Inquiries & Recommendations
Ngā ketuketutanga me ngā tūtohunga
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Rail
RO-1997-105
[A preliminary investigation showed that the circumstances were not likely to have significant implications for transport safety. Consistent with section 13 of the TAIC Act the Commission discontinued the investigation and no report was published.]
Incident date: Publish date:
Aviation
AO-2004-009
On Wednesday 22 December 2004, ZK-HHT, a Hughes 369D helicopter was carrying a party of 3 kayakers into the upper reaches of Wanganui River, South Westland. The party’s kayaks and paddles were suspended in a cargo net underneath the helicopter. As the helicopter flew up the river the net swung back and struck the tail rotor, resulting in an immediate loss of tail rotor control.
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Rail
RO-2007-111
Between March 2007 and October 2009 there were 5 derailments involving container wagons conveying single 6-metre (m) containers loaded with bulk grain, positioned on the leading ends of the wagons. The Transport Accident Investigation Commission (the Commission) combined the events into a single inquiry.
Incident date: Publish date:
Maritime
MO-2009-204
On 4 March 2009, the Tutukaka Coastguard vessel Dive! Tutukaka Rescue was tasked to assist a recreational vessel in difficulty in Ngunguru Bay south of Tutukaka. It was night-time and the sea condition was rough. The crew of the Coastguard vessel became so focused on locating the vessel in difficulty that they lost awareness of where their own vessel was and struck a rock at a moderate speed. The Dive! Tutukaka Rescue was extensively damaged and several crew members were seriously injured in the collision.
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Rail
RO-1998-105
On Saturday, 14 March 1998, at about 1802 hours a displaced stack of platform containers on Train 235, a Westfield to Wellington express freight train, struck a through-truss bridge at Ngaruawahia. As a result of the collision the train parted, six wagons were derailed, and major damage to the bridge occurred when five wagons and various loads concertinaed. The cause of the collision was the movement of inadequately restrained stacked platform containers. Safety issues identified were: • the serviceability and uniformity of integral interlocking devices fitted to platform containers;
Incident date: Publish date:
Maritime
MO-1998-209
On Thursday, 13 August 1998, at about 0120, the fishing vessel "San Rakaia" grounded on Ninepin Rock at the entrance to Pelorus Sound. The vessel had been on passage from Nelson to the Cook Strait fishery with seven persons on board. There were no injuries. With assistance of other vessels the "San Rakaia" was refloated on the next high tide. Safety issues identified included: • inadequate management of the crew working routine, leading to fatigue • under utilisation of available navigation aids • lack of a watchkeeper monitor alarm for single-handed bridge operation
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Aviation
AO-1996-019
[A preliminary investigation showed that the circumstances were not likely to have significant implications for transport safety. Consistent with section 13 of the TAIC Act the Commission discontinued the investigation and no report was published.]
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Maritime
MO-1998-211
At about 1710 on Saturday, 5 September 1998, the passenger sailing vessel "Phantom of the Straits" was engaged on a short sailing trip on Wellington Harbour when fire broke out near the engine enclosure. The fire was eventually extinguished, but not before the vessel had suffered extensive fire and smoke damage below decks. The skipper suffered from minor smoke inhalation; otherwise none of the four passengers or deck-hand were injured in the fire. Factors contributing to the fire included substandard features in the electrical and machinery installations on board the yacht.
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Rail
RO-2015-103
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.
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Rail
RO-2002-117
On Wednesday 31 July 2002, at about 1040, express freight Train 328 passed 6 Signal, Te Rapa, at stop. The train then ran through No. 2 points at Te Rapa, set in the reverse position, and travelled a further 9 km on the North Island Main Trunk up main before being stopped at Horotiu. A hi-rail excavator working on track between Te Rapa and Horotiu had just cleared the track before the train passed through the work area. A safety issue identified was the probable fatigue-related performance impairment of the locomotive engineer leading to his loss of situational awareness.
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Aviation
AO-2000-007
On Saturday 1 July 2000 at 1457, Great Barrier Airlines PA 32 aeroplane ZK-DSQ was on a charter flight to Great Mercury Island with 4 passengers when it overran the uphill grass runway on landing. No injury occurred, but the aircraft was substantially damaged. The overrun resulted from excessive tailwind, and the pilot’s decision to land was probably based on an incorrect assessment of the tailwind component on the runway. Safety issues identified include: • the definition of the tailwind limitation in the airline’s operations manual
Incident date: Publish date:
Maritime
MO-2004-202
On Friday 13 February 2004 at about 2220, the restricted limit passenger vessel "Queenstown Princess" with 17 passengers and 2 crew on board grounded on the western side of the southern arm of Lake Wakatipu while returning from an evening cruise. Three passengers received minor injuries.
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