CAA admits safety inspection capability was low at time of fatal 2015 Fox Glacier chopper crash, inspectors were 'too trusting'

May 20, 2019

The 2015 crash killed seven people.

The aviation watchdog has acknowledged that its oversight of the helicopter industry was not up to scratch at the time of the 2015 Fox Glacier crash, which killed seven people.

On November 21, 2015, an AS350 Squirrel helicopter crashed after taking off from the Chancellor Ice Shelf at the top of Fox Glacier, killing the pilot and six international tourists on board.

On Friday, James Patrick Scott and Aviation Manual Development were convicted over health and safety failings in the lead-up to the crash, with Mr Scott receiving a fine of $64,000.

CAA Chairman Nigel Gould said inspectors had failed to verify safety compliance for themselves.

The Transport Accident Investigation Commission (TAIC) has been investigating the cause of the crash, and is due to release its findings on Thursday.

At a media conference today, CAA Chairman Nigel Gould said that, now the court case had been settled, the CAA was able to reveal more about what it had done to improve since 2015.

Mr Gould first said the delay of several years between the crash happening and an investigation being completed was not to his liking, and apologised to family members of the victims.

Recovery workers had an hour window to recover those killed in a helicopter crash.

He went into the process of the CAA's inspection of Scott's business following the crash, saying that initially they had concluded it was safe for them to continue flying, but that as time went by "we became aware that there were discrepancies between what the operator was telling us and what our investigators were unearthing.

"Our formal investigation revealed that the operator had a poor safety culture, with significant shortcomings in its management and systems," Mr Gould said.

"We also discovered that the operator had previously on multiple occasions misled CAA officers about matters that were relevant to its compliance with Civil Aviation Rules.

"Our investigation concluded that JP Scott and AMD did not take all practicable steps to prevent employees and passengers being harmed."

Mr Gould said an internal review on the CAA's response to the accident was then undertaken in 2017, designed to identify shortcomings in their regulatory processes prior to the crash.

"This revealed that the way our inspectors documented their interactions with this helicopter operator were inconsistent," Mr Gould said.

"Non-compliances had not always been formally reported as 'findings' - inspectors were also too trusting and did not verify the information being given to them.

"With the benefit of hindsight we can say that our oversight of JP Scott should have been better - if it was, we would have placed more pressure on the operator to lift their safety performance."

Mr Gould stressed that the Authority has now substantially changed the way it trains inspectors, with a strong focus on rigorously reporting findings and asking for proof of compliance, rather than relying on assurances.

He also said that "the majority of staff who were involved in the oversight of JP Scott's operation have since moved into other employment".

Mr Gould said PricewaterhouseCoopers had been retained to audit all of the CAA's inspections between 2014 and 2018, which had revealed some "inadequate" evidence gathering by inspectors during the early part of that period.

He ended by saying he now has full confidence in the CAA's inspection and regulatory systems, adding that there has been a decline both in scenic helicopter flight accidents since the 2015 crash, and the number of CAA prosecutions brought against non-compliant operators.

"The CAA of 2019 is a considerably more effective regulator than when we conducted the oversight of J P Scott in the years leading up to the 2015 crash."

CAA Deputy Director Steve Moore said the number of CAA inspectors on staff had been quadrupled - from two up to eight - since the 2015 crash, and that all inspectors had been giving addition training in "critical thinking, problem solving and using judgement.

"A requirement has also been introduced for operators to have a formal system for safety management - this squarely puts the onus on operators to identify safety risks unique to their business and then prove to the CAA how they are managing those risks," Mr Moore said.

"This takes them beyond just complying with the rules."

OVER-WORKED INSPECTORS MAY HAVE BEEN AN ISSUE

New Zealand has the highest number of helicopters per capita in the world - about 900 helicopters and 100 operators - and about half of those helicopters operate in the tourism industry.

Mr Moore admitted that the fact there were only two inspectors to check on the compliance of that fleet "might have been a factor in the scrutiny that they were providing on the operators".

He also admitted the inspectors which worked for the CAA prior to the crash had not been fired from the Authority, but had left for other reasons - before Mr Gould interjected and said the CAA could not comment on employment arrangements for privacy reasons.

Mr Gould said that there had been a significant shortage of appropriately skilled inspectors, but that shortage has now been addressed.

"We had a difficulty filling some roles," he said.

"We were aware of the fact that we were having difficulty in maintaining a capability in that area."

Mr Gould said that he had disclosed the level of vacancies in the Authority to "appropriate Parliamentary committees" and through annual reports.

Footnote: CAA has since clarified it has five flight operations inspectors on staff. It has recently hired another inspector and has two vacancies. It has funding for eight positions.

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