Case 7: Air Adventure, charter flight, June 6, 2003

Dead: seven Crop & Food staff, and pilot

Seriously injured: two Crop & Food staff

Coroner Richard McElrea's inquest report describes the Piper Navajo Chieftain aircraft with 10 people on board crashing not far from Christchurch Airport as it approached a runway in the dark and in thick fog.

The pilot, Michael Bannerman, was a director, the sole shareholder and the chief pilot of Air Adventures. The coroner ruled pilot error and questioned whether the flight should have taken place at all. McElrea said the crash could have been prevented and made 30 recommendations designed to improve CAA air safety monitoring.

The CAA had been aware of concerns about Bannerman's flying, including a complaint from a former pilot with Air Adventures who allegedly told a field safety officer: "Stop him or he'll kill someone." Others discussed concerns with the CAA, which had investigated Air Adventures.

There were many rule breaches by Bannerman. In 1999 a CAA safety audit found serious shortcomings and spot checks in years to follow also raised concerns. The last safety audit, in 2003, the year of the crash, had seven findings against Air Adventure.

Among a list of criticisms, the coroner said the CAA did not investigate specific incidents which had raised "major concerns".

"The failure ... to investigate was potentially crucial to Mr Bannerman's future as pilot carrying fee-paying passengers, and to his company's ability to hold an air operator's licence.

"The CAA appears to have ignored its own risk assessments of Air Adventures. It took no action when the assessments indicated high or moderate risk. The CAA classified Air Adventures at the time of the crash as at moderate risk. The deaths of seven of the passengers and serious injuries to two others on the flight of June 6, 2003, cannot be justified by tolerance in a safety system designed to protect them."