Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

New Zealand has completed its support for this inquiry . For further information please contact Accident Investigation Commission, Nepal. Please note: TAIC will not be producing a report for this inquiry.

The ship hit a rock after different understandings between the harbour pilot and master led to a turn being taken late. Safety issues identified related to: the standard of bridge resource management, difficulties integrating the port and harbour risk assessments, and inadequacy of counting launch transits towards pilot proficiency for large ship transits through Tory Channel. Urgent recommendations were made in 2016.

A restricted-limits passenger vessel caught fire, burnt to the waterline and sank with 53 passengers and 7 crew on board. The fire very likely started in the engine room and rapidly spread through the vessel. There was no fire detection system to alert the crew of the fire until it had taken hold. The CO2 fire smothering system installed in the engine room was not effective in extinguishing the fire because the engine room could not be totally shut down to prevent oxygen entering and feeding the fire.

During an annual proficiency assessment, an air traffic controller lost situational awareness and a series of four incidents occurred, forcing the assessor to resolve the situation. There were no collisions and nobody was injured. Since then, the controller has passed annual proficiency tests; controllers reportedly benefit from mentoring and working together better; and ATC managers now have more time to focus on team and operational standards. TAIC made recommendations to resolve issues with air traffic congestion and controllers providing excessive traffic information.

A passenger train nearly ran into a track maintenance team working on a bridge near Taumarunui. The train had been cleared to pass through the work site, but the workers were also under the impression that it was alright to occupy the track. The Commission highlighted three safety issues: the burden of the dual roles as team leader and RPO; the workers' poor non-technical skills (eg teamwork, situational awareness); and the substance impairment.

New Zealand has completed its support for this inquiry. TAIC will not be producing a report on this inquiry. A copy of the report produced by the National Transportation Safety Board can be found in the associated links section.

On Tuesday 24 November 2015 at about 1830, a KiwiRail Holdings Limited (KiwiRail) light freight locomotive (EF30157) caught fire while parked at the Palmerston North rail depot. The Fire Service attended, but the fire was not extinguished until later that evening at 2023. The locomotive's transformer compartment suffered fire damage. No-one was injured during the incident.

The crash of this AS350 helicopter on Fox Glacier took the lives of seven people. Issues: Operator’s pilot training system did not fully comply with Civil Aviation rules, did not adequately prepare pilot; and managerial oversight. Lack of intervention allowed operator to continue operating. New TAIC recommendation addresses potential that other operators at that time could have significant non-compliances that were not identified or not resolved.

At 0420 on 18 October 2015 the skipper of the Jubilee made a radio 'mayday' call giving the Jubilee's location, saying that the vessel was taking on water and that they were abandoning the vessel into the liferaft. Later that day the wreck of the Jubilee was found by sonar on the seabed at the location given in the mayday call. During the following week divers identified the wreck of the Jubilee and recovered the bodies of all three crew members from the wheelhouse. The Commission found it was likely that flooding of the Jubilee’s fish hold was the main factor contributing to its sinking, o

New Zealand has completed its support for this inquiry. TAIC will not be producing a report on this inquiry. A copy of the report produced by the Italian investigaiton agency can be found on their website.

New Zealand has completed its support for this inquiry. For further information please contact TSB Please note: TAIC will not be producing a report for this inquiry.

Please contact Komite Nasional Keselamatan Transportasi (KNKT) for the final report.