Case 5: Waterwings Airways, scenic trip, April 18, 1999

Dead: four passengers and pilot

The TAIC report says the Cessna 206 floatplane on a round-trip scenic flight from Te Anau to overhead Milford Sound struck the top of a mountain ridge, killing the pilot and four passengers. The pilot may have misjudged the height of the ridge top and localised turbulence or downdraughts and the fast speed of the aircraft may have contributed to the accident.

"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."

This was not made known to the CAA, but CAA audits over the years had picked up concerns about the operation.

The CAA had also reported the chief executive had shown hostility to auditors and "generally displayed aggression" towards the CAA.

These were warning signals there may have been organisational shortcomings with the operator and might have justified a deeper audit, the report said.

"Had the CAA auditing process systemically examined the operator's organisational functioning and culture and required the chief executive to show he was meeting his responsibilities, the organisational and safety culture shortcomings that probably contributed to the accident might have been identified and rectified."