Appendix 1: Coroner's recommendations

Responses to the Coroner's recommendations on the June 2003 Air Adventures crash.
  1. That the Minister of Transport consider some form of independent assessment of the CA[A] Act in relation to the General Aviation sector and its reliance on industry responsibility and self-regulation. (Paragraph 544)
  2. That the Minister of Transport review whether the law enforcement role currently carried out by the CAA should be separated from the safety enforcement management role. (Paragraph 548)
  3. That the CAA reviews the adequacy of existing Rules as to:
    1. Minimum Decision Altitude requirements for single pilot IFR; and
    2. minimum visibility requirements for making an instrument approach. (Paragraph 552)
  4. That the CAA examines the requirement as to reporting of Occurrences to ensure understanding and consistency of application. (Paragraph 555)
  5. That the CAA in conjunction with the Airways Corporation consider the adequacy of compulsory reporting of certain categories of Incident including where safety has been apparently compromised by the actions of the pilot of an aircraft. (Paragraph 557)
  6. That the CAA urgently review and upgrade single pilot IFR training and testing requirements, including night flying and flying in adverse meteorological conditions. (Paragraph 559)
  7. That the CAA considers the adequacy of Rule 61.37(c) in relation to instrument approach and use of autopilot. (Paragraph 561)
  8. That the CAA urgently review single pilot IFR processes, requirements and best practices, including the use of coupled approaches and the identification and assistance to pilots who demonstrate any difficulty in IFR procedures. (Paragraph 564)
  9. That the Minister of Transport give consideration to amending section 17 of the CA Act to empower the Director of Civil Aviation to immediately suspend a General Aviation Air Operator Certificate in the case of seriously adverse findings against the operator affecting safety of air operations, whether such findings are determined at audit or otherwise. (Paragraph 565)
  10. That the CAA review the adequacy of Rules for non-certified GPS systems in relation to instrument landings to ensure a pilot-in-command cannot use the GPS system in instrument approaches and consider amending the Rules to require non-certified GPS systems to be disengaged before a pilot commences an instrument approach. (Paragraph 567)
  11. (To the Minister of Transport): That consideration be given to the feasibility and desirability of establishing an independent confidential air safety incident reporting system in New Zealand taking account of previous difficulties with the system known as Icarus, and/or an office of aviation ombudsman. (Paragraph 575)
  12. That there be a mandatory requirement for a mechanism of passenger complaint for passengers on commercial flights in the GA sector. (Paragraph 578)
  13. That the CAA give close consideration to Dr Sharples’ submissions and sources in considering outcomes from this inquest with particular reference to mandatory reporting of colleagues where aviation practice falls below acceptable professional standards. (Paragraph 581)
  14. That the CAA adopt a lower threshold than was apparent from the evidence at this inquest with respect to the activities of Air Adventures and Mr Bannerman, to toleration of deviation from the Rules that affect the safety of passengers. (Paragraph 582)
  15. That consideration be given to the CAA Rules being amended with respect to GA operators and pilots operating in the GA sector, to introduce a system of “demerit points” to take account on a cumulative basis (with appropriate time limitation periods) of any history of non-compliance with the Rules by the operator or, as the case may be, the pilot. (Paragraph 583)
  16. That the CAA gives consideration to implementing a system whereby consumers can gauge the safety record of an operator. (Paragraph 586)
  17. (To the Minister of Transport): That the Offences Regulations under the CA Act be reviewed, and wherever possible, be amended with every Rule change. (Paragraph 588)
  18. That the CAA strengthens the criteria for requiring dual pilots for flights with fee-paying passengers. (Paragraph 590)
  19. That the CA Act and/or the Rules be amended to allow for all Occurrence Reports, ARCs and safety information relevant to a pilot and/or an operator, to be made available to the Flight Examiner of that pilot or any Instructor conducting type rating training carrying out competency checks. (Paragraph 595)
  20. That the CAA implement a process of monitoring the individual pilot, separate from monitoring the operator, from a competency and safety perspective. (Paragraph 598)
  21. To monitor more effectively the safety of the General Aviation sector that the CAA obtain independent verification of all flight test results as they happen. (Paragraph 600)
  22. That the CAA take steps to encourage, where possible, Flight Crew Competency Checks for an individual pilot over a period to be carried out by different Flight Examiners. (Paragraph 602)
  23. That the CAA further consider and improve the effectiveness of its surveillance system for operators and pilots in the GA sector and give consideration to the merits of the information being made available to the operator. (Paragraph 605)
  24. That the CAA require operators with three or less aircraft operating from two or less bases to have a simple form of organisational management system which reflects the reality of the operation and reflects safe practices. (Paragraph 607)
  25. That the CAA be empowered to investigate the financial viability of an operator’s business, where the CAA has reasonable belief that the safety of the operation could be compromised. (Paragraph 609)
  26. That the CAA Rules requires all aircraft providing passenger air transport services, be fitted with appropriate safety warning devices and other up-to-date instruments, regardless of the age of the aircraft. (Paragraph 611)
  27. That the CAA reviews the MEL process to ensure the adequacy of the process to require safe, up-to-date and operable instruments for flights with fee-paying passengers. (Paragraph 612)
  28. That autopilots be subject to regular functional tests to ensure their reliability for all purposes. (Paragraph 614)
  29. (i) That the CAA implement measures to enforce the provisions of Rule 91.7(a) with respect to IFR flights; (ii) that the CAA consider Rules as to any pilot-in-command or co-pilot having a cell phone in his or her possession in the cockpit of an aircraft during flight. (Paragraph 616)
  30. That Crop and Food review its travel policy and procedures taking account of appropriate advice and add to that policy that air travel be through Airline sector operators (first priority) and if that is not possible, that it be in dual pilot aircraft. (Paragraph 620)
  31. (To the Minister of Transport and to the Commissioner of Police): That the circumstances of the search for ZK NCA and the response of emergency services as set out in Inspector Cairns’ report (exhibit 123) and Section 10 of these Findings (including the map of the search area with timings of significant events included as an annexure to the Findings) be considered as the basis of a case study for Airport Authorities other than Christchurch, and SAR personnel. (Paragraph 626)
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