Board Holds That Crash Resulted From Error Of Judgment By Captain

Gisborne Herald, Volume LXXVI, Issue 22851, 22 January 1949, Page 6

Board Holds That Crash Resulted From Error Of Judgment By Captain

KAKA AIR DISASTER

(PA.)

WELLINGTON, Jan. 22

NEW ZEALAND'S worst air disaster, which occurred on October 23 last, when the National Airways Corporation machine Kaka crashed on Mount Ruapehu with the loss of 13 lives, resulted from an error by the captain of the aircraft in calculating the course. However, the accident probably would not have happened had there been additional radio homers installed on the route.

These opinions are given by the Board of Inquiry in its report on the accident, which was released yesterday by the Air Minister, Mr. F. Jones.

The board comprised Sir Harold Johnston, K.C., chairman. Captain K. A. Brownjohn, of Tasman Empire Airways, and Wing Commander J. W- H. Bray, R.NZ.A.F. Replying to one of its terms of reference: “Did any act or omission of the captain and crew cause the accident?” the board says:— “It is the board’s opinion that the reason for the aircraft going off its prescribed course was due to an error by the captain in calculating the aircraft’s course.” The board found that there were no other factors which contributed to the accident. minimising Risks of Accident

have flown a reasonably accurate course, although one said that the Wanganui and Hamilton homers were unreliable and he had to rely on broadcast station bearings as navigational aids. Allowance For Drift

The board was asked what steps, if any, should be taken to ensure that the risk of similar accidents is eliminated or minimised. Its report states:

“We have no evidence before us which enables us to make general recommendations in regard . to the safety of all airlines in New Zealand such as the installation of radar in certain localities, or the installation of any one particular system to replace the present system of radio ranges and homing beacons. We have been told that such installations would be governed by economic considerations, or /by technical difficulties which are still the subject of international discussion, but we have also been told by Mr. A. G- Gerrand, N.A.C., operations manager, that the system in use in New Zealand is obsolescent “The Wanganui-Hamilton stage of the Whenuapai-Paraparaumu flight is over the most difficult country in New Zealand. Immediate steps should be taken for the installation of one or more radio homers between Wanganui and Hamilton to ensure that at no time is an aircraft on that route out of range of homing beacons to assist aircraft to make good its track. “The present arrangements whereby the pilot receives inadequate briefing and is permitted to depart from an airfield without a flight plan, or is asked to sign an incompleted flight plan, appears to be unjustifiably loose. In our opinion, steps should be taken to prevent any recurrence of such laxity. Estimates of Drift “Despite a suggestion made at the hearing that preparing pre-flight estimates of drift by a stand-by pilot was useless and should be abandoned, we consider this practice would assist the commander of an aircraft in making his calculations ;nd is a sound one. provided, of course, the officer making the calculation is, as he should be. fully qualified to perform this duty.” The board found that all the occupants of the aircraft must have met instant death when it crashed into the mountainThe absence of all evidence from those in the aircraft made any inquiry Into the cause of the disaster difficult, particularly as in this case no record of the fatal flight appeared to have been taken by either the commander jr the co-pilot. However, the evidence given as to the point of deviation from the normal route, as to the position the plane reached—2o miles off its course—and Its condition when found so narrowed the possibilities that a reliable conclusion on the cause of the disaster could reasonably be reached. The board considers that the Kaka’s radio equipment and the ground navigational radio aids were all operating normally and in no way contributed to the accident. Radio Aids Leave Much To Be Desired “At the same time,” the board contiders, “it is established that the radio aids for this route leave much to be desired and that had there been additional radio homers on the direct line between the Wanganui homer and the Hamilton homer so that the aircraft was at no time out of range of at least one of these installations it is nighly probably ,the accident would not have occurred since with such additional • homers any navigational error would have been immediately apparent to the pilot. “Evidence given by three other pilots who were flying the same route at approximately the same time indicates that there was a partial radio black-out in the area where the Kaka crashed and it appears that this condition invariably exists during bad weather conditions and in particular when there is a high static level.” The board considers it most unlikely that there was any con-

"If Commander Hare had made the minimum possible allowance for drift —that is 11 degrees—and had flown at an air speed of 130 miles an hour for the first five minutes after leaving the Wanganui homer —that is while he was climbing from 4500 to 6000 ft —and then had flown at his cruising air speed of 150 miles an hour until the time of the crash it would have required wind from 293 degrees true at 71 knots to take him to the scene of the crash. “An analysis of the weather conditions from all sources of information available exclude the possibility of wind of such velocity at the time of the accident. The evidence establishes that the wind at the time was from 320 degrees true at 47 knots, whereas Commander Hare’s forecast indicated wind from 310 degrees true at 30 knots. He may, therefore, have allowed for wind of only the latter strength. Investigation shows that the actual wind at the time would certainly have taken him east of his desired track, but he would still not have come closer than seven and a half miles to the actual scene of the accident.

"In the light of the evidence the board can only conclude that in some manner Commander Hare miscalculated his course.

“It was suggested during the hearing that he may have used the drift he encountered on his southbound trip for his northbound trip and inadvertently applied it the wrong way. While the board agrees that this theory does fit in extraordinarily well with the events as they happened, it cannot, in our opinion, be considered as more than a remote possibility. Operation of Aircraft

“In the section of its report dealing with the manner in which the aircraft was operated over the route by National Airways Corporation, the board says:— “Various matters arose during the investigation which call for comment, although in this case they cannot be said to have had a direct influence on the cause of the accident. But, as air accidents are generally associated with a combination of errors, each of which taken alone would not necessarily be disastrous, laxity of administration in even seemingly unimportant details adds to the chances of disaster. “The evidence disclosed that in this flight there was in some respects want of care and attention to essential detail. The procedure laid down for this section of the route is sound, but in some particulars it was honoured more in the breach than in the observance. “The evidence showed that on arrival at Paraparaumu Commander Hare hurried through his meteorolo l gical briefing. He signed an incomplete flight plan. Neither he nor the National Airways Corporation operations officer, the duty stand-by pilot, got a clearance for the aircraft’s departure. Each seemed to be concerned only with giving or receiving a signature and thus ridding himself of further responsibility. The flight plan was never telephoned from Paraparaumu to Palmerston North as was promised Commander Hare. It is true he made no request for the flight plan at Palmerston North but, on the other hand, no one informed him it was ready for him.

Navigation by Pilots

The standard of training and flight checking of air crews by National Airways Corporation was satisfactory. From an examination of documents removed from the wreckage it was apparent that little attention was paid by the crew to the recording of their navigational observations. The board considers it fundamental that pilot navigation should be by dead reckoning, assisted as much as possible by radio aids.

The practice indicated by Commander Hare’s very sparse air log of homing on one radio aid and then flying out of its range in the hope that another one would come within range in the near future and making no record of any geographical features or drift experienced or ground speed calculated was undesirable.

structional defect in the aircraft.

Lockheed Electras have a particularly good record, and in the opinion of pilots who have flown them they are af robust and rugged design. There was nothing to indicate that Either of the engines failed in the flight. Both were well within their prescribed time for overhaul. The board seriously considered the possibility of the aircraft having been struck by lightning on either the southbound or the northbound trip, causing a non - apparent compass deviation, but formed the opinion that the possibility of instrument defects because of electrical discharge could be dismissed.

Commander Hare’s maps were folded up in a satchel and were obviously not being used at the time of the accident. Had he been making an endeavour to confirm his navigation as he went along it should have been just as easy for him to see the township of Rangataua and thus orient himself as it was for the residents of Rangataua to see the aircraft. But it was apparent he flew over Rangataua, continuing on a wrong course to the scene of the accident.

All the other instruments had apparently been working satisfactorily on the southbound trip and were well within their prescribed periods for overhaul.

Not only should all pilots keep a chronological record of en route navigation, but as a matter of routine it should be seen that they do. The board was not told that the corporation took any steps to see that log books or other records were called for or checked.

Meteorological Hazards

The board said that meteorological hazards, such as lightning discharge, icing, or structural failure due to high turbulence, had not contributed to the accident. The possibility of the aircraft becoming out of control under instrument flying conditions was also eliminated.

The report says that the board, considering the weather conditions at the time of the accident to be of major importance, went to some trouble to check the analysis of the weather submitted to it during the inquiry by the Meteorological Division. It was unfortunate that Commander Hare made no effort to keep a record of the drift he anticipated, or of the courses he intended to steer on the northbound journey. “It is plain, however, from the forecast he received that he was not entitled to make an allowance for drift of less than 11 degrees,” continues the report. “This would be calculated from his track and air speed, coupled with the forecast wind of 310 degrees true at 30 knots.

“Three other commanders flying .the same route at approximately the same time had the same information on the weather conditions as Commander Hare and we consider he should have acted as they did and made an allowance of considerably more than 11 degrees for drift. These commanders did not experience any particular difficulty in nagivating the route on that particular day and each appears to

The report is dated December 23,