The cause of a crash that killed a Canterbury pilot towing a glider has been revealed - more than a decade after the fatal incident.
Coroner Anna Tutton apologised to the family of Martin Timothy Lowen - who died in 2014 - for the “extensive delays” in releasing her findings, made public today.
Lowen, 55, died on January 19, 2014, after taking off in his Piper PA28-236 fixed-wing plane from the Canterbury Gliding Club’s Springfield airfield about midday towing a two-person glider.
The coronial inquest into Lowen’s death was delayed until 2021, while official crash investigations were carried out.
There were also Covid-19 delays and other adjournments.
Coroner Tutton released her final report today, outlining nine separate issues she looked at during the inquest and summarising all of the evidence presented by witnesses and experts - including a crash report from the Civil Aviation Authority - during the process.
She also made recommendations in a bid to prevent similar deaths in future. The findings are extremely detailed and span 84 pages.
Lowen, a member of the Canterbury Gliding Club, was rostered on for glider-towing duties there on the day he died.
At 12.01pm, Lowen took off in the aircraft, towing another pilot and instructor behind him.
Just 65 seconds into the flight the tow plane crashed into the ground and caught fire - a second after the tow rope suddenly tightened, jerking the tow plane out of control.
Lowen died at the scene. The glider was able to return to the runway and land safely.
The Coroner said Lowen sustained critical high-energy injuries which were “likely to have proved fatal regardless of the subsequent fire”.
During the inquest, she heard hours of evidence about how the glider and plane were connected, communications before and during the flight, whether those involved responded in accordance with guidelines, and if those guidelines needed reviewing.
In her findings, she outlined all of the evidence relating to each of the nine issues she considered, before making her final ruling.
“I find, on the balance of probabilities, that the crash occurred as a result of the glider he was towing becoming and remaining out of position, to the extent that pressure was applied to the tail of the tow plane he was flying, exacerbating the turn to the right and, ultimately, lifting the tail, and resulting in the crash,” she said.
“Ultimately, after weighing the evidence carefully, I have reached the conclusion that some of the decisions made, and actions taken, by [the instructor] constituted factors contributing to Mr Lowen’s death.”
She said a number of actions had been taken since Lowen’s death “in an attempt to avoid any further such crashes occurring”.
New Zealand gliding guidelines in relation to glider tow pilot training and the Gliding New Zealand Instructors’ handbook have been amended in respect of lateral upsets.
And the CGC has actioned a number of changes including additional training for pilots and the expansion of pre-take-off checks.
The manual of glider tow pilot training and towing procedures was updated; additional portable fire extinguishers were purchased and are located around the airfield; and the club’s critical incident action plan has been upgraded for any emergency.
A number of recommendations were suggested to the Coroner by Lowen’s family and others involved in the inquest and industry.
Based on the evidence Coroner Tutton concluded it would be " beneficial to strengthen and improve the consistency of processes relating to the development, recording and dissemination of information and guidance available or provided to glider pilots and tow plane pilots relating to safety issues”
“I consider that the recommendations … may if drawn to public attention, reduce the chances of further deaths occurring in similar circumstances,” she said.
Coroner Tutton’s recommendations centred around making sure there was national consistency around towing and gliding, auditing instructors’ manuals to ensure “adequate, clear guidance”, making sure the manuals were updated routinely and there was mandatory distribution rather than just having them available.
She said the CAA, GNZ, regional gliding clubs and, if necessary, the Ministry of Transport should work collaboratively to consider and implement the recommendations.
“I acknowledge the extensive delays involved in bringing this matter to inquest and in completing the inquest,” Coroner Tutton said.
“I regret, and apologise for, the time it has taken to complete my findings.”
Coroner Tutton also extended “sincere condolences” to Lowen’s wife Elisabeth, their three children and other family and friends.
She acknowledged Lowen’s death and subsequent investigations would have been “extremely stressful” and commended the family for their “dignity and courage”.
Anna Leask is a Christchurch-based reporter who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 18 years with a particular focus on family violence, child abuse, sexual violence, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz