Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

A tourist jet boat impacted a rock face when its steering and propulsion failed. 9 injuries. Fatigue cracking broke bolts holding steering nozzle and tailpipe together. Operator's hazard focus was more on operating conditions and driver training than mechanical matters. Regulatory practice should address the need for every jet boat operator to have a regime to maintain safety-critical components.

Points on the main line were incorrectly set and a freight train diverted into a loop holding 3 parked track maintenance rail vehicles. From 20 km/h, the train applied emergency braking, stopped about 1km from parked vehicles. No injuries. Factors in incident: train speed, procedures not followed, and work team communication. Operator taking appropriate safety actions. No need for TAIC recommendations

Derailment of three freight train wagons was very likely due to "dynamic interaction" – a combination of excessive speed, track geometry and wagon centre of gravity. Train was exceeding maximum permissible track speed on a downhill gradient with a distracted driver. The operator has addressed the safety issues raised in this report. Lessons on driver distraction and acting on safety knowledge.

This report examines 6 track heat buckle incidents that occurred in different localities throughout New Zealand in the summer of 2000/2001, 5 of which resulted in derailments. Safety issues identified by these incidents included: • the need for training of track staff to ensure they recognise and respond to visible track defects • the possible need to protect continuous welded rail, formed at an unknown neutral temperature, during hot weather • the need to control tamping and lining to ensure track is not realigned leaving increased compressive stress in the rails

This report examines 6 track heat buckle incidents that occurred in different localities throughout New Zealand in the summer of 2000/2001, 5 of which resulted in derailments. Safety issues identified by these incidents included: • the need for training of track staff to ensure they recognise and respond to visible track defects • the possible need to protect continuous welded rail, formed at an unknown neutral temperature, during hot weather • the need to control tamping and lining to ensure track is not realigned leaving increased compressive stress in the rails

This report examines 6 track heat buckle incidents that occurred in different localities throughout New Zealand in the summer of 2000/2001, 5 of which resulted in derailments. Safety issues identified by these incidents included: • the need for training of track staff to ensure they recognise and respond to visible track defects • the possible need to protect continuous welded rail, formed at an unknown neutral temperature, during hot weather • the need to control tamping and lining to ensure track is not realigned leaving increased compressive stress in the rails

At about 1610 on Friday, 2 October 1998, the jet boat "Terminator" was proceeding at a speed of about 65 km/h down one of many secondary channels on a braided section of the Dart River, when the driver was confronted with an obstacle partially blocking a left hand turn in the channel. As the driver attempted to make the turn around the obstruction, his boat struck it, the driver lost control and the boat skidded sideways into a shingle bank and flipped, trapping some of the passengers beneath the boat. The 11 passengers plus the driver suffered minor to serious injuries.

On June 4, 2017, at 0917 mountain standard time, an experimental amateur-built Titan T-51 Mustang, N51FB, lost thrust to the propeller during the initial takeoff climb from Phoenix Goodyear Airport, Goodyear, Arizona. The pilot was not injured, and the airplane sustained substantial damage to the left wing and aft fuselage during the forced landing.

On Wednesday 21 October 1998, at approximately 0840 hours, Train 700, the northbound Coastal Pacific express passenger, collided with No. 2 shunt standing in the loop at Rangiora. Train 700 was unintentionally routed onto the loop as it approached Rangiora on the main line. A passenger and crew member sustained minor injuries in the collision.

At approximately 1351 hours on Tuesday 11 October 1994 an AS350B helicopter, ZK-HZP, flew into the sea near Needle Rock, 10 nm north-east of Whitianga. Two of the five passengers lost their lives in the accident and the pilot received serious injuries. The safety issues discussed include the hazards associated with hydraulic jack stall, and the necessity for pilots to make sound command decisions appropriate to air transport operations.

The Commission resumed its AO-2015-003 inquiry to reconsider information it had received about the causes and circumstances of an aviation incident near Waikaia Southland in January 2015. While spraying gorse, the pilot of a Robinson R44 helicopter felt an unusual and significant vibration, landed immediately, and found a crack in a main rotor blade. The Commission’s final amended report includes findings that match the original, plus technical clarifications and expert metallurgical examination of the main rotor blades.

Two broken springs in the landing gear of an ATR passenger aircraft caused it to divert and make an emergency landing. Little damage, no injuries. Springs broke when cracks formed due to corrosion. Operator found no other such problematic springs on its ATR72 fleet, has new maintenance & replacement plan. Manufacturer updated maintenance manual worldwide, added training scenario based on this incident