Nine Dead in Fox Glacier Crash, New Zealand

[remoak]

Well... if the trim was found set fully nose-down... and the pilot had insufficient time to reset it once he realised that he had a problem... and the aircraft STILL over-rotated... well everyone must have been well aft.

So, Prospector, it would appear that the findings so far agree with your second supposition, but disagree with your first.

It reminds me a lot of an accident I saw at Guernsey in the Channel Islands. An F27 took off with a load of newspapers. The cargo was not secure and moved aft as the aircraft rotated. Aircraft basically went into a vertical climb before stalling and spinning in. It hit a house across the road from our crew hotel, and it had no forward motion when it hit.

Watching the video reveals one thing though - the cowboy nature of much of GA in NZ.

[remoak]

Yep.

The thought process goes something like this:

"Hmmm this adventure tourism stuff is the go, you can make sh#tloads of money taking people up and letting them jump out of a perfectly good aeroplane. Now - what do we need?

1 - a really, really cheap means of getting them to altitude. I wonder if I can weld some wings on the old Hilux and use that? What? The CAA might not allow that? Well what's a really cheap Hilux-like aeroplane... I know, a shagged out old cropduster. We'll stick a Holden V8 in it and cut a door in the side. Can't use a Holden V8? Well what's the cheapest possible engine that will do the job? An Eastern bloc turbine? Well... is it cheap? Righto then!

2 - some skydivers to act as jumpmasters. Now, who can we use? Maybe those two pot-heads that hang around the place? Why not, I mean all you have to do is pull the ripcord, right? How hard can that be, even after a night on the wacky baccy?

3 - Some manuals and procedures. Oh sh#t, do we really have to have all that crap? Oh alright then, we'll have a flight manual to keep the Feds happy - all they care about is whether the books are up to date anyway. But we won't have it in the aircraft, some noob pilot might actually read it and work out that our operation is essentially illegal. Can't have that!

4 - A pilot. Hmmm, we need one good enough that he won't crash while breaking the rules that we haven't told him about, and dumb enough to go flying with no Flight Manual. We'll also need to convince him that Weight and Balance is only for fairies and Air NZ pilots (basically the same thing he he he). We can't have any paper records of what we do 'cos it's illegal anyway. Geez, hope the Feds never ask to see them... nah, not much chance of that. Just as well there are hundreds of desperate pilots willing to look the other way in order to get some turbine hours.

Great - job done. Now all we need are some punters who are silly enough to believe that the Regulator is ensuring their safety. Easy-peasy..."

And that, folks, is pretty much how a lot of NZ GA works. You can thank Swedavia for that. How do I know? Because I have been part of it (within the last year or two), and saw it from the inside. Makes me yearn for the airlines again...

[framer]

Which video shows the cowboy nature?

[remoak]

The one in post 95 of this thread (TAIC investigation)

[Ornis]

Since the owner-operator was killed I think the cowboy epithet is as unlikely as it is unfair. Ignorance more likely.

I belong to Sport Aircraft Association (SAANZ) whose members amateur-build aircraft. I find it incredible that nobody did a Weight & Balance after the major modification. Paperwork and box ticking should ensure checks are done and recorded but it is no substitute for know-how and nouse.

I claim no expertise but it's possible the pilot climbed out more steeply than hitherto. A lower airspeed would mean less elevator authority and just one jumper-pair falling back would be enough to upset the apple cart.

[remoak]

Cowboy operators cannot be the authors of their own demise?

It is clear from what information we have so far that there were serious issues with the aircraft and the operation in general. It may turn out that the final straw was a piloting error, however if the operation was professional, it is unlikely that this accident would have happened.

If there is one thing in NZ aviation that really annoys me, it is the general reluctance to call a spade a spade. We saw it with the Iroquois crash near Pukerua Bay, the clown that hit a van with his Cessna while doing a beat-up, the Seneca that smashed into Mt Tauhara, the Fouga that speared in near Thames - to name but a very, very few. Everyone goes into denial mode and refuses to call it what it really is - a pilot or operator screwing up. The regulator is as bad at this as anyone.

Well, I'm over it - every time I read of an accident like this, and the lack of professionalism that emerges, I'm more than happy to conclude what is bleedingly obvious to anyone with half a brain. The eventual report will only confirm what most of us figured out a year earlier.

In this case, we have a classic "Swiss cheese" scenario.

Paperwork and box ticking should ensure checks are done and recorded but it is no substitute for know-how and nouse.

I'm afraid there isn't a (competent) airline on the planet that would agree with that. We have SOPs, forms and checklists to ensure that NOBODY relies solely on "know-how and nouse". Fine attributes they may be, but they are by no means the whole story. Unfortunately, GA in this country is somewhat the other way... there's an awful lot of "she'll be right" going on. And now you see the results.

[Lepper Messiah]

This report has completely missed the point.

The supposed primary cause of the crash was the fact it was over loaded and out of c of g limitations. What a load of rubbish.

I've seen these aircraft operating with 9 people in the back, and I've heard of the odd occasion of 10. These aircraft can physically handle it, as proven many many thousands of times in other aircraft and 70 odd times in this particular aircraft.
Monte carlo reckons this was the heaviest most rearward flight yet ??
Come on, pull the other one
Look at those on board. 3 of the tandem masters were rather average to slight in build and none of the passengers were anything more than average to slim either. By all accounts this was probably a light load. Definitely not the heaviest and most rearward.
So why hasn't it crashed on an earlier flight ? Why haven't the other Fletchers crashed with even much greater loads in the back ??
They've never come close.

Did they flight test an aircraft at altitude with different c of g / weights as part of this investigation to determine its characteristics ?

Yes for sure, a not so favorable c of g definitely would not help with the recovery, but cause the fatal pitch up ??
No way.

If the c of g was that far out the arse to cause this, so tail heavy the tail would have been scraping all the way down the runway and the thing would have hardly got airborne before stalling and going splat then and there. Could anyone agree with that ?
In this case the aircraft flew off the runway and FLEW up to the near (apparently ) vertical.

The primary cause of this accident lies in what caused the aircraft to fly up so steeply. It could be many things, like some of those mentioned in the report (yet quickly dismissed). But it wasn't the c of g.

An overloaded aircraft and two pot smoking tandem masters. I hope these clowns get taken to the cleaners by the affected families.

These "clowns" died in the crash. I'm sure their families are effected by that.

I do however think it is a disgrace that anybody responsible for the lives of others should be under the influence of drugs.

There is a difference between "Traces in the system" and "Under the influence". Just like Alcohol.
Since when was anyone "under the influence"

Would this be a case of skydivers and customers crowding the door to get a look at the view?

No. Have you seen inside the cabin of a fletcher ? Have a look and think how the hell do you fit 8 people and 4 tandem rigs in here, then see how much room there is to move about and have a look out the door.
None.

Perhaps more of a case of the pax sliding to the rear for some reason, making already aft C of G even worse

Sliding I very much doubt. And not on take off. There is simply bugger all room. The 4 people up the front are almost wedged in next to each other (due cabin width). There is plenty to hold on to and simply no sliding (on a normal take off), there just isn't that much room.

However, when the aircraft went up so steep, what all the forward people falling back down on top of the others ? Then you would really be up **** creek without a paddle. That would make recovery pretty hard...

We don't know - maybe they moved aft for some inexplicable reason

No. As above.

The main point about the drugs is that the presence of them in the blood of the two tandem jumpmasters is indicative of attitudes and practices in this part of GA.

No Remoak, trying not to get personal, but thats a load of crap.

But I do dare you to tell me that no airline pilot has ever tested positive for any recreational drugs in their system, even just before boarding a flight...

In my experience, a lot fo these companies focus on providing an adrenaline rush first and foremost, with safety coming a distant second. Not all of them, but a lot of them.

Clearly then, you have very little experience in this area.

Should be pretty easy to establish where the trim was though, if it was that simple I would have expected a mention of it.

3.5.6 and 4.2.12 of the report mention the possibility of the manual trim not being reset prior to the take-off.
Para 3.2.5 did say the handle was found to be in a position that would indicate full nose forward trim had been wound in. Being manual in operation the pilot probably would have been unable to wind it in after the premature rotate..

I know that if I took off with the trim right back, and it did cause a big pitch up as prospector said (and I totally agree) then I would be winding like mad to get that trim forward. No way I would just leave it there. There was a bit of time from lift off to impact, I'm sure enough to move that trim forward ?

Well... if the trim was found set fully nose-down... and the pilot had insufficient time to reset it once he realised that he had a problem... and the aircraft STILL over-rotated... well everyone must have been well aft

They weren't well aft. There is insufficient room. This isn't a half loaded airbus with all the punters seated in the rear half of the aircraft. They were in the same positions as all the other flights, and the many many thousands of flights of other aircraft in this role.

I read an article in the newspaper which stated that only one skydiving outfit was able to produce the necesscary documentation by the rule deadline. If that is correct then it just goes to show how hopeless some of these GA goons are.

You have got to be kidding me ! In a news paper ?!?! Gosh that must be true !!
It's like getting an AOC. It costs time and money. You can't just do it over night. I believe all the major operators are operating now, with minimal down time, a day or 2 before receiving their certificates.

The thought process goes something like this:

"Hmmm this adventure tourism stuff is the go, you can make sh#tloads of money taking people up and letting them jump out of a perfectly good aeroplane. Now - what do we need?

1 - a really, really cheap means of getting them to altitude. I wonder if I can weld some wings on the old Hilux and use that? What? The CAA might not allow that? Well what's a really cheap Hilux-like aeroplane... I know, a shagged out old cropduster. We'll stick a Holden V8 in it and cut a door in the side. Can't use a Holden V8? Well what's the cheapest possible engine that will do the job? An Eastern bloc turbine? Well... is it cheap? Righto then!

2 - some skydivers to act as jumpmasters. Now, who can we use? Maybe those two pot-heads that hang around the place? Why not, I mean all you have to do is pull the ripcord, right? How hard can that be, even after a night on the wacky baccy?

3 - Some manuals and procedures. Oh sh#t, do we really have to have all that crap? Oh alright then, we'll have a flight manual to keep the Feds happy - all they care about is whether the books are up to date anyway. But we won't have it in the aircraft, some noob pilot might actually read it and work out that our operation is essentially illegal. Can't have that!

4 - A pilot. Hmmm, we need one good enough that he won't crash while breaking the rules that we haven't told him about, and dumb enough to go flying with no Flight Manual. We'll also need to convince him that Weight and Balance is only for fairies and Air NZ pilots (basically the same thing he he he). We can't have any paper records of what we do 'cos it's illegal anyway. Geez, hope the Feds never ask to see them... nah, not much chance of that. Just as well there are hundreds of desperate pilots willing to look the other way in order to get some turbine hours.

Great - job done. Now all we need are some punters who are silly enough to believe that the Regulator is ensuring their safety. Easy-peasy..."

And that, folks, is pretty much how a lot of NZ GA works. You can thank Swedavia for that. How do I know? Because I have been part of it (within the last year or two), and saw it from the inside. Makes me yearn for the airlines again...

Remoak. I do believe you are talking out of your anus, without a clue.
Why waste bandwidth with that drivel ?

[Ornis]

remoak, I think we are at cross purposes.

You didn't mention Bannerman, who killed the science workers on approach to Christchurch. Enough paperwork to paper over the cracks.

After we did the Weight & Balance on my aircraft, I was able to say: I can take the front seat passenger out and stick him in the back and the CoG is still well within limits. With a front seat passenger I can stick bikes in the back and as much luggage as will fit and it won't go out of balance. Overloaded maybe.

Here was a major modification of a (factory-built) aircraft. Did anyone who knew what he was about inspect it, do some calculations, get a clear picture of how it would fly? Who did the test flying? If it was loaded as intended for use wouldn't the pilot realise it was tail heavy, run out of elevator? What actually did the CAA require? The paperwork should be the gravy not the meat.

There are two boxes I want to see ticked yes: Is the aircraft safe; Is the pilot safe. To decide that requires know-how and nouse, not a great wall of rules and regulations, behind which, in my unprofessional opinion, the CAA hides.

[remoak]

Lepper Messiah

But I do dare you to tell me that no airline pilot has ever tested positive for any recreational drugs in their system, even just before boarding a flight...

No, I would be the first to agree that it isn't confined to GA, however it is far more prevalent in GA.

Clearly then, you have very little experience in this area.

Other than acting as Chief Pilot for one of them, no...

If the c of g was that far out the arse to cause this, so tail heavy the tail would have been scraping all the way down the runway and the thing would have hardly got airborne before stalling and going splat then and there. Could anyone agree with that ? In this case the aircraft flew off the runway and FLEW up to the near (apparently ) vertical.

The primary cause of this accident lies in what caused the aircraft to fly up so steeply. It could be many things, like some of those mentioned in the report (yet quickly dismissed). But it wasn't the c of g.

Not to let the facts get in the way of a good story... but the TAIC report says:

"As a result the aeroplane was being flown outside its loading limits every time it carried a full load of 8 parachutists. On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable. The pilot was unable to regain control and the aeroplane continued to pitch up, then rolled left before striking the ground nearly vertically."

So TAIC are lying, are they? They obviously feel that it was the aft C of G that caused the pitch up. As far as the trim goes, the aircraft was only airborne for seconds, and I have a hard time believing that the pilot did anything other than use both hands on the stick in an attempt to pitch down. To recognise the trim problem, and wind it all the way forward while maintaining sufficient pressure on the stick to counteract the pitch up, in only a few seconds - highly unlikely.

Remoak. I do believe you are talking out of your anus, without a clue.

Whatever. I have seen enough to know differently, and it is obvious from what we know of this accident already, particularly regarding the dodgy mods on the aircraft, the lack of weight and balance calculations, the use of incorrect information from another aircraft, the lack of a Flight Manual in the aircraft, that it was a long way away from being a professional operation.

And if your (and Prospector's) trim theory is correct, where were the preflight checks? Even the most basic and rushed checks should include trim position, particularly with this sort of operation. Even less professional...

[baron_beeza]

I am sure a weight and balance was done Ornis.
When we mod an aircraft we fill in the blue pages at the back of the logbook and raise a new 2173 and insert in the Flight Manual. The report did say that had all been done.

The Flight Manual was not with the aircraft and the W&B calculations the operator had chosen to use were from another example of a similar aircraft. You could suggest that perhaps they knew theirs was heavier and could struggle to carry 4 pairs and remain within limits.
Perhaps the same could be said of the preflight W&B calculations. Pointless if it is only going to hi-lite a known issue.

The guys doing the reweigh only weigh the empty aircraft in the current new configuration. It is up to the owner and operator to then use that data to do the calculations prior to flight.
The aircraft was well within limits after the modifications.

They may not have entered the new aft limit information in the AFM correctly though.

The empty weight and balance for ZK-EUF was properly recorded in the flight manual, but the stability information in that manual had not been appropriately amended to reflect its new role of a parachute aeroplane. Nevertheless, it was still possible for the aeroplane operator to initially have calculated the weight and balance of the aeroplane for the predicted operational loads before entering the aeroplane into service.

The problem only existed when you filled in with parachutists and equipment.

As for the aircraft pitching up on rotate. I would have though the pilot would be pushing forward with both hands, I could not see how he could turn the trim handle if it was selected incorrectly.

DHC4-T Crash - N400NC - YouTube

[prospector]

As soon as you realize the trim has not been set correctly for T/O both hands are initially used, then a knee is used to take some of the load whilst the trim is readjusted. All this happens in a very short time span.

If however the pax/load has shifted to the back, with the resultant aft C of G, then even having the trim correctly set will not necessarily retrieve the situation.

It is a very busy few seconds even with the load in a hopper, and the C of G in the proper position.

To recognise the trim problem, and wind it all the way forward while maintaining sufficient pressure on the stick to counteract the pitch up, in only a few seconds - highly unlikely.

Not necessarily so, the wrong trim setting shows up during the latter part of the ground run, the trim may have been reset, but to late to affect the outcome given the other factors involved.

[Ornis]

The aircraft was well within limits after the modifications.

Thank you everyone for helping me understand this crash. My concern is that apparently nobody asked: Is this aircraft safe for the purpose? There is nothing about the aircraft, modification, purpose or operation that is not clearly understood.

I accept that ultimately the pilot is responsible for the load, but we can't have passengers die because one enthusiastic and exuberant young pilot doesn't have a nose for trouble.

[27/09]

How long does it take to trim from full nose up to take off trim or nose down trim in a FU24. I've heard that it can take several seconds and many many winds of the trim handle though I'm not sure if this is correct.

This one didn't have electric trim?

[remoak]

I suspect that TAIC have rightly concluded that the trim position was academic. We'll never know for sure anyway.

The clue is in their report:

"On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable."

Not slightly rear...

And, of course, unlike a hopper full of super, this cargo could, and almost certainly did, move. Whether there was much room or not, everybody piled against the rear bulkhead will obviously result in a far more rearward C of G than if they were evenly spread throughout the cabin - all the more critical when the load is rearwards of the spar.

As I mentioned, we'll never know for sure whether it was the chicken or the egg, but either way, there were serious deficiencies in the operation.

[prospector]

"On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable."

The question being why was it well aft of the rear limit??

As previously stated this aircraft had carried out a number of sorties without any obvious problems. The load in itself was not excessive, in as much as the pax were not unduly heavy. To put the C of G well aft on this particular flight, far enough so as to be uncontrollable, some of the load must have moved either just prior or during lift off. The question is then why? and any answer to that question can only be speculation.

How long does it ta ke to trim from full nose up to take off trim or nose down trim in a FU24. I've heard that it can take several seconds and many many winds of the trim handle

It does take a number of turns, from a dim memory maybe 10 to 12, but it can be done in a very short time, 2 or 3 seconds maybe, there is no load on the trim handle.

[baron_beeza]

3.5.4. An elevator trim system was fitted to assist the pilot and ease elevator control forces when operating in a range of speeds and loading conditions. Fletcher aeroplanes had either electrically or manually operated trim controls. The trim control for ZK-EUF was manual, with a rotating handle located on the left side of the cockpit, aft of the power-control lever (see Figure 6). The trim could therefore be moved with the pilot’s left hand while at the same time the right hand held the control column. The trim took about 25 turns of the handle for full travel.

The aircraft obviously pitched up on rotate, possibly even slightly before.
The investigator knows how to fly an aircraft, many here have worked alongside him. I am sure he would have a fair idea or perhaps a personal belief. He is much closer to the action than any of us.
I would have thought the pilot, yes I knew him also, would have been very busy with the felt hand. pitching up with low airspeed..... hmmm I think whacking full power on would be high on the list of priorities, or at least confirming full power if that is the Walter system.
25 is the maximum number of turns so I guess 15 would be a good guess from landing to fully nose done. Still a lot of cranking to do when the nose is already pointed well above the horizon.
Perhaps the pilot did manage to crank all the turns in but by then the aircraft was already doomed.
The C of G would have caused a crash sooner or later. It truly is the Swiss cheese sequence yet again.

I also can't believe the operator did not at least have a series of standard W&B sheets prepared and approved. ie, Standard loads with various trip fuels.

I operate both NZ and Australian engineering licences..... the NZ is very good for normal GA operations. A lot of reliance is put on the IA and unfortunately this one and the balloon tragedy are not helping the industry.
It would appear the IA in each incident may have a case to answer.

The operations should be a lot more professional than these appear to have been. I am sure we will be seeing some increased audit activity there also.
You have to feel for the families, this report must be difficult reading.

[Ornis]

The father of a young man killed is quite right, we are amateurs. In my experience the response from the CAA to reporting a safety issue is defensive. Others have had similar treatment.

Is there going to be a report to the minister or Parliament when the CAA has its house in order?

I hope the emphasis is showing people how to get it right, in broad terms, when a proposal is made for an operation. I remain unconvinced the key to safety is paperwork, however necessary that might be.

[gobbledock]

The spread of bureaucratic pony pooh eeks it's way from Australia to New Zealand

This was an interesting account on 60 Minutes that I just watched. It would seem that Director Harris (CAA), and Australia's very own Director Screaming Skull (CASA) have much in common?

One Way Ticket

Well I guess for starters;

• Both don't seem to be able to answer a straight question (well not without looking like they had just had a giant unlubricated pineapple rammed up their klacker).
• Both have delivered public performances that are about as convincing as a crack whore porno actress pretending to have an orgasm.
• CAA and CASA don't appear to blink an eyelid when deaths, yes I mean deaths - You know, people's loved ones are reduced to body parts, lifeless limbs, bloody masses and unrecognizable pulps and torso's occurs. Mere collateral damage of a poorly oversighted regulatory inept regulator.
• As usual and rightly so, the regulator (or lack of) played a huge part in this accident, however in standard fashion the witch hunt and blame has been thrown squarely at the deceased pilot.
• Both regulatory bodies purpose and structure is to protect, shield and deflect moral and ethical accountability and blame away from an incompetent trough dwelling spin spewing taxpayer funded Minister for uselessness.
• Both the CAA and CASA should have their Wikepedia pages updated to include 'pony pooh' as part of their mantra and core function.

It is a shame that Senator X doesn't have jurisdiction and a large jackboot that spreads beyond Australia's boundaries and over to our comrades in NZ? Then again, one mans crusade, as admirable and respected as it is, won't reshape our industry before 'the big one' occurs.

A TICK TOCK for Australia and a TICK TOCK for NZ........

[Waghi Warrior]

I totally agree, I saw the interview and it was disheartening to watch how the CAA Director reacted to the interviewers questions.

Blame the dead pilot, easy!

Problem is that having unsuitable so called experts in a regulator with no initiative to change things for the better is becoming more of a norm.

Tick Tock Tick Tock is totally correct, you don't only have to look at Oz and Nz either!

[Elevator Driver]

That 60minutes story was the biggest load of one sided 'pony pooh' seen on TV for sometime.

There was not one mention of the changes & introduction of part 115, which has introduced a raft of safety measure's including a calculated W&B for each load minimum experience and recurrent training. Which is far more than a drop pilot in oz gets.....

Having worked on both sides of the ditch recently, NZ has a much better regulatory system to work under & a far more approachable regulator.