police inquiries into the accident, told the court details surrounding a phone call made from Mr Bannerman's cellphone two minutes before the crash were still being confirmed.

An expert from the Netherlands would take at least another month to find out if the keylock on Mr Bannerman's phone was deliberately activated before a call was made or if Mr Bannerman accidentally knocked the dial button.

Mr Millen told the court police had not conducted an independent scene examination, or inquiries into Mr Bannerman's flying background, his failure to use autopilot, or his contact with Christchurch Air Traffic Control, instead relying on information from the Transport Accident Investigation Commission (TAIC).

A TAIC report released in March concluded Mr Bannerman was simply flying the wrong path on his final approach to the runway.The path put him on a collision course with trees about 2km from the runway.

Coroner Richard McElrea yesterday told the court the inquest would run independently of TAIC investigations.

The two surviving passengers from the flight, Richard Barton and Tim Lindley, are expected to give evidence during the inquest. The hearing continues tomorrow.

- NZPA


Six Lima - This could be where the "too much fuel" speculation came from.





Crash pilot was keen to get home, says expert

29.09.2004


Michael Bannerman had a case of "get-home-itis" the night his Air Adventures plane crashed, killing himself and seven passengers, says an aviation expert.

Keith Mitchell, a pilot and aviation assessor, told a coroner's inquest into the accident that Mr Bannerman's flight path indicated his thoughts were on getting home, not safety.

The crash on June 6 last year killed Mr Bannerman, 52, and Crop & Food Research employees Howard Bezar, 55, Katherine Carman, 35, Alistair Clough, 37, Richard Finch, 41, Desma Hogg, 41, Andrew Rosanowski, 37, and Margaret Viles, 53.

Christchurch coroner Richard McElrea reconvened a hearing into the deaths this week.

Mr Mitchell told the court yesterday Mr Bannerman had approached the Christchurch Airport runway too low and too fast.

"It was an unstable approach. You can deduce from that approach that he had 'get-home-itis'. The thought of having to go back to Woodbourne [the airbase in Blenheim] was not very palatable."

Mr Mitchell gave extensive evidence on Mr Bannerman's failure to capture the correct glide-slope path into Christchurch airport, again saying the pilot may have fallen victim to the "black hole approach" - landing short of the runway on a night-time, visual approach.

The Bannerman family put questions to Mr Mitchell about equipment on the plane, suggesting the interference of Mr Bannerman's cellphone signal could have meant he received the wrong flight path information.

Mr Mitchell and Qantas pilot Peter Wyatt agreed that, regardless of electronic equipment failure or the interference of a cellphone call at the time of landing, Mr Bannerman should have checked his barometric altimeter to see he was too low on approach.

David Viles, Margaret Viles' husband, also questioned both witnesses on Mr Bannerman's failure to monitor his barometric altimeter.

Mr Viles raised the issue of introducing an aviation ombudsman for increased safety measures in the industry.

He said the Civil Aviation Authority's role as the regulatory body meant pilots were often reluctant to report incidents for fear of being identified.

Pilots were "reluctant to dob in to the CAA" because under other circumstances, they were beholden to the authority for their right to fly.

- NZPA

[Six Lima]

Thanks S2K and Obiwan, like I said I have read the TAIC report and was more interested where the idea of too much fuel could have come from.

Few questions; coroner's inquest seems to be looking at whether he had become visual after the approach and then suffered from the Black Hole Effect. I'm aware that visual aids can be affected by moisture giving illusions at night but that would not account for the significant deviation from the centreline of the crash site. If he was visual, I find it hard to believe he could be that far off unless he was distracted/had his head down.

From the TAIC report:

1.17.7 CAA additionally carried out spot checks on Air Adventures. One of these, in May 2000, had been triggered by company pilots or ex-pilots complaining to CAA, mostly about being pressured to conduct VFR flights in unsuitable weather. CAA analysed the company operational risk as high at that time. A spot check a year later found improvements, and a subsequent risk assessment was moderate.

That would tend to make nonsense of the last two paragraphs of that second article.

I would also be interested to get opinion on what would be an appropriate approach speed for a Chieftan on an ILS. I have only flown a Navajo but was trained to fly at 150kts to 5nm so as to attempt to comply as closely as possible with the speed requirement of 160kts at WN. I found this quite comfortable and stable, 1st stage of flap and gear down. Also complies with Cat B speeds.

It would appear to me that the coroner's inquest is a little bit of a circus, either that or the media are slipping in their high standards of reporting. I don't know that a phrase like "get-home-itis" really belongs in court either.

[NoseGear]

Expert?

Who is this "expert" Mitchell at this hearing? I would be interested to know his experience. He claims that the pilot flew a mix of a visual and an insturment approach, which is surprising considering the wx was Sct002 and OVC007 with 500m viz! It may be that the cellphone was interfering with the g/s or the llz, but I think Mr Bannerman, with all due respect, was simply out of his depth. The approach was flown too fast with regard to the prevailing condx, it was never really stable and I think towards the end he had tunnel vision with respect to the llz and never noticed his g/slope was showing a full fly up deflection, and of course the altimeter reading. Flying a piston at speed on an ILS has its own problems, such as trying to reduce to flap and gear speed whilst not pulling the power levers to idle, as we have all been taught not to do. It is a busy time, concentrating on flying an accurate ILS whilst trying to slow without harming the engines in order to configure for a landing, all at the same time. Some items that point to possible overload, his navaids, ie the ADF's were not tuned ahead for the missed approach. Considering the condx, that is a little concerning, as a missed approach must have been considered a possibility.
A sad day, perhaps some lessons for all to be learned, as always the hard way.

[chicken6]

Six Lima

I used to fly a Navajo as well (wonder if it was the same one????? ) and a couple of flights in a Cheiftain, and 130kt was better than 150kt but then it's different at WN coz DH is 500' not 200'. 130kt gave an easier attitude to land from because with the speed gradually reducing at DH you didn't have to do much at all to actually land it.

For those who missed it, and Cloud Cutter

Tue, 28 September 2004 on TelstraClear's homepage link
Altimeter unplugged in doomed aircraft


It has been revealed that the device used to measure the height of a doomed Air Adventures aircraft was unplugged as it plunged to the ground.


Seven senior managers from Crop and Food Research were killed, along with the pilot Michael Bannerman in the crash, north of Christchurch, in June last year.


At an inquest into the deaths today, lawyers representing family members of those killed, questioned Mr Bannerman's incorrect gliding slope as he approached Christchurch airport.


Aviation expert Keith Mitchell said Mr Bannerman was forced to fly visually, as the radar altimeter was not connected.


He told the court a working altimeter would have activated a red flashing light, alerting the pilot to the low level he was at.

my bold

CC, what I was alarmed at was the apparent causal link between having a rad alt disconnected and being forced to fly visually. What I was referring to with the 'reporting' thing was what I think happened, the journo left off the end of Mr. Mitchell's sentence where he could have said, ..."or conduct a missed approach".