The CAA said that it had put in place changes in policy and training for its inspectors by February 2014. Leading up to that date, and afterwards, CAA inspectors had overlooked significant non-compliances by the operator of the helicopter at Fox Glacier and they had not raised findings on matters of non-compliance with Civil Aviation rules.
In this case the CAA had had good cause and ample opportunities to intervene at an early stage. Instead the operator was allowed to continue, with little change to improve its systems. Those systems put the pilot in a position of responsibility that the pilot was not sufficiently trained or experienced for.
The Commission is concerned that there could be a wider safety issue whereby other Part 135 operators that were in the civil aviation system during the same period could have significant non-compliances that have either not been identified or not been resolved.
On 21 February 2019 the Commission recommended that the Director of Civil Aviation initiate an independent review of CAA surveillance reports and any findings raised for Part 135 operators since 2014 to measure the effectiveness of the surveillance policies and procedures that the CAA has put in place, including the effectiveness of their implementation. If the independent review finds unidentified or unresolved safety issues with specific operators, it is recommended that the Director of Civil Aviation take the appropriate urgent action to resolve those issues.