Inquiries & Recommendations
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Maritime
MO-2004-214
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
Incident date: Publish date:
Rail
RO-2004-123
Between Friday 7 May 2004 and Thursday 30 September 2004, four incidents involving traction motor fires on Tranz Metro electric multiple unit passenger services occurred on the Wellington suburban passenger network. This report incorporates reports 04-114, 04-122 and 04-124. These incidents occurred on 4 different driving sets, and all resulted in smoke entering the passenger compartments. There were no injuries to passengers or crew in any of the incidents. Safety issues identified included: - the use of incorrect crimp lugs in cable connections
Incident date: Publish date:
Aviation
AO-2004-005
[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.]
Incident date: Publish date:
Rail
RO-2004-122
[Investigation incorporated in report 04-123. Please refer to that report.]
Incident date: Publish date:
Rail
RO-2004-121
On Friday 24 August 2004 at about 1530, locomotive DBR1199 derailed while hauling a set of empty passenger cars into Britomart Station in Auckland. The passenger cars and second locomotive were not derailed. The derailment occurred when a tyre, which had worked loose from a wheel on DBR1199, struck the frog in a set of facing points and derailed all wheels of the trailing bogie. The safety issue identified was the susceptibility of tyred wheels to loosen due to excessive heat.
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Maritime
MO-2004-213
On Sunday 22 August 2004 at about 1708, the passenger ferry "Superflyte" was proceeding from Matiatia on Waiheke Island to Auckland, with 6 crew and 311 passengers on board, when a fire was discovered in the port engine room. The master issued a distress call and all passengers were evacuated in due course to other vessels that responded to the call. Carbon dioxide flooding was used in an attempt to extinguish the fire, but this was unsuccessful due to a fault in the system. The fire was eventually extinguished manually by the crew with assistance from the Fire Service.
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Rail
RO-2004-120
On Wednesday 18 August 2004, at about 0815, an unmanned DFT locomotive, that had been stabled in the loop at Pines, ran away on to the Main North Line and collided with stationary Train 726, a Christchurch-Picton express freight service. The runaway locomotive struck the second wagon in the consist of Train 726, which was standing over No.3 motor points at the south end of Pines. There were no injuries and only minor damage to the DFT locomotive and one wagon on Train 726. Safety issues identified were: - the procedures for the application of the handbrake on the locomotives
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Maritime
MO-2004-212
On Monday 16 August 2004, the restricted limit fishing vessel "Iron Maiden" foundered to the south of Pandora Bank, off the Northland west coast, with the loss of the 2 crew. The boat was on a delivery voyage from Mangonui on the east coast to Raglan about halfway down the west coast of North Island.
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Rail
RO-2004-119
On Wednesday 28 July 2004 at about 1320, during a wrong line running operation, Train 3358 a Tranz Metro Papakura to Britomart diesel multiple unit passenger train passed Signal 8B at Tamaki, at Stop, without verbal authority. The train continued on the Down main towards Britomart Station without the required Track and Time Permit. There was no conflicting movement approaching Train 3358. Safety issues identified included: - training regime for locomotive engineers multiple units - the identification in the field of the start point for wrong line running
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Rail
RO-2004-118
On Tuesday 20 July 2004, at 1345, Train 725, a Picton to Christchurch express freight service, was authorised to travel through the Tormore to Scargill section of the Main North Line that was already occupied by a track maintenance gang. Two track maintenance personnel had just completed their work and were stowing equipment on their vehicle parked trackside when the train travelled through their worksite. There were no injuries or equipment damage. Safety issues identified included: - the certification process for trainee train controllers
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Rail
RO-2004-117
[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.]
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Maritime
MO-2004-211
On Sunday 4 July 2004 at about 1517, while on passage from Chatham Islands to Napier in heavy weather, the coastal cargo vessel "Southern Tiare" lost its rudder below the rudder head. The master was able to manoeuvre the ship, using the bow thruster to maintain the ship’s head into the sea, until a tug arrived to take the ship under tow to Napier, where it berthed without further incident. The crew sustained no injuries during the incident. Safety issues identified included:
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