Executive summary
On 4 March 2009, the Tutukaka Coastguard vessel Dive! Tutukaka Rescue was tasked to assist a recreational vessel in difficulty in Ngunguru Bay south of Tutukaka. It was night-time and the sea condition was rough. The crew of the Coastguard vessel became so focused on locating the vessel in difficulty that they lost awareness of where their own vessel was and struck a rock at a moderate speed. The Dive! Tutukaka Rescue was extensively damaged and several crew members were seriously injured in the collision.
On 31 May 2009, the Manukau Coastguard vessel Trusts Rescue was on a combined promotional and training exercise over the Manukau Bar at the entrance to Manukau Harbour. It was night-time and the sea conditions were moderate. The vessel was travelling at moderate speed when it encountered a series of large and steep waves that could not be seen in the dark in time to reduce speed. The vessel fell off the top of one wave into the following trough with enough force to break the casting securing the navigator‘s seat to the floor, and the skipper broke his ankle.
On 31 August 2009, the Riverton Coastguard Incorporated (Coastguard Riverton) vessel Russell John Chisholm was on a night training exercise south of Riverton. It was night-time and the sea conditions were moderate. The vessel was travelling at moderate speed when it encountered 2 large waves that caused the vessel to fall heavily into a trough, resulting in moderate injuries to 3 crew members.
On 6 March 2010, the Coastguard Hibiscus Incorporated (Coastguard Hibiscus) vessel Hibiscus Rescue One had been tasked to assist a vessel in distress on the eastern side of Tiri Tiri Matangi Island in the Hauraki Gulf. It was night-time and the sea conditions were slight to moderate. The vessel had just left the shelter of the Gulf Harbour Marina when the crew lost awareness of where their vessel was in relation to the shoreline and the vessel ran aground on submerged rocks at high speed. There were minor injuries only, but the vessel sustained damage to its 2 outboard engines and minor damage to the hull.
The Transport Accident Investigation Commission (Commission) made the following observations:
- each occurred at night
- occurred when the skipper was at the helm rather than a dedicated helmsperson
- 3 occurred during inclement weather
- in each case there had been inadequate planning before the vessels departed the base
- in each case there was inadequate crew resource management (CRM)
- 3 involved below-standard navigation for dedicated emergency response vessels.
These observations led the Commission to look at the Coastguard NZ systems and the wider search and rescue (SAR) system in which Coastguard NZ operated.
The report discusses the inherent risk of SAR work and how the sense of urgency associated with such work can adversely affect decision-making processes from initial tasking to the completion of the task. The decisions for tasking such vessels should not be made by one person only, and should preferably involve someone unaffected by the sense of urgency. Planning is a fundamental requirement for the success of such operations. The Commission has made safety recommendations to improve the process for tasking SAR vessels and improve the planning before a task begins.
Night navigation for small craft in rough seas presents unique challenges for coastguard crews. The Commission has made recommendations to lift the standard of training for Coastguard NZ crews, particularly around night navigation, the use of electronic navigation equipment and enhancing training in CRM.
The Commission has also made a recommendation on the suitability of the Coastguard NZ vessels for the task, particularly in relation to the types and distribution of the vessels and how they best fit in with the much larger pool of SAR resources available to the organisations co-ordinating SAR operations (SAROPS).
Finally, the Commission makes a recommendation on ensuring that the qualifications of Coastguard NZ crews are compatible with the non SAR work occasionally undertaken and that the operating areas to which the craft have been assigned are compatible with the SAR areas they have to cover.