June 2, 2011
The New Zealand Transport Accident Investigation Commission (TAIC) determined that a distraction during the pre-flight inspection failed to reveal an unlocked cargo door on a Beech 1900. The cargo door opened during takeoff.
A Beechcraft 1900D, registered ZK-EAQ, departed from Auckland International Airport, New Zealand. As the airplane became airborne the rear cargo door opened. The crew returned and landed safely. There were no injuries to the twelve occupants and minor damage only to the airplane.
The Beech 1900D was being operated with a permitted inoperative warning system that provided an indication to the crew when the cargo door was unlocked. An engineer had cleared the aeroplane to operate provided a crew member visually checked that the door was closed and locked before each departure. As the airplane was prepared for departure, the loader closed the cargo door but did not fully rotate the handle to lock the door. The first officer was distracted during the final pre-flight inspection of the aeroplane and did not positively check the condition of the door.
The captain and first officer did not adequately confirm that the cargo door had been visually checked and confirmed locked before departure. As the airplane was taxied, the door handle vibrated loose, allowing the door to open during the take-off.
As a result of the safety actions taken by the operator, TAIC did not need to make any recommendations.
The lessons to be learned from this incident were relevant to all pilots and included:
- cargo doors and other openings on an aircraft must be securely latched and positively checked before flight,
- the need to strictly follow and complete checklists, and
- should there be an interruption of a checklist, the checklist should be recommenced either from the beginning or the last confirmed item completed.
April 5, 2011
On 10 February 2010, ZK-TZR, a Cessna 208 Caravan aeroplane, had just taken off from Nelson Aerodrome, New Zealand on a scheduled commercial flight to Wellington when the pilots noticed a reduction in engine performance and a strong smell of fuel in the cabin. There were 2 pilots and 4 passengers on board at the time.
The pilot contacted the aerodrome controller and arranged for the flight to return to Nelson; he did this without declaring an urgency or distress situation. The aeroplane made a successful landing back at Nelson, with the engine still operating on reduced performance. There were no injuries and no damage to the aeroplane.
The NZ Transport Accident Investigation Commission found that the reduction in engine performance was due to fuel leaking past damaged o-rings that should have sealed fuel being delivered to the engine. The o-rings had been damaged by movement of the fuel-transfer tubes, which had been reduced in size at some time during maintenance by a chemical milling process that had removed the anodic protective coating.
The Commission also determined that the pilots should have declared an urgency or distress situation to ensure that emergency services were on standby in the event of a different outcome.
The Commission also found that the Civil Aviation Authority of New Zealand (CAA) system for classifying accident and incident notifications needed reviewing, because the potential seriousness of the defect that led to the forced landing, while initially recognised, was incorrectly classified and not assigned for investigation until 2 months after the Authority was first notified.
Actions taken by the CAA to address the safety issue regarding the classification of occurrences meant that no recommendation was required to be made. A recommendation was made to the Director of Civil Aviation regarding the use of correct radio telephone phraseology in the event of an emergency.
December 24, 2010
The New Zealand Transport Accident Investigation Commission (TAIC) published the final report of their investigation into a serious runway incursion accident at Dunedin, 25 May 2010. A patrol vehicle had entered the runway at night and almost collided with a landing Metro III cargo plane.
The Swearingen Metro III plane operated on a night time cargo flight from Christchurch International Airport (CHC/NZCH) to Dunedin International Airport (DUD/NZDN). The usual arrival time at Dunedin was between 0200 and0300, but the flight was delayed that night. The Dunedin control tower was unattended and was not scheduled to beoperational until 06:30.
At approximately 06:00 the first officer of the Metro plane transmitted on the local Dunedin control tower frequency of 120.7 megahertz that “Post 91″ was 10 nautical miles out and inbound for an ILS approach to runway 21. At about 06:06, he reported that Post 91 was on final approach.
After touchdown the crew selected reverse thrust. At about that time they saw some flashing vehicle lights to their right. After the pilots had turned the aeroplane around the first officer advised they were back-tracking on runway 21. As they began taxiing to the terminal the night security agent advised them on the local radio frequency that an Avsec vehicle had been on the runway without a clearance when they landed.
The driver of the vehicle had intended to use the runway as a means of conducting an airfield perimeter fence check because recent heavy rain had flooded parts of the dirt perimeter road and the grassed areas from which such checks were normally accomplished.
The driver was unaware that an aeroplane had just landed when he drove onto the runway. Likewise, the pilots were unaware that a patrol vehicle had entered the runway after they landed, and they would have been in no position to take avoiding action to prevent a collision had the vehicle been driven in front of their aeroplane.
The main issues that led to the incident were a lack of awareness by aviation security officers of the significance of the runway lights being on, and inadequate local procedures for aviation security officers to access the runway safely outside the hours of service of air traffic control (ATC). Actions taken by the Aviation Security Service (Avsec) since the incident to improve the training of aviation security officers and procedures should help prevent a recurrence.
Therefore, the Commission did not make any recommendation as a result of this inquiry.
April 16, 2010
A TAIC New Zealand incident investigation report indicates that an unstable night-time visual approach lead to a Metro III runway excursion at New Plymouth Aerodrome, New Zealand.
On 30 March 2009 at 23:40, a Swearingen SA227AC Metro III air ambulance aeroplane, registered ZK-NSS, took off from Auckland International Airport (AKL/NZAA) on a night flight to New Plymouth Airport (NPL/NZNP) to uplift a patient. On board were 2 pilots and a medical team of 3. The flight was without incident until the approach at New Plymouth.
The pilots carried out a visual approach, although that was generally not permitted by the aeroplane operator at an uncontrolled aerodrome, and without the help of approach slope indicator lights. During the landing checks the right engine did not go to high speed as selected, and the pilots were distracted in trying to find the reason. The base turn was carried out close to the aerodrome and involved a high rate of descent that generated ground proximity warnings. The pilot flying reduced the rate of descent and continued with the approach, rather than carrying out an immediate go-around.
Late on final approach the pilots realised that the aeroplane’s current glide path would result in a landing very close to the runway end. The pilot flying said that he had difficulty controlling the aeroplane when power was increased, which he assumed was caused by the engine speed anomaly. He judged that it was preferable to continue and land rather than to attempt a go-around with an apparent control problem, so he left the power unchanged. The aeroplane landed heavily at the runway end and immediately ran off the side of it. No-one was injured and apart from minor damage to the tyres the aeroplane was undamaged.
The approach was rushed because of the pilots’ decision to commence a visual approach from a point close to the aerodrome. The resultant high rate of descent, together with the distracting engine speed anomaly, led to the ground proximity warnings. The lack of approach slope indicator lights denied the pilots a useful aid for establishing a stable approach. The runway excursion occurred because the pilot flying had a control difficulty and was not in full control of the aeroplane during the landing.
If the pilots had conducted an instrument approach as the operator had required, the approach would likely have been stable and given them more time to deal with the engine speed issue, the cause of which was not determined. Had they applied typical cockpit resource management techniques and the operator’s approach monitoring requirements had been better defined, the unstable approach should have been detected and discontinued. The lack of intervention by the pilot not flying might have been caused by a less-than-optimum trans-cockpit authority gradient.
A few days later, before the aeroplane had been released back to service, a fuel bypass event caused the right engine to run down. Trouble-shooting suggested the Single Red Line interface unit was defective.
Although some defects were found in the unit, they would not have led to a fuel bypass, the cause of which remained undetermined. A fuel bypass was not considered to have occurred at New Plymouth, and the 2 events were likely to have been unrelated.
The Transport Accident Investigation Commission (the Commission) made a safety recommendation to the Director of Civil Aviation regarding delays in the notification of serious incidents to the Civil Aviation Authority and to the Commission.