The Milford Sound Scenic Flights' Cessna 207 plane carrying five passengers moved off without its pilot because he did not follow recommended manual starting procedures on September 5 last year.
The report, released yesterday, found Milford Sound Scenic Flights had established a procedure for hand-starting aircraft in exceptional circumstances, but it did not meet the standards recommended by the Civil Aviation Authority. In any case, the pilot failed to follow the procedure.
The report says the unnamed 38-year-old senior pilot did not adhere to the operator's documented hand-starting procedure, which was inadequate and not supported by a training programme.
The aircraft would not start using the conventional key-start system because of a faulty battery. The pilot then asked the flight co-ordinator to bring a back-up starter pack to the aircraft. The pilot asked the flight co-ordinator, who had no piloting experience, to sit in the pilot's seat and hold his feet on the brakes while the pilot attempted a hand-start.
While the pilot showed the flight co-ordinator the location of the foot brakes, he did not ensure the flight co-ordinator knew how to use them, the report said.
"While the flight co-ordinator was able to turn off the ignition switch, of concern was his inability to control the direction of the aircraft as it accelerated. Had the aircraft continued straight ahead or veered right it could have struck an obstacle, causing significant damage to the aircraft and possible injury to the passengers," it said.
The aircraft started moving forward at a speed the pilot could just match. He tried unsuccessfully to lean in the door and reach past the flight co-ordinator to close the throttle.
The aircraft veered left, crossed the apron and moved on to the grass towards the runway. The flight co-ordinator turned off the ignition switch and stopped the engine.
As the aircraft slowed, it ran on to the grass area next to the runway and struck and damaged a marker board. The aircraft came to a halt a few metres past the marker board about 40m from the runway. There were no injuries.
"The potential existed for serious damage or injury to have occurred because of the proximity of other aircraft, buildings and potentially people and other aircraft operating on the apron area and active runway," it said.
A similar incident happened to another Milford Sound Scenic Flights pilot at Milford Sound in 2007.
No pilots had received any practical training in hand-starting.
The commission has recommended the Civil Aviation Authority make the aviation industry more aware of the risks involved in hand-starting aircraft.
Authority spokesman Bill Sommer said the authority would be publishing articles in its industry magazine to alert pilots to the risks.
Milford Sound Scenic Flights director Mark Quickfall said the pilot no longer worked for the company, but his employment was not terminated as a result of the incident.
The hand-starting of planes was only to be used as a last resort, in remote areas, he said.
"Any pilot should follow procedure set down by the company. Pilots should not be prop-starting planes. They should engage an engineer to rectify the situation," he said.
He would take on board any recommendations to improve procedures as a result of the investigation.
