Executive summary
At about 0130 hours on Wednesday 11 June 1997 ZK-KVL, a Beechcraft BE58 Baron twin-engined aircraft, on a night freight flight from Palmerston North to Christchurch, disappeared from radar. The aircraft wreckage was subsequently located in the Tararua Ranges 21 km south-east of Paraparaumu. The aircraft had struck a wooded slope at high speed in a steep spiral dive, and fragmented. The pilot was killed on impact. The aircraft had probably encountered severe in-flight icing at 10 000 feet, in the area of a convective cell, resulting in a loss of control. An ingress of carbon monoxide to the cabin of the aircraft probably impaired the pilot’s mental functioning and induced a loss of situational awareness. Factors contributing to the accident included a flawed operational environment, inadequate flight planning by the pilot to minimise the exposure to icing conditions and the lack of an appropriate safety culture within the operating company. The performance of the Civil Aviation Authority conducting its audits and subsequent supervision is critically examined.
Related Recommendations
Review the likely safety benefits of the installation of suitable carbon monoxide detection devices in the cabins of aircraft which have potential for an ingress of carbon monoxide, with a view to making the installation of such devices mandatory in appropriate circumstances.
Require the CAA to implement, as soon as practicable, a system which will ensure any instances of operator non-compliance and non-conformance which are identified by, or to, the Authority are corrected promptly or sanctions automatically follow.