Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

A fractured section of rail caused the derailment of a passenger train with about 130 passengers on board at Britomart Station, Auckland. Nobody was injured but there was damage to train and track. A machining defect likely reduced the rail’s resistance to fatigue and fracture. KiwiRail has improved track inspections. A new multi-agency group is studying the effect of rolling stock on rail and to resolve potential rail wear issues.

The fire on the fishing trawler Dong Won took hold because the fire alarm did not sound, the crew’s initial firefighting was inefficient; and the ship was exempt from and did not comply with current structural fire protection standards. On any such vessel, the crew may not be as safe as they would be on a newer vessel constructed to newer standards. TAIC recommendations address the key issues.

At the request of the Kiribati Government, New Zealand provided a team to assist the Kiribati Government in its investigations into the sinking of the MV Butiraoi. The investigation team was seconded from TAIC to the Kiribati Government. The investigation was completed and a report provided to the Kiribati Government.

The Commission is assisting the Australian Transport Safety Bureau’s investigation.

A skydive tandem pair crash-landed into a lake following a double parachute malfunction. The tandem rider’s lifejacket did not properly inflate, and the rider was lost in the lake, presumed deceased. Parachutists everywhere need to practice water landings, which are even riskier than you might think. TAIC recommends changes to aviation rules and incident reporting.

TAIC has resolved this inquiry, satisfied that the Interim Report published in May 2018 identified the salient safety issues, which Rolls-Royce had already addressed. The Commission’s early investigations prompted the engine manufacturer to improve its system for forecasting when the fatigue might happen. Affected turbine blades have been replaced in 99% of the global flying fleet.

TAIC has resolved this inquiry, satisfied that the Interim Report published in May 2018 identified the salient safety issues, which Rolls-Royce had already addressed. The Commission’s early investigations prompted the engine manufacturer to improve its system for forecasting when the fatigue might happen. Affected turbine blades have been replaced in 99% of the global flying fleet.

The Commission assisted the Australian Transport Safety Bureau’s investigation. A New Zealand-registered Boeing 777 reportedly descended below the minimum altitude for a part of its arrival procedure on approach to Brisbane International Airport. New Zealand has completed its support for this inquiry. Please note: TAIC will not be producing a report for this inquiry but you can find a copy of the report produced by The Australian Transport Safety Bureau on their website.

A pair of coupled loco-motives ran through wrongly-set points, dislodged fail-safe equipment, and carried on into a maintenance depot, shunting a maintenance vehicle into a rail wagon. There were no injuries. The wrong-routing happened because nobody checked to ensure correct setting of the points, and local procedures to prevent wrong-routing did not conform fully to KiwiRail rules. Safety actions taken by the operator precluded any need for recommendations.

A refuse collection truck entered a level crossing, very likely without stopping at the Stop sign, and was struck by a log train. The truck driver died in the accident. Even if the truck had stopped, the view lines weren’t good enough for the truck to clear the crossing if a train had been just out of view. Legislation is unclear on allocation of responsibility for safety of crossing users. Road users must be cautious. Wearing seatbelts will increase the chances of survival.

There was a fire in the cargo hold of the Kokopo Chief while berthed at the Port of Tauranga. An alarm alerted the crew to smoke in one of the cargo holds and they activated the fire extinguishing system. The main cargo on the ship was understood to have been dressed timber. Deck containers with dangerous goods were removed. There were no reported injuries. [As initially reported, subject to change, not official findings.]