Accident Bell UH-1H Iroquois NZ3806,
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ASN Wikibase Occurrence # 74062
 
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Date:Sunday 25 April 2010
Time:06:00
Type:Silhouette image of generic UH1 model; specific model in this crash may look slightly different    
Bell UH-1H Iroquois
Owner/operator:3 Sqn RNZAF
Registration: NZ3806
MSN: 11705
Year of manufacture:1969
Fatalities:Fatalities: 3 / Occupants: 4
Aircraft damage: Destroyed
Category:Accident
Location:Pukerua Bay, Wellington 2 -   New Zealand
Phase: En route
Nature:Military
Departure airport:Ohakea-Royal AFB (OHA/NZOH)
Destination airport:Wellington
Confidence Rating: Information verified through data from accident investigation authorities
Narrative:
Three persons were killed and a fourth seriously injured when their Iroquois crashed in heavy fog. The wreckage was found on a farm, on a hillside above the Centennial Highway just to the northeast of Pukerua Bay, about 40km north of Wellington.
The helicopter was one of 3 travelling to Wellington to perform a flypast at the ANZAC Day dawn service.
The surviving crewman was taken to Wellington Hospital in a stable condition.
Flight Lieutenant Hayden Madsen, Flying Officer Daniel Gregory and Corporal Benjamin Carson R.I.P.

The Court of Inquiry found that a number of predisposing factors had created an environment where the supervisors and crews of IROQUOIS BLACK underestimated operating risks and, consequently, undertook inadequate preparation and mitigation for the task and, in particular the risk of IIMC. A number of decisions that were made in the preparation, planning and conduct of the flight progressively narrowed the margin for error for IROQUOIS BLACK or raised the risk profile for the flight. As IROQUOIS BLACK approached Pukerua Bay, the formation was flying on NVG, over water at 300ft under a 350ft cloud base. There was no visual reference beyond Pukerua Bay, or to the right of track. The formation were not adequately prepared for IIMC, including an under-assessment of the likelihood, and inadequate procedures and training. During the turn back two of the three aircraft inadvertently flew into IMC. Formation integrity was immediately lost and all three aircraft were then forced to fly independent and unrehearsed escape profiles.

From BLACK 2’s last known position and heading, the necessary escape action after entering IMC was to turn the aircraft onto a safe heading within 5 seconds, before crossing the coast, or execute a safe rate of climb. Critically, BLACK 2 delayed executing an effective escape and then did not compensate for the delay. This was probably due to a loss of SA brought on by the high workload of the surprise IIMC event, resulting in the overload of crew capacity. The workload was probably exacerbated by the unaddressed flying issues of the captain, the low recent
flying experience of both pilots and a lack of suitable IF SOP, which they could immediately employ. The accumulation of factors overwhelmed the crew’s capacity to determine and fly the necessary escape, resulting in loss of SA followed by Controlled Flight Into Terrain (CFIT) without warning to the crew.

Accident investigation:
cover
  
Investigating agency: 
Report number: 
Status: Investigation completed
Duration:
Download report: Final report

Sources:

https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10640771
http://tvnz.co.nz/national-news/thorough-probe-underway-into-crash-3488770\
http://www.nzdf.mil.nz/downloads/pdf/public-docs/2012/redacted%20coi%20report%20for%20iro%2006_updated.pdf
https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11295749
https://www.beehive.govt.nz/release/anzac-day-2010-helicopter-crash-desktop-review-released

Images:


RNZAF Base Ohakea 16Mar2008

Revision history:

Date/timeContributorUpdates
24-Apr-2010 15:32 angels one five Added
24-Apr-2010 15:56 angels one five Updated [Source, Narrative]
24-Apr-2010 15:57 RobertMB Updated [Time, Aircraft type, Registration, Operator, Total fatalities, Location, Nature, Departure airport, Destination airport, Source, Narrative]
24-Apr-2010 22:26 da1434 Updated [[Time, Aircraft type, Registration, Operator, Total fatalities, Location, Nature, Departure airport, Destination airport, Source, Narrative]]
24-Apr-2010 22:34 angels one five Updated [Operator, Total fatalities]
25-Apr-2010 00:21 RobertMB Updated [Source, Narrative]
25-Apr-2010 02:29 da1434 Updated [Total fatalities]
25-Apr-2010 04:37 RobertMB Updated [Narrative]
25-Apr-2010 12:12 angels one five Updated [Total fatalities, Source, Narrative]
25-Apr-2010 12:19 angels one five Updated [Time, Source, Narrative]
25-Apr-2010 21:25 flyernzl Updated [[Time, Source, Narrative]]
25-Apr-2010 21:25 flyernzl Updated [Registration, Cn]
01-May-2010 16:58 angels one five Updated [Operator, Location, Nature, Narrative]
16-Feb-2012 02:50 Nepa Updated [Time, Operator, Source, Narrative]
24-May-2014 00:11 angels one five Updated [Operator, Location, Narrative]
18-May-2018 03:35 Ron Averes Updated [Location]
20-May-2018 01:27 Ron Averes Updated [Operator, Narrative]
23-Jun-2020 20:42 Aerossurance Updated [Operator, Nature, Source, Narrative]
25-Jun-2020 13:33 AlLach Updated [Operator, Departure airport, Operator]
13-Feb-2022 01:56 Ron Averes Updated [Location]
26-Mar-2024 06:34 ASN Updated [Departure airport, Accident report]

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