Executive summary
On Sunday 18 April 1999 at around 1538 hours, ZK-EKJ, a Cessna 206 floatplane on a round-trip scenic flight from Te Anau to overhead Milford Sound, struck the top of a vertical craggy mountain ridge. The pilot and 4 passengers died during the impact.
The pilot probably attempted to cross the ridge crest at low level and might have misjudged the height of the ridge top because of visual illusions or distraction. Some localised turbulence or downdraughts and the fast speed of the aircraft may have contributed to the accident. Had the pilot applied a safe ridge crossing technique, including maintaining a sufficient height margin above the ridge, the accident could have been avoided.
The pilot was reported to have carried out unnecessary low flying and crossing of ridge crests with minimal clearance on scenic flights, on a number of occasions over several years before the accident.
The operator did not, adequately supervise the pilot, independently investigate an allegation of the pilot low flying or establish a system to control or monitor the pilot's performance and compliance with safety requirements.
The pilot's reported acts of unnecessary low flying were not made known to the Civil Aviation Authority. The operator's organisational shortcomings that probably contributed to the accident were not identified by or made known to the safety authority.
Safety recommendations were made to the operator's chief executive and the Director of Civil Aviation to address safety issues identified during the investigation.
Related Recommendations
Initiate rule making to require information to be available and visible to passengers on air transport flights, such as on cards in seat pockets, that outlines the operating standards and how passengers can contact the operator or the CAA if they have any concerns about safety.
Emphasise to all senior managers of air transport operations the need for them to be aware of their responsibilities, including: • identifying the foreseeable risks to their operations; • putting in place suitable defences to minimise those risks, which might go beyond what the generic rules require; • maintaining those defences.
Recommend to all air transport operators that they develop pro-active monitoring strategies such as occasionally using passengers to carry out spot, passive checks to report on the conduct of flights.
Examine the CAA auditing process and determine if it needs to be enhanced by periodically, or with reasonable justification, requiring general aviation document holders involved in air transport operations to demonstrate, to the auditors, how in practice they follow, and maintain, an appropriate safety management system.
Consider requiring early re-certification under appropriate civil aviation rules (which embody the management system approach to safety) of those general aviation air transport operators, which, in his assessment, appear to be at risk because of a poor safety culture, poor attitudes, or poor systems or practices, and ensures that there are no undue delays in the certification of other operators.