Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Fatal helicopter crash. An Airbus AS350 B3e helicopter ZK-ITD was being flown from the operator’s base in Milton to a client’s cherry orchard near Alexandra to conduct frost protection operations. The helicopter conducted a series of turns immediately before, and after, reaching the township of Lawrence. Soon after, the helicopter made a descending right-hand turn through nearly 160 degrees before entering a left-hand spiral dive that ended in a near vertical nose-down impact with the ground.

Safety issues for Airwork Flight Ops: fuel checklists, crew training, control centre comms, weather info, crew compliance with manuals, safety management system. No new recommendation because all issues addressed. A Boeing 737 freighter landed with fuel exhaustion imminent because centre fuel tank pumps were switched off for whole flight.

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.

The Fiordland Navigator ran aground after the fatigued master almost certainly fell asleep at the helm. TAIC found gaps in fatigue management, monitoring of medical fitness, and risk controls for sole-charge masters. Several passengers and crew suffered minor injuries, but the emergency response was effective. The vessel’s operator has since strengthened fatigue policies, added support roles, and improved safety oversight. TAIC made one recommendation—to Maritime NZ—to improve awareness of ongoing medical fitness responsibilities for seafarers.

Balloon landings are a safety-critical phase of flight. If anyone or anything is ejected from basket during landing, an accident is virtually certain because balloon is uncontrolled, passengers unattended. To avoid this, all balloon pilots should wear safety harnesses. Owners/operators should install them. Also, passenger safety briefings must be clear, concise, easy for all passengers to follow.

A BK117 helicopter was transporting a power pole. Pilot at risk of distraction, didn’t recognise and respond promptly to unanticipated yaw (helicopter unexpectedly turning about its vertical axis). The pilot lost control and ditched in shallow water. Minor injuries for pilot, substantial damage to helicopter.

A factory trawler worker died on becoming trapped in machinery. Safety for machinery operators depends on everyone understanding how a piece of machinery works; how people work with it; and thinking about the hazards. In this case: not enough understanding; too much reliance on crew following all instructions; and training likely confused workers about which emergency stops serviced which system.

A freight train was passing through points at above maximum authorised line speed. Part of the train derailed when a wagon wheel climbed the outer rail of a set of points. Key factors: track alignment & twisting, speed, suspension, centre of gravity. TAIC recommends KiwiRail identify, evaluate & rectify repetitive cyclic track twists. Drivers must always correctly control their trains.

Aerial firefighting operators need to respond to the latest advice about monsoon bucket structure and sling line length. Firefighting helicopter significantly damaged in heavy forced landing when tail rotor was disabled by lifting line of underslung collapsible monsoon bucket. Bucket aerodynamics changed when a steel ring holding top mouth open came loose. Hook-and-loop fasteners had come undone.

On a ship loading logs, crew were using a crane to tension a wire rope to secure the load. When a wire snapped, equipment recoiled. It struck and fatally injured a seaman. It snapped due to the load from the crane and configuration of pulleys. Crew lacked information and guidance on hazards and doing this work safely. Operator’s safety management system lacked a safety assessment for the work.

A recreational jet boat with four people on board crashed on a gravel river bar. One passenger died; two others hospitalised. Risk factors: insufficient planning; insufficient daylight; too much speed and too much alcohol. TAIC is calling for more data collection on alcohol impairment, and new legislation or rules to prohibit people in safety-critical roles being impaired by alcohol or drugs.

A rail signal technician was potentially put at risk from rail traffic, unaware that the line was not protected. People didn't follow rules & procedures for everyone working on a safety-critical task to: share a clear understanding of the task and how everyone will do it. Wrong assumptions about nature of the signals task and how the technician was protected. Everyone should ask; don't assume.