Cessna 152 ZK-ETY and Robinson R22 ZK-HGV, mid-air collision, Paraparaumu, 17 February 2008
Status
Closed
Occurrence Date
Report Publication Date
Jurisdiction
NZ
Legacy Inquiry Number
08-001
On 17 February 2008, a mid-air collision between a light aeroplane and a small helicopter over Paraparaumu resulted in the deaths of 2 student pilots (aged 17 and 19 years) and a flight examiner (aged 30). Both aircraft were destroyed and several homes and commercial premises damaged, but no persons on the ground were injured.
The pilot of the aeroplane was following a standardised joining procedure for a sealed runway that took it into the path of the helicopter operating on a parallel grass runway. Had the conflict been recognised, the pilot of the aeroplane should have given way to the helicopter under general conflict-avoidance rules.
The investigation determined that the 3 pilots were concentrating on flying their aircraft and planned manoeuvres to the detriment of maintaining an effective lookout. Despite the pilots of both aircraft making appropriate radio calls that should have alerted the other and ensured adequate separation was maintained, as the 2 aircraft closed on each other, the pilots appeared to have made no attempt to continue their lookout until positively identifying the other aircraft and turning away. All pilots have a responsibility to maintain a good lookout and avoid a collision, regardless of who has the right of way.
A review of international standards and relevant research taken together with the accident circumstances found no evidence to support a review of pilot minimum age limits in New Zealand, with pilot competency being a more relevant consideration than age.
The potential for a mid-air collision at Paraparaumu, with its parallel runways and multiple and diverse operations, had been well recognised, but little had been done to mitigate the risk. Why the regulator did not act on the recommendation of a 1996 risk assessment to introduce specific joining procedures could not be explained. Neither the aircraft operators based on the aerodrome, the aerodrome owner and operator nor the regulator had maintained a coordinated approach to identifying and managing safety issues and risks at the aerodrome.
The absence of an air traffic control or information service on the aerodrome was not considered a significant factor, as the pilots were almost universally operating in accordance with visual flight rules where "see and avoid" is the primary and final defence in avoiding a collision. Further, there had been no appreciable change in the rate of near misses or other traffic conflicts since the removal of a staffed air traffic service. But there may have been a general reluctance among pilots to report such incidents.
Mid-air collisions are rare events. There was no evidence found in a review of New Zealand and
international data that the risk of impact damage to property or people on the ground near aerodromes merits consideration of a specific response for Paraparaumu or elsewhere. However, future planners and regulators need to be aware of the risks to ensure continued safe operations around aerodromes. Since the accident the aerodrome operator has held several user meetings, and conducted a risk review of aerodrome operations that has recommended a range of changes to aerodrome configuration, circuit procedures and requirements that should reduce the risk of mid-air collisions. The regulator has issued a general reminder to pilots of circuit procedures at uncontrolled aerodromes, and issued improved aeronautical charts containing circuit and runway information for Paraparaumu Aerodrome, including the adoption of specific joining procedures.
The Transport Accident Investigation Commission has recommended to the Director of Civil Aviation
that he act to increase his staff’s promotion of safe management of flying activities at all aerodromes and help educate pilots on effective visual scanning and active listening to radio calls. Further, to review operations at aerodromes around New Zealand with similar circuit patterns to help prevent future mid-air collisions.
(Note: this executive summary condenses content to highlight key points to readers and does so in simpler English and with less technical precision than the remainder of the report to ensure its accessibility to a non-expert reader. Expert readers should refer to and rely on the body of the full report.)
The pilot of the aeroplane was following a standardised joining procedure for a sealed runway that took it into the path of the helicopter operating on a parallel grass runway. Had the conflict been recognised, the pilot of the aeroplane should have given way to the helicopter under general conflict-avoidance rules.
The investigation determined that the 3 pilots were concentrating on flying their aircraft and planned manoeuvres to the detriment of maintaining an effective lookout. Despite the pilots of both aircraft making appropriate radio calls that should have alerted the other and ensured adequate separation was maintained, as the 2 aircraft closed on each other, the pilots appeared to have made no attempt to continue their lookout until positively identifying the other aircraft and turning away. All pilots have a responsibility to maintain a good lookout and avoid a collision, regardless of who has the right of way.
A review of international standards and relevant research taken together with the accident circumstances found no evidence to support a review of pilot minimum age limits in New Zealand, with pilot competency being a more relevant consideration than age.
The potential for a mid-air collision at Paraparaumu, with its parallel runways and multiple and diverse operations, had been well recognised, but little had been done to mitigate the risk. Why the regulator did not act on the recommendation of a 1996 risk assessment to introduce specific joining procedures could not be explained. Neither the aircraft operators based on the aerodrome, the aerodrome owner and operator nor the regulator had maintained a coordinated approach to identifying and managing safety issues and risks at the aerodrome.
The absence of an air traffic control or information service on the aerodrome was not considered a significant factor, as the pilots were almost universally operating in accordance with visual flight rules where "see and avoid" is the primary and final defence in avoiding a collision. Further, there had been no appreciable change in the rate of near misses or other traffic conflicts since the removal of a staffed air traffic service. But there may have been a general reluctance among pilots to report such incidents.
Mid-air collisions are rare events. There was no evidence found in a review of New Zealand and
international data that the risk of impact damage to property or people on the ground near aerodromes merits consideration of a specific response for Paraparaumu or elsewhere. However, future planners and regulators need to be aware of the risks to ensure continued safe operations around aerodromes. Since the accident the aerodrome operator has held several user meetings, and conducted a risk review of aerodrome operations that has recommended a range of changes to aerodrome configuration, circuit procedures and requirements that should reduce the risk of mid-air collisions. The regulator has issued a general reminder to pilots of circuit procedures at uncontrolled aerodromes, and issued improved aeronautical charts containing circuit and runway information for Paraparaumu Aerodrome, including the adoption of specific joining procedures.
The Transport Accident Investigation Commission has recommended to the Director of Civil Aviation
that he act to increase his staff’s promotion of safe management of flying activities at all aerodromes and help educate pilots on effective visual scanning and active listening to radio calls. Further, to review operations at aerodromes around New Zealand with similar circuit patterns to help prevent future mid-air collisions.
(Note: this executive summary condenses content to highlight key points to readers and does so in simpler English and with less technical precision than the remainder of the report to ensure its accessibility to a non-expert reader. Expert readers should refer to and rely on the body of the full report.)
Location
Paraparaumu (-40.902518,174.996843) [may be approximate]