Inquiries & Recommendations
Ngā ketuketutanga me ngā tūtohunga
Ngā ketuketutanga me ngā tūtohunga
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Rail
RO-2017-104
TAIC has published its Final Report on the immobilisation and tagging of an Auckland metropolitan passenger train in September 2017. TAIC recommended that the train operator improve training for train crews, including liaising with emergency services. A fast and efficient emergency response depends on first responders receiving clear, concise and timely information.
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Aviation
AO-2017-007
An Airbus A320 inadvertently flew below minimum safe height on approach to Christchurch Airport. It landed safely. Lesson: properly used automated flight navigation systems will reduce crew workload and result in safer flight operations. Crew chose not to use auto, did not stay aware of their location compared to standard arrival route, and air traffic controller did not alert the flight crew.
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Aviation
AO-2017-005
The Australian Transport Safety Bureau has commenced an investigation and requested assistance from TAIC as an Accredited Representative in accordance with Annex 13 to the ICAO Convention. A fatal accident occurred on 16 June 2017, involving an Australian-registered Fletcher aeroplane near Bathurst, Australia. The aeroplane was manufactured in New Zealand. The aeroplane was involved in aerial agricultural operations when it collided with terrain. The pilot was fatally injured and the aeroplane destroyed. [As initially reported, subject to change, not official findings.]
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Aviation
AO-2017-006
An accredited representative has been appointed to assist the investigation of the United Arab Emirates General Civil Aviation Authority. Royal New Zealand Air Force C130 was on approach to Dubai aerodrome in instrument meteorological conditions under the control of local Air Traffic Control. The controller cleared the aeroplane to descend to 2,000 feet, which was 800 feet below the minimum radar vectoring altitude of 2,800 feet. The aeroplane had only 200 feet clearance above the highest obstacle in the area. [As initially reported, subject to change, not official findings.]
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Aviation
AO-2018-004
New Zealand has completed its support for this inquiry. Please note: TAIC will not be producing a report for this inquiry.
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Rail
RO-2017-103
A loaded passenger train had perceived brake problems and halted soon after departure from Wellington Station. There were differences between track hardware, the signaller’s information screen, and mistaken impressions that resulted. With authorisation from the signaller, the train began to return to the station. Just then, the signaller saw that the returning train was heading into the path of an inbound train. The signaller called the driver, who stopped the train. No collision, nobody injured.
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Aviation
AO-2017-004
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.
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Aviation
AO-2017-003
Two broken springs in the landing gear of an ATR passenger aircraft caused it to divert and make an emergency landing. Little damage, no injuries. Springs broke when cracks formed due to corrosion. Operator found no other such problematic springs on its ATR72 fleet, has new maintenance & replacement plan. Manufacturer updated maintenance manual worldwide, added training scenario based on this incident
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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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Aviation
AO-2017-002
Circumstances of this fatal helicopter crash into dense forest included: risky take-off towards and over treetops; old worn engine lacked power; and aircraft not airworthy. Also private pilot licence conditions breached (flying for payment or reward). Lessons about obeying Civil Aviation Rules; reporting concerns; CAA monitoring of nominally private aviation participants.
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Aviation
AO-2017-001
An AS350 helicopter fighting wildfires on the Christchurch Port Hills crashed after up-swinging monsoon bucket cable hit tail rotor assembly. Pilot fatally injured, helicopter destroyed. Key lessons: need for vigilance during turbulence; always fly within aircraft’s limitations; operators should record and investigate all operational incidents; and performance-impairing substances pose a serious risk to aviation safety (NB: very unlikely pilot was impaired at time of accident).
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Maritime
MO-2017-204
The Seabourn Encore was berthed at PrimePort Timaru. In strong south westerly winds, a number of wharf mooring bollards and ship mooring lines progressively failed allowing the ship to swing off the berth and collided with a nearby cement carrier. Nobody harmed, but some damage to wharf infrastructure and both ships. Final Report addresses matters concerning mooring equipment; mooring procedures; and planning for, and responding to, a change in the weather. Recommendations apply both locally and nationwide to all ports in New Zealand.
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