More details here:
http://www.nzdf.mil.nz/news/media-relea ... 18-aic.htm
investigation completed 18 October 2011
“Today the Royal New Zealand Air Force (RNZAF) delivered the Court of Inquiry (COI) findings on the air accident that took SQNLDR Nick Cree’s life on January 14, 2010,” said Chief of Air Force, Air Vice-Marshal Peter Stockwell.
“We are deeply saddened by SQNLDR Nick Cree’s death,” said Air Vice-Marshal Peter Stockwell.
The RNZAF completed its investigation into the Airtrainer accident that occurred during a Red Checkers formation aerobatic display practice on 14 January 2010. SQNLDR Cree was practising with the Red Checkers display team near Ohakea Air Force Base when the aircraft crashed during a routine manoeuvre and SQNLDR Cree was killed.
“SQNLDR Cree was an experienced pilot and was highly regarded by those at the Central Flying School and within the wider Air Force. He was also a previous winner of the Lawson trophy for low level aerobatics on his Flying Instructor’s Course,” said Air Vice-Marshal Stockwell.
“The COI found that SQNLDR Cree had flown the Fishtail Pass using an unstable technique. A Fishtail Pass is a manoeuvre flown at slow speed, where the pilot moves the tail of the aircraft left and right while keeping the wings level. On the day of the accident the aircraft suffered a sudden loss of lift and rapid roll to the left. As SQNLDR Cree was flying low at the time, there was insufficient height to recover and unfortunately the aircraft crashed,” said Air Vice-Marshal Stockwell.
The COI identified a number of factors that were causal to the accident. They are:
• Orders and procedures relating to the supervision and conduct of display flying were not adequate to ensure appropriate training, workup, conduct, supervision, and oversight of the Red Checkers aerobatic team, in particular for the Fishtail Pass.
• Standard Operating Procedures had not been formally published for the Red Checkers, and the draft document did not provide sufficient guidance on the appropriate techniques to be used in flying the Fishtail Pass.
• Training was not provided to ensure that the Fishtail Pass was flown appropriately and safely.
• SQNLDR Cree developed and used an unstable and dangerous technique to fly the Fishtail Pass.
• SQNLDR Cree accepted frequent minor departures from controlled flight without reporting them to, or discussing them with, flying supervisors, experienced flying instructors or other team members.
• External supervision and monitoring, and/or internal peer review was not sufficient to note and correct the unstable and dangerous manner in which the Fishtail Pass was being flown.
• SQNLDR Cree persevered with the Fishtail Pass following a departure from controlled flight to the right, resulting in an unrecoverable departure from controlled flight to the left.
The COI made a number of recommendations aimed at preventing a reoccurrence of a similar accident, including a review of the orders and instructions for the training, supervision and conduct of flying displays and practices in the RNZAF.
The RNZAF has accepted all the COI recommendations and has acted upon those recommendations.
“We have introduced a new Wing at Ohakea - No. 488 Wing - which was established in December 2010. No. 488 Wing will command and supervise Ohakea based flying operations. The Red Checkers are flying again and we have improved our processes to help ensure safe formation aerobatic and display flying.
“I would like to thank SQNLDR Cree’s family for their patience and understanding throughout this process and hope that completion of the COI process will help them understand what happened on that tragic day last January,” said Chief of Air Force Air Vice-Marshal Peter Stockwell.
Notes:
The COI involved more than 10 external agencies including the Civil Aviation Authority, the Transport Accident Investigation Commission and the Australian Transport Safety Bureau. Over 20 RNZAF personnel were involved in the investigation.
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