Who was to blame when seven people lost their lives on Fox Glacier?
Friday, 24 May 2019
The owner of a helicopter which crashed on Fox Glacier killing seven people had numerous crashes to his name and was known for breaching rules. So why were his choppers still flying? JOANNE CARROLL investigates.
When six tourists stepped into a helicopter on November 21, 2015, they were on a trip of a lifetime.
Within 20 minutes they lost their lives when the AS350 Squirrel helicopter crashed at high speed into a crevasse high up on Fox Glacier.
They were Britons Andrew Virco, 50, Katharine Walker, 51, Nigel Charlton, 66, Cynthia Charlton, 70, and Australian's Sovannmony Leang, 27, and Josephine Gibson, 29 and 28-year-old Queenstown pilot Mitch Gameren.
The exact cause of the crash will never be known, but investigations by the Civil Aviation Authority and the Transport Accident Investigation Commission have revealed woefully inadequate oversight of the helicopter company, inspectors who were 'too trusting' and operators who allowed substandard health and safety practices and inadequate pilot training.
The findings are a shame on not only New Zealand's health and safety culture but its tourism industry and international reputation.
**READ MORE:
* Fatal Fox Glacier helicopter crash report finds major failings.
* Company director fined $64,000 four years after fatal Fox Glacier helicopter crash
* No resolution for fatal Fox Glacier helicopter crash pilot's family nearly four years on
* Pilot farewelled after crash
* Pilots slam CAA over red-flagged inspector who investigated fatal helicopter crash
Nigel Charlton's brother Paul said New Zealand agencies had to up their game.
'New Zealand punches above its weight in many areas, rugby springs to mind immediately. Please make all helicopter operations in New Zealand world champions in safety too,' he said.
TAIC's final report into the crash found all seven on board died of multiple, high-energy impact injuries. Four were ejected from the helicopter, when it hit the glacier at high speed.
The 76-page report found no identifiable cause for the crash but said it was 'very likely' the weather caused the pilot to lose awareness of the helicopter’s height above the glacier until it was too late to avoid a collision.
The challenge for investigators was that there were no witnesses to the accident and no survivors. Nor could the front section of the cabin be recovered and there were no on-board recorders.
What is known is TAIC found serious failures by the helicopter operator James Patrick Scott, its quality assurance manager Barry Waterland, and the CAA. The CAA allowed Scott to continue operating with little or no intervention, despite having found he had not been complying with some regulations in the years leading up to the crash.
Scott and Aviation Manual Development, owned by Barry Waterland, both pleaded guilty to health and safety breaches in the Christchurch District Court this month.
Scott was fined $64,000. Waterland's company was not fined because his lawyer told the court it had no means to pay.
The Civil Aviation's summary of facts said Scott was a sole trader who ran the operation from his home and farm in Karangarua. He did not often visit the offices or bases.
'His lack of supervision or oversight is not covered by clear instructions to senior staff,' it said. And his operation specification document (op spec) was found to be sorely lacking.
Waterland had been quality assurance manager since 1998, responsible for ensuring that the op spec was current and up to date.
Scott has the largest fleet of helicopters in New Zealand, and was first granted his pilot's licence in 1976. Only 17 of the company's 21 helicopters were listed on the op spec. The helicopter that Gameren was flying on November 21 was not included.
The op spec listed Chris Green as responsible for crew training and competency assessment, but he had stopped training in 2012.
The training at the company was actually being carried out by pilot Jamie Henery, without CAA approval. Helicopter flying at the glaciers is highly specialised mountain flying and requires pilots to have completed a mountain flying training course.
'Mr Henery had not attended and/or completed a CAA approved mountain flying course and therefore was not adequately qualified to train pilots in mountain flying techniques,' the summary said.
Gameren's logbook shows he had completed 1792 hours’ total flight time, which included 415 hours on the AS350, but less than five of those were supervised. CAA rules require pilots complete five supervised hours' flying time before operating AS350.
CAA audit reports show that the CAA was aware from 2013, that Henery had assumed Green's role. But did nothing about it. Henery has since become CAA-approved to carry out pilot training but did not respond to request for comment.
THE DAY OF THE CRASH
November 21, 2015 was a rainy, cloudy day at Fox Glacier. Early morning flights booked for that day were cancelled.
At 8.30am, the weather improved so Gameren, after consulting with Fox Glacier office staff member Brendan Cathro, flew heli-guides up to the glacier.Only one other operator did a scenic flight later that morning but because of low cloud did not land on the glaciers.
The summary said Cathro was acting as both the office person and the loader for the helicopter that day and was rushed. He had only received loading training the day before the flight.
He assessed the six passengers as being within the acceptable weight limit, without actually weighing them. It proved a lethal mistake.
The helicopter was 65kg too heavy on take-off.
Gameren did not double check the weight calculation and took off at 9.45am, landing on the glacier's Chancellor Shelf six minutes later. There was no further contact with the chopper.
When it was realised the chopper was overdue, and unable to reach it, Morris and another pilot flew to the scene. There worst fears were realised.
The chopper wreckage was clearly visible, strewn about 40 metres across the snow and ice.
TAIC concluded Gameren's decision to fly in the weather conditions was 'imprudent' while the CAA found Scott and Waterland failed to ensure pilots were supervised in making those decisions.
CAA also noted there was self-imposed pressure on Scott's pilots to get passengers off the ice when the weather closed in rather than waiting for the weather to clear.
CAA 'TOO TRUSTING'
Scott's helicopters were involved in numerous accidents since 2004, including four serious ones resulting in CAA identifying issues with training and supervision. In the six years before November 2015, seven aviation-related concerns had been lodged with the CAA about Scott.
A CAA audit after a non-injury helicopter rollover in 2012 noted Scott did not properly oversee and supervise his pilots and questioned the abilities of Henery as training supervisor.
CAA chairman Nigel Gould said the organisation was now a 'considerably more effective' regulator than it was leading up to the 2015 crash.
He said Scott had misled investigators who were 'too trusting'. The majority of staff involved had since left the CAA.
CAA's deputy director for general aviation Steve Moore said it had increased the number of its inspectors from two to eight since the crash. They oversee 100 helicopter operators.
In 2014, TAIC recommended CAA have stricter requirements on operators to correct any identified deficiencies in 2014 and was assured by the CAA that changes were in place. Despite this, it continued to overlook significant non-compliances by Scott.
'The CAA had had good cause and ample opportunities to intervene at an early stage. Instead the operator had been allowed to continue, with little change to improve its training and management system, and little improvement in senior management oversight of the Fox Glacier operation,' it said.
'Ultimately … the accident was a culmination of deficiencies in the system,' TAIC concluded.
Scott did not respond to requests for interview but his lawyer told the court he was remorseful and had paid the families $125,000 each. He continues to own the helicopter operation in Fox and Franz Josef, but no longer holds an air operator certificate. The company is now being run by senior managers. Waterland said it was a conflict for CAA inspectors who had overseeing the company prior to the crash, to be also investigating the operators for culpability.
One of the inspectors who has since left the organisation, was found to have overstated his CV.
'To become a senior person in a helicopter company you have to go through a fit and proper person process, but CAA do not put their own staff through it,' Waterland said.
'IT SHOULD NEVER HAVE HAPPENED'
Gameren's mother Adrienne Bray said the crash was preventable.
'It hurts. It should never have happened. He should still be here.They have made changes but it is too late for Mitch,' she said.
Three weeks after the accident, senior pilots from the competing operators at Fox Glacier agreed not to fly if one of them thought weather was too bad.
Bray believes there was too much commercial pressure on pilots to fly.
'We don't understand why he wouldn't sit there and wait it out. To me the chief pilot on the day should have drawn a line in the sand and said no we're not flying.'
Nigel Charlton's brother Paul said the family wanted lessons learned, above all else.
'If improved health and safety behaviours in the New Zealand heli-tourism industry result from this case, then the sense of wasted lives would be mitigated.'