Part 1: Introduction

Responses to the Coroner's recommendations on the June 2003 Air Adventures crash.


The Civil Aviation Authority of New Zealand (the CAA) was set up on 10 August 1992 by an amendment to the Civil Aviation Act 1990 (the Act). The CAA’s functions include:

  • promoting civil aviation safety and security; and
  • promoting civil aviation security beyond our borders in accordance with New Zealand’s international obligations.1

The Coroner’s recommendations

On 6 June 2003, a Piper Navajo Chieftain aircraft operated by Air Adventures New Zealand Limited crashed on approach to Christchurch International Airport in darkness and thick fog. The pilot and seven of the passengers died, and two passengers received serious injuries. The Coroner conducted an inquest into the deaths, with hearings held in July 2003, September to December 2004, and June 2005.

The Coroner released his report on 30 May 2006. The report raised a number of concerns about the general aviation sector (smaller planes, agricultural operators, and helicopters) and about the regulation of that sector. The report contained 31 recommendations, of which:

  • 24 needed to be addressed by the CAA;
  • six needed to be addressed by the Minister of Transport, through the Ministry of Transport (the Ministry); and
  • one required the New Zealand Institute for Crop and Food Research to review its internal travel policy.

Appendix 1 lists the Coroner’s recommendations.

Our performance audits of the Civil Aviation Authority

We carried out a performance audit in 1997 that identified some serious problems with the standard of the CAA’s safety audits. Two follow-up audits in 2000 and 2005 established that, while the CAA had made progress by 2005, we still had significant concerns with the certification and surveillance functions.

Our 2005 report contained 10 recommendations for the CAA. They are listed in Appendix 2.

Civil Aviation Authority’s projects to improve certification and surveillance

In 2004, the CAA launched two major projects: the Surveillance Review Project and the Risk Assessment and Intervention Project. The objective of these projects was to improve the efficiency and effectiveness of the surveillance process. A further project, the Certification Project, began in 2005 to improve processes for initial certifications and renewals.

We have met regularly with the CAA to monitor the progress that it has made in implementing the projects.

Changes to the original intent of our audit

We intended to carry out a follow-up audit on the CAA’s response to the 10 recommendations in our 2005 report. However, the CAA did not implement its redeveloped certification and surveillance systems, which are part of its response to our recommendations, until the beginning of May 2007. The final version of the system software was introduced in February 2008. The CAA’s surveillance staff have not yet carried out enough audits and follow-up actions for us to test a representative sample. Therefore, we have agreed with the CAA to delay this work until later in 2008.

However, in July 2006, the Auditor-General agreed to a request from the Minister of Transport to check, as part of our audit, whether the CAA and the Ministry had taken action to address the Coroner’s recommendations. Therefore, this audit has:

  • examined the responses of the CAA and the Ministry to the Coroner’s recommendations;
  • looked at the design of the new certification and surveillance systems;
  • assessed whether they are likely to address the recommendations in our 2005 report; and
  • established the expectations we will use to audit the CAA later this year, when there will be enough data available for us to properly assess the CAA’s response to our recommendations.

Scope of this audit

We have examined the responses of the CAA and the Ministry to the Coroner’s 30 recommendations that were to be addressed by either the CAA or the Ministry. We have formed a view on whether the recommendations were properly considered, and if the CAA and the Ministry took timely action based on that consideration. We also looked at whether the CAA and the Ministry reported accurately on their progress in responding to the recommendations.

We have not formed a view about whether a particular response was the right response to make, because doing so would require aviation expertise. We did not seek independent advice from aviation experts because judging the responses was not the focus of our audit. Our audit sought to provide assurance that the recommendations had been properly considered, acted on in a timely way, and reported accurately.

Where appropriate, we established whether the actions taken in response to the Coroner’s recommendations were in line with international practice in the aviation industry by checking the New Zealand standards against the relevant international standards.

The Coroner’s recommendation that required the New Zealand Institute for Crop and Food Research to review its internal travel policy did not pertain to the ongoing safety of the civil aviation sector. Although we have focused on the CAA and the Ministry, we were interested in whether all 31 of the Coroner’s recommendations had been responded to. We are following up separately with the New Zealand Institute for Crop and Food Research about whether it has properly considered the Coroner’s recommendation and taken timely action to respond to it.

1: Section 72B of the Civil Aviation Act 1990.

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