Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

A train was wrong routed onto a line not adjacent to a station platform. Two passengers got off and walked across the Main Line. Train control didn’t know, and rail traffic wasn’t blocked from passing through. Nobody hurt. KiwiRail fixing wrong routing of passenger trains at Rolleston, instructing crews on disembarking passengers when platform unavailable. Safety-critical personnel must communicate about who is doing what, when, to complete tasks safely.

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.

A Cessna light aeroplane and a Tecnam microlight collided on final approach parallel runways at Masterton. Tecnam had right of way but Cessna pilot did not see Tecnam. Both pilots died. Pilots should always keep a lookout for other aircraft, listen out for radio calls, obey Civil Aviation Rules, and follow standard operating procedures. CAA and WorkSafe should work with aerodrome owners and operators to ensure that operators and managers of aerodromes receive appropriate training and support.

A work train was allowed to travel through an area where a hi-rail excavator was on the track. The excavator driver cleared the track. No damage, no injury. A local procedural work-around had been prioritised over established safety rules -- risky. TAIC recommends KiwiRail review its Rules and Procedures to provide appropriate guidance for operation of work trains.

On 22 April 2019, a BK117-C1 helicopter (ZK-IMX) on a medical evacuation positioning flight to the Auckland Islands arrived after dark and continued under visual flight rules using night vision goggles. While attempting to descend below cloud near Enderby Island, the helicopter impacted the sea. The three crew escaped, swam to shore, and were rescued the next day with minor injuries. The helicopter was recovered three weeks later.

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.

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.

Derailment of three freight train wagons was very likely due to "dynamic interaction" – a combination of excessive speed, track geometry and wagon centre of gravity. Train was exceeding maximum permissible track speed on a downhill gradient with a distracted driver. The operator has addressed the safety issues raised in this report. Lessons on driver distraction and acting on safety knowledge.

New Zealand has completed its support for this inquiry. Please note: TAIC will not be producing a report for this inquiry.

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.

A fatal controlled flight into terrain occurred after aircraft turned away from planned/ authorised route in uncontrolled airspace. Terrain proximity awareness system either too dim or not selected. All pilots should follow Civil Aviation Rules, apply validation steps such as cross-checking altitude and distance for flight plans, use onboard safety equipment. Flight training schools should have robust flight authorisation systems.