A coroner's calling for changes to the Aviation Act, to allow police and Civil Aviation Authority staff to carry out random drug testing.
They come following an inquest into the 2012 Carterton balloon crash in which all eleven people on board the hot air balloon died when it crashed into power lines and caught fire, before plummeting to the ground.
Coroner Peter Ryan has made 19 recommendations - following the eight day hearing last year.
Pilot Lance Hopping was known to be a habitual cannabis user - and Coroner Ryan says it's possible subsequent impairment lead to Mr Hopping making several errors which resulted in the fatal accident.
He wants the Civil Aviation Act to be amended so police and the CAA can undertake random drug and alcohol testing of adventure aviation pilots.
He also wants the industry to consider making safety briefings more comprehensive, and for operators to make the details of the certification and medical certificates of pilot's public.
A lawyer for three victims' families, Alastair Sherriff, says the coroner called for recommendations from the main players, asked for feedback on proposed recommendations, then made his final decision.
"I think that's very robust and I think that sends a message that all the regulators have had an opportunity for input but this is the conclusion that the judicial officer who's tasked with these responsibilities has come down with."
Minister of Transport Simon Bridges says random testing of pilots is being done by the Civil Aviation Authority at the moment.
"I think we do have to look at whether we can in a sense dot the 'i's and cross the 't's and make sure there's absolutely no wriggle room, there's no tolerance for drugs and commercial transport."
Family members say the release of a coroner's report hasn't brought closure.
Alan Still's daughter died after she jumped from the balloon just after it hit power lines and caught fire.
He says the report doesn't give him closure, as there's still some work to be done in getting the recommendations made into legislation.
"I think if you ask any member of any families that have lost loved ones through this incident, I don't think that there is a thing called closure. I think you just learn to live with it."
"How do you value those eleven lives if you don't make some attempt to improve things and make things safer for everybody?"
Valerie Bennett, 70, Diana Cox, 63, Howard Cox, 71, Ann Dean, 65, Desmond Dean, 70, Denise Dellabarca, 58, Belinda Harter, 49, Stephen Hopkirk, 50, Lance Hopping, 53, Chrisjan Jordaan, 21, and Alexis Still, 20.
CORONER PETER RYAN'S RECOMMENDATIONS:
• The CAA should continue its current efforts to educate and remind holders of commercial pilot licences of the legal requirement and importance of maintaining a current medical certificate.
• The CAA should identify opportunities to encourage third parties to notify it of any concerns about the medical certification status of pilots, and implement strategies to achieve that end.
• The CAA should monitor medical licences for all adventure aviation pilots so they are alerted when they expire.
• The CAA should ensure that all pilots carrying out flights for an adventure aviation operator are required to undergo drug testing as part of their initial and ongoing medical certification.
• All adventure aviation operators should obtain approval from all pilots employed by them and then post on their websites information about those pilots, including their certification or licensing and medical certification status to enable the public to assess whether to fly with those pilots.
• The CAA and Ministry of Transport should consider making info about pilots and operators involved in adventure aviation industry, accessible to the public.
• The CAA and Ministry of Transport should consider requiring adventure aviation operators to provide medical certificate information for the pilot in command of a particular flight to intending passengers, prior to the flight occurring.
• The Ministry of Transport should consider an amendment to the Civil Aviation Act, so the CAA or Police are able to undertake random drug and alcohol testing on adventure aviation pilots.
• The Ministry of Transport should consider whether the act should be amended to include tougher sanctions if an adventure aviation pilot tests positive for drugs or cannabis.
• The CAA should continue its efforts in engaging with operators, through its certification activities, to identify areas where the expositions can be improved and/or where they might benefit from the experience or practice of other industry participants.
• The operations manuals of commercial balloon adventure aviation certificate holders should require carriage of GPS systems to assist operators and the CAA to determine proximity of the balloon to power lines during flights.
• The CAA should consider instructing passengers to be vigilant for wires and poles and alert the pilot to power line proximity in pre-flight briefings. Passengers should also be made aware that commercial balloons do not fly within certain distances of power lines at any times, and be instructed on how to make a complaint if they consider there has been a breach of flight rules explained in the briefing.
• The CAA should consider whether adventure aviation operators should be required to have a second crew member on board balloon flights, where the passenger count exceeds a specific number.
• The flight test standard guide should be amended to include specific training on the topic of power line contact.
• Consideration should be given to "satisfactory performance" of the flight review task relating to power line contact requiring the pilot to demonstrate a high level of situational awareness in regards to obstacles, understanding of dangers associated with power lines and understanding of procedures for avoidance.
• The CAA should consider providing advice to international regulators and other relevant agencies on the details of this particular case and potential lessons learned for balloon operation safety in other jurisdictions.
• The CAA should give consideration to requiring balloon baskets used by adventure aviation operators to be fitted with some means to prevent power lines becoming trapped over the rim in the event of contact with power lines.