Inquiries & Recommendations

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The container ship Leda Maersk, with harbour pilot on board directing the course and speed of the ship, grounded on a channel bank while entering Port Otago. Nobody was injured and damage to the ship was minor. The Commission’s recommendations address pilots’ technical skills and accuracy; bridge resource management; on-board navigation technology.

The catamaran Dolphin Seeker was conducting a dolphin-watching tour and ran aground in the Bay of Islands. The Commission found that the skipper was focusing on providing a good tour experience and didn’t notice the vessel moving towards shallow waters. The company’s safety management system did not adequately address the risks associated with the skipper’s role and was subsequently updated to address this safety issue.

On Friday, 6 September 1996, at about 0200 hours, P35 Shunt operated by Tranz Rail Limited was shunting in Palmerston North Yard. During a propelling movement to place wagons the shunter fell under the wagons and was killed instantly. Safety issues addressed in the report are the frequency of shunting fatalities, and the effectiveness of compliance monitoring of recently certified and relatively inexperienced staff.

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

On 31 October 1994 the Locomotive Engineer on Train 776, a northbound express freight operated by New Zealand Rail Limited (NZRL) advised Train Control that he was at Oaro, and in response to the question from the Train Control Officer, cancelled the track warrant he held to Oaro. A southbound passenger train, Train 701, arrived at Oaro to cross 776, but 776 was not there. Subsequently it was discovered that 776 was at Claverley, some 12 kilometres south of Oaro. A track warrant was issued for 701 to continue southwards.

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.

On Tuesday, 17 November 1998, at approximately 1040 hours Train 700, the northbound Coastal Pacific passenger express, was travelling through Hapuku when dragging brake gear on a high speed goods wagon at the head of the train struck and damaged the main line turnouts. The train continued for a further 26 km before the locomotive engineer noted track ballast being thrown up by the dragging brake gear and stopped the train.

Revised investigation 94-117: On Saturday 2 July 1994 at approximately 1025 hours, a child fell from the gangway between a carriage and the end platform of the power van on New Zealand Rail Limited's "Coastal Pacific" express near Hundalee when a handrail dislodged. The child was seriously injured.

On Monday 4 December 1995 at approximately 2010 hours a shooter fell from a Robinson R22 helicopter, ZK-HDD, during an airborne deer hunting operation 18 km north of Karamea, and sustained fatal injuries. The probable cause of the accident was the opening of the karabiner used on the shooter's harness arrangement, by equipment or clothing, thereby causing him to become unrestrained in the helicopter. The safety issue identified is the need to have a restraint system which incorporates safety features to guard against inadvertent release.

The aircraft was flying from Hamilton to Napier at night in instrument meteorological conditions, and had commenced an instrument approach procedure for Napier. The aircraft collided with a hill. The pilot and two passengers received fatal injuries in the accident.

A Robinson Helicopter Company R22 helicopter was being used to transfer two passengers from Karamea to a remote landing spot in Kahurangi National Park, from where the passengers were to go hunting. On the return flight to Karamea the pilot experienced a vibration and heard an associated noise. During the landing sequence at Karamea, the helicopter broke up in the air and struck the ground. The helicopter was destroyed. Pilot survived, seriously injured.

TAIC report presents rail safety issues with working practices, engineering protections, and safety guidelines - factors that contributed to unintended shunt movement, in Picton. A remote-controlled shunt loco and wagon moved off the end of the quay-to-ferry rail linkspan and into the harbour.