Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On 9 July 2021, a Kavanagh Balloons E-260 carrying 10 passengers and a pilot on a scenic flight over the Wakatipu Basin made a hard landing after two aborted attempts. The impact ejected the pilot and two passengers, causing serious injuries, while others sustained minor or no injuries. The balloon slid about 150 metres before coming to rest with minor damage.

Fire in engine room on factory trawler (quickly extinguished). Diesel oil sprayed onto hot engine exhaust, under pressure when an accumulator in the fuel system unwound from its pipe connector and dislodged. Lessons and recommendations for Marine sector relate to maintenance of safety-critical and remote-operated systems; Command and control for fire response; and design of gaseous fire-extinguishing systems.

New Zealand has completed its support for this inquiry. Please note, TAIC will not be producing a report for this inquiry.

KiwiRail’s system for work in the rail corridor should satisfy the needs of the contractors as well as KiwiRail, and it should not deter contractors from applying to enter the rail corridor. A fatal accident where a train impacted a road contractor’s truck on a level crossing happened because KiwiRail was unaware the road-marking crew would be there; they had not applied for a permit to work in the rail corridor.

People can make safety-critical errors when they take risks due to focusing too much on completing a job task. Safety-critical tasks should be designed so that it is easy to get the job done safely. TAIC reports on why a worker remote-controlling a shunt locomotive received serious injuries, caught between wagons on board the rail ferry Aratere.

A commercial jet boat lost control, crashed into trees. Injuries to two of the twelve persons on board. Jet boat engine failed, so no steering. All due to a single failure in an engine control fuse that broke from metal fatigue. The fuse box, bolted to the engine, was vibrating too much. TAIC recommends urgent action to address risks associated with single points of failure.

Molten material from the hot work caused fire, burned 7 days, extensive damage to high-value fibre-glass cargo, no fatalities, no serious injuries. TAIC calls on Fire and Emergency NZ to improve training in fighting fires on ships. Crucial tactics (close cargo hold cover, release CO2 into hold) weren’t done. Valuable time lost because people lacked a good understanding of each other’s roles and objectives. One new recommendation to Pacific International Lines to address safety issues over fire response and gas cutting hot work.

A pilot qualification, licence or aircraft-type rating does not in itself confer expertise. Pilots need to be familiar with the aircraft they are flying and their own capability as they gain experience. Pilots also need to ensure they are fully aware of the increased risks of flying at low level and monitor the performance of their aircraft accordingly.

TAIC calling for improvements in ship safety management systems (Singapore) and mooring winch installation. On container ship Rio De La Plata, a rope handler suffered serious injuries to hand and face when they were trapped between incoming rope and winch. Issues with the ship’s safety system; equipment installation not optimised for safety; and loss of situational awareness. www.taic.org.nz/mo-2020-204

Railway track workers were at risk when a train approached in what they thought was a protected work area. Administrative procedures like forms and radio calls are not enough to mitigate this sort of risk. Everyone involved in workplace safety needs to communicate clearly. TAIC recommends KiwiRail improve engineering failsafes to mitigate risk of human error.

Bus drove into side of locomotive at level crossing. Bus driver fatally injured. Bus driver likely expected empty tracks and drove to go straight across. Did not notice in time that lights and bells were active. TAIC calls for NZTA to review road rule, consult rail sector, consider all risks for level crossing risks – especially those near road intersections.