Witnesses to the recent Black Cat cruise boat accident after it grounded just outside the Akaroa Heads are urged to submit a statement to TAIC immediately.
On Friday 3 October 2003 at 2126, Convair 580 ZK-KFU was on a scheduled night freight flight from Christchurch to Palmerston North, when it was observed on radar to enter a tightening left turn and disappear. Attempts to contact the aircraft were unsuccessful and a search for the aircraft was started.
The aircraft had impacted the sea about 10 km north of Paraparaumu about vertically and at high speed. The crew of 2 was killed on impact.
After crossing Cook Strait the aircraft probably became heavily iced up while descending through an area of severe icing, and stalled after flying level for a short time. The crew was unable to recover from the ensuing spiral dive and the aircraft broke up as it descended.
Safety issues identified included:
• the need for all pilots and operators to have a better understanding of aircraft icing
• the use of air reports to alert pilots to hazardous meteorological conditions
• the adequacy of aircraft, operator and CAA documentation to assist pilots encountering adverse weather conditions, particularly for IFR and night freight operators in icing conditions
• the adequacy of the installation, performance and capabilities of cockpit voice and flight data recorders
• the requirement for a suitable tracking device to be readily available to find underwater location beacons.
Safety recommendations were made to the Director of Civil Aviation and the operator to address these issues.
Use this report to re-emphasise to pilots and operators the hazards of icing, in particular tailplane icing and freezing rain.
As a matter of urgency inspect his fleet of Convair 580 aircraft to ensure the cockpit voice recorders are correctly installed and are functioning as required.
Draft an amendment to Civil Aviation Rules for the Minister’s approval, upgrading the standard of recorders carried on board New Zealand registered aircraft to a minimum of an 11-parameter capable FDR and a TSO-C123a compliant CVR, without reducing any higher standard already contained in Civil Aviation Rules.
Review and update company manuals and procedures to ensure they are correct and provide the best available guidance for pilots to detect, avoid and escape from adverse or hazardous conditions.
Ensure that, in addition to the current installation and operating requirements, all CVRs and FDRs are periodically interrogated to ratify the content and quality of the information recorded.
Educate pilots on the benefits of transmitting AIREPs, and amend the AIP to better reflect the objectives of the AIREP
Complete the recommendations of the independent report, New Zealand Aircraft Icing Hazards, in particular: a. ensure all IFR operators provide adequate written guidance for operations in adverse or hazardous weather conditions, b. Audit air operators to ensure they have clear and unambiguous procedures for avoiding not only turbulence and thunderstorms, but also severe icing conditions, and