De Havilland DHC-8 ZK-NEY, controlled flight into terrain, near Palmerston North, 9 June 1995
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
Legacy Inquiry Number
95-011
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.
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.
Location
near Palmerston North (-40.333321,175.800004) [may be approximate]