Inquiries & Recommendations

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A freight train passed two stop signals, entered section of track without authority, narrowly avoiding a collision with a hi-rail truck that had permission to be there. Train driver expected a clear track and misread signals and radio calls while using mobile phone. The train had no engineering safeguards to stop it. TAIC found over-reliance on rail people being perfect, and a rising nationwide rate of signals passed at danger, calls for stronger engineering controls and oversight.

Helicopter maintenance error passed duplicate inspections, leading to flight control failure. Distraction, fatigue and weak assurance processes meant a critical fault was not detected before release.

Aratere grounded after unintended turn while on autopilot. Report highlights management of safety-critical equipment change, operational differences not known, gaps in management oversight, training

An Airbus A320 veered off a taxiway after landing. A hydraulic failure during the flight had disabled nosewheel steering and one engine’s thrust reverser. Uneven thrust sent the plane onto the grass. Nobody was injured, but one engine was significantly damaged. TAIC calls on Airbus to update manuals, and stresses careful inspection of high-pressure hydraulic parts.

The Japanese fishing vessel Chokyu Maru No.68, with 27 crew aboard, grounded on rocks near The Noises island group while inbound to the Auckland pilot boarding area.

Bridge collapse highlights need for stronger inspection, asset management and severe-weather controls as transport operators adapt to more frequent extreme weather events.

In the early evening of 2 April 2024, the crew of an Air New Zealand Airbus A320 reported seeing what they described as a drone while at 2000 feet on the final approach for runway 23L at Auckland. As a result of the drone sighting, and for the safety of other aircraft, Air Traffic Control closed that portion of the Auckland airspace for 15 minutes, resulting in delays to other inbound aircraft.

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.

TAIC provided support for an investigation by Chilean investigation authority, the Dirección General de Aeronáutica Civil into an incident involving a Boeing 787 aircraft in international air space on its way to New Zealand. Chile, as the State of Registry, is investigating this incident and has requested New Zealand’s assistance. TAIC is gathering evidence on behalf of Chile. TAIC will not produce a report for this inquiry. This is a responsibility of Chile authorities.

A trainee rail protection officer authorised 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 Commission assisted an investigation by the Swiss Transportation Safety Investigation Board (STSB) into a fatal accident involving a Pacific Aerospace PAC 750 aircraft, registered HB-TCP.