Executive summary
While attempting to land at Tiraora Lodge the pilot was dazzled by low sun and elected to overshoot. The aircraft made a low turn to avoid high ground, struck a telephone wire and descended out of control into the sea. The pilot and five passengers were rescued but suffered varying degrees of injury.
Related Recommendations
Until such time as the "Quality Audit" system proved to be able to establish the safety of air transport operations, routine inspections in accordance with ICAO Doc 8335 be re-established.
He require the "brace for impact" position to be included as part of the pre-flight passenger briefing by demonstration or by reference to a briefing aid.
He review whether the standards for air transport operations from ALG's where a missed approach could not be performed safely from the runway threshold were acceptable.
He require the operator to provide some accurate source of wind speed indication at Tiraora Lodge airstrip.
He require the [recommendations 018/90, 019/90, and 020/90) as airworthiness requirements for all imported aircraft.
He review the wind limitations in the light of these studies especially in relation to go-around procedures.
The provision of Area Forecasts and Aerodrome forecasts to general aviation pilots be reinstated.
Soundsair be subject to an Audit by the Air Transport Division with a minimum delay, unless such action had already been taken or the company was no longer operating.
He require operators to produce for approval, a mandatory syllabus of training for pilots intending to engage in air transport operations into confined airstrips and require such training for pilots already so engaged.
He inspect the various types of aircraft used for air transport operations and identify each door which a passenger might use as an exit in an emergency.
He require operators to produce detailed studies of potential downdraught or wind-eddy situations in the vicinity of airstrips that they use or intend to use for air transport operations in the Marlborough Sounds.
He redraft paragraph 3.3.1 on page MET 3-2 of the Aeronautical Information Publication to clarify whether or not the General Aviation Weather is intended for use by pilots planning VFR air transport operations.
He require pilots engaged in air transport operations into confined airstrips to demonstrate the missed approach procedure with the aircraft in which they intend to operate, ballasted to the authorised mass and most adverse C of G position for that airstrip, and require that such demonstrations be used for checking in accordance with Regulation 76 and 77.
He require owner to level the threshold of runway 08 at Tiraora Lodge airstrip.
He design and fit suitable handles for opening such doors from the inside in an emergency.
Air Transport Operations into One-way Airstrips: When the Operations Manual called for a particular missed approach procedure then the Operations Manual identify the physical feature to determine the missed approach point.
He ensure each emergency exit has a readily identifiable and effective handle on the inside of the aircraft.
He require an examination of the key personnel of airline operators on their knowledge of their regulatory responsibilities and of any special hazards associated with their operation as part of the Quality Audit of Air Transport Operators.
The procedure for the issue of Landing Ground Authorisations by Air Transport Division staff be reviewed to ensure that the persons to whom this task was delegated were familiar with the standards required and the implications of granting exemptions.