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A coroner probing one of New Zealand's worst-ever helicopter crashes has released in-depth findings and made a series of recommendations and comments to improve industry safety.
Queenstown pilot Mitch Gameren, 28, died alongside six passengers when the Alpine Adventures' AS350 Squirrel helicopter he was flying on a sightseeing trip plunged into a deep Fox Glacier crevasse on November 21, 2015.
Gameren died along with Australians Sovannmony Leang, 27, and Josephine Gibson, 29, and two UK couples; Cynthia, 70, and Nigel Charlton, 66, and Andrew Virco, 50, and his partner Katharine Walker, 51.
Mrs Charlton's body was only found two years later by a tramper.
Coroner Marcus Elliott held an inquest last year into the circumstances leading up to the crash, to see if any recommendations could be made to try and prevent any future tragedies.
Mitch Gameren was killed when his helicopter crashed on the Fox Glacier in 2015. Photo / Supplied
In his 62-page finding released on Friday, Coroner Elliott issued recommendations and comments around training, calculating the weight of passengers, condensation on windscreens and the use of webcams in alpine environments.
Coroner Elliott also urged pilots to take a conservative approach when deciding to fly in certain conditions.
The coroner concluded that the cause of the crash - which had no survivors, witnesses, or on-board recorder to examine - was adequately established by the Transport Accident Investigation Commission (TAIC) inquiry.
TAIC found that the total weight of the helicopter, including the passengers, exceeded the maximum allowable internal weight limit throughout the flight and that it is "virtually certain" it was not in "vortex ring state" when it crashed below the Chancellor Shelf at Fox Glacier.
On November 21, 2015 the weather was rainy and cloudy.
Some flights had already been postponed and cancelled that morning.
At some point, Gameren decided that the weather had improved enough for a scenic flight with six passengers.
The flight took off at 9.45am and was due back at 10.05am.
During the flight, some passengers took photographs, which were later recovered.
The wreckage after the crash at Fox Glacier in November 2015. Photo / Supplied
They show the helicopter landing on the glacier at Chancellor Shelf where some passengers got out to walk on the snow.
It was snowing, the inquest heard, with cloud coming and going.
The helicopter took off again, but crashed soon after into a deep crevasse about 600m south of the shelf.
The weather conditions were unstable and unsuitable for a scenic flight, TAIC found.
It was very likely that when the helicopter took off from Chancellor Shelf and flew down the valley, Gameren's perception of the machine's height above the terrain was affected by one or more of several factors.
These were: cloud, precipitation, flat light conditions and condensation on the front windscreen.
"In the absence of other identifiable causative factors, it is very likely that the helicopter struck the glacier due to the pilot losing awareness of the helicopter's height ... until it was too late to avoid a collision," the findings say.
Coroner Elliott offered his condolences to the families of "those who died in this tragic accident".
The Civil Aviation Authority (CAA) suspended the Air Operating Certificate (AOC) of Alpine Adventures' managing director and owner James Patrick Scott after the tragedy, grounding his 15-strong helicopter fleet.
In June 2016, the CAA charged Scott and quality assurance manager Barry Waterland's company, Aviation Manual Development (2009) Ltd, under Health and Safety in Employment Act legislation.
Scott and Aviation Manual Development later admitted failing to take all practicable steps to ensure no action or inaction of any employee while at work harmed any other person.
The maximum penalty is a $250,000 fine. Waterland was discharged without penalty after the court heard he was not in a financial position to pay any fine.
Before sentencing at Christchurch District Court in 2018, Scott made a voluntary reparation payment of $125,000 to each of the seven families, totalling $875,000.
He was then fined $64,000. Aviation Manual Development escaped a fine after the court heard it had no financial means to pay one.
At sentencing, a family friend of the Charlton family called for changes to health and safety rules in the New Zealand adventure tourism industry to prevent future tragedies.
