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


In 1997, we carried out a performance audit that identified some serious problems with the standard of the safety audits done by the Civil Aviation Authority of New Zealand (the CAA). Two follow-up audits in 2000 and 2005 established that, while the CAA had made progress by 2005, we still had significant concerns with its certification and surveillance functions.

On 6 June 2003, an aircraft crashed on approach to the Christchurch International Airport, killing the pilot and seven passengers, and two passengers received serious injuries.

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

  • 24 needed to be addressed by the Civil Aviation Authority;
  • 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. We are following up on this recommendation separately with the New Zealand Institute for Crop and Food Research.

Our audit

We have assessed, at the Minister of Transport’s request, whether the CAA and the Ministry had properly considered the Coroner’s recommendations. We looked at whether they took timely action based on that consideration, and reported accurately on their progress.

We intended to follow up on our own recommendations, made in 2005. However, the CAA had not had its new certification and surveillance systems in place long enough for us to audit them. Instead, we have looked at whether the systems have the potential to address our recommendations. Later in 2008, we will audit the CAA again and see whether the systems have improved the CAA’s approach to certification and surveillance.

Our conclusions

Overall, the CAA and the Ministry responded systematically to the Coroner’s recommendations. The process used to examine each recommendation, and the range of information used by the CAA and the Ministry in forming their conclusions, provides evidence that each of the Coroner’s recommendations was properly considered. Most were responded to in a timely manner.

The CAA’s process for monitoring its response to each of the Coroner’s recommendations was robust. The Ministry could have better managed the process it used to monitor its own progress to ensure that it completed its responses. The Ministry’s process for monitoring the CAA’s progress in responding to the Coroner’s recommendations should have been more comprehensive.

We were not satisfied that the Ministry adequately considered the need for an independent review of the CAA’s responses.

The Civil Aviation Authority’s response to the Coroner’s recommendations

Of the 24 recommendations the CAA was responsible for, the CAA:

  • accepted and completed (or was still taking action to complete) 11;
  • concluded that nine were already addressed through the current aviation rules or international standards; and
  • had not accepted four but had carried out alternative action in those areas.

The Civil Aviation Authority assigned responsibility for the recommendations to qualified personnel. The recommendations were assessed by the CAA’s executive management team (the Executive), and most of the recommendations were assigned to a small project team headed by the retired Deputy Director of Civil Aviation.

The Executive monitored the project team’s progress, and progress against “target dates” was regularly reported on the CAA’s website. The Executive and the Board reviewed the project team’s response before it was accepted, and decisions about responses to the recommendations were documented and supported by appropriate evidence.

The Ministry of Transport’s response to the Coroner’s recommendations

Of the six recommendations the Ministry was responsible for, the Ministry:

  • implemented two;
  • concluded that one was covered by the existing legislation; and
  • decided not to implement the remaining three.

In one case, two previous studies had found the safety regulation framework to be sound and consistent with international good practice. In the second, changes the CAA had initiated since the Coroner’s findings were published put the CAA in a better position to manage its business as the Coroner intended. In the third case, the Ministry carried out a cost-benefit analysis that did not support setting up a Confidential Incident Reporting Scheme at this time.

The Ministry assigned responsibility for the recommendations to qualified personnel, and decisions about responses to the recommendations were documented and supported by the appropriate evidence. The Ministry’s process in monitoring the CAA’s progress should have been more comprehensive.

Although the Minister had been briefed about progress on three of the six recommendations, the Ministry did not provide the Minister with a final briefing until February 2008.

The Ministry did not monitor proactively enough the timeliness of its own action or the timeliness of the CAA’s performance against its project plan. A planned review of progress after three months by the Ministry’s internal auditors was not commissioned. It did not carry out any independent assessment to ensure that the CAA was taking appropriate action.

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