Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The Fiordland Navigator ran aground after the fatigued master almost certainly fell asleep at the helm. TAIC found gaps in fatigue management, monitoring of medical fitness, and risk controls for sole-charge masters. Several passengers and crew suffered minor injuries, but the emergency response was effective. The vessel’s operator has since strengthened fatigue policies, added support roles, and improved safety oversight. TAIC made one recommendation—to Maritime NZ—to improve awareness of ongoing medical fitness responsibilities for seafarers.

Balloon landings are a safety-critical phase of flight. If anyone or anything is ejected from basket during landing, an accident is virtually certain because balloon is uncontrolled, passengers unattended. To avoid this, all balloon pilots should wear safety harnesses. Owners/operators should install them. Also, passenger safety briefings must be clear, concise, easy for all passengers to follow.

A BK117 helicopter was transporting a power pole. Pilot at risk of distraction, didn’t recognise and respond promptly to unanticipated yaw (helicopter unexpectedly turning about its vertical axis). The pilot lost control and ditched in shallow water. Minor injuries for pilot, substantial damage to helicopter.

A factory trawler worker died on becoming trapped in machinery. Safety for machinery operators depends on everyone understanding how a piece of machinery works; how people work with it; and thinking about the hazards. In this case: not enough understanding; too much reliance on crew following all instructions; and training likely confused workers about which emergency stops serviced which system.

A freight train was passing through points at above maximum authorised line speed. Part of the train derailed when a wagon wheel climbed the outer rail of a set of points. Key factors: track alignment & twisting, speed, suspension, centre of gravity. TAIC recommends KiwiRail identify, evaluate & rectify repetitive cyclic track twists. Drivers must always correctly control their trains.

Circumstances of this fatal helicopter crash into dense forest included: risky take-off towards and over treetops; old worn engine lacked power; and aircraft not airworthy. Also private pilot licence conditions breached (flying for payment or reward). Lessons about obeying Civil Aviation Rules; reporting concerns; CAA monitoring of nominally private aviation participants.

Aerial firefighting operators need to respond to the latest advice about monsoon bucket structure and sling line length. Firefighting helicopter significantly damaged in heavy forced landing when tail rotor was disabled by lifting line of underslung collapsible monsoon bucket. Bucket aerodynamics changed when a steel ring holding top mouth open came loose. Hook-and-loop fasteners had come undone.

On a ship loading logs, crew were using a crane to tension a wire rope to secure the load. When a wire snapped, equipment recoiled. It struck and fatally injured a seaman. It snapped due to the load from the crane and configuration of pulleys. Crew lacked information and guidance on hazards and doing this work safely. Operator’s safety management system lacked a safety assessment for the work.

A recreational jet boat with four people on board crashed on a gravel river bar. One passenger died; two others hospitalised. Risk factors: insufficient planning; insufficient daylight; too much speed and too much alcohol. TAIC is calling for more data collection on alcohol impairment, and new legislation or rules to prohibit people in safety-critical roles being impaired by alcohol or drugs.

A rail signal technician was potentially put at risk from rail traffic, unaware that the line was not protected. People didn't follow rules & procedures for everyone working on a safety-critical task to: share a clear understanding of the task and how everyone will do it. Wrong assumptions about nature of the signals task and how the technician was protected. Everyone should ask; don't assume.

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.