LOSS OF AIRLINER

Ashburton Guardian, Volume 69, Issue 269, 26 August 1949, Page 4

LOSS OF AIRLINER

Board of Inquiry’s Report CAPTAIN COMMITS ERROR OF JUDGMENT / (P.A.) WELLINGTON, This Day. “We do not accept the suggestion that some outside factor of a disabling character intervened to cause this disaster,” said the re- . port of the Board of Inquiry into the Waikanae air disaster on March 18, when the National Airways Corporation aircraft ZKAKX crashed with the loss of 15 lives within a few miles of its destination—Paraparaumu aerodrome.

The board’s report says that this accident had, in common with the crash of the Kaka on Mount Ruapehu, last October and with an earlier accident at Port Underwood in August, 1948, faulty navigation involving collision with mountains or hills in cloud. “This conclusion is a matter for concern, for while the standard of training and flight checking of the air crew by National Airways Corporation appears satisfactory, and in accordance with the corporation’s training policy, events associated with the violation of visual flight rules by entering cloud in both Port Underwood and this accident relate to the primary principles of flying discipline, the observance of which should never be in question. In a country with such geographical features, in spite of the most up-to-date navigational aids, the dangers from high country are ever present, and a high standard of flight discipline is an insistent essential if avoidable accidents are to be kept to a minimum. There is justification for the view that strict observance of procedures and regulations is not as general as it ought to be, and we are of the opinion that experts capable of reviewing existing methods in the selection, training,' discipline and check training of air crew personnel of National Airways Corporation should be instructed to perform such duty as a safeguard to public interest. We recommend that this course be taken.” Error of Judgment The report also stated: “The captain’s election to go by visual flight rules was a fundamental error of judgment from which flowed cumulative errors terminating in a critical situation from which the aircraft could not be extricated. We are acutely aware of the pressure of time under such circumstances.”

The board’s report, which was tabled in the House of Representatives to-day by the Minister of Civil Aviation, the Hon. F. Jones, says this in reviewing the evidence in an attempt to find a possible factor which may have influenced the captain, Commander R. W. Bartley, in his decision to change to visual flight rules. It draws an inference that when the captain sent his last message from the plane to the ground he already knew he could not arrive at Paraparamau at his estimated time of arrival. In other words, he felt himself pressed for time. In these circumstances the temptation may have been to complete the flight under visual flight rules .to save at least nine minutes which, would be involved in an instrument approach.

Maintenance Satisfactory

The report says the evidence showed that the maintenance of the Kereru had been satisfactory, and there was no indication of structural fail' ure or mechanical malfunctioning prior to the accident. There was no suggestion of any instrument failure. Radio reception was normal, and checks immediately after the aircraft was reported missing showed that all radio navigational facilities in the region south of New Plymouth were functioning normally. There were no electrical disturbances and no exceptional weather conditions which, in themselves, could have contributed to the accident. Winds as forecast proved from the evidence of pilots to be correct. Commander Bartley and the co-pilot, First-Officer R. A. Boys, were both experienced men. It was a minimum requirement of visual flight rules (to which the commander changed after reporting his position near the Otaki river mouth) in relation to cloud that, whether in or out of control zones and controlled areas, the aircraft must be flown clear of cloud and must not fly above more than fhis cloud. The report examined the theory of the Assistant-Director of Civil Aviation and others that the Kereru was flown from Wanganui to Paraparaumu on radio compass Avithout allowing for drift, and was consequently near or over the mouth of the Otaki River when it reported itself five miles further west. “After close consideration of all submissions by the authors, Ave reject the theory propounded because it Avas not supported by linoAvn facts,” says the report. “The board differs from the opinion of some Avitnesses that the captain’s decision to proceed visually Avas operationally sound. It Avas unsound because it Avould have been justified at that stage only if it a degree of safety equal to that maintained until the moment of the change from instrument flight rules. The'"eaptain actually met cloud conditions Avhicli did not justify the change. BetAveen the Otaki River mouth and the point of impact, the pilot may have continued to lose, height, having misjudged his geographical position Avhile thinking lie Avas clear of hills, or, finding himself in eight-eighth cloud, he attempted to turn to get back out of the cloud as quickly as possible Avithout full reference to his altitude instruments, and so lost height until he struck the ground. It Avas clear from the evidence that no provision Avas made in pre-flight planning for the time required to descend from 9000 feet at Paraparaumu, or alternatively to make an instrument let-doAvn.

Pre-Flight Planning “We are strongly of the opinion, that pre-flight planning should make such provision, and that NAO should be responsible for the arrangement necessary to see that this is done. This will avoid any temptation for a captain to complete a flight in the shortest possible time in unfavourable conditions.” '

The report says the evidence- indicated a degree of slackness on the captain’s part in compiling a flight plan, and on the part of the Whenuapai duty officer in receiving same and clearing the aircraft. A strict keeping of log records should be made obligatory and, in the board’s view, the proposed regulations to introduce a system of aircraft “despatches” used in the Unjted States were tvell justified.

The introduction of these regulations should be expedited. The CiA'il Aviation Branch, said the report, Avas anxious to improve instrumental facilities for flying in New Zealand, and desired to instal surveillance radar. Though very expensive, its cost had not delayed the installation of the system, but the earliest possible date of supply was 1951 from the United States and 1952 from the United Kingdom. The board suggested that until surveillance radar became available, an improvement might be effected on the ground by the provision of a further radio beacon near the' Otaki river mouth to provide for south-bound traffic into Paraparaumu. Specialist attention should also be given to the use of the Deeca imdgator. which was apparently available. The report added: -‘Due to its physical characteristics, including extensive mountain systems, and much hill country with resultant cloud conditions. the Dominion presents greater flying risks within a comparatively small compass than do many larger countries Avhich frequently have the advantage of extensive and reliable radio navigational systems, which simpl.vfy and- ensure greater general safety in flying. In the absence of such extensive aids in this Dominion, a very high standard of training, strict observance of all procedures and regulations, and strict personal discipline is demanded of pilots, together with a very high standard of ground control and organisation.’’