On a cold winter's night nine years ago pilot Timothy Thompson spiralled nose down in the dark, the small plane he was flying plummeting more than 8000 feet a minute.
The twin-engine Beechcraft Baron slammed into dense trees on a steep slope in the Tararua ranges and smashed into pieces.
Thompson was dead at 27, needlessly so. In ensuing reports the airline he worked for, United Aviation, was criticised for its poor safety. The Civil Aviation Authority, too, was under the gun, held responsible for contributing to the accident which took the young man's life. The CAA is responsible for monitoring air safety culture.
Investigators from the Transport Accident Investigation Commission concluded that if the CAA had enforced non-compliance issues raised in audit after audit of United Aviation "the potential for this accident to occur would have been significantly reduced".
It was a big case and sparked a ministerial inquiry. Even though the controversial outcome of the inquiry was that CAA practices were sound, the crash investigation report had been stinging.
Lessons should have been learned within the CAA. Six years later, when seven people from Crop and Food died in a crash near Christchurch, the CAA was again implicated.
The dead pilot, Michael Bannerman, was known to the CAA. Their contact regarding him is revealed in a coroner's report released this month and in which the CAA, once again, is held partly to blame.
These crashes are high profile but there are plenty of others in which the CAA is implicated, or criticised in crash investigation reports.
There are also three critical reports by the auditor-general, spanning 1997 to last year and which, again, the CAA is accused of taking little heed.
The CAA says it will adopt the 30 recommendations from the coroner's report into the deaths of the food and crop staff. It remains to be seen if safety improves in small airlines.
CAA chief executive John Jones, appointed one month after September 11, at a time of upheaval in the local aviation industry, was asked for a response. He said: "Every operator had to be re-certificated, and there were more than 600 operators. New rules had to be completed. New surveillance and intervention processes were being introduced.
"The new rules are in place and the important process of reviewing them to make them even better has started."
The number of operators, aircraft, pilots, engineers and air traffic controllers had increased significantly.
"The safety performance of New Zealand's General Aviation operators has improved significantly, with a 39 per cent reduction in accidents per 100,000 flying hours over the last six years, and a 20 per cent reduction in the social cost of accidents over the last three years. These are enormous improvements.
"The number of incidents reported to CAA per year is up by 13 per cent because more people are bringing their concerns to us. We are seeing the growth of a real safety culture in General Aviation here."
additional reporting Phil Taylor
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