Recommendation Date
Recipient Name
The CAA said that it had put in place changes in policy and training for its inspectors by February 2014. Leading up to that date, and afterwards, CAA inspectors had overlooked significant non-compliances by the operator of the helicopter at Fox Glacier and they had not raised findings on matters of non-compliance with Civil Aviation rules.

In this case the CAA had had good cause and ample opportunities to intervene at an early stage. Instead the operator was allowed to continue, with little change to improve its systems. Those systems put the pilot in a position of responsibility that the pilot was not sufficiently trained or experienced for.

The Commission is concerned that there could be a wider safety issue whereby other Part 135 operators that were in the civil aviation system during the same period could have significant non-compliances that have either not been identified or not been resolved.

On 21 February 2019 the Commission recommended that the Director of Civil Aviation initiate an independent review of CAA surveillance reports and any findings raised for Part 135 operators since 2014 to measure the effectiveness of the surveillance policies and procedures that the CAA has put in place, including the effectiveness of their implementation. If the independent review finds unidentified or unresolved safety issues with specific operators, it is recommended that the Director of Civil Aviation take the appropriate urgent action to resolve those issues.
Reply Text
The CAA undertook its own investigation into this crash and subsequently successfully prosecuted the operator for not taking all practicable steps to ensure the safety of its pilot and his passengers. Participants in the aviation system have a responsibility to maintain compliance with regulatory requirements and this operator failed to do that.

The CAA investigation also identified that its safety oversight of this operator in the period leading up to the accident – particularly during the period 2010-2012 – didn’t meet its own standards. In summary, it lacked the rigour demanded by its policies and procedures.

The analysis of those shortcomings was conducted in early 2017 and it was concluded that the work already underway to improve the CAA’s regulatory performance (the start of which is referred to by the Commission in its recommendation) was addressing the deficiencies observed in the dealings with this operator. Since initiating that work in mid-2013 the CAA has made significant changes to improve its regulatory performance and oversight of aviation system participants, and this work continues. Significant capability building initiatives have been implemented and further initiatives will continue to be progressed as the CAA works to further enhance its performance and regulatory oversight. As a result of the work undertaken to date, and that currently in progress, the CAA of 2019 is a much more effective regulator than the one that was dealing with this operator in the period leading up to the 21 November 2015 crash.

The CAA has already commenced implementation of the Commission’s recommendation. PriceWaterhouseCoopers (PwC) was appointed to undertake the independent review, which will sample 200 inspection activities conducted over the period 1 January 2014 to 1 December 2018. At the time of writing, the PwC review was well advanced but was not yet complete. The work done to date has not identified any operators with significant non-compliances that have either not been identified or not been resolved. The independent review is expected to be completed by 31 March 2019 and the report will be made available to the Commission as soon as it is available.
Related Investigation(s)