Executive summary
On Thursday 21 October 1999 at about 1810, jet boat "Shotover 14" entered the first canyon on the Upper Shotover River with the driver and 9 passengers on board, travelling at about 65 km/h. While travelling close to the left side of the canyon a component in the steering system caught on a bracket, preventing the driver from steering to the right.
The driver overcame the jammed steering by applying considerable force through the steering wheel, but too late to prevent the jet boat glancing off the canyon wall into a rock face. Eight passengers and the driver received minor injuries and one passenger received moderate injuries in the impact. The boat was extensively damaged.
On Friday 12 November 1999 at about 1415, jet boat "Shotover 15" entered the second canyon on the Upper Shotover River with the driver and 12 passengers on board, travelling at about 65 km/h. While the boat was travelling close to the right canyon wall the steering locked and the boat struck the canyon wall. The passenger in the right rear seat struck his head on a rock overhang and was fatally injured. The other passengers and driver received minor injuries.
Safety issues identified included:
• standards of maintenance
• standards for design of jet boat components
• small safety margins designed into the trip
• driver training
• the effectiveness of Rule Part 80 in ensuring safety in the jet boat industry
• management style and its effect on safety.
Drawing on lessons learned from these 2 accidents and others investigated in the past, several safety recommendations were made to the director of Maritime Safety, the operator and a manufacturer of water jet units, to address the safety issues.
This report includes inquiry 99-213.
Related Recommendations
Review the company policy on driver working hours to reduce the possibility of drivers operating fatigued.
Consider either recalling all old HJ-212 steering nozzles or producing a service bulletin warning users of possible failure and the consequences.
Upgrade the Shotover Jet Limited fleet to a level that both complies with Rule Part 80 [Marine Craft Involved In Adventure Tourism] and is commensurate with the type of trip being offered.
Critically review the design of the jet boat trips offered by all its subsidiaries and ensure that passengers are exposed to a lower level of risk than they were on the Shotover Queenstown operation at the time of the accidents involving Shotover 14 and Shotover 15.
Critically review the design of the new steering nozzle and associated components on HJ-212 jet units and ensure that it is strong enough for its intended purpose.
Implement a system for recording and tracking in-use and spare critical components that enables the history of any critical component to be monitored and traced.
Recommend the fitting of steering limit stops in the installation manual for all HJ-212 jet units, and other model jet units as appropriate.
Fit steering limit stops to all boats in the Shotover fleet fitted with HJ-212 jet units.
Conduct an independent inspection of all commercial jet boats by suitably qualified persons, to assess the compliance with Rule Part 80 [Marine Craft Involved In Adventure Tourism] with regards to occupant protection in event of collision, and withdraw any operator's certificate of compliance where their boats do not comply.
Incorporate any manufacturer’s recommended maintenance schedule in the Shotover Jet inspection and maintenance system.
Use only authentic or approved parts when replacing worn or damaged critical components, or use parts reconditioned, either to the manufacturer’s specifications or to the approval of an appropriate surveyor.
Identify on each jet boat all components that are critical to the safe operation of the boat, and have a documented inspection and maintenance system in place that covers those critical components. The inspection and maintenance system should complement rather than replace any existing system of daily checks.
Ensure that sufficient resources are put into maintaining the Shotover Jet Limited fleet in a state of repair appropriate for its intended use.
Conduct a risk analysis on the various jet boat activities of commercial operators in the New Zealand jet boat industry and set a benchmark of identified risk against which a risk assessment for each operator can be measured.
Require all commercial jet boat operators to incorporate any manufacturer's recommended maintenance schedule in their own inspection and maintenance system.
Require MSA-approved authorised persons to have undergone safety audit training.
Conduct an independent review of the jet boat activity each commercial jet boat operator in New Zealand is offering, to measure the type of activity and the manner in which it is conducted against the benchmark of identified risk. For any operations carrying more than the identified level of risk, either take the necessary action to reduce the risk level, or allow the operation to continue but require the operator to give passengers an appropriate warning of the high risk factor, before they commit to embarking on the trip.
Require all commercial jet boat operators to have a system for recording and tracking in-use and spare critical components that enables the history of any critical component to be monitored and traced.
Develop an MSA Commercial Jet Boat Driver Licence, which every commercial jet boat driver must hold. The licensing system should be structured with: • a detailed training syllabus and a driving test, for the basic licence • several levels of endorsement, each dependent on specified numbers of driver hours and a further driving test • restrictions on all-up weight (boat and passengers) for each endorsement • endorsements for each river on which the holder intends to operate, following a specified number of hours on each river
Require all new commercial jet boats intended to be operated in braided rivers, or existing boats being purchased for operation on braided rivers, to be constructed with roll protection that allows sufficient occupiable space under the boat for its full complement, should it roll
Require the fitting of an inclined footplate in front of each passenger seat, having first assessed what the optimum angle for such a footplate is.
Require all commercial jet boat operators to identify on each jet boat all components that are critical to the safe operation of the boat, and to have a documented inspection and maintenance system in place that covers those critical components. The inspection and maintenance system should complement rather than replace any existing system of daily checks.
Produce a manual of procedures and guidelines for those MSA-approved authorised persons to follow when assessing, approving or auditing commercial jet boat operators' activities and safe operational plans.
Require all commercial jet boat operators to use only authentic or approved parts when replacing worn or damaged critical components, or to use parts reconditioned, either to the manufacturer's specifications, or to the approval of an appropriate surveyor.
Require all commercial jet boat drivers to keep a log book of hours and training.