A Change in the Weather

Taken by a passenger during its fatal last flight, this photo of the Fox and Franz helicopter parked on Chancellor Shelf shows the flat-light conditions that contributed to the accident. Photo by TAIC Photo

Part of being a pilot is knowing when not to fly.

The interplay between training, judgment, procedure, and environment reaches its greatest complexity in weather decisions, especially when conditions are unstable. A lack of definitive answers can leave pilots susceptible to well-known cognitive traps, including plan-continuation and confirmation biases—weaknesses well-constructed operating rules can help counter.

On May 23, 2019, New Zealand’s Transport Accident Investigation Commission (TAIC) released its final report on what became known nationwide as the Fox Glacier accident: an apparently routine 20-minute sightseeing flight that ended in seven deaths. The commission noted a number of irregularities related to record-keeping, pilot training and qualifications, and the questionable use of standardized rather than measured passenger weights. However, the TAIC attributed the destruction of the AS350 B2—pieces of which still remain embedded in the ice—primarily to the VFR-only pilot’s having been put into the position of making operational decisions without sufficient experience in reading rapidly changing weather or avoiding loss of visual cues in flat, low-contrast lighting.

The Operator

Since 1986, privately held Fox and Franz Heli Services had offered scenic flights and charters for climbing, hunting, and fishing parties in the mountains of South Island’s Westland Tai Poutini and Aoraki/Mount Cook National Parks. On November 21, 2015, its fleet included 13 helicopters with nine full-time pilots, four part-time pilots, and 24 ground staff spread among five locations: a headquarters at Franz Josef and four satellites, including the Fox Glacier base from which the accident flight was launched. Day-to-day operations were managed by the company training supervisor, while the owner and CEO signed off on seasonal flying assignments.

The company was known for a career track that placed low-time pilots in the ground crew for a year or more, learning the nature of the business and local weather patterns before training to fly turbine helicopters into the mountains. Graduates of this system described it as “effective and valuable.”

Once on flying status, pilots usually began in C category, taking the controls only under the direct supervision of a ­higher-rated pilot. Flying in the B category, usually reached after another season or two, required indirect supervision, while A category pilots were authorized to operate to all landing sites without supervision. The company training manual did not define specific criteria for promotion to higher categories, which the CEO decided case-by-case based on the recommendations of the training supervisor and other senior pilots. The company’s operating certificate had been reissued on December 1, 2012, after a full recertification audit.

The Pilot

The 28-year-old pilot earned his commercial license in 2009 and his AS350 type rating in 2010. That year he’d worked on Fox and Franz’s ground crew. Between 2011 and 2013, he flew Robinson R44 and Bell 206 helicopters overseas.

He rejoined the company in September 2014, completing an AS350 flight review plus an additional 40 minutes of training in mountain flying and emergency procedures. Late that month he was signed off as an AS350 pilot-in-command “for glacier hiking flights only” despite having slightly less than the five hours of supervised experience New Zealand’s Civil Aviation Rules require of the pilot-in-command of any commercial flight. He left the following April for “a job overseas flying a different helicopter type” but returned in October 2015.

He passed a flight crew competency check on October 8, the day after a nine-minute solo AS350 ­“re-familiarization” flight. The examiner did not certify the check flight in the pilot’s logbook as required. Following a further “route check” on October 23 (again marred by missing signatures on the training form and pilot’s log), including “dual training to all landing sites Fox and Franz Joseph glaciers … discussion about flat light, snow conditions, weather,” the CEO signed him off for A category responsibilities in the AS350. This form, too, lacked the pilot’s signature.

On the day of the accident, his logbook showed 1,792 hours of total flight time. Of 415 hours of make-and-model experience, 406 had been flown for that employer.

The Route

Though the passengers had purchased a 30-minute flight over both the Fox and Franz Josef glaciers, low clouds precluded crossing the ridge separating the two. Instead, they were offered a 20-minute cruise up the Fox Glacier valley that included a snow landing. Chancellor Shelf, a ridge about 800 feet above the glacier itself that is approachable from almost any direction, was the preferred landing site.

Conditions

Spring weather in the Southern Alps is notoriously changeable, a fact underlined by the emphasis on “flat light, snow conditions, [and] weather” in the pilot’s training records. Three earlier sightseeing flights that morning had already been canceled and two transports of professional glacier guides postponed due to low clouds and diminished visibility in the valley. The TAIC report includes a sequence of photographs taken from the Fox Glacier heliport. The first, taken at 7:00 a.m., shows the mountains completely obscured by cloud.

By 8:32 a.m., visibility had improved enough to allow the pilot to ferry a group of guides to the lower end of the glacier. While doing so, he decided that ceilings had lifted sufficiently to allow a sightseeing flight. By the time it departed, though, the highest peaks were again obscured by cloud.

The Flight

Six passengers were boarded, two “of lighter stature” sharing the dual front seat. The helicopter took off at 9:45 a.m. Once airborne, the pilot asked the ground crew to phone the Franz Josef base for a weather report, but no one there answered. He did reach a company pilot flying near Franz Josef, who advised that conditions wouldn’t permit touring both glaciers. Five minutes later, two pilots near the lower Fox Glacier landing zone heard a position report and saw the AS350 fly up the valley toward Chancellor Shelf. There were no further contacts.

The ship was expected to return about 10:05 a.m. Ground staff made several attempts to reach the pilot by radio before declaring the flight overdue. The Franz Josef pilot flew up the Fox Glacier valley and spotted fresh skid tracks in the snow on Chancellor Shelf. About 10 minutes later, he located the wreckage near the upper edge of the glacier itself, less than half a mile south and about 800 feet below the landing site.

No radar tracks, satellite position data, or onboard recordings were available to reconstruct the flight. Passengers’ cameras recovered from the debris field show the helicopter flying up the valley through rain and mist above wisps of cloud and approaching the landing zone in near-whiteout conditions. A photograph of it parked on Chancellor Shelf seems to show the aircraft floating in an undifferentiated sea of white, with little contrast between shelf, sky, and mountainside.

The condition of the wreckage suggested that it struck the glacier in a near-level attitude at both a high forward speed and high rate of descent. There was no sign of impact between the shelf and the glacier.

The report noted that usual practice was to descend as soon as clear of the shelf and follow the right side of the glacier down the valley, descending more slowly in low visibility in order to preserve visual contact with the rock face to the right. With no indication of mechanical failure, the TAIC concluded that the pilot simply misjudged his distance from the glacier’s surface when attempting to return in flat light and poor visibility … and noted that he might have chosen to wait for better conditions.

The Takeaway

The investigation cited numerous irregularities that did not directly contribute to the accident as indicative of lax operational controls and inadequate government oversight. Thanks to the use of standardized rather than actual passenger weights, the helicopter was an estimated 65 kg (143 pounds) over maximum gross at takeoff, though its center of gravity was within limits. Its tail rotor hydraulic servo had remained in service for 38 hours beyond an overhaul limit that had already been extended 180 hours, and when tested all four servos had high internal leak rates.

Perhaps more directly contributory was the informality of the operator’s training and sign-off procedures. Noting the CEO’s description of A category pilots as having “3,000 to 4,000 hours experience,” the commission questioned the decision to promote someone with less than 1,800 hours to that status, putting him “in a position of responsibility that the pilot was not sufficiently trained or experienced for.… Ultimately the pilot had been prematurely put in a position to make operational decisions unchecked. Whatever happened after the helicopter lifted off from Chancellor Shelf, the accident was a culmination of deficiencies in the system that put the pilot there on that day.”