Inquiries & Recommendations

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The ship was entering Milford Sound in the dark. The pilot lost awareness and bridge crew did not alert him or use on-board navigation gear correctly. The ship hit a stony bank causing light damage to the hull, no injuries. Safety issues related to electronic navigation use; standard of bridge resource management; and risk management of blind pilotage. The operator and Environment Southland have both taken actions since. Two previous recommendations were repeated, and a new one made.

In February 2017 the crew of the passenger cruise ship Emerald Princess were re-pressurising the gas cylinders after maintenance, when the cylinder burst below its normal operating pressure, causing the death of a nearby crew member. The cylinder had been weakened by corrosion. The inquiry report highlights a lack of global minimum standards for inspection, testing and rejecting pressure cylinders for stored energy systems on lifeboat launching installations – a system common on cruise ships.

Despite warning signs, a train driver only noticed a maintenance team working on a rail bridge as the train drew close. The train crossed the bridge without authorisation while the workers were still under it. No injuries, no damage to train or bridge. KiwiRail now has a system to investigate and resolve potential faults in safety systems. TAIC recommendations address medical data capture; sleep apnoea detection; and the need for a good fatigue risk management system.

The standard of bridge resource management and unfamiliarity with the ship’s electronic navigation equipment were factors in a January 2017 grounding of a cruise ship at the Snares Islands south of New Zealand. While the master focused on recovering boats from a shoreline excursion, the ship inadvertently entered the 300-metre zone that the ship was not permitted to enter. It struck an uncharted rock, the hull was pierced and an empty void space flooded. No passengers or crew were injured.

In November 2016, fishing charter vessel Francie capsized in rough water crossing Kaipara Harbour bar. 8 people died, 3 survived. More would have survived had all worn lifejackets, more so if fitted with crotch straps. TAIC calls for lifejacket types to match the activities of commercial restricted-limit vessels, rather than just how far out they can go. A higher standard lifejacket should be mandatory on commercial vessels operating out of bar harbours and off exposed coastlines.

The helicopter suffered extensive damage and the pilot escaped with minor injuries during an emergency landing attempted after rotor power was lost during an agricultural spraying operation. Contaminated fuel was very likely the cause of the power loss; the operator’s refuelling procedures left opportunities for contamination to occur. TAIC made recommendations for more educational material to alert operators to contamination risks, and for the promotion of lessons learned from this accident.

In November 2016, the bulk carrier New Legend Pearl was about 125km east of Coromandel. A crew member working on a crane jib was changing his safety harness securing point when he fell 8 metres to the deck below. Paramedics helicoptered to the ship but were unable to revive him and he died from his injuries. Working at height is risky, so all crew should use suitable safety harnesses correctly.

A Robinson R44 helicopter crashed into dense bush in Glenbervie Forest near Whāngārei. The two occupants – the pilot and a forestry contractor – died in the crash, and the helicopter was consumed by fire. Crash and fire damage destroyed evidence, so the cause or causes could not be determined. The Commission has previously recommended that recorders be fitted to certain classes of helicopter to aid accident investigation.

To enable a good run at the hill, the driver of a fully loaded coal train reversed past one red light and when warned stopped just before another, just avoiding a collision with an empty passenger train. The three KiwiRail staff directly involved neither knew nor followed correct procedure. One was not asked to undergo a post-incident drug and alcohol test. All staff should know and follow safety procedures; and ensure they jointly understand what’s being planned.

A Squirrel helicopter was making a snow landing on Mt Sale in Central Otago when it struck the ground hard and finished, badly damaged, on its side. There were no fatalities; one passenger received minor injuries. The fast, low and close landing approach may have limited the pilot’s ability to confirm actual wind direction and usable escape routes. This was the fourth serious helicopter landing accident for this operator in three years.

In August 2016, bulk cargo ship Molly Manx was inbound to Dunedin (Ravensbourne pier) with a harbour pilot on board. On approach to the narrow passage between the Halfway Islands, the ship ran aground on a sandbank. Damage was limited to the bottom paintwork. Nobody was injured. Key lessons are that a bridge team must: work with the pilot on route (planning and monitoring); incorporate pilots into bridge resource management; and ensure they can be warned of risks by a correctly configured electronic chart display and information system.

New Zealand has completed its support for this inquiry. For further information please contact ATSB using the link in the sidebar to the right. Please note: TAIC will not be producing a report for this inquiry.