Investigations – Civil Aviation, Investigate magazine and Coroner Mori

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.


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