ASN Aircraft accident de Havilland Canada DHC-8-102 ZK-NEY Palmerston North

Home » Database » 1995

Status:	Accident investigation report completed and information captured
Date:	Friday 9 June 1995
Time:	09:22
Type:	de Havilland Canada DHC-8-102
Operator:	Ansett New Zealand
Registration:	ZK-NEY
MSN:	055
First flight:	1986
Total airframe hrs:	22154
Cycles:	24976
Engines:	2 Pratt & Whitney Canada PW120A
Crew:	Fatalities: 1 / Occupants: 3
Passengers:	Fatalities: 3 / Occupants: 18
Total:	Fatalities: 4 / Occupants: 21
Aircraft damage:	Damaged beyond repair
Location:	16 km (10 mls) E of Palmerston North ( New Zealand)
Phase:	Approach (APR)
Nature:	Domestic Scheduled Passenger
Departure airport:	Auckland International Airport (AKL/NZAA), New Zealand
Destination airport:	Palmerston North Airport (PMR/NZPM), New Zealand
Flightnumber:	703

Narrative:
At 08:17 Ansett New Zealand Flight 703 departed Auckland (AKL) as scheduled bound for Palmerston North (PMR).
To the north of Palmerston North the pilots briefed themselves for a VOR/DME approach to runway 07 which was the approach they preferred. Subsequently Air Traffic Control specified the VOR/DME approach for runway 25, due to departing traffic, and the pilots re-briefed for that instrument approach. The IMC involved flying in and out of stratiform cloud, but continuous cloud prevailed during most of the approach. The aircraft was flown accurately to join the 14 nm DME arc and thence turned right and intercepted the final approach track of 250° M to the Palmerston North VOR. During the right turn, to intercept the inbound approach track, the aircrafts power levers were retarded to 'flight idle' and shortly afterwards the first officer advised the captain ".... 12 DME looking for 4000 (feet)". The final approach track was intercepted at approximately 13 DME and 4700 feet, and the first officer advised Ohakea Control "Ansett 703" was "established inbound". Just prior to 12 miles DME the captain called "Gear down". The first officer asked him to repeat what he had said and then responded "OK selected and on profile, ten - sorry hang on 10 DME were looking for four thousand arent we so - a fraction low". The captain responded, "Check, and Flap 15". This was not acknowledged but the first officer said, "Actually no, were not, ten DME were..... (The captain whistled at this point) look at that". The captain had noticed that the right hand main gear had not locked down: "I dont want that." and the first officer responded, "No, thats not good is it, so shes not locked, so Alternate Landing Gear...?" The captain acknowledged, "Alternate extension, you want to grab the QRH?" After the First Officers "Yes", the captain continued, "You want to whip through that one, see if we can get it out of the way before its too late." The captain then stated, "Ill keep an eye on the airplane while youre doing that."
The first officer located the appropriate "Landing Gear Malfunction Alternate Gear Extension" checklist in Ansett New Zealands Quick Reference Handbook (QRH) and began reading it. He started with the first check on the list but the captain told him to skip through some checks. The first officer responded to this instruction and resumed reading and carrying out the necessary actions. It was the operators policy that all items on the QRH checklists be actioned, or
proceeded through, as directed by the captain. The first officer started carrying out the checklist. The captain in between advised him to pull the Main Gear Release Handle. Then the GPWSs audio alarm sounded. Almost five seconds later the aircraft collided with terrain. The Dash 8 collided with the upper slope of a low range of hills.

Probable Cause:

CAUSAL FACTORS: "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."

Accident investigation:

Investigating agency:	TAIC New Zealand
Status:	Investigation completed
Accident number:	95-011
Download report:	Final report

Classification:

Distraction in cockpit
Controlled Flight Into Terrain (CFIT) - Mountain

Sources:

» SKYbrary
» Flight International 14-20 June 1995(4)
» ICAO Adrep Summary 4/95 (#11)

Follow-up / safety actions

TAIC issued 29 Safety Recommendations

Issued: 21-JUN-1995	To: Ansett NZ	042/95
Ensure, with immediate effect, that each Ansett pilot assigned to crew a Dash 8 aircraft practise and remain familiar with the alternate gear extension procedure under suitably qualified supervision. (Closed acceptable)
Issued: 21-JUN-1995	To: Ansett NZ	043/95
Issue an interim instruction that, unless overriding considerations prevail, in the event of any system abnormality occurring during an instrument approach in instrument meteorological conditions the Captain shall discontinue the approach and climb to or (Closed acceptable)
Issued: 21-JUN-1995	To: Ansett NZ	044/95
Re-emphasise, to each of the Company\'s pilots, the potential for the pilot flying to be distracted from the routine operation of the aircraft during the execution of an emergency procedure or even a relatively minor system abnormality procedure, particula (Closed acceptable)
Issued: 02-AUG-1995	To: Air NZ	045/95
Review your decision to disconnect the existing cockpit voice recorder in Boeing 737 aircraft with a view to bringing them back into service as soon as practicable. (Closed acceptable)
Issued: 18-DEC-1995	To: Minister of Transport in Canada	122/95
In conjunction with the aircraft manufacturers and the manufacturers of the GPWS and the radio altimeter he promote a study to determine why the GPWS did not provide a greater degree of warning in the environment of the DHC-8 accident near Palmerston Nort (Unconfirmed)
Issued: 29-APR-1996	To: Ansett NZ	103/95
Review the status of the Flight Safety Co-ordinator to ensure that officer has a balanced input from the company\'s management, operations, and engineering staff on which to base an accident prevention programme. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	104/95
Enhance the opportunity for the Flight Safety Co-ordinator to attend international flight safety conferences and training seminars. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	105/95
Explore ways of making Ansett New Zealand\'s CRM training more realistic by use of a flight simulator or otherwise. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	106/95
Review Ansett\'s QRH checklists for "Landing Gear Malfunction Alternate Gear Extension" and "#2 Engine Hyd Pump Caution Light on with Hyd Qty Below Normal, Gear Extension" with a view to standardising the procedures where actions should be identical, and e (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	107/95
Take immediate steps to embody the modifications designed to minimise nuisance warnings by the Dash 8 GPWS. (Unconfirmed)
Issued: 29-APR-1996	To: Ansett NZ	108/95
Review Ansett New Zealand\'s use of configuration procedures designed to obviate unwanted GPWS warnings. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	109/95
Review Ansett\'s practice of setting MDA once established on the approach, with a view to implementing a procedure which will not set the MDA before it is safe to descend to that altitude. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	110/95
Explore the practicality of connecting the radio altimeter output into the DFDR. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	111/95
Investigate the practicability of using the radio altimeter to give back-up warning during non-precision instrument approaches. (Closed acceptable)
Issued: 29-APR-1996	To: Ansett NZ	112/95
Investigate the practicability of using the FD and autopilot to alleviate the load on the pilot flying during non-precision instrument approaches in IMC. (Closed cancelled)
Issued: 29-APR-1996	To: Ansett NZ	113/95
Initiate instructions to flight attendants that: are specific for each aircraft type which they operate, enhance the concept of a sterile flight deck during critical phases of a flight, clarify the need for them to be seated as soon as practicable after t (Closed acceptable)
Issued: 29-APR-1996	To: Airways Corp	119/95
Investigate with the equipment manufacturer the practicality of developing and incorporating a minimum safe altitude warning system (MSAW) for the Airways Corporation\'s AIRCAT 2000 radar system as soon as practical. (Closed acceptable)
Issued: 29-APR-1996	To: Airways Corp	120/95
Put in place a system, to be available on request, to recover and make available as soon as practicable any relevant recorded radar information which might assist the Search and Rescue Co-ordination Centre to locate a missing aircraft. (Closed acceptable)
Issued: 29-APR-1996	To: Airways Corp	121/95
Review the terminology used by approach controllers, in RTF with pilots, when they wish to restrict an aircraft\'s descent on the DME arc to an altitude greater than the minimum depicted on the applicable VOR/DME chart. (Closed acceptable)
Issued: 29-APR-1996	To: NZALPA	123/95
Renegotiate, as soon as practicable, the pilots\' contract with Ansett New Zealand to remove the condition which is intended to prevent Ansett New Zealand from installing Cockpit Voice Recorders in their aircraft. (Closed cancelled)
Issued: 29-APR-1996	To: Ansett NZ	126/95
Renegotiate the pilots\' contract with NZALPA to remove the condition which is intended to prevent the company from installing CVRs in their aircraft. (Closed acceptable)
Issued: 10-MAY-1996	To: CAA NZ	114/95
Take urgent steps to complete his review of the adequacy of CAA audit staff numbers for carrying out safety audits on operators in accordance with their stated policy. (Closed cancelled)
Issued: 10-MAY-1996	To: CAA NZ	115/95
Require better information to be displayed by aircraft operators to aid passengers and potential rescuers to locate onboard first aid kits and fire extinguishers. (Closed acceptable)
Issued: 10-MAY-1996	To: CAA NZ	116/95
Initiate with the aircraft manufacturers an investigation into the practicality of enhancing the survivability of the aerials of any ELTs in passenger transport aircraft which are hard wired into aircraft. (Closed acceptable)
Issued: 10-MAY-1996	To: CAA NZ	117/95
Expedite the implementation of his plans for obtaining the appropriate staff numbers to achieve their planned safety audits in the appropriate time scales. (Closed cancelled)
Issued: 10-MAY-1996	To: CAA NZ	118/95
Explore the practicability of instituting check flights to supplement the audit process on approved operators. (Closed acceptable)
Issued: 24-MAY-1997	To: CAA NZ	035/97
Require a one time inspection of all aircraft which have a radio altimeter installed to determine whether the radio altimeter antennae are free from paint. (Closed acceptable)
Issued: 24-MAY-1997	To: CAA NZ	036/97
Require regular inspections to determine that the "Do not paint" decals are in place and legible. (Closed acceptable)
Issued: 24-MAY-1997	To: CAA NZ	037/97
Emphasise to aircraft owners and operators the necessity of determining the location of such antennae and providing suitable masking to prevent any paint being applied to them. (Closed acceptable)

Show all...

Photos

accident date: 09-06-1995
type: de Havilland Canada DHC-8-102
registration: ZK-NEY

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Auckland International Airport to Palmerston North Airport as the crow flies is 374 km (234 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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