Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The Commission has closed its inquiry into this occurrence. It is satisfied on the facts before it that the circumstances of the accident do not allow the Commission to establish findings or make recommendations which may increase transport safety.

A trainee rail protection officer authorized workers to start work on the main south line in Hornby before a scheduled train had passed through. The workers realized a train was approaching when level crossing bells started ringing and were able to get off the track in time. TAIC identified failings in supervision and in training RPOs to supervise trainees. Further, available engineering controls (which physically reduce hazards) were not being used.

Employers and managers of safety-critical workers, please note: workplace safety risk from after-effects of acute illnesses such as COVID-19. Can impair workers’ concentration, memory and thinking, including their ability to reliably self-assess as being fit to return to work. TAIC reports on occurrence where coal train missed and passed a stop signal, potentially into conflict with oncoming freight train.

The Fiordland Navigator ran aground after the fatigued master almost certainly fell asleep at the helm. TAIC found gaps in fatigue management, monitoring of medical fitness, and risk controls for sole-charge masters. Several passengers and crew suffered minor injuries, but the emergency response was effective. The vessel’s operator has since strengthened fatigue policies, added support roles, and improved safety oversight. TAIC made one recommendation—to Maritime NZ—to improve awareness of ongoing medical fitness responsibilities for seafarers.

Passenger train parts at low speed, inspection and response gaps exposed. A cracked coupler, unnoticed in maintenance, caused carriages on the TranzAlpine tourist train to part. Power braking stress, missed alarms, and no procedure for crew to deal with partings revealed wider risks.

A track machine derailed in Auckland’s Purewa tunnel after being authorised to enter a worksite where track had been removed. Key safety information wasn’t shared and staff were under-resourced. No one hurt, but lead machine was heavily damaged. Three TAIC recommendations to KiwiRail: verify track status, improve authorisation processes, and ensure safe staffing levels for safety-critical roles.

Two aircraft came within 20 feet of each other on final approach at night at Ardmore Airport. TAIC report highlights safety lessons for pilots, aircraft owners, engineers, and aerodrome operators at busy unattended aerodromes. It shows how communication, visibility, and access to shared procedures can make all the difference and makes recommendations to improve night flying safety across New Zealand.

New TAIC report on a failure to ensure safe navigation while the crew were fishing. Fishing vessel Austro Carina stranded because a turn took it toward land and nobody was in the wheelhouse to stop it happening. Maritime NZ and vessel’s operator need to improve watchkeeping standards and practices.

An air ambulance helicopter was dispatched from Hamilton Airport to recover a trauma patient on Mount Pirongia. While descending on the windward side of a ridge line to recover the patient, the helicopter rapidly and unexpectedly dropped in height. The helicopter impacted the terrain on a west-facing escarpment covered by dense native forest. The helicopter was severely damaged. The pilot, crew member and paramedic escaped without injury.