Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

To enable a good run at the hill, the driver of a fully loaded coal train reversed past one red light and when warned stopped just before another, just avoiding a collision with an empty passenger train. The three KiwiRail staff directly involved neither knew nor followed correct procedure. One was not asked to undergo a post-incident drug and alcohol test. All staff should know and follow safety procedures; and ensure they jointly understand what’s being planned.

On Friday 23 April 2004, Helicopter Services UH-1B helicopter ZK-HSF was on a ferry flight to Gore to facilitate maintenance work. En-route near Mokoreta a main rotor blade separated, the helicopter broke up and fell to the ground. The pilot, the sole occupant, was killed and the helicopter was destroyed. The accident resulted from fatigue failure of a tension-torsion (TT) strap, a critical rotor hub component. The fatigue cracking had probably been initiated by an unreported rotor overspeed event. Safety issues identified included:

On Monday 18 June 2007 at 0812, ZK-EAK, a Hawker Beechcraft Corporation 1900D, was on approach to land at Wellington when the landing gear failed to lower. The 2-pilot crew completed a missed approach and further attempted to lower the landing gear by both normal and emergency means. The landing gear remained retracted, so the crew elected to divert to Woodbourne where a wheels-up landing was made. The aircraft sustained moderate damage consistent with a wheels-up landing. There was no injury to the crew or the 15 passengers.

At about 1915 on Saturday 22 September 2007, southbound express freight Train 239 parted between the 22nd and 23rd wagons while the train was travelling on the North Island Main Trunk line between Te Awamutu and Te Kawa. The emergency brakes applied automatically as the air pressure in the brake pipe reduced and both portions of the train rolled to a stop, some distance apart.

[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.]

[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.]

[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.]

Two persons fell while being winched in from the ship "Pacific Ariki", by a hoist installed in Bell 212 helicopter ZK-HNO on 14 November 1993. The ship was at sea 2nm west of Oaonui.

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.

On 30 December 2006, a fire occurred in the left General Electric CF6-80C2 engine nacelle of a Boeing 767 aircraft as it taxied clear of the runway after landing at Auckland International Airport. The fire was promptly extinguished and the minor damage was confined within the nacelle.

Two trains were put into conflict due to a signal box display not showing track and points layouts correctly, but a driver realised he was on wrong track and stopped his train. Safety issues related to the change management process for upgrading the signal box, and signaller familiarity with the actual track layout and equipment capabilities. Two recommendations have been made to KiwiRail, on top of safety actions taken.

On Friday 27 June 2003, Tranz Metro Train 3347 was an Auckland to Papakura diesel multiple unit passenger train. At about 0915, a driveshaft on passenger car ADL 810 failed as the train approached Purewa Tunnel, between Meadowbank and Glen Innes stations. The DMU driver stopped the train about 200 m short of the tunnel. The free end of the failed driveshaft was not sufficiently restrained and it punctured the floor of the passenger compartment. The 3 passengers travelling in ADL 810 were not injured. The safety issues identified included: