What happened
On 5 September 2009, a Cessna 207, registration ZK-DEW, was prepared for a scheduled scenic flight from Queenstown to Milford Sound. After loading five passengers, the pilot attempted to start the engine using the standard electric starter, but a faulty battery prevented the engine from firing. After several unsuccessful attempts using a backup battery pack, the pilot decided to perform a hand-start procedure.
To facilitate this, the pilot requested that a company employee, who was not a pilot or engineer, sit in the left-hand seat to manage the brakes. The pilot set the engine controls and the handbrake, then moved to the front of the aircraft to manually rotate the propeller. Once the engine ignited and reached high RPM, the aircraft began moving forward. During the movement, the employee inadvertently disengaged the handbrake. The aircraft accelerated across the apron and entered the Zone 2 protection area adjacent to the active runway, eventually striking a marker board before coming to a halt. There were no injuries and no damage to the aircraft.
The investigation
The investigation examined the sequence of events, the aircraft's mechanical state, and the procedures used during the start attempt. Investigators reviewed CCTV footage, interviewed the pilot and the employee, and analyzed the operator's documented hand-starting procedures. The investigation also looked into the regulatory standards for hand-starting and the communication between the operator and the Civil Aviation Authority.
Findings
- The Cessna 207 moved uncontrolled toward the runway because the pilot performed a hand-start while an untrained person was at the controls.
- The pilot failed to follow the operator's established hand-starting procedure.
- The aircraft's forward motion was triggered almost immediately after the engine started because the unqualified person in the cockpit accidentally released the park brake.
- The movement resulted in an unauthorized entry into a protected runway zone, creating a potential for serious injury or damage to other aircraft and personnel in the area.
Safety action
Following the incident, the operator prohibited the use of hand-starting procedures on all company aircraft.