Executive summary
The aircraft was flying from Hamilton to Napier at night in instrument meteorological conditions, and had commenced an instrument approach procedure for Napier. The aircraft collided with a hill. The pilot and two passengers received fatal injuries in the accident.
Related Recommendations
Require that the Airways Corporation put in place plans for the mandatory replacement of controllers after an accident, or alternatively to close aerodromes or declare them uncontrolled after an accident for which the controller was providing air traffic service, until such time as the controller can be replaced.
Review the policy on the provision of information on instrument approach plates, relating to navigation lights visible to pilots and the depiction of spot heights.
Devise regulatory requirements for air traffic service standards, incorporating such a requirement.
An additional statement made in paragraph 2.1 to the effect that if communications are interrupted after approach clearance is received, the approach profile is to be flown irrespective of any previous height limitation.
Consider introducing training on the limitations of human performance and methods of handling excessive workload, as part of the flying training syllabus. • Require aircraft used for IFR air transport operations to be fitted with digital altimeters. • Apply the requirements for additional familiarisation flying after gaining a type rating, prescribed for air transport flights under IFR, to the pilots of any IFR flight carrying passengers
Review Section 7 paragraph 2.1 of the Instrument Flight Guide and amend it so as to clarify which phase of flight is being referred to in the various parts.
Consider establishing a requirement for a minimum level of experience for controllers who perform solo duties.
If it is decided that these features [from recommendation 047/90: information on instrument approach plates, relating to navigation lights visible to pilots and the depiction of spot heights] will be depicted amend all approach plates as soon as practicable to: • Delete spot heights from them, other than the boxed height for the highest ground and; • Ensure all navigation lights are depicted or include a notice to pilots on the chart advising which categories of navigation lights are depicted.
Promulgate as soon as practicable, by NOTAM or otherwise, a warning to pilots that the information on approach plates, which relates to spot heights and lights, may be incomplete an in particular the highest ground in the immediate area of the spot height may not be depicted.
Review the supervision of inexperienced controllers with a view to preventing the development of undesirable habits and unsatisfactory techniques.
Harmonise the provisions relating to separation after loss of communications in the Manual of Air Traffic Services and the Flight Guide.
Promulgate in the Local Unit Orders at each aerodrome, specific procedures to be followed in the event of loss of communications.