Pilot's decision to fly alone cost 8 lives, coroner says

[prospector]

You will no doubt note that the CAA, once again, state that the coroners recommendations are already being implemented. Surely when a coroner can see what was so glaringly wrong with this operation, the regulatory body, with all its expertise??? could have seen before these people lost their lives??

http://www.stuff.co.nz/stuff/0,2106,3684928a10,00.html

Prospector

[DickyPearse]

There is a difference between a regulator and an administrator. Unfortunately, the CAA and Australia's version, CASA, are more like an administrator these days...

[prospector]

Maybe so, but surely even an administrator should have been able to see the folly of letting one man wear the caps of Chief Executive, Director of Operations, Chief Pilot and Instructor of a company when it is stated that "inexperience in IFR flying and inexperience in night flying" was a major factor in the so called "accident".


Safety factors in the rules allowing single-pilot IFR flight were broached by Mr Bannerman by a combination of his inexperience in IFR flying and inexperience in night flying, Mr McElrea found. The rules, nevertheless, allowed him to have the accreditation he had.

Prospector

[bushy]

I seem to remember reprts of the pilot making a mobile phone call while doing an ILS approach.
Strange!

[prospector]

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. "

[Sqwark2004]

Pilot's decision to fly alone cost 8 lives, coroner says

3.05pm Tuesday May 30, 2006

A coroner has found the deaths of eight people in an air crash near Christchurch Airport three years ago was the result of the pilot deciding to fly alone.

Christchurch coroner Richard McElrea found the decision of Air Adventures pilot Michael Bannerman to fly without a co-pilot was a major factor emerging from the crash on the night of June 6 2003.

Mr Bannerman, 52, was flying a Piper Navajo Chieftain twin-engined aircraft carrying nine Crop and Food Research employees when it ploughed into farmland.

He was killed in the crash, along with Howard Bezar, 55, Katherine Carman, 35, Alistair Clough, 37, Richard Finch, 41, Desma Hogg, 41, Andrew Rosanowski, 37, and Margaret Viles, 53.

Two people survived with serious injuries.

The Crop and Food staff had been returning to Christchurch after a one-day conference in Palmerston North.

A Transport Accident Investigation Commission (TAIC) report in 2004 blamed pilot error as the most likely cause of the crash.

Today, Mr McElrea reached similar conclusions after conducting one of the largest coronial inquests since coroners were established in New Zealand 160 years ago.

Mr Bannerman's decision to fly without a co-pilot in marginal weather conditions and at night was "always going to test the outer limits of his competency" as a pilot flying under instrument flight rules, he found.

On a flight with a full complement of passengers just three weeks before the crash, Mr Bannerman "appropriately" flew with a co-pilot.

"Why Mr Bannerman chose to undertake the Crop and Food flight on June 6 2003 without the assistance of a co-pilot is unknown, but is very likely to have been a reflection of the difficult financial circumstances of Air Adventures and that he was the only pilot," Mr McElrea said in his findings.

Evidence at the inquest from Civil Aviation Authority (CAA) principal medical officer Dougal Watson was that having a second pilot in the cockpit gave a "one-in-100 protection factor". Evidence from other pilots had also confirmed that a second pilot would substantially reduce risk.

Risk reduction

Mr McElrea said the passengers on Mr Bannerman's aircraft on June 6 2003 "did not have the benefit of such risk reduction".

CAA rules allowed the flight to go ahead on a single-pilot basis and a competent single-pilot instrument flight rules (IFR) approach "should have and would have landed the aircraft successfully".

Safety factors in the rules allowing single-pilot IFR flight were broached by Mr Bannerman by a combination of his inexperience in IFR flying and inexperience in night flying, Mr McElrea found. The rules, nevertheless, allowed him to have the accreditation he had.

The coroner said the "other factor in that combination" was Mr Bannerman's decision to fly from Palmerston North in marginal weather conditions without discussing other options with his passengers.

Mr Bannerman had a global positioning system (GPS) unit as an aid to navigation, but was required under CAA rules to disregard the unit completely on making an instrument approach to the airport.

"The evidence would indicate that he was placing at least some reliance on it, and it is most likely that he had loaded an incorrect waypoint into the unit by a factor of 1.2 nautical miles, causing the aircraft to crash 1.2 nautical miles short of the runway," Mr McElrea said.

Mr McElrea noted that the CAA "not unnaturally" had defended its position as to the application of the rules. Deficiencies , "at least in part" were to be put into the context of a regulatory regime.

While a preferred approach to to ensure standards were met by "encouragment rather than by enforcement" might be admirable in many situations, Mr McElrea said the inquest findings had highlighted that the "tolerance factor" where safety was an issue had been "shown to be too great".

- NZPA

[MOR]

The origins of this accident (and many others) lie in the Swedavia Report of the late '80s, when the NZ government started to move away from the old MoT-CAD model (ie the British system) to the pseudo-American system we have now. The focus shifted from regulation to what could best be described as a kind of hands-off self-regulation.

I once went through the process of applying for a job with the CAA as an Ops Inspector. Nearly took it, too, until it was explained to me that my job would consist of making sure that operators had up-to-date manuals. If the manuals were up to date, I was told, it was assumed that the operator was doing the right thing and obeying (all) the rules. The obvious stupidity of this assumption has apparently never been seriously addressed, despite United Aviation, Koromiko, various light aircraft ploughing into terrain for no good reason, and so on.

The non-interventionist policies of the CAA are a joke, and it is about time somebody challenged them. As a regulatory body, the CAA fail on a variety of levels. Hopefully some good will come from this accident, but I'm not holding my breath. There simply isn't the quality or depth in the organisation to raise standards to where they should be.

And we pay for it, yet... :ugh: :ugh: :ugh:

[Sqwark2004]

Government demands answers from CAA over fatal air crash

Wednesday May 31, 2006
By Paula Oliver

The Government is demanding "urgent" answers from the Civil Aviation Authority after yet another report criticised the watchdog's air safety monitoring role.

The CAA - already under fire from the Auditor-General for taking too long to act on serious safety issues - was yesterday chastised in a coroner's report which found that a fatal air crash in 2003 could have been prevented.

Eight people were killed and only two survived the crash of a light plane near Christchurch Airport, making the tragedy the seventh-worst air crash in New Zealand aviation history.

Pilot Michael Bannerman, 52, was flying a plane carrying nine Crop & Food Research Institute employees home from a Palmerston North conference when it went down in farmland, 2km short of the runway.

Mr Bannerman, director, sole shareholder and chief pilot of Air Adventures, and seven Crop & Food staff died.

Christchurch coroner Richard McElrea identified a series of failings by Mr Bannerman before the crash. But he also put the spotlight firmly on the CAA's monitoring of pilots and aircraft charter companies, noting that there had been complaints about Mr Bannerman's flying.

The coroner went on to suggest that the Transport Minister consider splitting some of the aviation watchdog's duties.

In particular, it should be considered whether the law enforcement role carried out by the CAA should be separated from its safety enforcement management role.

Acting Transport Minister Michael Cullen last night demanded answers from the CAA board.

In a strongly worded statement, he said he had asked the board to explain what "urgent action" it was taking in response to the critical coroner's report and a damning Auditor-General's report released last year.

"The coroner's report has raised a number of concerns about the general aviation sector," Dr Cullen said, referring to smaller aircraft.

He wanted assurances that lessons would be learned quickly from the crash and that the CAA would move speedily to address any issues in its rules and procedures.

In a hint that the Government may be open to altering its role, Dr Cullen also noted that the Transport Ministry was reviewing the Civil Aviation Act.

The Government has also instructed the ministry to report on the coroner's recommendations and create a monitoring system to ensure they are acted on.

CAA director John Jones yesterday answered criticism by saying the watchdog had made changes to its practices since the crash.

Much of the information which the coroner had produced about Mr Bannerman and his operation was as a result of hindsight.

"We are saying, yes, we could have done things better," Mr Jones said.

"But we are also saying we would have liked to have the information which has come out subsequently to the crash three years ago given to us."

Mr Jones' defence risked falling on deaf ears last night because the CAA already has a record of failing to respond to criticism.

The Auditor-General's report released just over a year ago expressed concern "that little action" was taken by the CAA to address recommendations made in audits in 1997 and 2000.

The latest Auditor-General's report revealed that in some cases the CAA had taken more than 300 days to address examples of questionable safety.

The families of some of the victims of the Air Adventures crash expressed doubt yesterday that the CAA would follow through on changes.

They said they had "no faith" that it would adopt the recommendations of the coroner.

National Party transport spokesman Maurice Williamson last night called for heads to roll at the CAA.

"How many times can you hear the excuse, 'We're still working on this', before you finally don't have any confidence that what's going on is being done properly?"

- Additional reporting: NZPA

--------------------------------------------------------------------------

Looks like the CAA are finally getting the hurry up they have been needing for the last decade or so.

[prospector]

Squark2004,
Did you change the thread title?? if so how??? if not why was it changed??????:confused:

Prospector

[pakeha-boy]

Prospector....I would have to agree with the findings,to a certain degree....I like you and MOR have spent many hours flying single pilot operations,with the approval of the ops specs,knowing full well that under certain conditions another set of Qualified eyes would have been an asset,but because single pilot ops were approved it was now "okay"....I have a type rating in the Metro 3 with the provision "a second in Command' IS REQUIRED!!!!...for good reason...I do CAT 3A/B apps now that without an F/O would not be possible...how is it that under Part 91 I was able to do 0/0 weather mins and all sorts of other ****e with low hours,yet for some reason with over 18,000 hrs+.NDB APPS have higher mins,circle to land apps are severly restricted,VOR apps have 18m added to the MDA and various other measures are enforced !!! obviously to stop the "rouge" pilot in me.....

This is sad story for sure,and we all remember reading about this tradegy...my condolences to all involved.....we have ,previously talked of other accidents on this site,......accidents will happen,and this was a very costly accident,to say we will hopefully learn from this seems very shallow as it could of have been prevented,but it is only by discussing these happening,s that we do learn......

"To fly west my friend is a checkride we must all take"

[tinpis]

Sadly poorly trained or not trained at all "second pilots "in ticklish situations are only a further distraction .

Im sure yer not a "rouge" pilot pakeha . :hmm:

[pakeha-boy]

MOR....maybe you should have taken the position....I would agree with your assessment totally,..maybe its time to step up to the plate????PB

[MOR]

Nah mate they wouldn't have me! Dissenting voices not allowed, and all that. Rampant nepotism, a bunch of sychophantic yes-men and a director who shouldn't be in charge of the corner dairy. Not only that, but they seem to have this pre-occupation for nailing people to the mast who turn out to be innocent. And if you saw their performance in the CHC Chieftain/Bannerman enquiry, you would wonder about their competence.

Don't think I would want to work for an organisation like that...

[prospector]

Hopefully something will happen this time round, going back through past Coroners reports makes very sad reading, hopefully the next select committee investigating the department, due sometime in the next month or two will require answers to statements like this dated 25 Mar 2004.

"For the Coroner to criticise the CAA for not preventing an operator from failing to comply with its maintenance programme would be to radically shift the ultimate responsibility from the operator actually implementing the programme, to the regulator. This would be entirely contrary to the philosophy behind the Civil Aviation Act

1990"

From Coroners report 30 Oct 2002.
"Such report records that there is evidence of poor aviation safety culture in New Zealand, particularly with small-operators. It was concluded by the Commission in its report that CAA should have taken regulatory action against United Aviation, given the many shortcomings identified by successive CAA audits."

From personal dealings with the CAA when it was pointed out that requirements under the act were not being complied with, and complete lack of any action from CAA, one must ask what is their interpretation of
" Philosophy behind the Civil Aviation Act"

Prospector

[MOR]

It's very simple. The whole philosophy behind the CAA is to shift the burden of compliance from the regulator to the operator. You could easily argue that, under this philosophy, you don't even need the CAA, just a book of rules that all operators would comply with, because we all know that all operators always obey all the rules... right?

We need to get back to a philosophy that is somewhere between the FAA and JAA - preferably a system that is recognised by both.

Even on the level that I have to deal with the CAA on most often - licensing - you find an incompetent collection of jobsworths that have probably never had an original thought in their lives. Very frustrating - but you can forgive them a little for having to work under a system that makes no logical sense.

Time to get rid of these clowns and put a system in place that actually reflects the realities of aviation.

Sadly the disease seems to have spread to the authors of Vectors (have a look at the wake turbulence article).

[pakeha-boy]

MOR..couldnt find the article you referenced,but how can you screw up the availible info (from reliable sources)regarding Wake Turbulence,??????

[prospector]

Pakeha Boy,
Go to http://www.caa.govt.nz
Safety Information
Publications
Vector
May/June 06

Prospector

[MOR]

The technical info is mostly fine, but the advice is nonsense. Have a look under "recovery techniques", where we are advised how to recover from a wake turbulence encounter - however this information contains the rider "Note that this technique is primarily designed for wake turbulence encounters for aerobatic aircraft manoeuvring in tailchase or dogfight conditions." WTF does that have to do with GA? The methods suggested could be quite dangerous for inexperienced pilots, particularly when you consider that earlier in the article, we are told that most Wake Turb encounters take place in the takeoff or landing phase, below 200'AGL. Nowhere in the article is there any advice on what to do if you encounter wake turbulence at low level during takeoff or landing, in a non-aerobatic aircraft with limited power. In other words, they have completely misread their target audience. Just another example of disconnection between the regulator and the operator.

BTW it isn't really that big a deal, most people will instinctively roll upright the quickest way. Trying to apply rehearsed recoveries in wake turbulence encounters is problematical!

[prospector]

Swedavia report recommendation 10.4 reads:

"The aviation safety goal is: that the civil aviation system takes all measures that would improve safety at reasonable cost, subject to the state meeting its minimum obligations under I.C.A.O.. Reasonable cost is interpreted as meaning that the cost to the nation is exceeded by the benefit to the nation"
--------------------------------------------------------------------------------------------------------------------------------
" 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"
---------------------------------------------------------------------------------------------------------------------------------
Have they achieved the safety goal, and has it been at reasonable cost??????

This report was lodged with The Minister of Civil Aviation April 1988, has it proven to be an effective Philosophy?? one would think the results show otherwise as far as the General Aviation sector is concerned.

Prospector

[pakeha-boy]

MOR.....now that Ms King in back in Godzone,...heads may roll...you never know..time to put your CV in mate?!!..PB

[Chimbu chuckles]

Sorry MOR but most people finding themselves inverted or nearly so the first time will, at lowish level, (below 1000') spear straight into the ground. Pushing forward to keep the nose up is not a normal, instinctive response. It feels uncomfortable and unnatural so 'most' people wont push hard enough nor use top rudder to help roll rate and hold the nose up passing through wings verticle.

Below 500' no-one short of a trained aerobatic pilot will get away with it...and maybe not even then.

The quality of and the way 'most' pilots wear their seatbelts suggests to me they would be lucky to retain enough control to have any positive effect.

As far as this accident is concerned I don't think the fact he was alone is the kicker. Training and standards are the issue...plenty of people have logged many 1000s of hours SP IFR and lived.

Just plain stupid was probably the biggest contributing factor.

[Cloud Cutter]

MOR, I completely agree.

I almost choked reading that wake turbulence article. Why describe a recovery technique and then disclaim that it doesn't apply to 99% of the audience. Better to focus on the avoidance of low level wake turbulence.

The CAA is clearly not doing their job, and now the government is starting to sit up and notice. Perfect time for all of us to lobby for change. What can we do?

[Speeds high]

What can we do?

Vote McGuilly Cuddy Serious Party!:\ :ok: