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The Christchurch coroner has found that the deaths of eight people in one of New Zealand's worst air disasters were preventable.
"The deaths should not have happened. There has been a huge human cost," coroner Richard McElrea said yesterday in his 113-page ruling.
Mr McElrea outlined a series of failings by pilot Michael Bannerman before the crash, which claimed his life and those of seven employees of the Crop & Food Research Institute at Lincoln, near Christchurch.
Rules governing the general aviation industry were also criticised in the coroner's findings, released almost three years to the day after the Air Adventures plane went down.
The chartered Piper Navajo Chieftain aircraft crashed near Christchurch Airport on June 6, 2003, on a flight from Palmerston North.
It disappeared from radar as it was approaching a runway at 7.07pm, and was reported missing three minutes later.
A search was immediately launched but because incorrect co-ordinates were followed, the wreckage was not found until 9.25pm.
The bodies found in the wreckage were those of pilot Mr Bannerman, and Crop & Food Research managers Howard Bezar, aged 55, Margaret Viles, 53, Alistair Clough, 37, Richard Finch, 41, Desma Hogg, 42, Katherine Carman, 35, and Andrew Rosanowski, 37.
Crop & Food managers Tim Lindley and Richard Barton survived but were seriously injured.
It was the seventh equal worst air crash in New Zealand aviation history, in terms of people killed.
Mr McElrea has made a host of recommendations to the Civil Aviation Authority (CAA) and Minister of Transport to prevent another similar tragedy.
He asked the minister to consider some form of independent assessment of the Civil Aviation Authority Act, and a review of whether the law enforcement role carried out by the CAA should be separated from the safety enforcement management role.
Among many recommendations to the CAA, he urged the authority to consider:
* Its training and testing requirements.
* Its monitoring of pilots and aircraft charter companies and their past records.
* Rules about landing approaches.
Complaints about Mr Bannerman's flying had been made in the past, and other incidents that caused passengers concern had gone unreported.
Mr McElrea found the ill-fated flight was "in breach of the rules that should have prevented it happening at all".
"Not all the instruments were operable. [Mr Bannerman] was in breach of flight and duty requirements.
"The aircraft was overloaded on take-off from Palmerston North.
"When nearing Christchurch, it is questionable whether he had sufficient fuel to reach an alternate aerodrome."
Mr Bannerman was using Global Positioning System (GPS) as an aid to navigation, but was required to disregard it and use his instruments on approach to the runway.
Evidence was that he did have some reliance on the GPS and loaded in incorrect co-ordinates that caused the aircraft to crash 1.2 nautical miles short of the runway.
Mr Bannerman was inexperienced in night flying, but was still accredited to take the flight.
"The marginal weather conditions put serious question marks over his leaving Palmerston North, certainly without discussing other options with the passengers."
In a flight just three weeks earlier, Mr Bannerman had chosen to fly with a co-pilot. Evidence given to the inquest was that a co-pilot would "substantially reduce risk".