Case 4: Southern Air, scheduled flight, August 19, 1998

Dead: Three passengers, pilot

Rescued: Five passengers

Missing: One passenger

The Cessna 402C was on a scheduled flight from Stewart Island to Invercargill when both engines failed and the plane ditched in Foveaux Strait. Five passengers were pulled out of the water but three passengers and the pilot did not have lifejackets and died of hypothermia. One passenger was missing, presumed drowned.

The TAIC report said the cause of double engine failure was not conclusively established but may have been associated with systemic fuel management.

Invercargill coroner Trevor Savage, however, found the plane had run out of fuel. The Southland Times said he had been critical of the CAA's audit procedures after he found the company's "longstanding and obvious failure" to keep proper records contributed to the crash.

Poor record-keeping, blatant non-compliance and problems at the airline should have been picked up in a CAA audit.

"Regrettably, the records most relevant to this inquest have been shown in almost every case to be incomplete or incorrect and unreliable ... I believe the absence and the casual attitude towards record-keeping that lies behind it have contributed to the outcome on August 19, 1998," said Savage in the Southland Times.