NEW ZEALAND FIXED WING AVIATION ACCIDENTS A review of all reported New Zealand registered aeroplane accidents from 1995 to 2004 (Prepared by Anthony Wackrow: 2005) Intentionally blank 2 This study used the Australian Transport Safety Bureau’s (ATSB) Paper B2004/0010 (General Aviation Fatal Accidents: How do they happen?) as a template. The author acknowledges the ATSB’s paper B2004/0010 as an important guide for grouping and preparation of this data. 3 Intentionally blank 4 EXECUTIVE SUMMARY This report aims to identify what caused New Zealand fixed wing aviation accidents over the ten year period from 1995 to 2004. The report did not identify any causes that were common to all fixed wing accidents. However, several trends and factors have been identified. For the purposes of this report fixed wing aircraft means a “power-driven heavier- than-air aircraft deriving its lift in flight chiefly from aerodynamic reactions on surfaces which remain fixed under given conditions of flight”. The sample does not include microlight aircraft, amateur built aircraft, gliders or any sports category aircraft. There were 461 fixed wing accidents (80 involving fatalities and/or serious injuries) involving New Zealand registered aircraft between 1995 and 2004. These accidents resulted in 123 fatalities. The data indicated a very low chance of any person escaping an aircraft accident involving fatalities. Since the year 2001 there has been a downward trend in the rate of fixed wing accidents. However, the fatal fixed wing accident rate has shown a strong upward trend since 2002. Private flights recorded the highest number of accidents and the highest rate of accidents. Agricultural aviation accidents also scored high numbers, but a lower rate. Transport passenger accidents were among the highest count of accidents, but scored the lowest rate of any operational group. Solo and dual training operations have close actual numbers of accidents, yet their rates (one of the lowest compared with other groups) differ significantly, with the solo training accident rate nearly double that of dual training operations. The average age of accident aircraft was 26 years. Single engine aircraft recorded a higher rate of accidents than multi engine aircraft but had a similar fatal accident rate. Single crew pilots were 42 times more likely to have an accident than multi crew pilots and 13 times more likely to have a fatal accident. Saturday was the most frequent day for fixed wing accidents while Friday was most common for fatal accidents. Midday to mid afternoon was the most common time for accidents, with most fatal accidents occurring between 1400 and 1500 local time. No clear explanation can be given for these results, although end of week fatigue and increased private flying during weekends may have played a part. The data showed that the risk of a pilot being involved in an accident increased with age, with the highest risk occurring in the 55 to 64 age bracket. Those pilots who gained their licence at an older age were more likely to be involved in an accident than those who gained their licence at a younger age. The longer the pilot had held their licence the less chance they had of having an accident (the most common licence 5 held by accident pilots was a Commercial Pilots Licence [CPL]). This agrees with the findings of a study conducted by the National Transportation Safety Board (NTSB)1. Pilots who had between 200 and 2000 flight hours were more likely to have an accident than other pilots. The data showed that time on type of aircraft was a good safety indicator with greater time equating to less risk of an accident. The greater the 90 day currency of the pilot the less risk they had of being involved in an accident. The data indicated that total flight time was not a good indicator of safety risk. Pilot gender did not seem to play a significant part in reducing the risk of an accident, although slightly less female pilots were involved in fatal accidents than were represented in the whole pilot population. Nearly half of all fixed wing accidents occurred during the landing stage of flight. However, there were no fatalities and few serious injuries as the result of these accidents. The majority of fatal accidents occurred during the cruise and after takeoff. The majority of accidents involved aircraft operating to Visual Flight Rules (VFR). There was a slight increase in Instrument Flight Rules (IFR) fatal accidents when compared to the percentage of IFR accidents for the total population. The most common type of fatal or serious injury fixed wing accident was Uncontrolled Flight into Terrain (UFIT) followed by Controlled Flight into Terrain (CFIT) and Managed Flight into Terrain (MFIT) accidents (see Appendix A for definitions). UFIT accidents happened for a variety of reasons but it is worth noting that inappropriate control inputs featured strongly as a contributing cause in most of these accidents. It is also worth noting that a high number of these accidents involved stalls (resulting in spins) while the aircraft was turning. Icing was a common cause for loss of control by IFR aircraft. Agricultural operations featured strongly among the CFIT low level accidents with a majority hitting trees or hills. This is consistent with New Zealand terrain. Most of the CFIT accidents during ‘normal’ operations involved VFR aircraft with limited or zero external visibility. All the IFR CFIT accidents occurred during instrument approaches. The MFIT accidents resulted in more serious injuries than fatalities. Most of the fatalities for MFIT accidents were the result of ditching. All these fatalities resulted from drowning rather than impact forces. All those who drowned were not wearing lifejackets. All the MFIT accidents were initiated by engine failure or lack of performance. Only one accident was the direct result of mechanical failure that was beyond the control of the pilot. A large percentage of these accidents involved fuel starvation or exhaustion. Overloading also featured as a common cause. 1 Safety Study: Risk Factors Associated with Weather-Related General Aviation Accidents. NTSB Report number SS-05-01. 6 It was determined that air transport passenger accidents were linked to inappropriate decisions rather than control inputs, while private accidents were a combination of inappropriate control inputs and decisions. The study concludes that many factors can put a fixed wing pilot at risk. Flight skills and decision making are vital in preventing accidents. The study suggests that IFR multi crew passenger transport flights are among the safest flights from a risk factor perspective, while VFR single pilot private operations are among the highest risk groups. The highest risk pilots are those who have only held their licence for 1 to 2 years and gained that licence after their 50th birthday. Those pilots with the lowest risk are those who have held their licence for more than 8 years and gained that licence before their 35th birthday. These pilots also have substantial time on the type of aircraft they are flying and logged 40 hours (or more) flight time every 90 days. Competency and currency were identified as key safety indicators. The data showed that training flights produce relatively few accidents compared to other types of operations. The data also showed that pilots with very low total time were less at risk than those with moderate amounts of flight time (200 to 2000 hours). Pilots with low 90 day currency were also at risk. This would suggest that pilots (particularly Private pilots) who are no longer under the supervision of an instructor and fail to maintain their skill base place themselves at risk. Pilots who blatantly disregard the rules (regardless of experience and age) present the greatest risk for having a fatal accident. 7 Intentionally blank 8 TABLE OF CONTENTS 1 INTRODUCTION .................................................................................... 11 2 RESEARCH OUTLINE ........................................................................... 12 2.1 Objectives ................................................................................................................................ 12 2.2 Methodology ........................................................................................................................... 12 2.3 Design ...................................................................................................................................... 12 3 FIXED WING AVIATION ACCIDENT DATA .......................................... 13 3.1 General data ........................................................................................................................... 13 3.2 Aircraft demographics ........................................................................................................... 17 3.2.1 Aircraft categories ............................................................................................................... 17 3.2.2 Pilot numbers required by accident aircraft ......................................................................... 19 3.2.3 Aircraft age .......................................................................................................................... 21 3.2.4 Aircraft engine type ............................................................................................................. 23 3.3 Type of operation ................................................................................................................... 25 3.3.1 Total accidents sorted by type of operation ......................................................................... 25 3.3.2 Fatal accidents sorted by type of operation ......................................................................... 26 3.3.3 Accident rates sorted by type of operation .......................................................................... 26 3.4 Injuries .................................................................................................................................... 29 3.4.1 Fatal injuries ........................................................................................................................ 29 3.4.2 Fatal injuries by aircraft category ........................................................................................ 31 3.4.3 Fatal injuries by type of operation ....................................................................................... 33 3.4.4 Survivors ............................................................................................................................. 35 3.5 Number of fixed wing accidents by day-of-week ................................................................. 42 3.6 Accident rates by time of day ................................................................................................ 48 3.7 Pilot demographics ................................................................................................................. 52 3.7.1 Pilot age ............................................................................................................................... 53 3.7.2 Pilot licence details .............................................................................................................. 55 3.7.3 Pilot flight experience ......................................................................................................... 59 3.7.4 Pilot gender ......................................................................................................................... 62 3.8 Phase of flight that accident occurred .................................................................................. 64 3.9 Flight rules at time of accident .............................................................................................. 66 4 FATAL AND SERIOUS INJURY ACCIDENTS ...................................... 68 4.1 Categorisation of fatal and serious injury accidents ........................................................... 68 4.2 Controlled Flight into Terrain (CFIT) fatal and serious injury accidents ........................ 70 4.2.1 CFIT fatal and serious injury accidents during low-level operations. ................................. 71 4.2.2 CFIT fatal and serious injury accidents occurring during necessary low-level flight ......... 72 4.2.3 CFIT fatal and serious injury accidents occurring during unnecessary low-level flight ..... 73 9 4.2.4 CFIT fatal and serious injury accidents occurring during ‘normal’ operations ................... 74 4.3 Managed Flight into Terrain (MFIT) fatal and serious injury accidents ......................... 78 4.4 Uncontrolled Flight into Terrain (UFIT) fatal and serious injury accidents .................... 80 4.4.1 UFIT fatal and serious injury accidents during low level operations .................................. 81 4.4.2 UFIT fatal and serious injury accidents during ‘normal’ operations ................................... 82 4.4.2.1 Inappropriate control inputs ....................................................................................... 82 4.4.2.2 Loss of visual reference ............................................................................................. 82 4.4.2.3 Weather related .......................................................................................................... 83 4.4.2.4 Icing conditions .......................................................................................................... 83 4.4.2.5 Aerobatics .................................................................................................................. 83 4.4.2.6 Loss of engine power ................................................................................................. 83 4.4.2.7 Flight controls failure ................................................................................................. 84 4.4.2.8 Avoiding obstacles ..................................................................................................... 84 4.4.2.9 Undetermined causes ................................................................................................. 84 4.5 Remaining fatal and serious injury accident types. ............................................................. 86 4.5.1 Impact to external parties .................................................................................................... 86 4.5.2 Take-off impacts .................................................................................................................. 87 4.5.3 Fatal and serious injury accidents resulting from landing impacts. ..................................... 88 4.5.4 Fatal and serious injury in-flight break-ups ......................................................................... 89 4.5.5 Fatal and serious injury accident with unknown causes. ..................................................... 90 4.5.6 Fatal and serious injury accident with ‘other’ causes. ......................................................... 90 5 SEPARATE EVENT ANALYSES ........................................................... 92 5.1 Agricultural fatal and serious injury accidents ................................................................... 93 5.2 Private fatal and serious injury accidents ............................................................................ 95 5.3 Transport passenger fatal and serious injury accidents ..................................................... 97 6 CONCLUSION ...................................................................................... 100 7 APPENDIX A ........................................................................................ 102 8 APPENDIX B ........................................................................................ 104 10