Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

On the first topdressing flight for the day the take-off run was longer than normal due to a blocked injector in the number 8 cylinder. During the take-off the right wing passed through a six foot tall hedge of dense thistles which bordered the downsloping airstrip for the lowest third of its length. The thistles had not been present when the pilot operated from the airstrip previously. Thistles became entrained between the wingtip and the aerodynamic balance horn, deflecting and jamming the ailerons, causing the aircraft to roll uncontrollably to the right.

On 5 November 1994 ZK-EFO was being used to top-dress a farm near Kaikohe Aerodrome. During a turn the aircraft stalled and collided with the hillside.

At approximately 1100 hours on Wednesday 7 June 1995 a Fletcher FU24A-954, ZK-EMU, collided with the face of a hill during a sowing run and caught fire. The aircraft was destroyed, and the pilot lost his life in the accident. Pilot incapacitation was the probable cause of this accident. The incapacitation was sufficient to cause loss of situational awareness and loss of aircraft control at a critical phase of flight. No safety issues were identified as a result of this investigation.

On Tuesday 14 October 1997, at about 0815 hours a 3.7 m log fell from a wagon forming part of Train C25, a Kinleith to Mount Maunganui log train, as it passed through Tokoroa. The log cartwheeled for 38 m, cleared a 1.8 m high fence and came to rest on a trampoline in a residential property.

At about 1040 hours, on Saturday 24 August 1996, at the conclusion of a local flight, Jodel D11 ZK-EJP made an approach and go-around over the farm airstrip where it was based. The aircraft subsequently flew downward at a lower height than usual and was seen to bank steeply to the left in an apparent attempt to land on the airstrip or in adjacent paddocks. It levelled momentarily then rolled to the right, descended rapidly, and struck the hillside. The pilot sustained fatal injuries on impact.

An engine failure, and subsequent forced landing, occurred to an Aerospatiale AS 350D helicopter during a scenic flight over the Fox Glacier on 17 March 1993. The safety issues discussed in the report are related to the promulgation and implementation of manufacturer's Service Letters and the inspection of unmodified fuel pump assemblies.

During the course of a scenic flight over Fox Glacier, the helicopter's engine seemed to lose power and the pilot made an autorotational descent on to the glacier. Two of the passengers were fatally injured during the ensuing impact on the extensively crevassed and pinnacled ice-fall, and the pilot and one of the two surviving passengers received serious injuries.

On 10 December 1993 express freight train 210 encountered a "stop and proceed" signal at Stop at Puhinui, 1.5 km south of Papatoetoe. In accordance with the signalling rules, the Locomotive Engineer stopped, and after a short interval, proceeded. He subsequently had to make an emergency brake application to avoid a collision with a stationary train ahead of him. The safety issues identified in this report were the need for guidelines for Locomotive Engineers to assess their fitness for duty and rest facilities for Locomotive Engineers while waiting for trains.

At 1651 on 19 July 2021, the second and third carriages parted on a KiwiRail-operated Auckland to Hamilton southbound Te Huia passenger train travelling at 91 kilometres per hour. The parting occurred at about 636.9 kilometres (see Site Information paragraph 2.76) between Papakura and Pukekohe on the North Island Main Trunk (NIMT), and caused the brakes to automatically apply in both train portions as air hoses between the carriages separated. There were no injuries, but some damage to inter-carriage electrical jumper cables.

When the pilot of ZK-EVA attempted to join formation with ZK-EQM, the aircraft collided and ZK-EQM entered a spiral descent into a paddock. A portion of ZK-EQM struck the passenger of ZK-EVA, ZK-EVA returned to Palmerston North Aerodrome.

On 22 December 1994, Piper PA 32-260 (Cherokee Six) ZK-DDF landed heavily on Waiheke Island Aerodrome. The aircraft sustained wing and undercarriage damage, but none of the four occupants was injured. The causal factor in this accident was the turbulence encountered during the approach and landing phase of the flight. No safety deficiencies were revealed by the investigation.