Coroner Anna Tutton apologised to the family of Martin Timothy Lowen - who died in 2014 - for the “extensive delays” in releasing her findings, the New Zealand Herald reported.
Lowen, 55, died on January 19, 2014, after taking off in his Piper PA28-236 fixed-wing plane from the Canterbury Gliding Club’s Springfield airfield towing a two-person glider.
The coronial inquest into Lowen’s death was delayed until 2021, while official crash investigations were carried out. There were also Covid-19 delays and other adjournments.
In her report, Tutton outlined nine separate issues she looked at during the inquest and summarised all of the evidence presented by witnesses and experts - including a crash report from the Civil Aviation Authority - during the process.
Lowen, a gliding club member, was rostered on for glider-towing duties on the day he died.
At 12.01pm, Lowen took off in the aircraft, towing another pilot and instructor behind him.
Just 65 seconds into the flight the tow plane crashed into the ground and caught fire - a second after the tow rope suddenly tightened, jerking the tow plane out of control.
Lowen died at the scene. He sustained critical high-energy injuries which were “likely to have proved fatal regardless of the subsequent fire”
During the inquest, she heard hours of evidence about how the glider and plane were connected, communications before and during the flight, whether those involved responded in accordance with guidelines, and if those guidelines needed reviewing, the NZ Herald reported.
“I find, on the balance of probabilities, that the crash occurred as a result of the glider he was towing becoming and remaining out of position, to the extent that pressure was applied to the tail of the tow plane he was flying, exacerbating the turn to the right and, ultimately, lifting the tail, and resulting in the crash,” she said.
“Ultimately, after weighing the evidence carefully, I have reached the conclusion that some of the decisions made, and actions taken, by [the instructor] constituted factors contributing to Mr Lowen’s death.”
She said a number of actions had been taken since Lowen’s death “in an attempt to avoid any further such crashes occurring”.
New Zealand gliding guidelines in relation to glider tow pilot training and the Gliding New Zealand Instructors’ handbook have been amended in respect of lateral upsets.
The manual of glider tow pilot training and towing procedures was updated; additional portable fire extinguishers were purchased and are located around the airfield; and the club’s critical incident action plan has been upgraded for any emergency.
Tutton’s recommendations centred around making sure there was national consistency around towing and gliding, auditing instructors’ manuals to ensure “adequate, clear guidance”, making sure the manuals were updated routinely and there was mandatory distribution rather than just having them available.
She said the CAA, GNZ, regional gliding clubs and, if necessary, the Ministry of Transport should work collaboratively to consider and implement the recommendations.
