Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The Commission investigated a worksite incident on the Main South Line, near Mataura in Southland. A KiwiRail freight train was travelling at line speed (80 km/h) when it passed a group of workers who were close to the track, maintaining a signal system. Initial reports suggest that the drivers of trains on this line were unaware of the temporary speed restriction of 10 km/h that had been authorised for this section of track. In the event, no injuries were reported.

At about 0100 on Monday, 28 December 1998, the container vessel "Gao Cheng" was entering the Port of Nelson with a pilot on board and two tugs in attendance. As the vessel was approaching the entrance to the harbour the pilot reportedly suffered a sudden loss of vision in his right eye.

Two aircraft came within 20 feet of each other on final approach at night at Ardmore Airport. TAIC report highlights safety lessons for pilots, aircraft owners, engineers, and aerodrome operators at busy unattended aerodromes. It shows how communication, visibility, and access to shared procedures can make all the difference and makes recommendations to improve night flying safety across New Zealand.

An Air New Zealand Q300 and a Beech 76 Duchess ZK-JED were on reciprocal tracks when a close proximity event occurred, requiring avoiding action.

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.

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 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.

An air ambulance helicopter was dispatched from Hamilton Airport to recover a trauma patient on Mount Pirongia. While descending on the windward side of a ridge line to recover the patient, the helicopter rapidly and unexpectedly dropped in height. The helicopter impacted the terrain on a west-facing escarpment covered by dense native forest. The helicopter was severely damaged. The pilot, crew member and paramedic escaped without injury.

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

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.

A loaded freight train derailed when departing Wellington Freight Terminal, dragged derailed wagon through 6 sets of points. Automated systems eventually halted train 256 metres along the track. No injuries, but substantial damage to rail infrastructure led days of passenger service disruption. Very likely contributing factors: track alignment, track faults and track twist; and rough wheel flange.

Worse-than-expected sea conditions caused capsize of a perceived very safe ‘pontoon’ design water taxi. Skipper rescued all six passengers trapped inside, all survived. Lessons for passenger boat sector: know vessel stability as well as buoyancy; prioritise safety over commercial expectations; manage risks; ensure the right safety equipment is available; actively lead safety on-board.