The death of an Auckland company director in a tragic heli-skiing crash has prompted a Coroner to reiterate previous calls by crash investigators and Coroners for helicopters to be fitted with cockpit video recorders.
Jerome Benjamin Box, 52, was heli-skiing with four friends in the Mt Aspiring National Park on August 16, 2014 when the Eurocopter AS350-B2 'Squirrel' helicopter they were in came to land on the steep 2339m snow-clad summit of Mt Alta.
On approach to the landing site, on a bluebird day, the overloaded helicopter struck the slope heavily and rolled 300m down the mountain, breaking up the cabin structure.
Father-of-two Box was ejected and was crushed by the machine, dying at the scene.
A coronial inquiry into his death was delayed until an investigation by the Transport Accident Investigation Commission (TAIC) and a subsequent Civil Aviation Authority (CAA) prosecution had concluded.
The Helicopter Line (THL) company, which owned the helicopter, was convicted and fined $47,600 at Queenstown District Court in 2018 after pleading guilty to two health and safety charges brought by the CAA.
Today, Coroner Sue Johnson has released her findings, concluding that Box's cause of death was high energy impact injuries to his chest, spine and head due to being ejected from a helicopter crash into mountain terrain.
His death was accidental in circumstances explained in her 58-page findings, which highlights that the helicopter was at least 27kg over its maximum permissible internal weight at the time of the attempted landing.
On behalf of THL, its then operation manager Grant Bisset carried out an internal investigation into the fatal accident and gave evidence at the inquest.
Bisset concluded the crash was caused by the pilot's failure to recognise the existence of conditions conducive to encountering Vortex Ring State (VRS) - a flight condition that occurs when a helicopter that is receiving power from its engine, loses main rotor lift and experiences loss of control.
The Coroner, however, agreed with TAIC's finding that while it cannot be ruled out that helicopter was affected to some degree by VRS at some stage as the pilot carried out his escape manoeuvre, it is "unlikely [less than 33% occurrence/improbable] that VRS was a significant contributing factor to the crash".
"It is highly likely that [the helicopter] began an uncommanded descent during the final phase of the landing because it had minimal performance capability to hover at that weight, altitude and outside temperature," Coroner Johnson said.
"This was despite the fact that the helicopter was operating normally and delivering a high level of power."
Box's widow, Adelle Box, represented herself at the inquest and called for industry changes to improve safety, particularly in helicopter tourism and heli-skiing.
After the crash, the CAA issued an emergency airworthiness directive around the loading of AS350 and AS355 helicopters, requiring the actual weights of passengers to be recorded before take-off.
Coroner Johnson noted that had that requirement been in place at the time of the 2014 accident, the passengers could not all have flown at once.
A cockpit video recorder continuously recording instrument positions and flight control inputs – something that TAIC recommended to the Secretary for Transport in 2016 after a fatal Robinson R44 crash, and something which is often recommended by Coroners - would have "greatly assisted my inquiry", the Coroner noted in endorsing her calls from colleagues.
"Jerome's death was an absolute tragedy," Coroner Johnson concluded in her findings.
"He is missed enormously by his family and friends and especially by Adelle, [their two children], and Gregory [his brother].
"Their distress and grief have been compounded by the length of time it has taken to conclude this inquiry. I thank them for their patience and apologise for the time it has taken to bring this inquiry to its conclusion."