Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On 23 May 2010 the general-purpose oilfield support vessel Marsol Pride was conducting underwater operations within the Tui oil and gas field off the west coast of New Zealand. The Marsol Pride was fitted with a fixed carbon dioxide (CO2) fire smothering system for its engine room. Late that night a valve on one of the CO2 pilot cylinders developed a leak and charged the system ready for release. A second leak in the main control valve then caused the entire system to activate resulting in an uncontrolled release of CO2 gas into the engine room.

[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 Wednesday 10 April 2002 at about 1435, Cessna 210N Centurion ZK-TWA departed from Dunedin bound for Masterton. The aircraft did not arrive at Masterton, but was not reported overdue until the next day. After a search the aircraft was found on the Friday morning near Conical Peak, 34 km southwest of Oamaru. The aircraft was destroyed and the pilot did not survive. The aircraft had struck the side of a ridge in an upright attitude, having descended as it approached the ridge, due either to pilot inattention or incapacitation.

On Tuesday 28 March 2000 at 1014 hours, ZK-HJN, a Hughes 369FF helicopter, was on a charter flight from Te Anau Aerodrome to West Arm, Lake Manapouri. Approaching to land, the helicopter struck a power line and impacted the ground heavily. The pilot and 4 passengers on board died in the accident and the helicopter was destroyed. Safety issues identified were the criteria for the marking of wires and overhead structures, and the requirement to expedite amendments to Civil Aviation Rules for wire marking. Safety recommendations were made to the Director of Civil Aviation.

On 29 May 2007, a Saab SF340A aircraft that was holding on an angled taxiway at Auckland International Airport was inadvertently cleared to line up in front of a landing Raytheon 1900D. The aerodrome controller transmitted an amended clearance, but the transmission crossed with that of the Saab crew reading back the line-up clearance. The pilots of both aircraft took action to avoid a collision and stopped on the runway without any damage or injury.

On the morning of 30 May 1994 a Fairchild Metroliner, ZK-NSW, while cruising at 17,000 feet suffered a rapid depressurisation following the failure of the First Officer's cockpit side acrylic window. ZK-NSW subsequently diverted to Palmerston North Aerodrome and landed safely. The safety issues discussed are the adequacy of the inspection procedures for the detection of cracks in the acrylic window panels.

Between June 2006 and April 2007 the Transport Accident Investigation Commission (the Commission) launched inquiries into 5 separate platform overrun events on the Auckland suburban rail network. Because there appeared to be a number of common factors contributing to the overruns, they have been combined into this one report.

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.

The Commission is assisting the Australian Transport Safety Bureau’s investigation.

On Wednesday 24 March 2004, at about 0149, USQ 7663, the 27th wagon on southbound express freight Train 237, derailed while negotiating a left-hand curve between Puketutu and Kopaki on the North Island Main Trunk. The wagon ran derailed for about 750 m until it struck the spreader bar on the north-end facing points at Kopaki, derailing the following 4 wagons and parting the train between the 29th and 30th wagons. The condition of the trailing bogie of wagon USQ 7663 was a significant contributing factor to the derailment. Safety issues included:

On Thursday 13 November 1997, at about 2130, the tug "York Syme" with six persons on board and with a loaded barge "H7" in tow, grounded on a reef north-east of Maria Island in the Hauraki Gulf. "H7" passed partly through the reef and grounded. The trailing towline fouled the propeller of "York Syme" while its engine was going astern. There were no injuries. Safety issues identified were poor watchkeeping practices, failure to keep a proper lookout and working routines leading to fatigue.