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Report 99-004 Cessna 206 ZK-EKJ Impact with Mountainous Terrain By

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Report 99-004 Cessna 206 ZK-EKJ Impact with Mountainous Terrain By Report 99-004 Cessna 206 ZK-EKJ impact with mountainous terrain by Mount Suter 17 km south of Milford Sound 18 April 1999 Abstract On Sunday 18 April 1999 at around 1538 hours, ZK-EKJ, a Cessna 206 floatplane on a round-trip scenic flight from Te Anau to overhead Milford Sound, struck the top of a vertical craggy mountain ridge. The pilot and 4 passengers died during the impact. The pilot probably attempted to cross the ridge crest at low level and might have misjudged the height of the ridge top because of visual illusions or distraction. Some localised turbulence or downdraughts and the fast speed of the aircraft may have contributed to the accident. Had the pilot applied a safe ridge crossing technique, including maintaining a sufficient height margin above the ridge, the accident could have been avoided. The pilot was reported to have carried out unnecessary low flying and crossing of ridge crests with minimal clearance on scenic flights, on a number of occasions over several years before the accident. The operator did not, adequately supervise the pilot, independently investigate an allegation of the pilot low flying or establish a system to control or monitor the pilot’s performance and compliance with safety requirements. The pilot’s reported acts of unnecessary low flying were not made known to the Civil Aviation Authority. The operator’s organisational shortcomings that probably contributed to the accident were not identified by or made known to the safety authority. Safety recommendations were made to the operator’s chief executive and the Director of Civil Aviation to address safety issues identified during the investigation. The Transport Accident Investigation Commission is an independent Crown entity established to determine the circumstances and causes of accidents and incidents with a view to avoiding similar occurrences in the future. Accordingly it is inappropriate that reports should be used to assign fault or blame or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. The Commission may make recommendations to improve transport safety. The cost of implementing any recommendation must always be balanced against its benefits. Such analysis is a matter for the regulator and the industry. These reports may be reprinted in whole or in part without charge, providing acknowledgement is made to the Transport Accident Investigation Commission. Transport Accident Investigation Commission P O Box 10-323, Wellington, New Zealand Phone +64 4 473 3112 Fax +64 4 499 1510 E-mail: [email protected] Web site: www.taic.org.nz y of The Southland Times Courtes EKJ - ZK Cessna 206 floatplane Contents List of Abbreviations ............................................................................................................................ii Data Summary .....................................................................................................................................iii 1. Factual Information .............................................................................................................. 1 1.1 History of the flight .................................................................................................. 1 1.2 Injuries to persons .................................................................................................... 3 1.3 Damage to aircraft .................................................................................................... 3 1.4 Pilot information ...................................................................................................... 3 Background ......................................................................................................... 3 Checking .............................................................................................................. 3 Work hours and requirements ............................................................................. 5 Other information ................................................................................................ 6 1.5 Aircraft information ................................................................................................. 7 1.6 Meteorological information ..................................................................................... 8 1.7 Navigation aids ...................................................................................................... 10 1.8 Communications .................................................................................................... 10 1.9 Wreckage and impact information ......................................................................... 10 1.10 Medical and pathological information ................................................................... 11 1.11 Survival aspects ...................................................................................................... 11 1.12 Tests and research .................................................................................................. 11 1.13 Organisational and management information ........................................................ 12 Organisational factors ....................................................................................... 13 Operator surveillance......................................................................................... 14 2. Analysis ................................................................................................................................. 16 Human factors.................................................................................................... 19 The operator....................................................................................................... 20 The safety authority ........................................................................................... 22 3. Findings ................................................................................................................................ 23 The operator....................................................................................................... 23 The safety authority ........................................................................................... 24 Summary of factors relating to the accident ...................................................... 24 4. Safety Recommendations .................................................................................................... 25 Figures Figure 1 General area and accident site chart.......................................................................... 2 Figure 2 General accident area................................................................................................ 4 Report 99-004, page i List of Abbreviations amsl above mean sea level CAA Civil Aviation Authority CFIT controlled flight into terrain cg centre of gravity ELT emergency locator transmitter kg kilograms km kilometres NZST New Zealand Standard Time (UTC + 12 hours) UTC Coordinated Universal Time Report 99-004, page ii Aviation Accident Report 99-004 Data Summary Aircraft type, serial number Cessna U206G, U20604282, and registration: ZK-EKJ Number and type of engines: one Teledyne Continental IO-520-DCF Year of manufacture: 1978 Date and time: 18 April 1999, 1538 hours1 Location: by Mount Suter 17 km south of Milford Sound latitude: 44° 49.6¢ south longitude: 168° 01.5¢ east Type of flight: air transport, scenic Persons on board: crew: 1 passengers: 4 Injuries: crew: 1 fatal passengers: 4 fatal Nature of damage: aircraft destroyed Pilot’s licence: Commercial Pilot Licence (Aeroplane) Pilot’s age: 44 Pilot’s total flying 5325 hours experience: reported as some 4500 hours on type Investigator-in-Charge: K A Mathews 1 Times in this report are New Zealand standard time (UTC plus 12 hours) Report 99-004, page iii 1. Factual Information 1.1 History of the flight 1.1.1 On Sunday 18 April 1999 at about 1510 hours, ZK-EKJ, a Cessna 206 floatplane operated by Waterwings Airways (Te Anau) Limited, trading as Milford Sound Scenic Flights2 (the operator), took off from Lake Te Anau, alongside Te Anau township, on a routine round-trip scenic flight to overhead Milford Sound and back to Te Anau. The pilot and 4 passengers were on board the aircraft. 1.1.2 The pilot of ZK-EKJ (the pilot) contacted Milford Sound Aerodrome Flight Information Service by telephone for a weather briefing before the flight departed. 1.1.3 The flight was planned to take about one hour. The records for the aircraft showed that it had enough fuel for about 1.6 hours of flying. 1.1.4 The aircraft departed normally. Shortly after take-off the pilot tried to contact Milford Flight Service via the high frequency transceiver3 in the aircraft, but after a short delay Queenstown Information responded and asked the pilot if they could help. The pilot replied, “just airborne Te Anau, five POB [persons on board], we’re doing a Milford overhead, overhead Milford at four five, over.” Queenstown acknowledged, “Roger overhead Milford four five and Milford QNH4 one zero zero two.” The pilot read back the QNH. 1.1.5 The pilot’s usual route was to fly north via Lake Te Anau to its head, pass near Lake Erskine, circle Mount Tutoko to the north-east of Milford Sound, circle Milford Sound township and return via the western side of Lake Te Anau to land on the lake near Te Anau township. 1.1.6 The aircraft climbed to an altitude of about 6000 feet above mean sea level (amsl). The pilot gave a position report 12 km south
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