Inquiries & Recommendations

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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.

ATC issues led to a loss of required separation and a near collision between a Cessna 182 parachute-drop aircraft with a single pilot on board and a Bombardier DHC-8 Q311 airliner with 3 crew and 31 passengers on board near Mercer on 9 August 2009. Both aircraft were operating as cleared by ATC when the airliner’s equipment detected the conflict and directed it away from a potential collision with the parachute-drop aircraft, which had just dispatched 4 parachutists and commenced its descent.

At approximately 1215 hours on Tuesday, 18 May 1999, a collision occurred between the north yard shunt and No. 1 shunt in Middleton yard. No injuries occurred but the locomotives sustained some damage and 3000 litres of diesel leaked from a ruptured fuel tank. The safety deficiencies identified included: • the suitability of the procedures and compliance monitoring in place to ensure the safe operation of remote control locomotives

On Sunday 18 April 1999 at around 1538 hours, ZK-EKJ, a Cessna 206 floatplane on a round-trip scenic flight from Te Anau to overhead Milford Sound, struck the top of a vertical craggy mountain ridge. The pilot and 4 passengers died during the impact.

On Monday 6 August 2001 at about 0730, a lifeboat and rescue boat launching drill was conducted on board the passenger and freight ferry "Aratere". At about 0750, during the recovery of the port lifeboat, the forward hook of the synchronous release equipment opened spontaneously when the lifeboat was about one metre above the water. The bow of the lifeboat fell back into the water. None of the 8 occupants were injured and the lifeboat sustained no damage. Safety issues identified included:

On Wednesday 29 September 2004 at about 1720, the passenger freight ferry "Aratere" was entering Tory Channel from Cook Strait when it failed to make a programmed course alteration while in automatic steering. The navigational bridge team had to intervene and make a manual alteration of course to prevent the Aratere from grounding at full speed on the north side of the channel. Safety issues identified included: - the adequacy of bridge resource management - the adequacy of training in the use of all integrated bridge systems

[A preliminary investigation showed that the circumstances were not likely to have significant implications for transport safety. Consistent with section 13 of the TAIC Act the Commission discontinued the investigation and no report was published.]

On Tuesday 7 March 2000, Aerospatiale AS 350BA helicopter ZK-HWK was on a local charter flight from Raglan to Mount Karioi, carrying technicians to service telecommunications equipment located on the summit. It was being flown in conditions of reduced visibility resulting from local cloud when it collided with trees and the ground, killing all 4 occupants. The time of the accident and the detail of the flight path could not be conclusively established, but the pilot may have inadvertently lost visual reference with the surface in deteriorating visibility.

This report examines 3 derailments due to washouts and slips (occurrences 02-101, 02-102 and 02-103) caused by inclement weather in the South Island during January 2002. No serious injuries were sustained but the opportunity existed in each case for more serious and potentially life threatening injuries to have occurred. Safety issues identified by these incidents included: • the lack of a formalised early warning river flow level notification process for the Rangitata River • the lack of staff available to respond to operating contingencies during the holiday period

On 21 December 1993 Train 573 struck and a pedestrian near Marton. The safety issue identified by this investigation was the lack of warning signs against trespassing over two rail bridges and along the track in the area of this accident.

On Saturday, 22 March 1997, at approximately 1848 hours Train 3656, a northbound suburban electric multiple unit service, collided with a car on Sutherland Avenue level crossing, Trentham. The three occupants of the car suffered minor injuries. The level crossing protection was not activated until the train was almost on the crossing. The cause of the incident was the failure of Train 3656 to stop at a signal displaying a red aspect.

On the morning of 27 April 2011, an instructor and a student pilot in a Robinson R22 helicopter departed from Wanaka Aerodrome on a cross-country training flight through part of the Southern Alps.