Recommendation Date
Recipient Name
Shotover Jet
Text
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.
Reply Text
Shotover Jet Limited (SJL) considers that the use of the word "design" is incorrect and should be replaced by the word "content". SJL also considers that the intent of this question is to examine all aspects of the business including training, standard and type of craft, maintenance, decision making operational conditions, "drive lines" and all other relevant factors. The company engaged in a thorough process of examining all aspects of its business in April 1999, but which continues now on an ongoing basis. As a result of the implementation of this programme, many of the issues raised in the draft report have already been dealt with and new systems and procedures put in place.
As an initial step in reviewing the content of the company’s jet boat trips, an extensive Risk Management Assessment evaluation has been completed.
Specific issues [were] undertaken (completed and ongoing) as part of the critical review of trip content. As part of the company’s Q20/20 system of reviewing its operations, the company has made a number of changes to its procedures, its craft, and its training and maintenance systems. These measures were accelerated as a result of the accidents involving Shotover 14 and Shotover 15 in October and November 1999, and as a result of the unsatisfactory audits of the SJL fleet earlier in 2000. In brief, these issues are:
Existing fleet
After undergoing three external audits and several internal audits identifying areas where the fleet required upgrading, all existing craft in all subsidiaries in SJL have been upgraded to ensure, at minimum, compliance with MSA Rule Part 80.
The only exceptions are the exemptions referred to in [our response to safety recommendation 069/00] as granted by the Director of Maritime Safety.
Apart from issues of compliance with MSA Rule Part 80, all craft have been critically reviewed in the interests of ensuring compliance with good engineering practices.
Regular reviews are taking place to ensure that the programme of off-season upgrade of craft is consistent with the timetable presented to the Director of Maritime Safety in April 2000.
Despite the decision to replace the fleet at Shotover Jet Queenstown (SJQ) within the next 12 to 18 months, the fleet at SJQ currently consists of two craft less than one year old, two craft which are older but which have been subjected to complete strip and refurbishment to "as new" condition and will see the introduction before the end of the calendar year 2000 of two brand new craft of the existing design. Other remaining craft have been substantially upgraded and reviewed as part of the process described earlier.
In view of the lack of suitable standards governing LPG installations, SJL had contracted an expert in the field of LPG management and installation to advise on installations in SJL boats. This arrangement was made despite the fact that LPG is likely to be phased out as a fuel at SJQ within the next 12 months and at Huka Jet Limited (HJL) within two years. Any recommendations by the LPG expert will be incorporated into the existing fleet.
All major changes and structural componentry will be approved by an external qualified professional engineer.
Technical
SJL has made substantial changes to the make up and numbers of personnel at its workshops at Queenstown, Glenorchy and Taupo. SJL considered that the staffing levels were adequate but has approximately doubled its technical staff numbers in the past eight months.
The decision to expand capacity recognises the work required to bring the existing fleet up to standard, as well as a desire to consistently exceed the standards set in MSA Rule Part 80.
SJL now operates four workshops: SJQ in Queenstown, Dart River Jet Safaris Glenorchy and HJL in Taupo with a boat refurbishment/major maintenance division at the Frankton Marina, Queenstown.
Technical staff rosters have been changed to ensure availability of technical staff to participate in after operation checks and urgent maintenance required to be done overnight prior to re-commencement of operations the next day.
Qualifications of technical staff have been reviewed to assess their suitability.
New workshop manuals have been drawn up using external professional assistance.
Systems
A new boat checking system is now in place. Craft are signed off jointly by a driver and technician.
All operational staff have been retrained in boat inspections and the critical areas to be observed.
All operational staff have been retrained to ensure that boat checks are capable of identifying problems rather than a system which simply ticks off lists of observations.
A system of "surprise" audits is now in place where all operations are subject to four internal checks per year (in addition to the MSA external checks) with one internal check undertaken by an independent suitably qualified expert.
SJL has introduced a system of monitoring incidents where any incident, no matter how small, is analysed, logged and reviewed with results monitored by SJL management and board. This system allows cross referencing of incidents which occur involving specific drivers, craft, components, sections of the rivers, manoeuvres etc to observe any recurrent factors. The system is designed to reduce incident occurrence to a minimum.
An aviation based safety engineer is to be appointed to the Audit and Compliance Committee of the SJL Board to assist and advise on issues of safety and compliance.
All critical components are now internally identified and date stamped on installation for replacement at the "use by" date.
SJL has contracted a suitably qualified external expert to examine the list of critical components drawn up internally, adding items where appropriate and providing an assessment of the components’ operational life times. This system is designed around that used in the aviation industry.
SJL has re-engineered the company’s maintenance systems to provide for replacement of critical components as required by "lifetime" assessments.
SJL has re-engineered the company’s maintenance systems to ensure the periodic testing of critical components by suitably qualified independent experts.
Personnel
SJL has critically reviewed driver-training systems and introduced changes where necessary.
SJL has critically reviewed the system of checking drivers (particularly new drivers) by the senior driver and confirmed it as adequate.
SJL has reinforced the drivers’ option to operate or otherwise depending on conditions.
SJL has reinforced to operational staff, and in particular drivers, their responsibility for boat condition and the decision whether or not to operate craft.
SJL has introduced a system of psychological assessment for new drivers.
Operations
SJL has reviewed all aspects of its subsidiaries’ trips to ensure strict adherence to company specified "drive lines".
SJL has reviewed the appropriateness of “drive lines” internally and with a suitably qualified independent expert.
SJL has reinforced drivers need to adopt a more conservative line in high water conditions.
SJL has discussed with operational staff any suggested changes and implemented them where appropriate.
SJL has reviewed the adequacy of its safety briefings.
SJL has reassessed its safety equipment and made improvements where appropriate.
SJL has reviewed the company’s Safe Operating Plan and rewritten it. It is now MSA/QLDC Harbourmaster approved.
SJL has reviewed its crisis management plan and confirmed that it is adequate.
SJL has reviewed its pre-departure facilities and upgraded these where appropriate.
Hamilton 212 Jet Units
SJL has, immediately after the Shotover 15 accident discarded all Hamilton 212 "Mk I" nozzles and replaced these with "Mk II" [nozzles].
SJL has commissioned a comprehensive independent report from a suitably qualified professional engineer on the design of Hamilton 212 jet unit [steering nozzles].
The report concluded the [steering nozzle] is under designed for its function.
Copies of the independent report have been provided to appropriate authorities.
SJL has requested a complete redesign of the 212 nozzle by CWF Hamilton.
Pending a complete redesign, SJL has commissioned external professional advice on the continued use of Mark II 212 nozzles.
SJL continues to use Mark II nozzles subject to rigorous daily inspections, and removal for crack testing at 250-hour intervals.
SJL has fitted steering stops to all SJL craft using Hamilton 212 units.
New Craft
SJL has completed a review of all design aspects of existing craft and elected to replace virtually its entire fleet.
While existing craft are adequate, it is recognised that they are evolutions of craft introduced in the 1970’s and it is time for a complete redesign.
The only common factor between new craft and existing craft is the shape of the below water hull.
Two prototype boats are now under construction at Dickson Marine of Nelson.
Depending on the success of these craft, a contractual agreement will be entered into to construct between 20 and 25 craft of the new design.
A critical path for delivery will see Dart River Jet Safaris and SJQ fleets replaced by June 2002.
The SJL board has approved a capital expenditure programme to cover the new boats.
Extensive external testing of a Kevlar carborundum composite material has proved satisfactory, with strength, weight and durability factors far exceeding those of comparable aluminium, resulting in a decision to construct hulls from this material.
The new craft will include ergonomically designed seats to assist with passenger safety and comfort with "soft" plastic fittings internally to protect passengers.
The new craft will incorporate crumple zones in bows, "positive buoyancy cell" and redesigned fuel systems to improve safety incorporating “anti explosion” fuel tanks.
The steering systems will be completely redesigned to incorporate a system of shafts and gearboxes replacing existing cables and pulleys. The new system will be considerably more robust, easier to maintain and less susceptible to failure. The system has been designed by a professional engineer and certified.
The motor and jet unit packages have been considered and this is likely to result in a decision (after testing) to install twin engines and twin jet units to improve safety through duplicated systems, allowing continuation of one engine/jet unit in the event of failure of the other.
All equipment installed in boats will be either certified by a suitably qualified professional engineer or will carry suitable manufacturer warranties.
Seatbelts
SJL has commissioned an extensive and comprehensive external report on the installation of seatbelts.
If installation proceeds, it will be in conjunction with an "automatic release" system, which provides for release in the event of swamping of the craft or by central driver control as well as individual passenger control.
A final decision on this issue will be made when all factors including an independent report have been considered.
As an initial step in reviewing the content of the company’s jet boat trips, an extensive Risk Management Assessment evaluation has been completed.
Specific issues [were] undertaken (completed and ongoing) as part of the critical review of trip content. As part of the company’s Q20/20 system of reviewing its operations, the company has made a number of changes to its procedures, its craft, and its training and maintenance systems. These measures were accelerated as a result of the accidents involving Shotover 14 and Shotover 15 in October and November 1999, and as a result of the unsatisfactory audits of the SJL fleet earlier in 2000. In brief, these issues are:
Existing fleet
After undergoing three external audits and several internal audits identifying areas where the fleet required upgrading, all existing craft in all subsidiaries in SJL have been upgraded to ensure, at minimum, compliance with MSA Rule Part 80.
The only exceptions are the exemptions referred to in [our response to safety recommendation 069/00] as granted by the Director of Maritime Safety.
Apart from issues of compliance with MSA Rule Part 80, all craft have been critically reviewed in the interests of ensuring compliance with good engineering practices.
Regular reviews are taking place to ensure that the programme of off-season upgrade of craft is consistent with the timetable presented to the Director of Maritime Safety in April 2000.
Despite the decision to replace the fleet at Shotover Jet Queenstown (SJQ) within the next 12 to 18 months, the fleet at SJQ currently consists of two craft less than one year old, two craft which are older but which have been subjected to complete strip and refurbishment to "as new" condition and will see the introduction before the end of the calendar year 2000 of two brand new craft of the existing design. Other remaining craft have been substantially upgraded and reviewed as part of the process described earlier.
In view of the lack of suitable standards governing LPG installations, SJL had contracted an expert in the field of LPG management and installation to advise on installations in SJL boats. This arrangement was made despite the fact that LPG is likely to be phased out as a fuel at SJQ within the next 12 months and at Huka Jet Limited (HJL) within two years. Any recommendations by the LPG expert will be incorporated into the existing fleet.
All major changes and structural componentry will be approved by an external qualified professional engineer.
Technical
SJL has made substantial changes to the make up and numbers of personnel at its workshops at Queenstown, Glenorchy and Taupo. SJL considered that the staffing levels were adequate but has approximately doubled its technical staff numbers in the past eight months.
The decision to expand capacity recognises the work required to bring the existing fleet up to standard, as well as a desire to consistently exceed the standards set in MSA Rule Part 80.
SJL now operates four workshops: SJQ in Queenstown, Dart River Jet Safaris Glenorchy and HJL in Taupo with a boat refurbishment/major maintenance division at the Frankton Marina, Queenstown.
Technical staff rosters have been changed to ensure availability of technical staff to participate in after operation checks and urgent maintenance required to be done overnight prior to re-commencement of operations the next day.
Qualifications of technical staff have been reviewed to assess their suitability.
New workshop manuals have been drawn up using external professional assistance.
Systems
A new boat checking system is now in place. Craft are signed off jointly by a driver and technician.
All operational staff have been retrained in boat inspections and the critical areas to be observed.
All operational staff have been retrained to ensure that boat checks are capable of identifying problems rather than a system which simply ticks off lists of observations.
A system of "surprise" audits is now in place where all operations are subject to four internal checks per year (in addition to the MSA external checks) with one internal check undertaken by an independent suitably qualified expert.
SJL has introduced a system of monitoring incidents where any incident, no matter how small, is analysed, logged and reviewed with results monitored by SJL management and board. This system allows cross referencing of incidents which occur involving specific drivers, craft, components, sections of the rivers, manoeuvres etc to observe any recurrent factors. The system is designed to reduce incident occurrence to a minimum.
An aviation based safety engineer is to be appointed to the Audit and Compliance Committee of the SJL Board to assist and advise on issues of safety and compliance.
All critical components are now internally identified and date stamped on installation for replacement at the "use by" date.
SJL has contracted a suitably qualified external expert to examine the list of critical components drawn up internally, adding items where appropriate and providing an assessment of the components’ operational life times. This system is designed around that used in the aviation industry.
SJL has re-engineered the company’s maintenance systems to provide for replacement of critical components as required by "lifetime" assessments.
SJL has re-engineered the company’s maintenance systems to ensure the periodic testing of critical components by suitably qualified independent experts.
Personnel
SJL has critically reviewed driver-training systems and introduced changes where necessary.
SJL has critically reviewed the system of checking drivers (particularly new drivers) by the senior driver and confirmed it as adequate.
SJL has reinforced the drivers’ option to operate or otherwise depending on conditions.
SJL has reinforced to operational staff, and in particular drivers, their responsibility for boat condition and the decision whether or not to operate craft.
SJL has introduced a system of psychological assessment for new drivers.
Operations
SJL has reviewed all aspects of its subsidiaries’ trips to ensure strict adherence to company specified "drive lines".
SJL has reviewed the appropriateness of “drive lines” internally and with a suitably qualified independent expert.
SJL has reinforced drivers need to adopt a more conservative line in high water conditions.
SJL has discussed with operational staff any suggested changes and implemented them where appropriate.
SJL has reviewed the adequacy of its safety briefings.
SJL has reassessed its safety equipment and made improvements where appropriate.
SJL has reviewed the company’s Safe Operating Plan and rewritten it. It is now MSA/QLDC Harbourmaster approved.
SJL has reviewed its crisis management plan and confirmed that it is adequate.
SJL has reviewed its pre-departure facilities and upgraded these where appropriate.
Hamilton 212 Jet Units
SJL has, immediately after the Shotover 15 accident discarded all Hamilton 212 "Mk I" nozzles and replaced these with "Mk II" [nozzles].
SJL has commissioned a comprehensive independent report from a suitably qualified professional engineer on the design of Hamilton 212 jet unit [steering nozzles].
The report concluded the [steering nozzle] is under designed for its function.
Copies of the independent report have been provided to appropriate authorities.
SJL has requested a complete redesign of the 212 nozzle by CWF Hamilton.
Pending a complete redesign, SJL has commissioned external professional advice on the continued use of Mark II 212 nozzles.
SJL continues to use Mark II nozzles subject to rigorous daily inspections, and removal for crack testing at 250-hour intervals.
SJL has fitted steering stops to all SJL craft using Hamilton 212 units.
New Craft
SJL has completed a review of all design aspects of existing craft and elected to replace virtually its entire fleet.
While existing craft are adequate, it is recognised that they are evolutions of craft introduced in the 1970’s and it is time for a complete redesign.
The only common factor between new craft and existing craft is the shape of the below water hull.
Two prototype boats are now under construction at Dickson Marine of Nelson.
Depending on the success of these craft, a contractual agreement will be entered into to construct between 20 and 25 craft of the new design.
A critical path for delivery will see Dart River Jet Safaris and SJQ fleets replaced by June 2002.
The SJL board has approved a capital expenditure programme to cover the new boats.
Extensive external testing of a Kevlar carborundum composite material has proved satisfactory, with strength, weight and durability factors far exceeding those of comparable aluminium, resulting in a decision to construct hulls from this material.
The new craft will include ergonomically designed seats to assist with passenger safety and comfort with "soft" plastic fittings internally to protect passengers.
The new craft will incorporate crumple zones in bows, "positive buoyancy cell" and redesigned fuel systems to improve safety incorporating “anti explosion” fuel tanks.
The steering systems will be completely redesigned to incorporate a system of shafts and gearboxes replacing existing cables and pulleys. The new system will be considerably more robust, easier to maintain and less susceptible to failure. The system has been designed by a professional engineer and certified.
The motor and jet unit packages have been considered and this is likely to result in a decision (after testing) to install twin engines and twin jet units to improve safety through duplicated systems, allowing continuation of one engine/jet unit in the event of failure of the other.
All equipment installed in boats will be either certified by a suitably qualified professional engineer or will carry suitable manufacturer warranties.
Seatbelts
SJL has commissioned an extensive and comprehensive external report on the installation of seatbelts.
If installation proceeds, it will be in conjunction with an "automatic release" system, which provides for release in the event of swamping of the craft or by central driver control as well as individual passenger control.
A final decision on this issue will be made when all factors including an independent report have been considered.
Related Investigation(s)