Deficiencies in operator's systems should have been spotted

Thursday, 23 May 2019

A helicopter recovers some of the wreckage from the crashed helicopter on Fox Glacier after the 2015 tragedy

OPINION: On Thursday the Transport Accident Investigation Commission released its final report into the November 2015 helicopter crash which claimed seven lives at Fox Glacier's Chancellor Shelf.

At times like this I'm reminded of the enormous personal toll fatal aircraft crashes take on victims' families, their communities, aircraft operators, and New Zealand's small, tight-knit aviation community.

In particular, my thoughts are again with the families this week as they relive the pain they first encountered in the days and weeks following the crash.

The Commission's long-awaited report makes for confronting reading, with its clinical account of what happened that fateful morning, as well as its critical findings around the operator's training and systems.

* Company director fined $64,000 four years after fatal Fox Glacier helicopter crash**

The report also makes it clear that the Civil Aviation Authority (CAA) did not do its job well enough in the lead-up to the crash, finding specifically that we had failed to intervene despite identifying 'significant and repetitive non-compliance issues'.

Shortly after I joined the CAA's board in April 2011 it became apparent that although the organisation did its best to oversee New Zealand's growing scenic tourist flight sector, it simply didn't have adequate systems in place and struggled to enforce minimum standards.

Since then the board and I have worked tirelessly to support the organisation in its Regulatory Craft Programme, which has been improving the CAA's systems, processes, training, and recruitment.

We have also been working towards a significant overhaul of the Authority's IT systems, which will include a state-of-the art aviation intelligence capability.

I believe that by November 2015, the CAA had already made significant improvements to how it conducted its oversight of the aviation industry.

But unfortunately the bulk of our interactions with the Fox Glacier helicopter operator occurred in 2011 and 2012, when the CAA conducted a number of inspections, and the business went through its re-certification process.

At that time, the CAA was less equipped to rigorously test the operator's safety systems, which should go above and beyond the minimum standards set by Civil Aviation Rules.

With the benefit of hindsight I can say that we should have placed more pressure on the operator to lift its safety performance. Ultimately the responsibility for setting appropriate safety systems lies with the operator, but we should have picked up on the deficiencies with this operator's systems.

In the days after the crash, the CAA launched its own investigation, quite separate to the commission's inquiry into the cause of the crash.

Our investigators sought to determine whether the helicopter operator had met its duties and obligations under New Zealand's health and safety legislation, as well as to identify whether the operator was safe to continue flying.

At first our inspectors concluded that the operation was safe to continue flying, but as we investigated further we became aware that there were discrepancies between what the operator was telling us and what our investigators were unearthing.

We also discovered that the operator had on multiple occasions misled CAA officers about matters that were relevant to its compliance with Civil Aviation Rules. In my view the CAA acted quickly and responsibly based on this information.

Our investigation led to the grounding of the operator's helicopter fleet, the suspension and revocation of its operating certificate, and a prosecution under the Health and Safety in Employment Act. The prosecution reached its conclusion last week in the Christchurch District Court with the conviction and sentencing of the operator and its quality assurance manager.

Since the Chancellor Shelf crash, the CAA has continued to make significant strides in the way it regulates New Zealand's aviation sector, but there is no room for us to be complacent and we will continue to view our oversight activities through a continuous improvement lens.

I firmly believe that New Zealand is a safe place for passengers to fly - whether on an A320 from Auckland to Wellington, or a helicopter on a scenic tourist flight.

Nigel Gould is the Chairman of the Civil Aviation Authority's board