Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On Wednesday 31 May 1995 at about 0400 hours the Te Rapa North Shunt operated by New Zealand Rail Limited was shunting at Frankton. The Senior Shunter in charge of movements was riding on the footplate on the rear of the locomotive when he lost his footing and fell under the single attached wagon. The Senior Shunter was seriously injured. The causal factor was the Senior Shunter's loss of balance while attempting to read the wagon destination card during the shunting movement.

On Wednesday, 24 May 1995 at about 0820 hours Q2 Shunt operated by New Zealand Rail Limited was shunting at Gracefield yard. During a propelling movement to attempt to catch and hook onto a moving wagon, the Rail Operator riding on the leading wagon fell under the Shunt and was killed instantly. Causal factors were unauthorised shunting procedures, wagon drawbar condition, limited experience of staff and effectiveness of compliance monitoring. Safety deficiencies addressed in the report are the suitability of and compliance with instructions covering loose shunting.

The aircraft departed from Palmerston North Aerodrome on the afternoon of 21 May 1995 on a solo cross-country flight to Napier, Gisborne and return. A touch and go landing was made at Napier in the course of the outbound flight, and following a similarly uneventful touch and go landing at Gisborne the aircraft departed for Palmerston North. During the return flight the pilot requested, and received, clearance to pass through the Napier Terminal Control Area. The pilot's acknowledgement of the clearance was the last recorded communication from the aircraft.

Addendum to report 95-008: The wreckage and occupant were found on 8 April 2001 in forested high terrain, substantially west of the planned track. The aircraft was probably in controlled flight when it collided with terrain, about 42 minutes after departing from Gisborne. No explanation for the track deviation was found.

On Thursday, 18 May 1995 at about 0710 hours a remote controlled locomotive operated by New Zealand Rail Limited (NZRL) was returning light from Kings Wharf to Wellington Yard when it struck a front end loader foul of the line. As a result of the impact the Remote Control Operator riding on the front of the locomotive was thrown to the ground and picked up and dragged by the cowcatcher of the locomotive. The causal factor was the uncontrolled operation of the front end loader obstructing a main shunting leg serving Wellington Wharf.

At approximately 0720 hours on 8 May 1995 a Fletcher FU24-950, ZK-EMB, flown by a recently qualified agricultural pilot, squashed onto the ground in a stalled condition at a high rate of descent, in a wings level attitude. The pilot received serious injuries in the accident.

On 2 May 1995 at about 2042 hours one wagon of an eastbound freight operated by New Zealand Rail Limited (NZRL) between Greymouth and Middleton, derailed near Omoto whilst ascending a grade at slow speed. The derailed wagon was the second last wagon on the train and derailed all wheels. As a result the coupling and air connections to the last wagon parted and it ran back down the grade for approximately 4 kilometres.

[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 16 April 1995 at 1425 hours the Wave-Piercing Catamaran "Condor 10", inbound on approaches to Picton Harbour, suffered a total blackout of main power and ran aground on "The Snout". No injuries were sustained by passengers or crew and damage to the vessel was slight. Causal factors included mechanical failure, fault analysis procedures, and faults in setting up and testing the vessel's electrical systems. Recommendations included design changes, better management of maintenance, and more stringent testing procedures on a more regular basis.

At approximately 1425 hours on Sunday 2 April 1995 a Cessna 152 aircraft, ZK-FJX stalled at a low height, dropped the left wing and collided with the terrain, near Matakana some 7 km north-east of Warkworth. The pilot and passenger lost their lives in the accident. The safety issue discussed relates to the need for pilots to resist the temptation to conduct impromptu low level flying The causal factors were failure to maintain a safe height above the terrain and inexperience in low flying.

At about 1225 hours on 29 March 1995, ZK-TIK stalled and spun from a low altitude after having both engines fail within a short space of time. The aeroplane had just departed Hamilton on a scheduled flight to New Plymouth. All six occupants died in the accident. Causal factors identified were a fuel tank mis-selection and failure to execute a forced landing. A contributing factor was a fuel management regime with potential for mismanagement. Safety issues discussed are checks and communications in emergency.

On Saturday, 25 March 1995 at 0312 hours the Bulk Carrier MV "Alltrans VKBE", outward bound from Tiwai Point, ran aground in "Number Three Reach" of the Bluff Harbour Channel. Causal factors included human fatigue, tension and loss of situational awareness. It was recommended to the Manager Operations for Southport New Zealand Ltd that he review the roster procedures for Southport Harbour Pilots.