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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 006/12
Issued To CAA on 22 Mar 12
The operator's fuel management policy, control of the flight manual and failure to ensure the aeroplane was being operated within its centre of gravity limits may be an indication of wider non-compliance issues. The Commission recommends that the Director takes the necessary action that ensures all parachuting operators are conforming to Civil Aviation Rules and operating safely
Implementation Status: Open
Reply: Accepted. Following the accident, the CAA carried out a series of spot checks on commercial parachuting operations, paying particular attention to flight manual data and the application of weight and balance limitations. In addition to this activity, the implementation of Civil Aviation Rule Part 115 (Adventure Aviation) will require tandem parachute operators to be certificated, and enable closer oversight of such operations.

Safety Recommendation 007/12
Issued To CAA on 22 Mar 12
In approving the change in airworthiness category, the CAA did not review all the required documentation and so missed the opportunity to ensure the aeroplane was fit for the purpose. The Commission recommends that the Director takes the necessary action that ensures there is a thorough and coordinated oversight when accepting aircraft modifications and approving changes in category, especially for specialised operations like parachuting
Implementation Status: Open
Reply: See Comment. This recommendation addresses 2 separate issues. First, with respect the review of documentation required for a change from 'restricted' to ?standard category, the Director will consider whether physical aeroplane inspections are warranted when an aircraft changes category. However, the resources and other implications of such inspections will need to be identified and evaluated before the Director accepts the recommendation in full.

Safety Recommendation 008/12
Issued To CAA on 22 Mar 12
The wearing of appropriate seat restraints can reduce injury and save lives. The Commission recommends that the Director monitor the outcome of the joint FAA/USPA study and determine if any findings are applicable for the New Zealand parachuting industry
Implementation Status: Open
Reply: Accepted. The Director will monitor the outcome of the joint FAA/USPA study, and consider their applicability/relevance to the New Zealand aviation environment.

Safety Recommendation 009/12
Issued To CAA on 22 Mar 12
The owner's introduction into service of ZK-EUF was not in accordance with Civil Aviation rules and there was no assistance or oversight provided by the CAA to ensure it was safely completed. The Commission recommends that the Director ensure there is a coordinated and proactive approach by relevant departments within the CAA to ensure safety efforts are best directed to promote the coordinated safe management of flying activities
Implementation Status: Open
Reply: See comment. The CAA is currently undergoing a major change programme to ensure that it is able to target its resources more effectively, and conduct its activities more consistently. To this end, the thrust of the recommendation is accepted.

Safety Recommendation 010/12
Issued To CAA on 22 Mar 12
Parachute-drop pilots can fly for many years without external validation of their parachuting related skills. The Commission recommends that the Director initiate a regular checking requirement to help ensure drop pilots remain skilled and current, similar to other commercial operators
Implementation Status: Open
Reply: See comment. The Director will consider the recommendation in light of the changes that are being brought about by the introduction of Civil Aviation Rule Part 115.

Safety Recommendation 011/12
Issued To CAA on 22 Mar 12
The use of performance impairing substances is known to have a detrimental effect on the ability of people to safely operate in critical transport environments. The Commission recommends that the Secretary for Transport promotes the introduction of a drug and alcohol detection and deterrence regime for persons employed in safety critical transport roles
Implementation Status: Open
Reply: I accept the specific recommendation 011/12 directed to the Secretary for Transport.
I also urge the Commission to note the existing health and safety in employment regulatory regime, where drugs and alcohol are specifically mentioned in the definition of hazard. This regime already places obligations on both employers and employees.
Since the Fox Glacier accident the Minister of Transport has approved a new Rule Part 115 that entered into force in November 2011. The Rule requires adventure aviation operations to be certified by 1 May 2012. Adventure aviation organisations, including commercial parachuting, now face the risk that their safety certification can be suspended and removed for safety violations. This gives such operators a stronger incentive to ensure they address alcohol and drug taking safety risks in their organisations.
Over the next two years the Government will be considering rule amendments that would require aviation organisations to introduce safety management systems. This would require certificated operators to assess and mitigate all safety risks relevant to their operation. This risk of intoxication of personnel by drugs and alcohol would clearly be a safety risk that we would expect both operators and the Civil Aviation Authority (when certifying and auditing aviation organisations) to be actively addressing under an SMS regime. Decisions will also be made in the near future to ensure that the Civil Aviation Authority is resourced to transition to the ICAO-endorsed SMS approach which has widespread industry support.
Whilst recognising that where the illegal use of drugs is involved, changing individual behaviour will be challenging, the Ministry will encourage the Civil Aviation Authority to step up its effort to alert the aviation community through education of the risks that drugs pose to the safety operation of aviation undertakings. This will require an ongoing effort.
As you are aware, the Ministry has developed a Transport Regulatory Policy Statement that specific rule changes may not always be the best interventions to achieve desire safety outcomes. Non-regulatory interventions can often be more appropriate. In this regard we appreciate the Commission's recommendation to promote a drug and alcohol detection and deterrence regime, rather than to implement a regime.
The Ministry of Transport has in the past sponsored an inter-agency Substance Impairment Group. This looked at whether or not compulsory random drug and alcohol testing, and specific breath alcohol limits, should be required by regulation in the aviation, marine and rail transports modes. In part because of a lack of data, we were not convinced at that time that the costs would outweigh the benefits. We will, however, monitor international experience in this regard and, in particular, the recent relevant changes in the Australian aviation regime.

Safety Recommendation 005/12
Issued To CAA on 22 Mar 12
The modification of ZK-EUF by the engineering company was not in keeping with required engineering practices and the supporting documentation was both incomplete and inaccurate. The Commission recommends the Director takes the necessary action that ensures that high engineering standards are maintained by this and other aircraft maintenance organisations
Implementation Status: Open
Reply: Accepted. Newly introduced risk based surveillance processes will improve the effectiveness of the CAA's audits, through better targeting and focus on 'risk issues'.

Safety Recommendation 012/12
Issued To CAA on 13 Mar 12
Ensures that the strategic plan being developed by Airways and the risk assessment being conducted by the CAA in regard to Queenstown address the following safety issues in respect of that aerodrome and, if applicable, generally i. the variability of procedures used by pilots when circling after a non-precision approach and in the event of not landing off an approach ii. The separation of aircraft making different types of instrument approaches in Queenstown controlled airspace iii. The appropriateness of the large aircraft visual circuit procedure at Queenstown iv. The naming convention for RNAV procedure waypoints, which makes waypoint recognition difficult for pilots who are not approved for the procedures.
Implementation Status: Open
Reply:

Safety Recommendation 013/12
Issued To CAA on 13 Mar 12
Takes action, in conjunction with certificated instrument flight procedure service organisations, to eliminate the use of similar procedure titles for different instrument approaches to the same runway.
Implementation Status: Open
Reply:

Safety Recommendation 015/12
Issued To CAA on 13 Mar 12
Ensures that operational material published by document holders and approved by the Director is accurate and consistent across all users and complies with the prescribed relevant standards.
Implementation Status: Open
Reply:

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