Inquiries & Recommendations

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New Zealand has completed its support for this inquiry. TAIC will not be producing a report on this inquiry. A copy of the report produced by the Italian investigaiton agency can be found at page 16 using the link in the sidebar to the right.

New Zealand has completed its support for this inquiry. For further information please contact TSB Please note: TAIC will not be producing a report for this inquiry.

Please contact Komite Nasional Keselamatan Transportasi (KNKT) for the final report.

On 2 July 2015 the container ship Madinah was preparing for arrival at the port of Lyttelton. Part of those preparations involved the bosun (deck crew foreman) and a deck trainee rigging the port-side accommodation ladder over the ship's side in readiness for the ship's docking.

NZ domestic air traffic control services suffered a four-minute interruption in radar and radio contact with aircraft, and standby radio and telephone systems didn’t all work as expected. It took several hours to get flights back to normal. Maintenance work to upgrade technical systems had caused a ‘broadcast storm’ that disabled the digital data network and restricted the flow of digital data traffic. Network architecture and management have since been improved. The Commission has recommended an update for Civil Aviation Rules.

New Zealand has completed its support for this inquiry. TAIC will not be producing a report on this inquiry. A copy of the report produced by the ATSB can be found on the link in the sidebar to the right.

On 19 February 2015 a Robinson R44 helicopter was returning to Queenstown from a training flight when it suffered a mast bump and crashed in bush near the Lochy River. The instructor and student on board were killed. The Commission investigated the accident, the cause could not be conclusively determined, and the Commission’s final report was published in August 2016. The Commission resumed the inquiry the following month after being advised of new evidence concerning the mental health of the instructor.

On 19 February 2015, a Robinson R44 helicopter was returning to Queenstown from a training flight when it broke up in mid-air and crashed in bush near the Lochy River, killing the instructor and student. The helicopter broke up in mid-air when one of the main rotor blades struck the cabin, which was caused by a phenomenon known as mast bumping, when the inner part of a main rotor blade or the rotor hub contacts the main rotor drive shaft. Mast bumping is typically caused by one or a combination of the following factors: - low main rotor revolutions per minute (RPM)

In February 2015 the Kea passenger ferry from downtown Auckland struck Devonport wharf at speed after the master was unable to properly control the vessel’s propulsion system. The Kea’s hull was damaged and seven passengers were hospitalised. Fullers Ferries have taken action to address personnel and training issues; to modify vessel systems and implement a new safety management system. Maritime NZ has responded positively to a Recommendation for businesses in the sector to adopt a risk-based approach to changes to critical systems.

Morningside Station in Auckland consists of an 'island platform' where the northbound and southbound rail tracks pass either side of the platform. At one end of the platform pedestrians have to walk down a fenced ramp to join a pedestrian level crossing, which is part of the Morningside Drive road level crossing. At the bottom of the platform ramp pedestrians have to turn either left or right to cross the relevant rail track.

The Commission resumed its AO-2015-003 inquiry to reconsider information it had received about the causes and circumstances of an aviation incident near Waikaia Southland in January 2015. While spraying gorse, the pilot of a Robinson R44 helicopter felt an unusual and significant vibration, landed immediately, and found a crack in a main rotor blade. The Commission’s final amended report includes findings that match the original, plus technical clarifications and expert metallurgical examination of the main rotor blades.

A Pacific Aerospace Limited 750XL aeroplane was being used for tandem skydiving from Taupō aerodrome. During the climb, a turbine blade in the single engine failed. The pilot put the aeroplane into a glide and all on board bailed out and landed without serious injury. With nobody on board, the aeroplane crashed into Lake Taupō and was destroyed.