Inquiries & Recommendations

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The crash of this AS350 helicopter on Fox Glacier took the lives of seven people. Issues: Operator’s pilot training system did not fully comply with Civil Aviation rules, did not adequately prepare pilot; and managerial oversight. Lack of intervention allowed operator to continue operating. New TAIC recommendation addresses potential that other operators at that time could have significant non-compliances that were not identified or not resolved.

The Seabourn Encore was berthed at PrimePort Timaru. In strong south westerly winds, a number of wharf mooring bollards and ship mooring lines progressively failed allowing the ship to swing off the berth and collided with a nearby cement carrier. Nobody harmed, but some damage to wharf infrastructure and both ships. Final Report addresses matters concerning mooring equipment; mooring procedures; and planning for, and responding to, a change in the weather. Recommendations apply both locally and nationwide to all ports in New Zealand.

On 24 July 2023, the fully loaded Achilles Bulker was departing the Port of Tauranga under pilotage when it began unexpectedly swinging to port after clearing the harbour entrance. As the bridge team attempted to correct the course, the ship’s rudder detached, causing it to drift out of the channel into shallow water. The pilots and crew managed to bring the vessel to a stop using both anchors, narrowly avoiding grounding.

An Airbus A320 inadvertently flew below minimum safe height on approach to Christchurch Airport. It landed safely. Lesson: properly used automated flight navigation systems will reduce crew workload and result in safer flight operations. Crew chose not to use auto, did not stay aware of their location compared to standard arrival route, and air traffic controller did not alert the flight crew.

The aircraft was returning to Gore Aerodrome from a private airstrip. A local farmer observed the aircraft pass over the property about 400 feet above ground level, in normal cruising flight. Shortly afterwards it rolled to the left and entered a steep dive from which it was not recovered. The two occupants received fatal injuries in the ensuing ground impact.

The aircraft was making an approach to the airstrip when it was observed to oscillate in pitch. The left wing failed and the aircraft dived into the ground, fatally injuring the pilot.

In February 2017 the crew of the passenger cruise ship Emerald Princess were re-pressurising the gas cylinders after maintenance, when the cylinder burst below its normal operating pressure, causing the death of a nearby crew member. The cylinder had been weakened by corrosion. The inquiry report highlights a lack of global minimum standards for inspection, testing and rejecting pressure cylinders for stored energy systems on lifeboat launching installations – a system common on cruise ships.

A refuse collection truck entered a level crossing, very likely without stopping at the Stop sign, and was struck by a log train. The truck driver died in the accident. Even if the truck had stopped, the view lines weren’t good enough for the truck to clear the crossing if a train had been just out of view. Legislation is unclear on allocation of responsibility for safety of crossing users. Road users must be cautious. Wearing seatbelts will increase the chances of survival.

A pair of coupled loco-motives ran through wrongly-set points, dislodged fail-safe equipment, and carried on into a maintenance depot, shunting a maintenance vehicle into a rail wagon. There were no injuries. The wrong-routing happened because nobody checked to ensure correct setting of the points, and local procedures to prevent wrong-routing did not conform fully to KiwiRail rules. Safety actions taken by the operator precluded any need for recommendations.

TAIC has published its Final Report on the immobilisation and tagging of an Auckland metropolitan passenger train in September 2017. TAIC recommended that the train operator improve training for train crews, including liaising with emergency services. A fast and efficient emergency response depends on first responders receiving clear, concise and timely information.

A Robinson R44 helicopter crashed into dense bush in Glenbervie Forest near Whāngārei. The two occupants – the pilot and a forestry contractor – died in the crash, and the helicopter was consumed by fire. Crash and fire damage destroyed evidence, so the cause or causes could not be determined. The Commission has previously recommended that recorders be fitted to certain classes of helicopter to aid accident investigation.

On Monday 12 February 1996 at about 2240 hours, Hughes 369D helicopter ZK-HLE, on a night rescue flight, collided with trees and the ground, and caught fire. The two crew were killed. Reduced visibility in poor weather was probably a factor in the collision. The details of the flight leading to the collision were not established.