Coroner’s Final Report

November 16, 2008

coroners-final-report may be downloaded here. It is critical of CAA and of WAW. Since the report has been released little has happened and releases by CAA suggest they believe all is and was under control. The Coroner’s tough message has certainly fallen on deaf ears in certain quarters. There has however been a number of articles in Wings and while a number there are trying to reinforce the Coroner’s message it is clear many in the field have little understanding of the nature of aviation fatigue and see the Coroner as another armchair critic. That is very sad for the pilots who have been killed: apparently the old ‘pilot error answers all’ is still the position of many.

Investigations – Civil Aviation, Investigate magazine and Coroner Mori

November 27, 2006

Civil Aviation Investigation

The CAA accident report for this accident can be found here
Other CAA fatal accident reports can be found here
The practice is that CAA investigate fatal topdressing accidents, but that decision rests with the Transport Accident Investiagtion Commission (TAIC) through their Act.
CAA accident reports are posted on the internet and they do not provide hard copies to libraries whereas TAIC do not post their accident reports on the internet and provide only hard copies, which can be access in public libraries.
While the CAA practice allows easy public access it also allows CAA to alter their reports after initial publication and even after presentation to a coronial inquest leaving no public trace of the original report.

Investigate Investigation
Neill Hunter also did a thorough investigation which was published in Investigate Magazine of March 2005. The title of the article was ZULU KILO DOWN and it showed inadequacies in the CAA report, the first coronial inquest and the problems with agricultural aviation in New Zealand.
A link to that article may be found here

First Coronial Inquest
The first coronial inquest was held in New Plymouth on 13 October 2004 before Coroner Roger Mori. The inquest was over in about an hour. Few had been advised of the inquest, contrary to the requirements of the 1988 Coroners Act. The company – Wanganui Aero Works – and the loader driver’s family found out by accident and so were able to attend. The family of the pilot never found out until after the inquest. The coroner did not allow the mother of the loader driver to present her evidence, evidence which conclusively showed the CAA report to be wrong on the crucial matter of flying hours preceeding the accident.
Coroner Mori delivered his findings at the time

The first two of his four recommendations refer to fatigue. They are :
1. Aerial top dressing carries significant inherent dangers, especially in Taranaki where the terrain is generally hilly. It is important that both employer companies and pilots exercise extreme care at all times. In particular, pilots should see that they are in tip top condition while in control of an aircraft. They should monitor their own physical and mental conditions. If they feel overtired they should cease operations for that day.
2. Companies employing top dressing pilots should have in place rules which ensure pilots do not operate when they are fatigued.

The third referred to carriage of a passenger

3. Top dressing pilots should not carry out aerial top dressing operations while carrying a passenger.

The fourth reiterated a CAA recommendation

4. I repeat Mr Buckingham’s [CAA investigator] suggestion that the emergency locator transmitter should be located on agricultural aeroplanes to the aft position of the fuselage, rather than in the cockpit area.

Regarding the fatigue recommendations CAA responded in April 2005 that Part 137 of CARules (Agricultural Aircraft Operations) is currently under review and one of the items for review is to require Part 137 operators to have in place a fatigue management plan.
In the event that did not happen.

What this site is for

November 26, 2006

On 4 April 2003 a topdressing plane, ZKLTF, crashed East of Stratford near Strathmore Saddle on the forgotten highway killing both the pilot and the loader driver.

Subsequent investigations have shown systemic problems with safe topdressing operation in New Zealand.

This site is here to open up the discussion to a wider audience and invite comments and insights with an aim to improve safety.