Pilots blamed for Air NZ crash

The tail plane wreckage from the Air New Zealand Airbus A320. Photo / Supplied

PARIS - France's air safety board overnight determined that flight-deck error, inadequate training and a maintenance slip caused the crash of an Air New Zealand jet while on a test flight over the Mediterranean, killing all seven on board.

The 2008 disaster was triggered by a test that was conducted at low speed and low altitude, throwing the plane into a stall from which it had no height to recover, the Bureau d'Enquetes et d'Analyses (BEA) said after a 22-month inquiry.

The ill-fated manoeuvre arose especially from makeshift preparations for the exercise and poor coordination between the German and New Zealand crew on board, it said.

But compounding their mistake was a malfunction in two out of three external probes that feed the A320's complex computerised flight system with vital data about air flow.

The plane had been repainted and rinsed by a French maintenance company three days before the test, the investigation found. Water entered these so-called angle of attack (AOA) sensors, causing them to freeze and thus skewing the avionics, it said.

"The decision to carry out the demonstration at a low height... inadequate coordination between an atypical crew... and absence of protection of the AOA sensors" during the washing operation helped doom the craft, according to the 222-page BEA report.

The disaster occurred on November 27 2008 seven kilometres off Canet-Plage, a small resort near the southwestern French city of Perpignan.

The plane had been on a routine test flight, prior to being handed back to Air New Zealand by XL Airways Germany, a charter company that had been leasing it for the previous two years.

Five New Zealanders were among the dead: Air New Zealand pilot Brian Horrell, 52; Air New Zealand engineers Murray White, 37, Michael Gyles, 49, and Noel Marsh, 35, and Civil Aviation Authority official Jeremy Cook, 58.

At the controls were two German pilots, Captain Norbert Kaeppel, 51, and co-pilot Theodor Ketzer, 58, under the instructions of the Air New Zealand pilot, who was also on the flight deck.

The inquiry highlighted a fateful exchange in which Kaeppel initiated a test to assess the plane's recovery from low speed at an altitude of just 3,000 feet (925 metres).

In less than two minutes, stall warnings began to sound and Kaeppel wrestled to stabilise the craft. To the horror of bystanders, the plane reared skywards before smashing nose-first into the sea at nearly 500 kph.

BEA investigator Sebastien David told a press conference that the test-flight schedule had been "improvised."

"There was no coordination between the three people on the flight deck," he said.

Following up on recommendations it made in a preliminary report, the BEA called on airlines to beef up pilot training for "non-revenue" operations, or flights that do not entail commercial passengers, and to ensure that test manoeuvres follow a carefully prepared schedule.

Asked by the Herald if Air New Zealand should have dedicated test pilots, BEA Director Jean-Paul Troadec said: "Yes."

"That is the case in some airlines, that they do have someone, because you can't train every pilot in the airline" to do test flights, he said.

"The solution is to train a little group of pilots for this type of flight."

With such training, the accident "probably" could have been avoided, he said.

The crash triggered wide concern in the air industry, for the A320, a single-aisle jet with a capacity of up to 150 passengers, is a workhorse used by around 155 operators.

More than 2,000 A320s have been built since 1988, but the plane's introduction was initially resisted by veteran pilots who objected to its computer-controlled avionics.

But this criticism soon abated. Air safety experts say the A320 has an excellent record, given the number of planes in service and the millions of flights over 22 years of service. The Perpignan was 19th loss of an A320.

The 22-month BEA probe scrutinised witness statements, the airliner's maintenance records and data from the "black box" recorders that registered the plane's final manoeuvres and cockpit conversations.

The investigative panel included experts from Airbus, the European consortium that makes the A320, and the New Zealand and German civil aviation and transport safety agencies. French prosecutors have carried a parallel investigation for possible manslaughter.

Air New Zealand Chief Executive Officer Rob Fyfe said the airline acknowledged the BEA's "exhaustive investigation and welcomes the opportunity to review the recommendations alongside Safety Regulators to identify where operational improvements to non-revenue flights can be made".

"While this report will not change the fact seven families lost dads, husbands, brothers and sons and we lost great colleagues, the findings will benefit the entire aviation industry," Mr Fyfe said.

He said the report highlighted the lack of a regulated standard for check-flights.

"We have been operating to the manufacturer's standard, in accordance with industry practice and with approval of our own NZCAA, but clearly a regulatory framework to create consistency and further minimise the opportunity for a tragedy like this to happen is needed."

- With NZHERALD STAFF