Executive summary
At approximately 0922 hours on Friday 9 June 1995 a de Havilland DHC-8 aircraft, ZK-NEY, collided with the terrain some 16 km east of Palmerston North Aerodrome while carrying out an instrument approach. One crew member and three passengers lost their lives and two crew members and 12 passengers were seriously injured in the accident.
The causal factors were: the Captain not ensuring the aircraft intercepted and maintained the approach profile during the conduct of the non-precision instrument approach, the Captain's perseverance with his decision to get the undercarriage lowered without discontinuing the instrument approach, the Captain's distraction from the primary task of flying the aircraft safely during the First Officer's endeavours to correct an undercarriage malfunction, the First Officer not executing a Quick Reference Handbook procedure in the correct sequence, and the shortness of the ground proximity warning system warning.
The safety issues discussed are: the need for pilots to continue to monitor the safe conduct of the flight while dealing with any non-normal system operation, the desirability of the Captain assuming manipulative control of the aircraft in the event of an abnormal situation arising, the efficacy of the operator's follow-up on their decision not to modify the aircraft's undercarriage, the efficacy of the operator's flight safety programme, the design of the Quick Reference Handbook checklists, the limitations of the knowledge-based crew resource management training, the Civil Aviation Authority's shortage of audit staff available to detect weaknesses in operating procedures during its audits, the standard of performance of the aircraft's ground proximity warning system, the completeness of the advice to passengers on the safety equipment carried in an aircraft and the implementation of a minimum safe altitude warning system for the Air Traffic Control radar.
Related Recommendations
Enhance the opportunity for the Flight Safety Co-ordinator to attend international flight safety conferences and training seminars.
Investigate with the equipment manufacturer the practicality of developing and incorporating a minimum safe altitude warning system (MSAW) for the Airways Corporation's AIRCAT 2000 radar system as soon as practical.
Review Ansett New Zealand's use of configuration procedures designed to obviate unwanted GPWS warnings.
Expedite the implementation of his plans for obtaining the appropriate staff numbers to achieve their planned safety audits in the appropriate time scales.
Investigate the practicability of using the radio altimeter to give back-up warning during non-precision instrument approaches.
Require regular inspections to determine that the "Do not paint" decals are in place and legible.
Explore the practicability of instituting check flights to supplement the audit process on approved operators.
Require a one time inspection of all aircraft which have a radio altimeter installed to determine whether the radio altimeter antennae are free from paint.
Renegotiate the pilots' contract with NZALPA to remove the condition which is intended to prevent the company from installing CVRs in their aircraft.
Issue an interim instruction that, unless overriding considerations prevail, in the event of any system abnormality occurring during an instrument approach in instrument meteorological conditions the Captain shall discontinue the approach and climb to or maintain a safe altitude until the appropriate procedures relating to the abnormality have been completed correctly.
Investigate the practicability of using the FD and autopilot to alleviate the load on the pilot flying during non-precision instrument approaches in IMC.
Put in place a system, to be available on request, to recover and make available as soon as practicable any relevant recorded radar information which might assist the Search and Rescue Co-ordination Centre to locate a missing aircraft.
Review Ansett's practice of setting MDA once established on the approach, with a view to implementing a procedure which will not set the MDA before it is safe to descend to that altitude.
Review your decision to disconnect the existing cockpit voice recorder in Boeing 737 aircraft with a view to bringing them back into service as soon as practicable.
Review Ansett's QRH checklists for "Landing Gear Malfunction Alternate Gear Extension" and "#2 Engine Hyd Pump Caution Light on with Hyd Qty Below Normal, Gear Extension" with a view to standardising the procedures where actions should be identical, and eliminating the possibility for confusion between "alternate release door" and "alternate extension door" during the reading of the checklist.
Renegotiate, as soon as practicable, the pilots' contract with Ansett New Zealand to remove the condition which is intended to prevent Ansett New Zealand from installing Cockpit Voice Recorders in their aircraft.
Re-emphasise, to each of the Company's pilots, the potential for the pilot flying to be distracted from the routine operation of the aircraft during the execution of an emergency procedure or even a relatively minor system abnormality procedure, particularly if an unexpected need to give assistance with the procedure develops.
Initiate instructions to flight attendants that: are specific for each aircraft type which they operate, enhance the concept of a sterile flight deck during critical phases of a flight, clarify the need for them to be seated as soon as practicable after the signal to do so is given.
Explore the practicality of connecting the radio altimeter output into the DFDR.
Initiate with the aircraft manufacturers an investigation into the practicality of enhancing the survivability of the aerials of any ELTs in passenger transport aircraft which are hard wired into aircraft.
Take urgent steps to complete his review of the adequacy of CAA audit staff numbers for carrying out safety audits on operators in accordance with their stated policy.
Review the terminology used by approach controllers, in RTF with pilots, when they wish to restrict an aircraft's descent on the DME arc to an altitude greater than the minimum depicted on the applicable VOR/DME chart.
Review the status of the Flight Safety Co-ordinator to ensure that officer has a balanced input from the company's management, operations, and engineering staff on which to base an accident prevention programme.
Explore ways of making Ansett New Zealand's CRM training more realistic by use of a flight simulator or otherwise.
Ensure, with immediate effect, that each Ansett pilot assigned to crew a Dash 8 aircraft practise and remain familiar with the alternate gear extension procedure under suitably qualified supervision.
Require better information to be displayed by aircraft operators to aid passengers and potential rescuers to locate onboard first aid kits and fire extinguishers.
Emphasise to aircraft owners and operators the necessity of determining the location of such antennae and providing suitable masking to prevent any paint being applied to them.