March 05

avplanes2.jpgZULU KILO DOWN

The mystery of Joe Lourie’s last flight
They make the news but fade away. Topdressing aircraft that crash in remote countryside. But behind every crash is a story, and behind the crash of ZK-LTF is a story that could shed light on many other similar tragedies. NEILL HUNTER has this exclusive investigation

The topdresser dipped silently into the gully ahead and the group of teenage surfies craned their heads searching for it, some balancing on fence posts along the ridge. Suddenly the plane burst into view and roared over our heads like a great flying beast, its proximity not just palpable, but so real it felt like we were almost wearing the machine. The scene was a remote Northland beach an hour’s walk from the road because the Volkswagens couldn’t handle the mud; the agricultural aviator had no such restrictions as he performed aerial tricks, some especially for us, displaying mesmerising skills.
That was back in the 1960s, but those first visions of a topdresser in action remain indelibly etched in my memory. And the culture surrounding the industry hasn’t changed much either over the four decades hence. The sky jockeys at the reins of these aerial workhorses pepper their speech with jargon like “strap on the aeroplane and take it for a ride”, “turn the plane inside-out”, “inverted”, “critical speed”, “stall”, “situ-ational awareness”. They’re held in such esteem that some call them “Super Pilots”. But it’s a moniker that’s swiftly passing its use-by date, because everywhere you look, from the Civil Aviation Authority (CAA) to the New Zealand Agricultural Aviation Association (NZAAA) and elsewhere, there is one controversial word buzzing the airfields: “fatigue”. And that’s what this story is about, the tale of a pilot, his loader driver, two grieving families and the plane with no name. The crash of ZK-LTF. Although it happened back in 2003, the rumours surrounding the last flight of ZK-LTF continue to swirl at Toko, the tiny farming community on the highway to what some call “the lost world”, that magnificent New Zealand hinterland between Taranaki’s Stratford and Waikato’s Taumaranui. On a soft summer evening, the appearance of a national magazine asking questions in their midst at the small village pub renews debate and rekindles memories.
ZK-LTF, you see, was a mongrel. Not in quality, in make. Once it was a fixed wing topdresser, resembling a Fletcher. But officially it was an FU24-950 born into civil aviation existence in 1973, lived 5332 flight hours and died peacefully when it was put into storage in 1990. This was ZK-LTF in Fletcher guise.
But the plane was, amazingly, resurrected in 1999, extensively rebuilt, and re-registered in March 2000 as a “Falcon”. Farmers knew ZK-LTF. Says one: “it was a Fletcher plane, Cresco wings and Falcon motor – 650 HP.” To experts, it was a Cresco main plane, Lycoming LTP-101-700A-1A turboprop with characteristics of a Cresco with an FU24 hopper capable of disgorging 979kg of fertiliser. Some readers will want to know these things, others will simply need to know it was a topdresser, fixed wing.

When ZK-LTF crashed in Taranaki killing pilot Joe Lourie and his loader driver passenger Richard McRae there were those in the farming community who thought it was the old plane, the one which had two near misses, “flame-outs” they said, which nearly killed Joe Lourie’s brother, they said. A jinxed aircraft, perhaps.
Then another farmer, who had remained silent at the pub back in 2003, spoke up telling his friends it was the “new” plane. The Falcon. He knew this because he and his son found the wreckage that night, and the bodies, nearly two years ago:
At about 6.15pm, on 4 April 2003, Barry Baldock sat on a motorbike near his woolshed about to put the sheep away for the night on an evening fine and clear, when he heard the sound of the plane he knew so well. “I knew what plane it was. I thought, ‘that’s Joe’”. The engine of the Falcon was distinctive and smooth: “it was humming,” he says of the Wanganui Aero Works’ Stratford operation topdresser piloted by his son’s good friend Joe Lourie. It was a sound he had heard earlier that day as well as on preceding weeks. He looked up as it roared into view, climbed steeply above the high green ridge, banked away from the tanned farmer, reverse-turned – in pilot jargon – and disappeared. The tall lean man in his sixties sat on his bike and watched briefly then thought to himself, “c’mon Joe, time to knock off.”
For a brief moment he watched the plane as it emerged again, lunging back up the wide open valley from whence it had come, towards the razorback ridges of high, green, steep jagged hills in the distance, into a narrow pass. The shattered horizon is cut by peaks and pinnacles, like broken glass, except near the Strathmore saddle where the serrated green line breaks form, becoming one long, high, straight, towering wall of land, and the valley begins to close.
Barry Baldock reckons he was the last to see ZK-LTF and says he might have heard the crash were it not for the sound of his bike starting as the plane disappeared. There were sheep to tend in these twilight moments, and no time to stand around daydreaming.
“I thought, ‘that’s Joe.’ Started the motorbike up. Probably the time of the crash was as the motorbike was turning over.”
Engine noises drowning the sound of a distant impact; no explosion, no fire.
At around 10.45 pm, when the All Blacks were playing on TV that night, the telephone rang in the modest Baldock farm house and the lifetime farmer told the caller, Allan Beck, local helicopter pilot and veteran search and rescue operator, that he knew the location of the plane they were searching for.
“If it’s gone down I know exactly where it is. I thought if it was the last flight before he went home…but he’d obviously gone through, turned around and made another approach. I started the motor bike up as I saw him disappear back down over the hill and rode off to put sheep away. Otherwise I would have heard it.”
Later, Search and Rescue headquarters in Wellington were so impressed they asked Beck: “how did you find it so fast”.
It was simple. He asked the farmers.
Although the plane wasn’t operating on Baldock’s farm – that had been scheduled for the following week – Allan Beck had a gut feeling he should call Barry Baldock. With his son and a son in-law, Baldock drove up to the Strathmore Saddle, five kms north east of Douglas in the Forgotten World, and he told the others to be alert for the smell of fumes. Then it came, wafting through their car like an invisible cloud, even before they stopped at the place where Baldock reckoned would be the nearest point in the road to the crash scene: the stench of aviation fuel permeating the still night air.
In the end it was not only the fuel smell, but a flight of others on the wing, which alerted the pilot’s friend to the wreckage of ZK-LTF. Says Barry Baldock: “A couple of ducks flew out of a little swamp and frightened him (his son). He had a torch on his head, spun around and his torch shone on a white thing on the side of the hill. He said ‘here it is up here Dad’,” and the search was over. All seemed very peaceful.
“Joe was still in the belts, up off the ground, very peaceful, not really a mark on him. Richard was lying about 20 metres away. I was glad there was no fire. Joe especially looked very peaceful.”
Richard, Wayne Baldock said to his father, “just looked like he was asleep.”
That was April 2003. On 13 October 2004, New Plymouth Coroner Roger Mori signed off his “Findings Of Coroner Under The Coroners Act 1988”, the official title given to his inquest into the deaths of a topdressing pilot and his loader driver passenger. It was supposed to be the final act of a three part process, of yet another investigation into yet another topdressing accident: (1) a police investigation (2) an aircraft accident investigation by the CAA and (3) an inquest, based upon those investigations, by the coroner. There were failures in all three, some small others substantial, but essentially the process failed to provide the families of those lost in the crash with that state of mind popularly known as “closure”.
For the mother of one of those lost in the wreckage of ZK-LTF, Ann Macrae (her surname is spelt differently to her son’s), closure would have been achieved if the inquest had included a full assessment of work pressure and fatigue, involving the pilot and loader driver, leading up to the time of the crash.
As she sits in her home at Sanson, calmly and clinically describing the failures of those charged with handling the investigation, it seems ironic that near her plain, neat home, is an Air Force base named Ohakea. The place where fighter jets once flew. Now this mother is taking up a fight for a lost son, once an Air Force mechanic, but she refuses to be drawn into arguments of blame.
“It would have been wrong to blame Joe Lourie for crashing the plane.” She says it goes beyond that. “Richard and Joe were right at the bottom of the chain.” The woman who loves to write, and grow huge healthy pot plants, says the investigations failed to examine the issues of work place health and safety.
So Investigate left Ann Macrae behind, and followed our own flight path to examine her assertions. Everywhere, even two years after the event, we found emotions still raw. But farmers and others opened their doors, offered opinions, shed tears, retrieved memories.
At the end of a blistering Manawatu summer day, where temperatures had soared as high as 42 in the shade, faces listen intently and fingers draw lines and shapes in the condensation on their beer glasses as the discussion of the crash and its aftermath swoops and dives with a life of its own.
A journalist’s mind, meanwhile, settles on a topdressing veteran describing his craft.
As Richmond Harding recalls it, crashing his father’s Tiger Moth in the 50’s while spreading grass seed left no time for fear because he was too busy.
“About 20 seconds” is all you have to find a place to land after running out of fuel, he tells me. At 66 he is still young enough to fly topdressers, so too his elder brother at 68, but it’s difficult to extract from the sun-drenched aviator the thoughts of a pilot about to crash. He walked away unscathed but wrote off his father’s plane, and
remembers the aftermath. “I hitched a ride back to Waiouru. Me father growled at me,” he chuckles.
“Why didn’t you bring back the Tiger Moth,” his father had asked, in an aviation variation of a teenager crashing dad’s car.
“I wrote it off.”
It’s a lighter moment, while interviewing the man who used to own – and remains general manager of – Wanganui Aero Works, the company he started after persuading his father to let him and his brother
go top dressing instead of farming. It was a pleasure interviewing the man who speaks in a measured, calm, sensible manner, who later sold the operation, one of the biggest in New Zealand, to Ravensdown Fertiliser.
So how did he crash the Tiger Moth? Focussing on the pattern of the grass seed he was spreading distracted the young pilot from monitoring his fuel consumption. When the penny dropped that he was going down, it was more of a Toyota ‘bugger’ moment than a wild panic.
“You’ve got a job to do…pretty urgent job to do. The crash investigator Paddy O’Brien once said ‘if you can put an aeroplane on the ground and run it say 20 metres you’ll probably walk away’. Control it to the ground, don’t stall it to the ground. If it’s hill country run it up the side of a hill. Run it into the ground, don’t smash it into the ground.”
avplane1.jpgSo what happened to Wanganui Aero Works’ ill-fated ZK-LTF? Timing is everything and the time of ZK-LTF’s crash is relevant to much of this investigation, central to issues of work pressure, fatigue and the demise of New Zealand topdressing pilots (and their families).
First: there are no flight and duty time (hours of working and flying) limitations either under OSH or CAA rules. In fact OSH has no jurisdiction over pilots/aviation employers; that’s done by CAA who have OSH personnel helping them. Truck drivers have limitations. Airline pilots have limitations. Australian ag’ pilots have limitations. But not NZ ag’ pilots. Once they did, 25 years ago, but it was too hard so it got scrapped. CAA recognised that ag’ flying was too dependent upon weather and seasons – “windows” – to have rules for pilots’ health and safety.
Whether that is a sensible stand or a facetious excuse for inaction is the point now thrown up for debate. The argument from those who believe the industry must be flexible enough to work during weather windows is essentially this: overall down time exceeds overall flying time, therefore there is no problem, no fatigue. The argument is based on total annual flying hours.
But in the real world there are those who point out some blindingly obvious problems with that analysis. The weather’s been bad for a month, and suddenly a week of fine weather arrives. A plane can be in the air from dawn till dusk; diving, swooping, landing, taking off, seven to ten days in a row to get the backlog of work cleared.
Was pilot fatigue a bigger factor in the demise of ZK-LTF than police, CAA and coronial investigations had suggested?
It would be fair to say that interviews with some became more “adversarial” as the logic of the counter-position sunk in. Credit must go to Bill Sommer, CAA media liaison and ex-RNZAF man who, after two long interviews, seemed to swing away from the entrenched employer and CAA positions of “downtime” and individual pilot responsibility for their own health and safety. The veterans with whom we went “adversarial” listened, but were basically immoveable.
There are some level heads in the industry who while maintaining their view that fatigue is not an issue, say they strive to teach their pilots good health and safety. Mike Keen of Hamilton’s Superair insists he is being accurate in his view that fatigue is not a problem in the industry, nor is work pressure.
“Where are the facts and figures?” he asks. In two long interviews we thrashed the subject and while the 10,000-hour veteran admits that there may have been cases in the past, it is not prevalent now. He says there is too much down time, they may work, say, a 14 hour day, but only fly for six hours and spend the remainder “sleeping under a wing or having a cup of tea with the farmer.” He insists that his company regularly reminds their pilots to take breaks and manage their work load and says most operators are the same. He recently sent a memo reminding pilots of summer temperatures and rest. Of a Pacific Wings magazine story about fatigue and stress, he says it’s inaccurate because there is no data to back it up. He rubbishes the reference to an “appalling” accident rate but admits at times, “it’s bad.”
Investigate’s argument: forget about annual flying hours and down time. We asked the question: “what is going to happen when, as exists now with companies three weeks behind in their work due to weather, suddenly the weather comes right, there’s a flood of work, and it’s game on, work ‘til you drop, pilots working / flying 14 hour days and taking one 15 minute meal break (we sighted records proving it)? It’s not the big picture (annual hours, down time etc) – it’s the micro one, of suddenly going for it over three days (or longer).”
“It’s a fair point you make,” says CAA’s Sommer, adding, “Everyone else has got responsibility as well. Not just us. The pilot has that responsibility to say ‘I’m too tired’. Now that’s clearly drummed into the guys who are flying passengers around. The safety of those passengers lies specifically with them. [But] In the case of the ag’ operator, well the feeling of responsibility that the pilot feels may be quite different.”
Is that “feeling” called peer pressure and subtle work pressure? Sommer believes things will change: “I’m not saying it’s not going to happen, I’m sure it will be. I’m sure it’ll be examined but I don’t know if it’s going to be that easy to do.”
So why not take advantage of a crash investigation and coroner’s inquest, go proactive, highlight the awareness? Our answer: You can’t if the crash investigator seems to pull punches, saying there may have been work pressure, might have been fatigue. There’s talk of reviews of working conditions pending, but apparently no real investigation into fatigue and work pressure until after the Coroner’s hearing.
You read correctly. Arguably crucial evidence was not obtained by CAA until after the Coroner’s investigation had wrapped up.
“It’s in writing on your own letterhead” we remind CAA. A clearly concerned official says he can’t comment because the staff involved are away and efforts to date by Investigate to contact them have been unsuccessful due to leave and overseas commitments we are told. More about the CAA bombshell soon.
Cut to the numbers, fatal and injury, what are they?
“Appalling…bad…trending upwards” are the various descriptions from CAA, aircraft magazine writers and the industry. Bill Sommer: “it’s trending up for ag’ ops and trending down for others…you can see it’s really quite something.”
One veteran said he thought about four were killed over about the last three years, perhaps about 15 accidents in total over that period. He knows that 200 have died since the 1940s when the industry began. This man has been flying for 40 years, operated a company for 23 years which had no accidents until 2001 when they suddenly had 3 in one year. (None were fatal and one of them was his first which he attributes to not flying for three weeks, not fatigue.) Veterans say CAA is fudging the numbers. CAA denies this, and says it has the graphs to prove it, that the accident numbers are climbing.
CAA admits that fixed wing topdressers combine with other light aircraft stats which, say some in the industry, is the reason the numbers aren’t accurate.
“That’s not correct, we can separate them out,” says Sommer of criticism that topdressers join hang gliders and balloons. CAA say they can extract the numbers and have done so on “ag’ ops” and besides, everyone in the industry knows the situation is bad.
Arguably though, it’s not the numbers, but the fact that flight and duty limitations do not exist for topdressing, except “civil twilight”: 30 minutes before/after sunrise/set. According to CAA technical examinations, 11 minutes had remained under the civil twilight rule for ZK-LTF to finish and go home. The device giving that data in ZK-LTF was a pseudo-cockpit recorder, a type of global positioning system (GPS), which could have been switched off due to screen glow distracting the pilot. “1826:50”, the last entry, may be early. The crash investigation says sunset was 1811hrs, “end of daylight” was 1838hrs, crash time “1830 approx”.
Says Mark Ford, a helicopter operator flying over ZK-LTF before the crash, “It was starting to get dark in the valleys, shadow-up. Fifteen to twenty minutes and it would’ve been pretty dark.” Ford believes he saw ZK-LTF well before it crashed because it was spreading on another farm, so by the time it finished that run, landed, reloaded, waited for the loader to park and lock up, transited to the farm and crash scene for its last job of the day, we estimate it could have consumed most of the “15 to 20 minutes to dark” that Ford says was remaining. But there is a variable. The CAA report says Ford told them the time was 5.45pm. Ford told Investigate he was only “five to six” minutes from home, which would mean his sighting was well before sundown at 6.11pm. Even considering the diminished light in the valleys, one would expect there to have been ample light, if Ford’s original sighting time was correct. In the final analysis, according to the technical data, the crash happened just on dark.
Mark Ford is a veteran helicopter logging operator but initially nobody knew where we could find him. In the end of course it was easy, his is the only place in NZ with an ex-RAF Wessex military helicopter, in full camo, parked out the back, with another “squadron” of them in storage – plus the world’s supply of spare parts, literally, 100 containers-worth to be precise. His Wessex helicopter logging operation is as huge as the scrap he is embroiled in with CAA, an organisation he accuses of being rife with corruption.
Ford is one of those larger-than-life Kiwi blokes, a bull of a man and in his no-nonsense way and office, he shared his views of a topdresser crash. Unfortunately CAA, according to Ford, only briefly interviewed him on the side of the road near the crash scene and appeared to focus on an issue which Investigate elects to cover, despite its controversial significance, especially to bereaved families. We do so for completeness, and in the end we say it needs to be viewed in context: was it causative, or distraction from the real issues of pressure and fatigue? It concerns the flying style of the pilot.
Friday evening, nearly two years ago and two men in a helicopter are almost home, flying about 500 feet over the mottled greens of the Forgotten World, when they suddenly see ZK-LTF below them.
“You see an aircraft flying, doing its normal stuff, you think nothing of it, you fly across, see it, oh yeah, just another aeroplane, helicopter or whatever, but for something like that to take my specific bloody attention away, and think to myself, struth, look at that thing, that thing’s near inverted, because it’s frickin’ flying almost upside down. The turns were really tight. That’s why I noticed it…it made me look twice. For me to look back twice and say sheesh that guy’s turning it inside out. That’s exactly what I thought.”
And Ford knows all about fatigue after once taking off with running wheels (removable) still attached and on another occasion, nearly taking off with two heavy truck batteries on the ground, still attached to the helicopter. He says they now “run co-pilots and stop for lunch and breaks after about two hours”, and although it’s his own business he doesn’t pressure his pilots to keep working, “not at all.”
When asked his opinion on the difference between his industry and fixed wing topdresser he replies: “I believe there are a lot more getting killed in aeroplanes than helicopters.” (They’re not, but that’s another story.)
Others say it is not work pressure or fatigue. Hallett Griffin is a 40-year veteran who says his only accident came after three weeks of no flying and at an Australian Conference heard a military pilot lecture on BITS – “back in the saddle” – and its dangers. Griffin also acknowledges that things are not good but insists neither are they bad or appalling as alleged by others. Companies watch their pilots to ensure safety; he says he knows of pilots who have been grounded. So what does he do to instil safety and health, if a pilot is over-doing things? “Keep an eye on him. Bit of a cuff over the ear.”
We don’t know why ZK-LTF smashed into the side of a high buttress-like hill, yet there are clues. Experts have offered opinion: “The aircraft had struck the ground in an attitude that suggested it was pulling out of a dive, but with insufficient height for terrain clearance.
Possible reasons for the manoeuvre include a pull-out from a reversal turn…the aeroplane struck the ground very heavily on a heading of 210 degrees M while on a 55 degrees bank to the right and on descent path of at least 30 degrees…after rebounding and crossing an intervening small gully, the wreckage again collided heavily with the ground some 47m further on, coming to rest in several sections… The high ground surrounding the valley where the accident occurred would have increased the effects of the fading light, making height judgement progressively more difficult”, writes Alistair Buckingham, CAA crash investigator.
Ask the farmers and they say ZK-LTF was simply spreading the last of the fertiliser across the face of rising ground, wings at an angle matching the lower slope but in the darkening conditions, struck one of the low ridges of the small gullies near the base of a nameless hill. A farmer standing on the side of the road points to a patch of thistles as evidence: “you see those Kellies Thistles, he shaved them off like a mower, he skipped into the ground.” That from Barry Baldock, the farmer who found the wreckage; who knows his planes, and the land.
So would a diving heavy impact, offered by CAA, be consistent with shaving thistles? Despite that, for now we confirm that the CAA investigation was otherwise reasonably thorough and “exhaustive”, as they remind the reader.
There are other factors which investigators and the coroner say may have caused or contributed to the crash such as illegal carrying of a passenger during spreading; “exuberance of the reversal manoeuvres”; “sense of urgency to complete the job…”; “pilot’s judgement may have been further eroded by fatigue and a degree of carbon monoxide absorption (cma).” Let’s deal with the latter briefly for clarification. It relates more to internal rather than external (e.g. fumes) sources of toxicology, of blood saturation levels where normal
levels are 1% to 2% cma, 5% to 10% may affect the heart, 15% to 20% dizziness and nausea, 50% may kill. The CAA report includes findings relating to the pilot’s forensic results therefore it can be safely assumed that the cma was relevant, by virtue of the statement “…eroded by fatigue and a degree of carbon monoxide absorption”.
Those and other issues had to be considered by the coroner.
It is 9.30am, another fine day in the ‘naki, already signs of a scorcher but Coroner Roger Mori is happy with a simple desk-top fan in his office at the end of a long corridor in the chambers of Nicolsons, Lawyers and Notary Public. The tall lean father of a representative basketballer, calmly and fully expounds on the coroner’s role generally, and the inquest into the deaths of Richard Sinclair McRae and Jonathan Peter Lourie, ages 30 and 29 respectively.
“I’m required to make recommendations or comments in the avoidance of circumstances similar to those in which the death occurred, or in the manner in which any persons should act in such circumstances, that, in the opinion of the coroner, may if drawn to public attention reduce the chances of the occurrence of other deaths in such circumstances. So, there we are and of course it is only the sudden and unexpected deaths that are reported to me and of course obviously air accidents fall very fairly and squarely into that category.” He has dealt with about six air crashes over the 21 years but can not remember clearly if any included topdressing but may have. Sitting relaxed behind a large desk, in a casual shirt, no tie, one cannot help but be impressed with his professional yet open manner. Despite issues, some controversial, arising from this case, one of which he is unaware until informed in this interview, he clearly conveys an empathy of understanding towards families in grief. He has never lost a son or daughter and can not imagine the hurt, he says. He is probably being humble for someone having presided over countless enquiries and currently awaiting reports on the latest aircrash in Taranaki, that of a plane which slammed into such a precarious part of Mt Taranaki’s summit, two helicopters were required. “I try to keep myself as remote as I can from families”, ‘he says,but then explains examples of where that “rule” has been broken.
avchopper2.jpgZK-LTF’s case has at times been controversial. The families accuse authorities of prejudging “cause and effect” and to a degree, Mori even agrees: “to that extent they’re right because all the evidence is prepared in writing in advance.” While the coroner may direct further investigations after receiving reports, it is the police responsibility to call evidence, liaise with families and prepare the evidence in advance for examination at the inquest.
Mori is well versed in issues of fatigue, both professionally, and personally from a near-tragedy which could have had fatal consequences when a member of his own family, suffering fatigue, crashed a vehicle, escaping uninjured.
An expert from Massey University presenting evidence in Mori’s court about fatigue in another case, testified how physical functions may carry on normally until suddenly the brain literally stops.
“You get tired and the brain will shut off for some seconds… suddenly you’re out of control”, the coroner recounts.
But it is the question of whether the Civil Aviation Authority lost control of its own investigation that now rears its head. You see, at the end of the day a coronial inquest is only as good as the evidence that Coroner gets to see. If one of the investigating agencies gets facts wrong, or doesn’t cover all the bases, a Coroner may end up delivering an unsound report. And that’s what the families of Joe Lourie and Richard McRae are alleging.
The most telling piece of potential evidence in this regard is a letter written by a CAA investigator (the “bombshell”) which confirms crucial documents, the actual “flight records”, were not uplifted by CAA until “the day after the inquest”.
The letter goes on to confirm that CAA had vastly underestimated the actual flight hours of the pilot for the preceding days, and that an amended report would be filed by last December. As of the time of going to press, no such amended report has been filed that we can establish. So how could CAA get it so wrong, why do they appear to have not done the enquires “by the numbers”, checked the pilot’s flying hours, why change a report after an inquest? Because that is what this investigation reveals.
CAA’s Bill Sommer was unaware of the letter until Investigate raised it, but says he’s sure that if their investigator changed his report, they would “tell the coroner”.
Well, the investigator has changed his report; according to the document, he admits virtually (to his credit) that he got it wrong, but hasn’t told the coroner about his failure to properly investigate the issue of work pressure and fatigue, nor his amended report (after the inquest). Another expert witness present at the inquest has told Investigate that the coroner specifically asked the CAA investigator if he was sure the numbers (flying hours) were correct. According to the source, CAA replied they were. But they are not and Investigate has a copy of the CAA document to prove it. What is the significance of that to a re-hearing?
Mori has signalled he is open to a re-hearing and even quoted the rules allowing it but emphasises the application must come from the Solicitor-General. He cannot initiate it himself.
Quotes Mori: “Section 38… if satisfied that since an inquest was completed new facts have been discovered, make it desirable to hold another, the Solicitor-General may order another to be held and in that case another shall be held.”
So sayeth the Act. And the new facts (as well as breaches and failures under the Coroner’s Act) are these:
The CAA crash report states the pilot “had not flown on any of the seven days immediately preceding the accident date.”
New facts, verified by Investigate sighting documents and interviews: The crash was on Friday 4 April. On Wednesday 2 April the loader driver and pilot worked/flew from 0500hrs to 1900 hours with one 15 minute meal break! Thursday 3 April, the day before the crash: 0600 to 0645, then 0830 to 1945hrs and one 15 minute meal break! They were averaging twelve-and-a-half hour days with one quarter-hour break. The loader driver worked 25 out of 28 days, taking one small break per day and if the loader driver was working as the pilot’s loader, so was the pilot.
Investigate’s copy of a CAA document shows the agency admits not examining flight records fully until after their report was completed and after the inquest. That document proves that their statement about no flying by the pilot before the crash was wrong, by at least 17 hours. Why?
Because they didn’t investigate fatigue and work pressure properly.
While the CAA could argue that it doesn’t matter as work pressure and fatigue are mentioned in the report anyway, that would be disingenuous. It does matter, substantially. The CAA report forms the basis of the Coroner’s finding and recommendations. It makes minimal mention of pressure and stress, mixing them with items of blame on the pilot as possibilities only. So the Coroner accordingly agreed. It is like saying a driver may have had a bit to drink, but we didn’t take a blood/alcohol measurement so we’re only mentioning the “possibility” in passing.
The CAA report does at least acknowledge, “the accident occurred at the end of a long working day. The pilot had been on duty over 12 hours…80 take-offs and landings…carbon monoxide…a degree of fatigue…potential to dull the edge of the pilot’s skill and judgement.”
It’s all minimalist jargon; understandable, given the investigator is working on the premise the pilot hadn’t worked before the day of the accident. But, if one day’s long work hours were enough to warrant mention, what does the new evidence of flying almost all week do?
Second new fact: the police statement given in evidence at the inquest is that the passenger was sitting behind the pilot.
The CAA report states they were abreast. Which is it? We don’t know because nobody appears to have asked the question. In fact from enquiries, the passenger was beside the pilot, but it casts more doubt on the thoroughness of the original investigations.
Approximately one week prior to the accident Joe Lourie was so exhausted from working from dawn to dark that he sent his friend, a farmer, to get food and drink for him. On another occasion he called Stratford Aero Club and asked them to turn on the lights of their building as a navigational point for landing at night, illegally.
Self-imposed bad practice? Or signs of a responsible, well trained pilot under pressure? Farmers close to Joe Lourie and Wanganui Aero Works say that prior to him becoming manager of the Stratford operation it was losing business, attributed to the previous pilot nearing retirement and no longer buying into the work/fly-until-you-drop (or die) culture. That is not a reflection on the retiring pilot but rather a sign of pressure.
“The previous pilot was a lot older and probably ready for retirement,” opines a farmer. “The difference was one wanting to work and the other being very cautious. But they did lose a bit of business because they weren’t getting the manure on…Joe’s thing was to get that business back, plus a bit more.”
Topdressing companies are paid when all the fertiliser bought by the farmer has been spread. So if the job becomes disjointed, broken by weather, including wind, mechanical failures and the like, there is no income, no progress payments. Pressure may come from farmers, “standing over” the pilot pressuring him into flying to their farm “right now” because it looks fine and they want their fertiliser on the ground, now. The plane arrives and, as the pilot suspected, so too does the wind. He tries for half an hour, then flies home again, expenses soar, and net profit plummets.
“It happens,” says a farmer. “It’s pressure from farmers, not all…they want it on now…the job has to be finished, no manure on the ground, no money …weather can hold things up for quite a few weeks sometimes,” he explains.
Then a commercial pilot, after much procrastination and on condition of anonymity comes forward through a third party at first, and then speaks to Investigate directly.
Three weeks before ZK-LTF’s crash Joe Lourie was “doing stunts after work”. While that in itself is not bad he says, because most pilots do it, especially at the end of a day, if conditions are safe, but if a pilot is tired, the consequences may be fatal.
“It’s usually ridge-running, not barrel rolls.” It’s like a release from all the pressure which they say “will kill people”. He exclaims, when told of the flying hours, take-offs and landings logged by Lourie:
“I find that incredible”. Then he pauses and says he knows it’s happening. “Some of them are doing huge hours (flying time). I’ve done eight hours and even that’s too much.”
avmcrae.jpgWith 1400 hours logged, he rubbishes the veterans who say flying is no more complicated than driving a car. Investigate has been told on several occasions that for an experienced pilot, flying is easier and less tiring than driving. Our informant says that driving can be “automatic” but “in flying you’re constantly thinking and when you land you feel exhausted”.
When Investigate re-interviews a veteran about the informant’s statements, he scoffs and even laughs and we are told again, fatigue is not an issue. But, says our informant, six hours topdressing flying time in a day… “it’s big.” When a pilot gets tired they “get lazy and don’t pay attention.”
Make no mistake, Investigate accepts Lourie broke rules. Carrying a passenger restrained only by a lap belt (both were big men) while spreading was dangerous. Operating just on dark, soaring up into lighter conditions above the hills and back into dark valleys where shadows obscured the smaller ridges, was reckless.
But why, once again, was this experienced, well trained pilot making such mistakes? Was it pressure, squeezing in one more run just on dark, take the pilot home with him and save time, get back on the job early next morning, take him on the last spread instead of returning to the field, collecting him and flying straight home to Stratford, only minutes away by plane, perhaps an hour in an old slow loader on a narrow twisting country road punctuated by more stop signs and railway crossings than a Monopoly board?
We investigated suggestions it was all Lourie’s own fault: a pilot out of control, cavalier in approach. But to the farmers who knew the quiet pilot it was the opposite. “Very quiet,” is their description, “he would say what he had to and that was it kind of thing”. His employers, to be fair, are reluctant to blame Lourie but in interviewing them there is a clear perception that they discount fatigue, and blame pilot error. “He had been warned…” they explain but say no more, out of respect they say for the families.
Joe Lourie had to take responsibility, says a reliable neutral source in Manawatu (not the employers) who once met the young pilot.
He was closely supervised for six months at Hunterville with a veteran, where they say he was groomed for the Stratford position as manager/pilot. The source says he was very impressed after meeting the big, tall pilot whom he described as “the future of the industry.” Which again begs the question: what went wrong with the 1000 hour-plus, groomed pilot?
More enquiries and again the veterans say they know the cause and it wasn’t work pressure because there is nothing wrong with squeezing in one last load before dark. One says that if the conditions are perfect, as they were this day, then evening is the ideal time to fly, and goes on to describe the joy of doing the last loads late in the day, not because of pressure, but the elation of flying.
Farmers experienced in topdressing say Lourie was a good pilot. None say he was reckless, one talks of his so called exuberant flying (as in the CAA report where technical data confirms “exuberant” manoeuvres) adding that “he could fly, he could handle it, he was a bloody good pilot” but admits he was “starting to take a few risks.” A farmer who had watched him weeks before the crash thought to himself “take it carefully, Joe”, even telling his wife, but says it was paying off commercially: “he picked up a lot of work.” But it was reaching the point where it was raising concerns. A farmer says “a lot of people commented that Wanganui Aero Works should have pulled the pin on him and cut back his hours…they must have known how many tonnes he was putting on so they should have known the hours (the pilot would need to do) to put that tonnage on. It was a waste of two good lives, I know that,” he muses.
There is another reason for the Solicitor-General to re-open the Coroner’s inquest into the deaths of Lourie and McRae. The last error in the CAA report, perhaps only small, perhaps not. The crash report says “…both occupants were ejected from the cockpit.”
New fact: Witnesses to the crash scene, those who found the wreckage, say the pilot was in the wreckage, “Joe was still in the belts, up off the ground, very peaceful, not really a mark on him. Richard was lying about 20 metres away…”
Barry Baldock then went on to describe the state of the wreckage, and the pilot’s position in it which, for brevity and sensitivity, we have condensed as above. Investigate received allegations that Lourie was not the pilot. McRae, the loader driver was a trained pilot, with aspirations of becoming an ag’ pilot and it is not unusual for official and unofficial training to take place on the job. After enquiries however with police, crash scene witnesses and anonymous witnesses who have no agenda, we are reasonably satisfied that Lourie was the pilot. But cumulatively, the CAA report errors are such they raise substantial doubts about the integrity of the inquest.
So what does the Coroner think of all this?
Roger Mori hints that he is less than happy with the situation. Investigate contacted the Coroner again about the evidence, including the bombshell CAA admission that they got it wrong over the “the pilot hadn’t flown during the week”, and that CAA was intending to amend its accident report. His reaction? A typical no-nonsense one: “S**t, that’s all been done subsequent to my report!”
He adds, incredulously, “they (CAA) can’t change a report once it becomes an official document in a Coroner’s inquest.” He tells Investigate “it’s something that should be investigated.”
We then discuss apparent breaches in the Coroners Act about the informing of parties, such as families and employers. Neither family or employer were informed of the inquest and although blame for that falls on the police, Mori typically doesn’t duck the issue and talks about it being “extremely rare” and “system failure.”
He evinces clear frustrations over certain parties, such as the pilot’s wife, being inadvertently excluded from the inquest.
“I was bloody annoyed”.
Investigate explained to the Coroner the results of enquiries to date and the evidence that proximate cause could more strongly be fatigue. In legal terms, more commonly associated with the insurance industry, proximate cause means after weighing-up all other possible contributory causes, in the final analysis there is one direct, stronger cause. Mori replies with talk about that being “logical …best explanation…what you’re doing is researching and asking ques- tions…probably the answer is yes…I would say that’s fairly accurate”. If nothing else, let that at least be of some comfort to the families because blaming the pilot, as hinted in the CAA report, and by some industry members, is an easy assumption.
But it’s up to the Solicitor-General’s office to apply to the High Court, as provided for under the Coroners Act, on the grounds that there are sufficient new facts from the formal evidence: changes to CAA report after the inquest; their admission to erring; breaches of the Act due to the exclusion of families’ members; evidence presented but rejected without being heard.
A re-opened coronial investigation could not only put the pilot’s actions in a clearer light, but also bring an end to commercial and peer pressures that many in the agricultural aviation industry say are killing pilots.
“It was a beautiful sight,” says a farmer’s wife, describing ZK-LTF approaching their farm air strip in the low light of predawn. She says the combination of the plane’s lights, the early dawn colours, vapour streaming off the wings of the white Falcon like long white ribbons, was something she will never forget. The interview turns quiet as she recalls the image, describing it again, painting a word picture that stays in the mind. Later she says that I should go to a small airstrip, at night.
A quarter after nine pm on a country airstrip in Taranaki, and the pilot from the big Cresco topdresser, 3714kg fully laden, parked on the grass, walks through the darkness, and looks puzzled to find a journalist. There are no lights and nearby buildings are in darkness; the place is abandoned apart from pilot and scribe.
He says he landed about 8.15pm, is happy to talk about his job, a tall solid man who now leans over the roof of his car, slumping his body in a sign his day is over. He shares things like hours, working conditions and the importance of the industry.
“Seven hundred thousand tonnes of fertiliser per year, we have more turn-over than any other industry, it’s important we don’t fall over.” He says he manages his fatigue, “you’re not always flying…”, then hesitates. Later he says he’s off to the central North Island and as we talk more there’s a distant rumbling growl, rising like rolling thunder in the still night. From the track leading to the airfield, a monster lumbers suddenly into view, headlights blazing like eyes, a creature common to rural New Zealand: a topdressing loader. Truck-cab at the front, loader-cab and bucket at the back, Kiwi ingenuity at its best.
“My loader driver, he’s coming with me,” says the pilot. Then an older man in a black singlet climbs down and wanders over. The pilot and I exchange farewells, the other looks on silently, confused, then both get into the pilot’s car, and drive away, leaving me alone in the dark, imagining a different scene, two years ago, when pilot and loader took another way home, via grassy slopes of a valley, on a night in the Forgotten World.
The distant silhouette of a giant mountain looms, with snow still present where weeks earlier it too became a place of tragedy, scene of a fatal air crash. Time to go. I’ve booked a cabin overlooking the ocean hoping to enjoy the view but it won’t be, because it’ll be 10.10pm, and I’ve had no dinner, only a quick lunch and the first interview was at 9.30pm, later than the others on this long week when a chief reporter said they too “hate the early morning interviews.” Twice during the 45 odd minute drive to New Plymouth street lights from small towns in the distance seem like approaching car lights, illusions, eyes tiring, itching, then the realisation: could be fatigue.