Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

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.