Inquiries & Recommendations
Ngā ketuketutanga me ngā tūtohunga
Ngā ketuketutanga me ngā tūtohunga
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Aviation
AO-1993-017
Two persons fell while being winched in from the ship "Pacific Ariki", by a hoist installed in Bell 212 helicopter ZK-HNO on 14 November 1993. The ship was at sea 2nm west of Oaonui.
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Aviation
AO-2006-009
On 30 December 2006, a fire occurred in the left General Electric CF6-80C2 engine nacelle of a Boeing 767 aircraft as it taxied clear of the runway after landing at Auckland International Airport. The fire was promptly extinguished and the minor damage was confined within the nacelle.
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Rail
RO-2017-102
Two trains were put into conflict due to a signal box display not showing track and points layouts correctly, but a driver realised he was on wrong track and stopped his train. Safety issues related to the change management process for upgrading the signal box, and signaller familiarity with the actual track layout and equipment capabilities. Two recommendations have been made to KiwiRail, on top of safety actions taken.
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Rail
RO-2003-109
On Friday 27 June 2003, Tranz Metro Train 3347 was an Auckland to Papakura diesel multiple unit passenger train. At about 0915, a driveshaft on passenger car ADL 810 failed as the train approached Purewa Tunnel, between Meadowbank and Glen Innes stations. The DMU driver stopped the train about 200 m short of the tunnel. The free end of the failed driveshaft was not sufficiently restrained and it punctured the floor of the passenger compartment. The 3 passengers travelling in ADL 810 were not injured. The safety issues identified included:
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Aviation
AO-1992-017
ZK-KID, a high performance homebuilt design, was owned and operated by the pilot who had constructed the aircraft himself. He had flown to Alexandra to attend a Chapter meeting of the NZ Amateur Aircraft Constructors Association. A "mini-competition" was held to round off the afternoon's activities. Part of the set exercises involved flying a figure eight pattern at 500 feet above aerodrome level. During the second half of this manoeuvre ZK-KID was observed to lose height while turning from a downwind heading to crosswind at a steep angle of bank.
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Aviation
AO-2007-012
At about 1320 on 10 November 2007, a Fletcher FU24-950EX aeroplane, registered ZK-EGV, was engaged in aerial top-dressing of a farm near Opotiki when it descended into trees in a small gully about 600 metres from the area being top-dressed. The pilot, the only occupant, was killed.
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Rail
RO-2002-124
On Wednesday 12 June 2002 at about 1308, a partially-sighted passenger fell from the doorway of Train 2643 while alighting at Silverstream. The train, an Upper Hutt to Wellington Tranz Metro electric multiple unit service, had stopped at the platform but the last doorway of the rear passenger car, from which the passenger fell, was positioned off the north end of the platform. The passenger suffered serious injuries that required hospital treatment. The safety issue identified was the berthing of electric multiple unit passenger services at suburban stations.
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Maritime
MO-1997-211
At about 1545 on Friday, 26 December 1997, a jet boat carrying 10 passengers plus the driver, ventured into a shallow tributary of the Lower Shotover River. The driver turned hard left in an attempt to regain the main channel but the boat skidded sideways along a shingle bar for some 10 m before it rolled and came to rest upside down. Several of the passengers and the driver received minor to serious injuries in the accident.
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Aviation
AO-2007-013
The Commission was New Zealand's Accredited Representative to the Air Accidents Investigation Branch, Department of Transport, United Kingdom for their investigation into the above occurrence. Their report was published as "Luscombe 8E Silvaire Deluxe, G-AKUI and Pacific Aerospace PAC 750XL, ZK-KAY". Using the link in the sidebar to the right.
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Rail
RO-1996-110
On Thursday, 13 June 1996 at about 1035 hours Train 401, the southbound Geyserland Express passenger service, struck and killed a signal maintainer working alongside the track. The causes were the signal maintainer's lack of awareness of the train's approach and the absence of any warning to the locomotive engineer of the presence of this staff member. A safety issue identified was the need for the wearing of high-visibility clothing by all staff in such situations to be mandatory.
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Aviation
AO-1993-002
Severe "sink" experienced during an approach to a high level landing site resulted in a collision with terrain of Aerospatiale AS 350B helicopter ZK-HNH near the summit of Mt Fyffe, 12 km north-west of Kaikoura on 1 February 1993. The safety issues discussed in the report are: the ineffectiveness of the local wind indicators, the inaccessibility of the mountain survival gear carried in the aircraft and the need to develop local contingency plans for aviation emergencies in the Kaikoura area.
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Rail
RO-2003-107
On Thursday 15 May 2003, at about 1240 hours, bi-parting doors on Train 3247, a Tranz Metro Auckland to Papakura diesel multiple unit passenger service, closed on an alighting passenger at Glen Innes station and the train departed with the passenger trapped in the door. The driver heard the trapped passenger’s screams and stopped the train within about 15 m from where the train departed. The passenger suffered minor injuries. The safety issues identified were: · the door closure process · the inspection of safety critical door components.
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