Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

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.

An Airbus A320 inadvertently flew below minimum safe height on approach to Christchurch Airport. It landed safely. Lesson: properly used automated flight navigation systems will reduce crew workload and result in safer flight operations. Crew chose not to use auto, did not stay aware of their location compared to standard arrival route, and air traffic controller did not alert the flight crew.

The aircraft was returning to Gore Aerodrome from a private airstrip. A local farmer observed the aircraft pass over the property about 400 feet above ground level, in normal cruising flight. Shortly afterwards it rolled to the left and entered a steep dive from which it was not recovered. The two occupants received fatal injuries in the ensuing ground impact.

The aircraft was making an approach to the airstrip when it was observed to oscillate in pitch. The left wing failed and the aircraft dived into the ground, fatally injuring the pilot.

A Robinson R44 helicopter crashed into dense bush in Glenbervie Forest near Whāngārei. The two occupants – the pilot and a forestry contractor – died in the crash, and the helicopter was consumed by fire. Crash and fire damage destroyed evidence, so the cause or causes could not be determined. The Commission has previously recommended that recorders be fitted to certain classes of helicopter to aid accident investigation.