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Aviation Safety Recommendations

This page displays a list of safety recommendations that relate to the aviation mode.  You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.

Urgent safety recommendations

Urgent safety recommendations released publicly in advance of a final report are available here until release of a final report at which time they are incorporated into the database.

 

 

Keywords: Recipient: Mode: Status:

Safety Recommendation 009/17
Issued To CAA on 28 Jun 17
A safety issue identified during the inquiry was the widespread practice of allowing passengers to leave and return to helicopters parked on snow while the rotors are turning. Frequently the pilot will also disembark to guide the passengers while they move under the main rotor disc. There is a serious risk to people on the ground if a helicopter has settled into fresh snow or it breaks through an apparently hard surface crust. Should this happen the clearance between the rotor disc and people walking beneath could reduce sufficiently for someone to be struck by the rotor blades.

On 25 May 2017 the Commission recommended that the Director of Civil Aviation ensure that helicopter operators who conduct snow landings address in their safety management systems the hazard of passenger disembarkation and embarkation during those landings while the rotors are turning.
Implementation Status: Open
Reply: In accordance with the provisions of Civil Aviation Rules Part 119: Air Operator - Certification, helicopter operators have until 1 February 2021 to introduce a Safety Management System. Given that timeline, the Director accepts the recommendation and will ensure that when operators' Safety Management Systems are certificated all significantr aviation risks are identified and managed.

Safety Recommendation 019/17
Issued To CAA on 28 Jun 17
The medical practitioners associated with the care of the instructor, and many of the others spoken to during the course of the investigation, were unaware of their obligations under the Civil Aviation Act to inform the CAA about a licence holder who has a known or suspected medical condition that may affect their ability to conduct their duties safely. Despite the efforts of the CAA, this lack of awareness of the Civil Aviation Act appears to be wider than just among those involved with this case.

On 28 June 2017 the Commission recommended to the Director of Civil Aviation that he improve the mechanisms for informing medical practitioners of the requirement to report to the CAA any health issues with a CAA licence holder that may interfere with that person?s ability to exercise the privileges of their licence safely.
Implementation Status: Open
Reply: Notwithstanding past and ongoing effort to educate medical practitioners about their duty to report to the CAA any health issues with a CAA licence holder that may interfere with that person's ability to exercise the privileges of their licence safety it is acknowledged this activity needs to be ongoing and the results of the Commission's investigation highlight this need. Accordingly this recommendation is accepted and the work will continue on an ongoing basis. As this educational work will need to be enduring in its nature and will be undertaken on an ongoing basis it is not practicable to specify a final implementation date. In conducting this ongoing work will we however review the manner in which we have sought to educate medical practitioners in the past and look to identify additional pathways that may be complimentary to those previously used. This review will be completed by 1 December 2017.

Safety Recommendation 020/17
Issued To CAA on 28 Jun 17
Section 27C(1) of the Civil Aviation Act requires medical practitioners to inform the Director if they believe a person is a licence holder and is aware, or has reasonable grounds to suspect, that the licence holder has a medical condition that may interfere with the safe exercise of the privileges to which the licence holder's medical certificate relates.

The Civil Aviation Act defines a medical practitioner as a health practitioner who is registered as a practitioner of the profession of medicine. This does not recognise that other health professionals (as defined in the Health Practitioners Competence Assurance Act 2003) may be providing care to a licence holder. Other health professionals, such as psychologists, could know, or become aware of, a CAA licence holder having a medical condition that may interfere with the safe exercise of the privileges of their licence.

On 28 June 2017 the Commission recommended the Director of Civil Aviation consider measures to ensure that other appropriate health practitioners, not included under the current definition in the Civil Aviation Authority Act, notify the Director when they are aware, or have reasonable grounds to suspect, that the holder of a CAA licence has a medical condition that may interfere with the privileges to which their medical certificate relates.
Implementation Status: Open
Reply: We recognise the basis for this recommendation and the outcomes the Commission is seeking to achieve. We are supportive of these. However changes to the Civil Aviation Act 1990 (the Act) would be required to support any effective measures aimed at implementing the recommendation. The Act is administered by the Ministry of Transport. As such, any recommendation for a change to the content of the Act should be made to the Secretary for Transport.

Safety Recommendation 021/17
Issued To CAA on 28 Jun 17
The medical examiner did not, and saw no reason to, contact the instructor's GP as part of the medical assessment process. Had he done so, it is likely that he would have learned of the instructor's recent illness and initiated a more formalised review of the instructor's fitness to fly. A procedural requirement for medical examiners to consult GPs would help to ensure that they are fully informed about applicants' health.

On 28 June 2017 the Commission recommended to the Director of Civil Aviation that he review the medical application process:
- to ensure that it promotes a positive reporting culture for applicants
- that is more robust in identifying potentially serious health issues that may interfere with the safe exercise of the privileges to which applicants' medical certificates relate
- to ensure that the system supports medical examiners exercising their discretion to consult medical practitioners when assessing applications for medical certificates.
Implementation Status: Open
Reply: By way of context to the CAA's response, it should be noted that consistent with developments overseas, the CAA has recently consulted with stakeholders regarding the appropriate medical certification standard for the holders of a private pilot licence. The international trend is for a reduction in the standard of any aviation medical certificate or even the removal of the requirement for such a certificate altogether. This reflects a view that the regulatory burden that has been imposed in the past is unreasonable given the very small number of accidents with a medical cause factor. It is important to note, however, that if such a change were to occur in New Zealand it would be very unlikely to apply to the medical certification of pilots conducting hire or reward activity. Therefore, the preceding context does not reduce the validity of the Commission's recommendations as they might apply to the holders of the aviation documents required for the performance of hire or reward operations.

The CAA accepts the first element of this recommendation and will do what it can to promote a "positive reporting culture" for medical certificate applicants to the degree it can do so while still acting decisively to protect the public interest when it has reasonable cause for concern about matters of potential aeromedical significance. The CAA will review current processes in line with this recommendation by 1 December 2017.

The CAA accepts the second element of this recommendation as it applies to the holders of aviation documents utilised for professional purposes. The CAA will review current processes in line with this recommendation by 1 December 2017.

The CAA considers that the third element of the recommendation is unworkable in that it would currently be unlawful in terms of the Civil Aviation Act for the Director to require an applicant, as a precondition to the issue of a medical certificate, to provide information from their GP or other medical practitioner, or to authorise the CAA to access that information, in the absence of reasonable cause in a specific case for requesting that information. In addition, the CAA considers that the provisions of S27C (3) of the Civil Aviation Act which requires medical practitioners to inform the Director if they have reasonable grounds to believe that a licence holder has a medical condition that may interfere with the safe exercise of the privileges of the licence they hold does not provide sufficient authority for the GP to share all medical information regarding a licence holder patient with a Medical Examiner. Any effective system in support of medical examiners in the manner anticipated by this element of the recommendation would require changes to the Civil Aviation Act. Given the above and the fact that the Ministry of Transport administers the Civil Aviation Act, the CAA recommends that the Commission consider making a recommendation to the Secretary for Transport for amendment of the Civil Aviation Act requiring GPs to provide, on request from a Medical Examiner, medical information regarding a patient who holds, or is seeking, aviation medical certification.

Safety Recommendation 022/17
Issued To MoH on 28 Jun 17
There is the potential for applicants for medical certificates to attempt to circumvent the medical assessment process by inaccurately representing their state of health through the misreporting of their treatment, including undisclosed medications and possible multiple GPs and other health professionals. This risk is shared by other transport modes that require a person to hold a medical certificate or make a declaration on their health status. A national health database would provide one means of addressing this risk.

On 28 June 2017 the Commission recommended to the Chief Executive of the Ministry of Health that he consider adding the following functions to the national electronic health record database under development:

- that a person's occupation be added to the record to allow monitoring of individuals who hold transport-related documents that require periodic medical checks, and who have potentially adverse health conditions or medications, so that the appropriate authority can be alerted to possible public safety risks
- a mechanism to draw the attention of all health practitioners to their obligation to notify the appropriate transport authority when a person or patient has a health condition or need for medication that could pose a threat to public safety in that individual's occupation.
Implementation Status: Open
Reply: The National Electronic Health Record Business Case project is a significant project that is working though a Treasury Better Business Case (BBC) process. This process is for agencies that have significant proposals that will have a whole of life cost of more than $25 million.

The BBC process has a number of stages and at this point we are close to completing stage 2 of 4. At the completion of stage 4 we expect that we will begin to implement the solution for the National Electronic Health Record, timing for the duration of the implementation phase is yet to be determined. With our current timeline, we expect this to begin no earlier than late 2018 pending approval from Cabinet and successfully delivering the business case process and large scale procurements required.

With these timings in mind, we recognise that there is a requirement to hold the occupation for an individual and to be able to undertake reporting and processes related to the occupation should potentially adverse health and/or medications be identified. At this stage we cannot commit that the functionality that has been suggested will be implemented and will not be in a position to do so until the Business Case process is completed. However, while we cannot yet confirm the details of this type of functionality, we can and will take this into account during our deliberations and include in our business case documentation the advantages of having this type of functionality tied into the Electronic Health Record once established.

Safety Recommendation 018/17
Issued To Skydive Taupo on 26 Jun 17
Skydive Taupo did not equip its parachute drop pilots with lifejackets and was not required to do so, because its flights from Taupo aerodrome, which used the Taupo aerodrome parachute landing area, remained within gliding distance of land at all times. This accident illustrated how that scenario downplayed the possibility of a pilot having to ditch an aeroplane, or bale out and drift to a water landing.

Therefore the Commission is recommending that the Chief Executive of Skydive Taupo investigate options for equipping their parachute drop pilots with effective flotation devices.
Implementation Status: Open
Reply: I confirm I intend to implement the final recommendation in relation to equipping drop pilots with an effective flotation device. A Quality Action Request has been raised through the Skydive Taupo Ltd Quality Assurance system to address this. Once the suitable flotation equipment has been confirmed and made fit for purpose, pilot training will be introduced and conducted regarding water landing procedures. The recommendation will be fully implemented by the 31st of August 2017.

Safety Recommendation 007/17
Issued To FAA on 23 Feb 17
On 23 February 2017 the Commission recommended to the Administrator of the FAA that he:
- extend the limitations and requirements of FAA AD 95-26-04 that currently apply to the R22, in regard to operating in strong winds and turbulence, to the R44 and R66 models; and
- extend those limitations and requirements so that they apply to all R22, R44 and R66 pilots regardless of their experience levels.
Implementation Status: Open
Reply:

Safety Recommendation 008/17
Issued To CAA on 23 Feb 17
On 23 February 2017 the Commission:
- gave notice to the Director of Civil Aviation that recommendation 007/17 had been made to the Administrator of the FAA, which recommended the FAA extend the limitations and requirements of FAA AD 95-26-04 to the R44 and R66, and to all Robinson pilots regardless of their experience levels
- recommended to the Director of Civil Aviation that until such time as recommendation 007/17 is actioned by the FAA, he extend the limitations and requirements of FAA AD 95-26-04 to R44 and R66 helicopters in New Zealand, and to all pilots of Robinson helicopters in New Zealand regardless of their experience.
Implementation Status: Open
Reply: The Director will consider whether the action sought by the Commission meets the legislative threshold that must be satisfied for the issue of an Airworthiness Directive. In doing this he will take into consideration the fact there have been no 'mast bump'accidents in NZ during the past two years. In addition, at the time of providing this response, the CAA has a team in the US working with the FAA Rotorcraft Directorate and the Robinons Helicopter Company on possible amendments to the Limitations sections of the Pilot Operating Handbooks of the Robinson series aircraft and improvements to safety awareness training. It may be that this work will provide an outcome that will meet the intent of the Commission?s recommendation.

Safety Recommendation 019/16
Issued To CAA on 24 Aug 16
On 24 August 2016 the Commission recommended that the Director of Civil Aviation provide a clear statement to relevant sectors of the aviation industry on whether stock clearing is a permitted activity. If the Director decides it is a permitted activity under a particular Civil Aviation Rule part, he should provide clear guidance on the conduct of the activity.
Implementation Status: Open
Reply: In our response to the Commission's draft report, 11 August 2016, we explained there is no CAA rule provision for stock clearing; therefore, the Director cannot provide clear guidance on the conduct of the activity in the context of existing CA Rules.

However, the CAA recognises that an operation to a remote airstrip presents a risk to air transport in that the landing area may have visible hazards, including the presence of stock, which could affect the safety of a landing. Whilst there are no existing provisions in the rules to descend below 500 feet (aside for take-off/landing or a baulked landing/discontinued approach), the Director will agree to pursue a means to enable air transport operators to overfly a remote airstrip below 500 feet for the purposes of ensuring the landing area is visibly free from hazards.

The CAA remains focused on safety management based on risk mitigation. The CAA believes the alternative safety action will address the safety issue raised by the Commission and we will advise when the work has been completed.

Safety Recommendation 014/16
Issued To MoT on 27 Jul 16
On 27 July 2016 the Commission recommended to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.
Implementation Status: Open
Reply: The Ministry considers that such a recommendation is premature as the costs and benefits of such a recommendation have not been canvassed. The Ministry appreciates that the Commission may have been minded to make such a recommendation because of the lack of available data. The Ministry suggests that prior to making a recommendation, some more work should be undertaken to determine the benefits and costs of flight data and video recording in cockpits.

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