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Inquiry into civil flying training safety

Inquiry report published - March 2013

 
The inquiry report is available in .pdf from this page.

Inquiry update - July 2011

The Commission received more than 50 submissions which have now been analysed. Meetings continue to be held at investigator level with the submitters, or groups of submitters, and the current intention is that some key parties may be invited to attend a meeting with Commissioners in the next few months to discuss their views and answer questions.

Call for submissions

The Transport Accident Investigation Commission (the Commission) is inviting public submissions as it examines civil flying training safety in New Zealand. Any individual or organisation may make a submission.  Submissions close at midday on Monday, 21 February 2011.

(You may download this .pdf file of this page for offline use, but it is preferred that you download and use the Microsoft Word submission template as detailed in "Making a submission", below, if wanting to make a submission.)

Inquiry context

This inquiry will support the Commission’s current investigations into a fatal mid-air collision near Feilding in July 2010 and a mid-air near-collision near New Plymouth in May 2010. It also follows a significant increase in the number of midair collisions and near-collisions over the past 10 years of which nearly half have involved pilots undergoing training, including some with instructors on board. The Commission has become concerned that systemic or widespread matters may be affecting training safety. More background information is at Annex A. 

Submissions invited

The Commission is inviting public submissions, including from flying training industry participants, on matters related to civil flying training safety in New Zealand which may help it to understand the industry safety-related characteristics and issues, to substantiate any safety matters of concern, and to make findings and recommendations as may be appropriate.
 
Submissions should address the following terms of reference. The:
  • standard of flying instruction
  • standard of training of flying instructors
  • experience levels of instructors (both training industry experience and flying hours)
  • formal and informal management of flying training in controlled and uncontrolled airspace
  • radio communications related requirements, training and practice
  • submitters knowledge of, or any evidence-based comment on, midair collisions, near-misses and other flying training accidents, incidents or occurrences since 2000 related to flying training safety regardless of whether these were reported or subject to investigation, by the Commission, Civil Aviation Authority, or a sport flying body.
  • other matters which submitters consider directly relevant to the inquiry into civil flying training safety, including:
    • business (including not-for-profit) or industry dimensions
    • tertiary education environment
    • regulatory environment
    • other matters
The inquiry is concerned with flying training towards the issue of any Civil Aviation Authority pilot licence.

Making a submission

Submissions must be made in writing. They may address any or all of the terms of reference, above.
 
The preferred form of submissions is to download, complete and return by email this electronic Microsoft Word submission template to submissions@taic.org.nz. The template includes a cover sheet for submitter details and a table for submission content. The template is in .doc format; submissions may be provided in .doc or .docx or any Microsoft Word compatible format.  Providing a submission this way will simplify writing for submitters and the analysis and consideration of submissions by the Commission. 
 
Submitters may choose to include a .pdf of the finished submission, or to mail or fax in a hard copy if they want the Commission to have an non-editable “as received” version of the submission in addition to the emailed Microsoft Word (or compatible) version. The Commission’s postal address and fax number are given below.
 
Submitters may choose to provide a separate covering letter emphasising key points or introducing the general themes of their submission, but this is optional. Written submissions which do not use the electronic document will be accepted, but it would be appreciated if these could be structured to deal with one issue at a time, and to cover off the same information as sought by the cover sheet and table as may be applicable to the submitter or content. 
 
Submitters may ask to make oral submissions at a private or public hearing, but the Commission will decide if and who it is to invite to make oral submissions upon review of submissions received. Because there is no guarantee of oral submissions being heard written submissions should be comprehensive. If oral submissions are invited, then those submitters will have the option of presenting them to a Commission hearing in person or by telephone. Any submission hearings will be in Wellington, unless numbers/logistics suggest another location(s) is/are also desirable. The Commission will not cover travel costs, but it will pay for telephone calls.
 
Submissions must be received before midday, Monday, 21 February 2011. 

After submissions close

Each submission received will be acknowledged by email or letter sent within one working day of receipt (but not before 10 January 2011).
 
After submissions close and have been reviewed the Commission will determine whether to:
  • invite any submitters to present orally;
  • invite further submissions on any matter(s) from any particular individual or organisation, segment of the flying training industry, or the general public;
  • issue any report in respect of the submissions ahead of or separate to its specific accident inquiries.
In considering the submissions and other evidence presented to its inquiry the Commission will be concerned to maintain “natural justice” rights for any individual or organisation that may be identifiable in its final report(s) as the subject of adverse comment directly or if this could be inferred by report readers. These rights will generally be recognised by providing an opportunity to such individuals or organisations to provide evidence to the Commission or to make submissions on a confidential draft of its report which the Commission will then take into consideration in finalising its report for publication.
 
The Commission anticipates completing its inquiry by 30 September 2011, subject to the time needed to consider submissions received and to investigate matters raised in them, as well as unrelated demands on the organisation.

Protection of evidence

The Commission’s published reports cannot be used in regulatory, criminal or civil proceedings (although they may be produced to assist a Coroner’s inquest).
 
The evidence the Commission gathers for an inquiry (including written submissions) is protected from general disclosure except for the purposes of the investigation (which might include information derived from a submission appearing in a published report).
 
Submitters, witnesses, and event participants are mentioned by role (not name) when necessary for an inquiry report. Similarly, ‘who said what’ and direct quotes are only included when essential.
These protections make it easier for people and organisations to contribute freely and frankly to a Commission inquiry.
 
You may provide the same information which you have given to the Commission to others as you choose, but information so distributed has no protection under the Commission’s legislation.
 
This section has been extracted and adapted from “Providing evidence to a TAIC inquiry
 

The Commission

The Commission is established under the Transport Accident Investigation Commission Act 1990 as a Standing Commission of Inquiry, with powers under the Commissions of Inquiry Act 1908. It is an Independent Crown Entity under the Crown Entities Act 2004, making it free from Government direction in respect of the conduct of inquiries it opens. It may also examine matters of Government policy and agency performance in the course of its inquiries. 
 
Further information about the Commission is available.

For further information or to contact the Commission

Flying Training Inquiry
Transport Accident Investigation Commission
L16, Axa Centre, 80 The Terrace
PO Box 10 323
Wellington 6143
 
T 64 4 473 3112 or 0800 188 926
E submissions@taic.org.nz
F 64 4 499 1510
W www.taic.org.nz

Urgent matters of flying training safety

Urgent advice of new accidents, incidents, or other safety matters should be reported through the appropriate Civil Aviation Authority (the Authority) mechanism and not to the Commission or solely by way of submission to this inquiry (although submitters may mention such matters). Guidance on which matters to report and how is on the Authority’s website

Annex A – Flying training accident and incidents – further background

The following recent incidents and accidents have occurred while flight instruction was being given:
 
TAIC investigated:
  • 2 Dec 06, power loss, 30km west Waipukurau, B Cat’ [Instructor rating] (06-006) [Inquiry/report number]. The instructor ran 1 engine dry then mis-selected the fuel supply causing the 2nd engine to fail, resulting in a forced landing. No injuries.
  • 26 Oct 07, impact with terrain, Te Urewera, C Cat’ (07-011). The aircraft entered a narrow and steepening valley from which it was not possible to escape. The instructor was killed and the passenger received serious injuries.
  • 17 Feb 08, midair, Paraparaumu, A Cat’ (08-001). A light aeroplane being flown by a student pilot and a light helicopter being flown by an instructor and student collided. All 3 pilots were killed.
  • 9 May 10, near miss, New Plymouth, A Cat’/B Cat’ (10-005). Near-collision of a light aeroplane with instructor and student on board and a light helicopter with an instructor and student on board.
  • 26 Jul 10, midair, Feilding, B Cat’ (10-008). Mid-air collision of two light aeroplanes, one with an instructor and student on board who both died and the other with a student who survived uninjured. 

CAA investigated:

  • 5 Dec 03, impact with terrain, near L. Wakatipu, B Cat’. The light aeroplane crashed while the instructor was training a student in mountain flying. The instructor was killed and student seriously injured.
  • 12 Jul 10, impact with terrain, Ruahine Ranges, C Cat’. The light aeroplane entered a valley from which escape was not possible. Both instructor and student were injured.
Other recent midair collisions:
 
TAIC investigated:
  • 25 Nov 93, midair collision, Auckland (93-020). A Police helicopter and light aeroplane on traffic patrol collided killing the 4 occupants.
CAA investigated:
  • 8 Feb 06, midair, Shannon, Manawatu. Two light aeroplanes being flown solo by student pilots collided killing both students.
Other recent flight training accidents include:
 
CAA investigated:
  • 16 Jan 08, impact with terrain, Cass Saddle, Canterbury. Two student pilots were killed when their aeroplane impacted terrain while low flying.
(The above lists are not exhaustive.)
 
The following is an extract from: Interim Factual Report 10-008 – published Thursday, 30 September 2010
Cessna C152 ZK-JGB and Cessna C152 ZK-TOD, mid-air collision, near Feilding, Manawatu, 26 July 2010.
 
1.4. History of mid-air collisions and near misses in New Zealand
 
1.4.1. On 8 February 2006, 2 aircraft collided near Shannon in the Manawatu, resulting in the deaths of both student pilots. On 17 February 2008, 2 aircraft collided overhead Paraparaumu Aerodrome resulting in the deaths of the 1 instructor and 2 student pilots. Like the earlier accident, both aircraft were engaged in flight training activities at the time of the collision. The Commission’s investigation of the 2008 accident determined that the pilots of both aircraft had been following recognised procedures and had made radio transmissions at the appropriate time, but did not locate and avoid the other.
 
1.4.2. Initial Civil Aviation Authority data showed that recorded pilot training hours have doubled in the last 15 years to nearly 300 000 hours per year. A review of the accident and incident data showed that the reported number of near misses has increased significantly in the last 5 years (see Figure 3). The increase in reported near misses involving training aircraft has been more pronounced. The total number of reported near misses for the period 1990 to 1999 was 17, with 3 of these involving training aircraft. For the period 2000 to date, the total number of reported near misses has increased to 131, while the number involving training has increased to 60.
 

 
All Fatalities
Training Fatalities
All Collisions
Training Collisions
Near Misses
Training Near Misses
1990
1
0
2
0
0
0
1991
0
0
1
0
0
0
1992
1
0
1
0
0
0
1993
4
0
1
0
1
0
1994
0
0
0
0
1
0
1995
0
0
1
1
0
0
1996
0
0
0
0
0
0
1997
0
0
0
0
8
2
1998
0
0
0
0
5
1
1999
0
0
1
0
2
0
2000
0
0
0
0
7
2
2001
0
0
2
0
4
1
2002
0
0
0
0
7
3
2003
0
0
0
0
8
3
2004
0
0
0
0
6
4
2005
0
0
0
0
11
1
2006
2
2
1
1
9
5
2007
0
0
2
1
10
3
2008
3
3
1
1
26
18
2009
0
0
0
0
23
14
2010
2
2
1
1
20
6
1990-1999 Total
6
0
7
1
17
3
2000-2010 Total
7
7
7
4
131
60
Grand Total
13
7
14
5
148
63

 
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