Failures by the operator, engineers, and Civil Aviation Authority contributed to a plane crash in Fox Glacier that claimed nine lives.
The parachute drop plane had been modified from an agricultural plane three months before but document discrepancies weren't detected by the CAA.
The operator never did a weight or balance calculation, so it was loaded outside its limits with the centre of gravity too far to the rear on the 74 occasions it flew with eight passengers.
Transport Accident Investigation Commission investigator in charge Ian McClelland says this accident had its origins back during the modifications.
"If they'd been correctly done, the Civil Aviation Authority would've ensured that the aircraft was correctly introduced into service, and the operator themselves could also have ensured that they were flying the aircraft safely."
However Mr McClelland says changes to rules mean CAA has more power to monitor things like skydiving operators, but it's been a slow catch up.
"We had a disconnect between what was in place in terms of regulatory oversight and what was happening out there in the field."
A final report has found the Fox Glacier plane crash was caused by improper loading.
All nine people onboard the Fletcher FU24 Parachute Drop Plane died when it crashed in September 2010.
Two of the tandem skydiving masters in the Fox Glacier crash tested positive for cannabis use.
It's been identified in the final report and Mr McClelland says although it doesn't appear to have contributed to the accident, it's a safety issue with wider ramifications for the whole industry.
"This is an issue that's not just restricted to parachuting or aviation, but across all the transport modes," he says.
He says it's a very serious concern.
Mr McClelland says they've recommended the Secretary of Transport look at a drug and alcohol detection and deterrence regime.
Meanwhile West Coast Labour MP Damien O'Connor says he shares the sense of sadness that most families involved will feel reading the final report.
Mr O'Connor says the report will be a hard read for the families involved.
"It's clearly identified and exposed flaws in a system that was simply not able to keep up with Kiwi innovation and ingenuity, and that has unfortunately been at huge expense and cost to the families involved."
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