Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

A Robinson R44 helicopter disappeared while on a short flight over Lake Wanaka. Searchers found an oil slick on the lake surface and some debris on land nearby

Engine trouble unresolved by the pilot resulted in heavy landing. Helicopter destroyed by severe on-ground shaking. All five people on board injured to varying degrees, including head injuries, one fatally. TAIC recommendations address two key issues – importance of comprehensive practical training in aircraft type, and the benefits of wearing helmets.

The container ship Leda Maersk, with harbour pilot on board directing the course and speed of the ship, grounded on a channel bank while entering Port Otago. Nobody was injured and damage to the ship was minor. The Commission’s recommendations address pilots’ technical skills and accuracy; bridge resource management; on-board navigation technology.

A fractured section of rail caused the derailment of a passenger train with about 130 passengers on board at Britomart Station, Auckland. Nobody was injured but there was damage to train and track. A machining defect likely reduced the rail’s resistance to fatigue and fracture. KiwiRail has improved track inspections. A new multi-agency group is studying the effect of rolling stock on rail and to resolve potential rail wear issues.

The fire on the fishing trawler Dong Won took hold because the fire alarm did not sound, the crew’s initial firefighting was inefficient; and the ship was exempt from and did not comply with current structural fire protection standards. On any such vessel, the crew may not be as safe as they would be on a newer vessel constructed to newer standards. TAIC recommendations address the key issues.

At the request of the Kiribati Government, New Zealand provided a team to assist the Kiribati Government in its investigations into the sinking of the MV Butiraoi. The investigation team was seconded from TAIC to the Kiribati Government. The investigation was completed and a report provided to the Kiribati Government.

The Commission is assisting the Australian Transport Safety Bureau’s investigation.

A skydive tandem pair crash-landed into a lake following a double parachute malfunction. The tandem rider’s lifejacket did not properly inflate, and the rider was lost in the lake, presumed deceased. Parachutists everywhere need to practice water landings, which are even riskier than you might think. TAIC recommends changes to aviation rules and incident reporting.

TAIC has resolved this inquiry, satisfied that the Interim Report published in May 2018 identified the salient safety issues, which Rolls-Royce had already addressed. The Commission’s early investigations prompted the engine manufacturer to improve its system for forecasting when the fatigue might happen. Affected turbine blades have been replaced in 99% of the global flying fleet.

TAIC has resolved this inquiry, satisfied that the Interim Report published in May 2018 identified the salient safety issues, which Rolls-Royce had already addressed. The Commission’s early investigations prompted the engine manufacturer to improve its system for forecasting when the fatigue might happen. Affected turbine blades have been replaced in 99% of the global flying fleet.

The Commission assisted the Australian Transport Safety Bureau’s investigation. A New Zealand-registered Boeing 777 reportedly descended below the minimum altitude for a part of its arrival procedure on approach to Brisbane International Airport. New Zealand has completed its support for this inquiry. Please note: TAIC will not be producing a report for this inquiry but you can find a copy of the report produced by The Australian Transport Safety Bureau on their website.