The phone call scenario was mentioned, but it was never established that such a call was made. Here is a follow on from the same article above, it is the number of coroners reports that have the same general trend over a number of years that is so disquieting.
"A Transport Accident Investigation Commission (TAIC) report in 2004 blamed pilot error as the most likely cause of the crash.
Mr McElrea reached similar conclusions in his report released today and has made a raft of recommendations to both the Ministry of Transport and the CAA.
He urged the Minister of Transport to consider an independent assessment of the Civil Aviation Authority Act in relation to the general aviation sector and its reliance on industry responsibility and self-regulation.
Mr McElrea also recommended the minister review whether the law enforcement role currently carried out by the CAA should be separated from its safety enforcement management role.
The families of four of the crash victims welcomed Mr McElrea's findings today, but said they had "no faith" that the CAA would adopt them.
In a signed statement issued through a firm of solicitors, the families of Andrew Rosanowski, Alistair Clough, Richard Finch and Katherine Carman said they were impressed by the coroner's findings.
The families said the findings accurately portrayed evidence over the course of the inquest that stretched from July 2003 to June 2005.
"The onus now shifts to the Ministry of Transport and the CAA," they said.
Their lack of faith was "in broad terms" due to the history of the CAA "failing to implement a series of reports prepared by the Auditor General's Office and the Ministerial Report of 1998".
"More specifically, the CAA's failure to act upon numerous reported rule breaches by Air Adventures over a numbers of years," the families said.
The crash, they said, was a preventable tragedy.
"During the coroner's hearing, the stance of the CAA was not to acknowledge any serious shortcomings in their dealings with Air Adventures Ltd.
"By contrast, other organisations involved in this tragedy have acted upon their shortcomings and acknowledged the same."
The CAA's culture of "encouragement rather than enforcement" to oversee aviation rules needed to change, the families said.
An enforcement unit needed to carry out robust investigations of any "occurrence report and/or aviation related concern" about general aviation sector airlines.
"This may require a separation of the enforcement unit from the general aviation sector, so they may act independently as a body or through an office akin to an ombudsman's office."
The families said New Zealand had "one of the worst records for accidents involving general aviation in the developed world".
Alaska had the worst record, with New Zealand second.
"This was a preventable tragedy that has had an incalculable human cost.
"It is the sincere wish of the families that the CAA and Ministry of Transport will act on the recommendations of the coroner's findings, and that this tragedy will not be repeated," the families said in their statement. "
Last edited by prospector; 30th May 2006 at 05:57.