Date of event:

23 October 2004.

Location & aircraft:

New Zealand, Omihi Station, North Canterbury. Cessna A188 Agwagon (ZK-CSM).

Human Factors:

The post-mortem report, when read in conjunction with the evidence gathered during the accident investigation, provides grounds to conclude that the pilot suffered a medical incapacitating cardiac event that rendered him unable to maintain control of his aircraft.Post-mortem examination found that the pilot had sustained fatal injuries associated with a high-energy impact. Also discovered was "profound pulmonary oedema and evidence of a component of chronic congestive heart failure". The pathologist explained in his report: "while the pulmonary oedema might in part or entirely represent neurogenic pulmonary oedema in response to head injury, the time course is very short. I prefer the interpretation that there has been an acute cardiac event, most likely cardiac arrhythmia, resulting in sudden onset (acute), severe congestive cardiac failure prior to impact. Such an event would likely render him incapable of control of the aircraft in the take off run".In light of the fact that no medical certificate record could be found for the periods of December 2002 to 11 June 2003 and December 2003 to 16 June 2004 it appears that the pilot may have operated his aircraft for hire and reward without a current Class 1 medical certificate for two periods of 6 months within the 2 years and 3 months preceding the accident.Although the pilot had a current medical certificate at the time of the accident, accurate medical assessment of the pilot for risk of an incapacitating cardiac event was not possible, as the pilot had declared on his medical certificate application that he was a non-smoker. The accurate assessment of pilot cardiovascular risk depends on complete information being made available to the CAA medical examiners. Whether or not an applicant for a CAA medical certificate smokes cigarettes is an important factor in the calculation of cardiovascular risk. When an applicant's cardiovascular risk exceeds a certain level further investigations, usually an exercise stress electrocardiogram (stress ECG), are undertaken to exclude the presence of reversible myocardial ischaemia. Had the pilot declared,at the time of his most recent medical certification application in June 2004, that he had continued smoking he would have been required to undertake a stress ECG. While it may not have been conclusive in predicting the risk of an in-flight incapacitation, a stress ECG may have identified significant cardiac disease.

Brief description of event:

The Civil Aviation Authority was notified of the accident at 1800 hours on Saturday 23 October 2004. The Transport Accident Investigation Commission was in turn notified shortly thereafter but declined to investigate. A CAA site investigation was commenced the next day. The pilot was conducting an agricultural operation engaged in spreading solid fertiliser in suspension with water. The pilot appeared to commence his take off normally and continue out of line of sight of the ground crew, who were alerted to the accident by smoke coming from the direction of the end of the sloping airstrip. The first persons on the scene found that the aircraft was on fire and could see no signs of life.

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Date of event:

01 October 2003.

Location & aircraft:

Australia, 1 km WSW Mareeba Aerodrome, West of Cairns, QLD. PA-23-250 Aztec (VH-WAC).

Human Factors:

The reason for the loss of control could not be conclusively established, however the circumstances of the accident and the available evidence was consistent with pilot incapacitation associated with coronary artery disease. Post-mortem examination of the pilot, who held a valid medical certificate, identified significant narrowing of the coronary arteries.

Brief description of event:

The pilot, his wife and three children were conducting a private flight from Mareeba, to Roma, Queensland, in the Piper Aztec aircraft, registered VH-WAC. Witnesses reported that shortly after the aircraft took off from runway 28, it started to bank to the left. The left bank gradually steepened, after which the aircraft rapidly descended to the ground. Witnesses close to the aerodrome described engine noises consistent with normal operation. The aircraft was destroyed by impact forces and post-impact fire.

Injury profile:

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Date of event:

30 April 2000.

Location & aircraft:

New Zealand, Napier. Bantam microlight (ZK-TKF).

Human Factors:

Post-mortem examination determined that death was due to ischaemic heart disease.

Brief description of event:

The Bantam microlight was on a dual training exercise to the west of Napier. After practising forced landings, the pilot and instructor decided to return to Napier. On the return flight, the student noticed that the instructor appeared to be unconcious, and was unable to obtain a response from him. The student reported the situation to Napier Tower, and emergency services were called to meet the aircraft. The student landed the aircraft, and after examination by emergency services personnel, it was found that the instructor had died in flight.

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Date of event:

02 April 1999.

Location & aircraft:

New Zealand, Rowallan Forest, near Tuatapere, Southland. Aerospatiale AS 350B (ZK-HBH).

Human Factors:

The cause of the loss of control was not conclusively established, but the pilot's ability to control the helicopter may have been medically impaired by the sudden onset of a cardiac event.

Brief description of event:

On Good Friday the aircraft was on a charter flight from Clifden, carrying a hunting party into Fiordland when some loss of control occurred. The helicopter collided with trees and the ground in the Rowallan Forest, killing all five occupants.

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Date of event:

26 April 1998.

Location & aircraft:

Australia, 16 km W Eucumbene, NSW. Cessna 210R (VH-IOR).

Human Factors:

The possibility of pilot incapacitation cannot be excluded as a contributing factor in the occurrence. The reported operation of the aircraft engine to the point of impact, together with the uncontrolled nature of the descent, indicates that there had been no effective response initiated to counter the rapid descent of the aircraft. Although this testing (stress electrocardiogram) did not return an abnormal result, post-mortem examination of the pilot did reveal that he was suffering severe coronary artery disease. The examining pathologist commented that the stress associated with operating the aircraft in difficult weather conditions could have precipitated a sudden deterioration in his cardiac condition, possibly resulting in a sudden medical incapacitation.

Brief description of event:

The planned route was over mountainous terrain, in adverse weather conditions, and at an altitude above the forecast freezing level. Moderate to severe turbulence had been forecast in the vicinity of the Snowy Mountain ranges and the meteorological conditions were conducive to the formation of mountain waves. At the time radar contact with the aircraft was lost, the pilot was attempting to climb the aircraft to an altitude of 10,000 ft and appeared to be flying it at a lower than normal climb speed. The reason for the observed loss of climb performance as the aircraft approached 9,000 ft could not be positively determined. The aircraft impacted the ground in an attitude consistent with a loss of control.

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Date of event:

06 June 2003.

Location & aircraft:

New Zealand, 1.2 nm shot of runway at Christchurch. Piper PA 31-350 Navajo Chieftain (ZK-NCA).

Human Factors:

Safety issues identified by the accident investigation included: The desirability of adoption of TAWS equipment for smaller IFR air transport aircraft; The need for VFR/IFR operators to have practical procedures for observing cellphone rules during flight; The need for pilots on single-pilot IFR operations to use optimum procedures during instrument approaches.Other matters inquired-upon during the subsequent coronial inquest included cardiovascular risk assessment, and the use of over-the-counter reading spectacles by pilots.

Brief description of event:

On Friday 6 June 2003, Air Adventures New Zealand Limited Piper PA 31-350 Navajo Chieftain aeroplane ZK-NCA, was on an air transport charter flight from Palmerston North to Christchurch with one pilot and 9 passengers. At 1907 it was on an instrument approach to Christchurch Aerodrome at night in instrument meteorological conditions when it descended below minimum altitude, in a position where reduced visibility prevented runway or approach lights from being seen, to collide with trees and terrain 1.2 nm short of the runway. The pilot and 7 passengers were killed, and 2 passengers received serious injury. The aircraft was destroyed.

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Date of event:

24 November 2000.

Location & aircraft:

Australia, 53 km NE Oakey, Aero, Queensland (QLD). Amateur Built Aircraft RV-6A (ZK-VBC).

Human Factors:

Specialist medical opinion was that the possibility of the pilot suffering a heart attack induced by high stress levels after the propeller failed could not be excluded.

Brief description of event:

The owner/builder of the the Vans RV-6A aircraft was conducting a flight from Townsville to Toowoomba. The aircraft departed Townsville at 0846 local time. The pilot subsequently contacted Oakey Approach at 1324, and the aircraft was identified on radar at 3500 feet. The pilot was instructed to maintain that altitude. When the aircraft was about 26 nautical miles from Toowoomba, the pilot transmitted a mayday distress message stating that the aircraft's engine had failed. A short time later he reported that a propeller blade had failed. No further transmissions were heard from the aircraft. About 30 minutes later, a searching helicopter located the wreckage in a flat clear area amongst hilly, tree covered terrain.

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Date of event:

12 September 2000.

Location & aircraft:

Australia, 9 km NW Inverell Aero, NSW. Cessna A152 (VH-ADU).

Human Factors:

The reason for the loss of control of the aircraft could not be positively established. Pilot incapacitation leading to a loss of control was a likely factor. Due to his medical condition, the pilot might have suffered a coughing fit in flight that impaired his ability to fly the aircraft. Alternatively, the concentration of doxylamine in his system might have led to drowsiness or even disorientation associated with aerobatic manoeuvres. Other possible reasons for a loss of control of the aircraft include pilot incapacitation for some other reason, and loss of consciousness, or partial loss of consciousness, due to the onset of g loadings when conducting an aerobatic manoeuvre.

Brief description of event:

The Cessna A152 Aerobat aircraft was engaged on an aerobatics training flight with the pilot the sole occupant of the aircraft. The pilot was practising for an aerobatic competition and had been having problems conducting stall turn manoeuvres. Before the accident flight, the pilot had completed an aerobatic practice flight with an instructor. The pilot then decided to fly a solo flight to practise stall turns without the effect of a second person's weight on aircraft performance in aerobatic manoeuvres. He then intended to practise his full aerobatic sequence, which the instructor later stated was well within the pilot's capabilities. Between flights the pilot refuelled the aircraft and consumed a bottle of soft drink. After takeoff for the solo flight, the pilot discussed with his instructor by radio, his intentions for the flight and the criticisms of his manoeuvres during the dual flight. The instructor later reported that during the discussion, everything concerning the pilot and the aircraft seemed normal. Witnesses some distance away heard the aircraft fly over. They later heard a thump and noticed smoke rising from the same direction as the source of the sound. There were no witnesses to the impact.

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Date of event:

02 April 1999.

Location & aircraft:

New Zealand, Rowallan Forest. Aerospatiale AS 350B (ZK-HBH).

Human Factors:

The cause of the loss of control was not conclusively established, but the pilot's ability to control the helicopter may have been medically impaired by the sudden onset of a cardiac event.

Brief description of event:

On Good Friday the aircraft was on a charter flight from Clifden, carrying a hunting party into Fiordland when some loss of control occurred. The helicopter collided with trees and the ground in the Rowallan Forest, killing all 5 occupants.

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Date of event:

04 January 1999.

Location & aircraft:

New Zealand, Maramarua. Schempp-Hirth Ventus B/16.6 (ZK-GTR).

Human Factors:

A post-mortem examination of the pilot found severe coronary artery disease, which probably resulted in an in-flight incapacitation and loss of control. No indication was found of any pre-impact aircraft defect.

Brief description of event:

The glider was on a club-contest task that comprised two laps of a triangular course originating from, and terminating at, Drury. On the fourth leg, the glider was in company with two other aircraft, but near Maramarua the 59 year old male pilot reported that he was going to land. He did not, however, give any reason for his intention to land. A ground witness observed the glider pitch up from level flight and enter a steep nose-down spiral from which it did not recover before striking the ground.

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Date of event:

24 August 1996.

Location & aircraft:

New Zealand, 8 km South of New Plymouth. Jodel D11 (ZK-EJP).

Human Factors:

The pilot had a known medical deficiency, evidenced by severe coronary artery disease, which invalidated his CAA Medical Certificate. Pilot impairment or distraction as a result of the deficiency was a possible contributory factor in the accident.

Brief description of event:

At about 1040 hours, at the conclusion of a local flight, the aircraft made an approach and go-around over the farm airstrip where it was based. The aircraft subsequently flew downward at a lower height than usual and was seen to bank steeply to the left in an apparent attempt to land on the airstrip or in adjacent paddocks. It levelled momentarily then rolled to the right, descended rapidly, and struck the hillside. The pilot sustained fatal injuries on impact. The injured passenger escaped from the burning wreckage and was assisted to safety by farm workers who had observed the accident.

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