Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On Friday 15 March 2002, at about 0945, ZK-HIC, a Schweizer 269C helicopter, lost tail rotor authority during a low-level spraying run. Normal helicopter control was lost and the pilot, unable to arrest the ensuing spin, carried out an emergency landing. The pilot, the only occupant, was uninjured. A defective tail rotor driveshaft aft bumper plug permitted the driveshaft to disengage its drive coupling to the tail rotor gearbox.

On Sunday 18 September 2005, the "Milford Mariner" was on a cruise of Milford Sound with the Master, 9 crew and 56 passengers on board. At about 1438, both of the ship’s main propulsion engines stalled and just as they were restarted the ship ran aground.

[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.]

The ship was entering Milford Sound in the dark. The pilot lost awareness and bridge crew did not alert him or use on-board navigation gear correctly. The ship hit a stony bank causing light damage to the hull, no injuries. Safety issues related to electronic navigation use; standard of bridge resource management; and risk management of blind pilotage. The operator and Environment Southland have both taken actions since. Two previous recommendations were repeated, and a new one made.

On Wednesday 12 March 1997, at 0032 hours, Boeing 747-419 ZK-NBU was enroute from Auckland to Los Angeles as Flight NZ18. The Captain's electronic primary flight display no longer displayed flight reference information and appeared blank. An internal failure within the brake system control unit, due to water ingress, in turn caused a fault with the inertial reference unit data bus supplying information to the Captain's display. An alternate inertial reference unit was selected and it failed to supply the required information.

On Friday 31 August 2001 at about 1440, the commercial jet boat "Shotover 21" was proceeding down Shotover River at about 60 km/h with the driver and 11 passengers on board, when the engine stopped suddenly. With no propulsion the driver lost directional control of the boat and it continued in a straight line for some 60 m before colliding with a rock face at about 30 km/h. Five of the passengers suffered serious injuries, the other passengers suffered minor injuries and the driver was unhurt. The boat was extensively damaged.

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.

On Tuesday, 18 August 1998 at about 1845 the passenger cargo vessel "Stella" had an apparent loss of steering in heavy weather when attempting to turn around and head out of Omaha Bay. The vessel was on passage from Tryphena to Auckland with three persons on board. Due to a navigational error the "Stella" approached Omaha Bay although intending to approach the Auckland main channel. The "Stella" was held approximately in position under tow by the vessel Great Barrier Express. "Stella" was towed to the shelter of Bon Accord Harbour by HMNZS Kahu.

At approximately 1010 hours on Wednesday 24 November 1999, the Wellington to Auckland Overlander passenger express, Train 200, proceeded past a conditional stop board between Ohau and Levin without authority. Some 5 kilometres later Train 200 unexpectedly met a track maintenance gang, which had just cleared the track to allow the passage of the train. There were no injuries. The safety issues identified were: • the incomplete radio procedures for communication between locomotive engineers and track gangs working under conditional stop board protection

On 13 August 2010 a scheduled Auckland passenger train ('the passenger train') with about 100 people on board travelled from Papakura to Britomart Station in central Auckland via Westfield and Tamaki Stations. An unscheduled shunt was signalled to follow the passenger train from Westfield as far as Tamaki, so that it could enter a rail siding.

On Tuesday 17 December 2002, at 2036, ZK-TZC, a twin engine Piper PA31-325 Navajo, took off from Feilding Aerodrome on a visual flight rules flight to Paraparaumu. The pilot and his 2 young sons were on board.

On Sunday, 17 November 2002, at about 2353, Train 526, a Palmerston North to New Plymouth express freight service overran its track warrant limit at Waitotara by about 1.5 km. The incident occurred when the locomotive engineer did not identify and stop at the limit of his track warrant authority but continued on into the next section. There was no opposing traffic. The major contribution factor to the incident was the probability that the locomotive engineer lost concentration and situational awareness, which supported a misperception of the limits of the track warrant he held.