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00:01Nga mihi nui kia koutou katoi, tai mai nei, i tēnei rā, ka tūku mihi ki ngā iwi o te
00:08rohi nei, mi nā mā te kua whetu tu rangatia.
00:13Tātou mā, tēnā tātou kato.
00:15Good afternoon, I'm David Clark, I'm the Chief Commissioner.
00:17I lead the Three-Person Transport Accident Investigation Commission, which has authored the final report that's being published today.
00:27The Commission is a standing Commission of Inquiry whose mandate is to investigate the causes and circumstances of accidents and
00:34incidents without necessarily ascribing blame.
00:39We determine those circumstances and causes, identify safety issues and make recommendations to help lawmakers, policy agencies, regulators, owners and
00:48operators prevent similar accidents in future
00:51and to improve the safety of the New Zealand transport sector and keep people safe.
00:57Today, our focus is on a major maritime incident involving the Cook Strait Ferry Kaitaki,
01:05with 864 people on board, which lost power in Cook Strait and drifted towards the Wellington southern coast.
01:12It ended safely, this incident, but there were real and immediate safety issues, which the Commission considers must be addressed.
01:23Before I get into talking about the report, I want to acknowledge the passengers and crew and everyone involved in
01:29the response.
01:30While nobody was harmed in this incident, the risks they faced were serious and imminent,
01:36and the experience would have been stressful, distressing and frightening for many of those on board.
01:41The Commission is very mindful of the impact of events like this on the people involved and their families.
01:48We have taken this very seriously and conducted an in-depth and comprehensive investigation.
01:55And I want to thank the Commission's staff for their thorough examination of all the issues and their careful analysis
02:02across multiple lines of inquiry.
02:05The focus of this report is on future safety, and it deserves close attention.
02:12On 28 January 2023, the Kaitaki was sailing from Picton to Wellington, having left Picton about 2.15.
02:20Just over two hours later, at 4.30, off the Wellington coast near Sinclair Head,
02:26it lost all propulsion and all electrical power except emergency power.
02:31In rough conditions, with strong onshore winds, the ship began drifting towards the coast.
02:37This is a hazardous situation for any vessel, let alone one with 864 people on board.
02:44The Master issued a mayday, and the Rescue Coordination Centre initiated a mass rescue response involving multiple agencies.
02:53The blackout lasted over an hour, but the crew reacted immediately.
02:58They deployed one anchor which didn't hold, followed by the second anchor which did, halting the drift.
03:04Their actions prevented this incident from escalating.
03:08The Kaitaki at this stage was just under one nautical mile off the south coast.
03:13The engineers then identified the problem, made repairs, restored power and propulsion.
03:20The anchors were then raised, and the two harbour tugs escorted the ship towards Wellington.
03:25At the Wellington heads, just on the entry to Wellington harbour, a further issue with a gearbox fault meant the
03:32ship lost propulsion on one side,
03:35but this was rectified very quickly when a standby engine kicked in.
03:40Eventually, around 9pm, 9.20pm, some seven hours after the Kaitaki left Picton, the ship was brought safely to berth
03:49in Wellington.
03:50The Master cancelled the mayday, and the Rescue Coordination Centre stepped down its response.
03:58In every inquiry, we look beyond the immediate causes of the accident or incident to understand the wider circumstances in
04:06the system,
04:07what the failures were, and how we can prevent them in future.
04:10We are not limited to addressing the issues that contributed directly to the incident.
04:15We also consider safety issues that, while they may not have been directly contributing to the particular incident,
04:23could affect future incidents if circumstances were different.
04:27During the course of our investigation, remedial actions in relation to a number of the issues we identified
04:33during the course of the investigation have been completed or underway.
04:37As a result, there are a number of safety issues we had identified that are resolved,
04:43and no recommendation is required in respect of them.
04:48Our report being published today identifies six key safety issues and makes five recommendations.
04:56The first safety issue is the one that is most closely and directly related to the cause of the accident.
05:02That is the importance of lifetime management of safety-critical components.
05:08The immediate cause of this incident was the failure of a degraded rubber expansion joint
05:13in the cooling system of the Kaitaki.
05:16These joints provide flexibility for absorbing vibrations, noise, thermal expansion and pipe misalignment.
05:23When it ruptured, cooling water spilled out, draining the reservoir,
05:28and as a result, protection systems shut down the engines and generators
05:32to avoid catastrophic damage to them.
05:35That resulted in a loss of propulsion and electrical power.
05:40What we found in the course of our investigation was that that rubber expansion joint that failed
05:45was 13 years old when it was installed in 2018,
05:49and it was 18 years old by the time it failed.
05:53That was too old, and it should not have been in service.
05:57Lifetime care is crucial for rubber components
06:00because they deteriorate with age as well as with service life.
06:04They harden, they crack, they delaminate, and that's exactly what happened here.
06:09More broadly, it's essential that operators manage safety-critical components
06:14either in line with manufacturer guidance
06:18or with a more robust system of their own.
06:21These components should be identified and monitored throughout their life
06:25to ensure they remain fit for purpose and they should be replaced regularly.
06:31Rubber expansion joints are a common feature on Cook Strait fairies.
06:36There were 46 on Kaitaki alone,
06:38and so this risk was not limited to the particular rubber expansion joint that failed
06:42or to the Kaitaki.
06:44We identified this issue early in our investigation,
06:49and because of its scope and significance,
06:51we produced a preliminary report in 2023,
06:55three months after the incident,
06:57and that report made urgent recommendations
06:59directed specifically at this risk
07:02in ensuring the safety of passengers and crew on Cook Strait fairies.
07:06We are satisfied with Kiurao's corrective action to address this safety issue,
07:10and so we haven't repeated our safety recommendation from our May 2023 report.
07:17The remaining safety issues go not to the incident and its cause,
07:22but to the response and how those responses could be improved.
07:27The first of those is engineering support.
07:30What we know is that safety systems only work if people know about them,
07:34use them, and practice them.
07:35With the ship drifting towards a lee shore, time mattered.
07:42The response of the master and the bridge team to this
07:45was appropriate, structured,
07:47and followed a well-understood and well-rehearsed decision-making framework.
07:52But the engineering response was not so structured,
07:56and without a well-understood decision-making framework.
08:00The safety of life at sea or soulless convention requires
08:03emergency response planning to be part of a ship's safety management system.
08:07It does not require an engineering decision-making support system.
08:12However, Kaitaki's engineers could have accessed documentation
08:15and procedures dealing with cooling water failures.
08:19However, we found no evidence that they were familiar with them,
08:22or had practiced them or implemented them.
08:25That was a missed opportunity.
08:27A structured, rehearsed response could have resolved the failure sooner,
08:31and time was critical.
08:33As we identify in the report,
08:34if the ship had continued to drift to shore
08:36and not been arrested by its anchors,
08:39a serious marine casualty event was almost certain to follow.
08:44KiwiRail is addressing this issue.
08:46It is advised that it's undertaking a new analysis across its fleet,
08:49identifying and implementing system changes.
08:51It's also developing an updated engineer decision support system.
08:57The Commission welcomes KiwiRail's actions,
08:59but these actions are not yet complete,
09:01and we've made recommendations to support KiwiRail.
09:07Another component of the response to a major incident
09:11is the potential need to evacuate a ship.
09:14International rules introduced in 2016
09:17require operators of newer passenger ships
09:19to analyse escape, evacuation and rescue in a particular way,
09:24and on a particular regularity.
09:28The Commission considers that every ferry operator in New Zealand
09:31should apply the same standard of analysis,
09:34regardless of vessel age.
09:37Passenger ship design has moved on a long way
09:39since the Kaitaki was built in 1995.
09:42A key principle now in ship design
09:45is that the ship is its own best lifeboat.
09:48The Master in this case made the call
09:50to keep the passengers on the ship.
09:53That is consistent with the concept of a ship
09:55being its own best lifeboat
09:57and remaining on board unless demonstrably unsafe.
10:02Evacuating 864 people in severe weather
10:04near a lee shore and heavy seas
10:07and breaking waves and limited rescue resources
10:10would have been very high risk.
10:14KiwiRail has advised the Commission
10:16that it has commissioned an updated escape,
10:18evacuation and rescue analysis
10:20and created an emergency towing guide for the Kaitaki.
10:24And Maritime New Zealand advises
10:26that it is encouraging operators to conduct regular such reviews.
10:29The Commission welcomes this work
10:32but considers promulgation of the international guidelines
10:35to be a way to encourage consistent best practice
10:38across the industry.
10:42A further safety concern
10:46in any response
10:47is the need for emergency response coordination.
10:51If Kaitaki had grounded
10:53the Master would have needed external support
10:55to get the passengers and crew off the ship into safety.
11:00That would have been a complex undertaking
11:02in challenging circumstances
11:04involving multiple sea craft, multiple aircraft
11:07and multiple onshore agencies
11:09as well as the ship's crew.
11:12In those circumstances
11:13it's essential that responders
11:15have a shared operating picture
11:17and a common understanding of roles, authority and resources.
11:21And the ship's crew should have experience
11:23working with search and rescue
11:25through regular joint exercises.
11:29But we found that responders
11:31did not have a consistent picture of events or roles
11:33and coordination was not as effective
11:35as it could have been.
11:38Kiwi Role had conducted drills
11:40some with the rescue coordination centre
11:44but they were limited
11:45and didn't fully test the way
11:46in which the organisations would operate together
11:49in a real emergency.
11:51And nationally there is a need
11:53to ensure that maritime response coordination
11:55and integration
11:56is at an appropriate level
11:57at every New Zealand port.
12:00Maritime New Zealand has advised the Commission
12:02that it's developing a new version
12:04of its integrated maritime incident readiness
12:08and response strategy
12:09and it has formed a Cook Strait working group
12:12where it leads multi-agency operator
12:14tabletop practical exercises
12:15to ensure a common understanding
12:17of the response model.
12:19The work is not yet complete
12:20so I've made a recommendation
12:22to support Maritime New Zealand.
12:26Also important in any maritime response
12:29is the establishment of support structures
12:32to support that response.
12:34In this case,
12:36the Maritime Incident Response Team
12:37or MERT.
12:38This is a structure
12:40that enables the Director of Maritime New Zealand
12:42to have effective oversight
12:43so they can provide cross-agency support
12:45and information
12:46across the response as a whole.
12:49This incident made formal activation
12:51of the MERT necessary.
12:53While some staff informally fulfilled
12:56some of the MERT's functions,
12:58not all of the functions were fulfilled
13:00and some of those staff
13:01were operating remotely
13:02rather than in specific locations
13:04where they would be
13:05had it been formally established.
13:08In addition,
13:09there's a difference
13:09between acting informally
13:11and acting in a formal structure
13:13with guidance,
13:14with rules
13:15and with communication protocols.
13:17We found that a process
13:19existed for the establishment
13:21of the MERT
13:21in response to this incident
13:22but it was not followed.
13:25The failure to establish a MERT
13:27did not contribute to
13:28or affect the outcome in this case
13:30but had the situation escalated
13:33the time necessary
13:34to then formally establish the MERT
13:36would have affected
13:37Maritime New Zealand's ability
13:38to respond properly.
13:41Finally, the issue of salvage
13:44and towage capability.
13:46New Zealand does not have
13:48a reliable ocean-going
13:49salvage and towage capability.
13:52That increases the risk
13:54that a disabled vessel
13:55becomes a major casualty
13:57with the potential for fatalities,
13:59injuries and environmental damage.
14:01A tow attempt by the Wellington-based
14:04harbour tugs in these conditions
14:05could have made the situation worse.
14:08Neither the tugs
14:09nor the kaiteki
14:10or their crews were equipped
14:11or had practiced
14:12towing a ship of this size
14:14offshore in these conditions.
14:16We've recommended to Maritime New Zealand,
14:18the Ministry of Transport
14:19and others
14:19that they continue to work
14:21on strengthening capability
14:22in areas of New Zealand
14:23most susceptible
14:25to a very serious marine casualty event.
14:30This was a ferry
14:31with 864 people on board,
14:34784 passengers and 80 crew.
14:37It lost propulsion
14:39and all but emergency power
14:40in conditions
14:41in one of the roughest
14:42stretches of ocean in the world.
14:45The events ended safely
14:47but time was critical.
14:49A few minutes longer on the repairs,
14:52the anchors not holding,
14:53engines not starting
14:54or the need to evacuate
14:55and the outcome
14:56could have been very different.
14:58Our recommendations
14:59in this case
15:00have targeted the areas
15:01where we see improvement
15:02can be made to the response
15:04and if they are followed,
15:06New Zealanders will be safer.
15:07I'm happy to take questions.
15:10That single part,
15:12how old was it?
15:14It was 18 years
15:16when it failed.
15:17And what is typically
15:19its lifespan?
15:20So there are varying
15:22manufacturer requirements
15:23but a good rule of thumb
15:25which KiwiRail I understand
15:26is now applying
15:27is four years shelf life,
15:28four years operating life.
15:30So it was 10 years
15:32past its use by date essentially?
15:36Yes.
15:37Yeah, okay.
15:39And how much
15:40did one of those parts cost?
15:41I don't know.
15:42Why wasn't it replaced?
15:44You'd have to ask KiwiRail
15:46that it should have been replaced
15:49in our view
15:49but their management
15:51and maintenance processes
15:52didn't pick up.
15:53So it should have been replaced
15:55at the 8 year mark?
15:57That's our view.
15:59With the talk of the tide change
16:01in the report,
16:02can you talk us through that
16:03because that would have been
16:03switched to an oncoming tide
16:05right?
16:05Yes.
16:05It would have dragged the ship
16:06towards the coast.
16:07Is that what you can hear?
16:08Well, not so much
16:10dragged the ship
16:10towards the coast
16:11though that could have been
16:12the result.
16:12The focus we had on that
16:13was whether it would have
16:14affected the holding
16:15of the anchors.
16:16Certainly the onshore wind
16:17would have continued
16:18to push the boat towards.
16:19So the issue we considered
16:21in relation to the change
16:22in tide was how it would
16:23affect the anchors.
16:31Well, as I say,
16:35not all functions
16:35of the MERT
16:36were being fulfilled
16:37informally
16:38and there is a vast difference
16:40between informally
16:41fulfilling a role
16:42and a formal structure.
16:43And the MERT structure
16:45was established
16:46after a 2013 review
16:48of the response
16:49to the RENA grounding
16:51and that was where
16:53the concept of the MERT
16:54came from.
16:55So establishment
16:56of the MERT
16:57is a necessary
16:58and useful step
17:00in relation to
17:01major and significant
17:03maritime incidents.
17:04Have you given
17:05what's the only
17:06maritime incident
17:07had 10 years
17:08since the RENA
17:09to do that
17:11and the dispute
17:13of the facts
17:13now do you have confidence
17:14in the Director
17:15of Maritime
17:15being said
17:16to respond
17:17appropriately
17:18in a future emergency?
17:19So since the
17:20Kaitaki
17:21there have been
17:22two episodes
17:23the Arateri
17:25and the Shiling
17:25and both those cases
17:26the MERT
17:27was established.
17:28With regards
17:29to the tugboat's
17:31response
17:31and the risks
17:33that could have
17:34eventuated
17:34had they become
17:35fast to the Kaitaki
17:37why were the tugboats
17:40incapable in that
17:41scenario
17:41and what needs
17:42to happen
17:43to our emergency
17:44response
17:45for that style
17:48of rescue
17:49in that situation?
17:50So those tugs
17:51are designed
17:51for in harbour use
17:52so not for ocean going.
17:55They also hadn't
17:56practised
17:56or experienced
17:57in towing
17:58in those situations
17:59or a vessel
18:00of that nature
18:01in that location.
18:02In addition
18:03the bits
18:04or bollards
18:05on the ship
18:06were of a
18:07lower strength
18:08than the tow ropes
18:09on the
18:12tow vessels
18:14so that could have
18:15created more danger
18:16and damage
18:17on the ship.
18:18So one of the
18:18recommendations
18:19from the harbour
18:20master is that
18:21all ferries
18:22carry appropriate
18:23towing ropes
18:24and equipment
18:25for if necessary.
18:26Does the
18:28Wellington Cook
18:29Strait area
18:30need a dedicated
18:31tug system
18:33for larger
18:35passenger vehicles
18:36larger vessels
18:37sorry?
18:38So what we have
18:38identified is
18:39that there is
18:40a capability gap
18:41in the towing
18:43and salvage
18:44in ocean areas
18:46such as Cook
18:47Strait.
18:47The actual
18:48mechanism
18:49or way
18:51of resolving
18:52that safety issue
18:54is one for the
18:55people to whom
18:56we make recommendations.
18:57You'll notice
18:57that our recommendations
18:58don't solutionise.
18:59We don't say
19:00you must buy a tug
19:01or you must contract
19:02or a tug or a tug
19:03is the answer.
19:04What we provide
19:05is a clear description
19:07of the safety issue
19:09that alerts people
19:10to it.
19:11A recommendation
19:11that if met
19:12will satisfy it
19:14and that recommendation
19:15is made to people
19:16with the expertise
19:16who consider
19:17how and when
19:19the best way
19:20to respond to that
19:21and solve that
19:22safety issue.
19:22What's your awareness
19:24of the nearest vessels
19:25capable of such a rescue?
19:27Previously
19:28they have been
19:28offshore in Taranaki.
19:30I understand
19:31that there aren't
19:31any currently
19:32in place there.
19:34Just back
19:35on the rubber
19:36expansion joints
19:37Kevin Rowell's
19:38own policy
19:39said that they
19:40should be replaced
19:41no matter their
19:41condition every
19:42two years.
19:43This one
19:44was 18 years old
19:45and had been
19:46in place for five.
19:47It also
19:48from those photographs
19:49had stickers on it
19:50saying when it
19:51was produced.
19:52How shocking
19:53is this to you
19:54that it was still
19:56in place
19:56and in use
19:58that was a failure
20:00of their system
20:01and when our
20:02investigators looked
20:03at it and identified
20:04that age
20:05of that part
20:06it was clear
20:07and the state
20:08of that part
20:08it was clear
20:09that delamination
20:10and degradation
20:11had occurred
20:12so it was surprising
20:13to see that
20:14on board the vessel.
20:17And just generally
20:17speaking
20:18how well do you
20:19think authorities
20:19across the board
20:20talking about police
20:21here at Maritime
20:23New Zealand
20:23and the Harbour Master
20:24how well did they
20:25respond to the
20:26they all responded
20:27as to the best
20:29of their ability
20:29in the circumstances
20:30we've identified
20:31some areas
20:32where it could
20:33be improved
20:34but certainly
20:35those recommendations
20:36they will make
20:36incremental improvements
20:38to the response
20:39but the response
20:40other than those
20:41issues that we've
20:42identified
20:43was a good one.
20:44If
20:44hypothetically speaking
20:46we did end up
20:47with a mass casualty
20:48event
20:48which was a real
20:50possibility here
20:51how well prepared
20:52do you think
20:53that these organisations
20:54are for a
20:55people like this
20:56I remember at the
20:56time there were
20:57examples of
20:59four wheel drive
21:00pumps being called
21:01out to be
21:02parked on the rocks
21:03out there
21:03obviously
21:03if you were
21:04private helicopters
21:05that were mentioned
21:05in the report
21:06how much
21:07how well prepared
21:08are those organisations
21:09to respond to
21:10anything like that
21:11should it happen?
21:12That is what
21:13these organisations
21:14are established
21:15to do
21:15I think
21:15in the context
21:17of a significant
21:18maritime incident
21:19all possible
21:22help will be
21:23called in
21:24we've identified
21:25where coordination
21:26can be improved
21:27and improvements
21:28in that coordination
21:29will certainly
21:29improve the ability
21:30of those organisations
21:31to respond
21:33So there were
21:3446 of these
21:36rubber expansion
21:37journals
21:37did you check
21:38the others
21:39to see how old
21:40they are
21:41and have they been
21:42replaced?
21:42We did not
21:43check those
21:44we raised the issue
21:45made the recommendation
21:46my understanding
21:47is Kiwi Rail
21:48replaced the
21:49REJs
21:58So it was
21:59as I say
22:00just under
22:01one nautical
22:01mile
22:02in actual terms
22:03about 1.4
22:04kilometres
22:05from shore
22:05with about
22:07900 metres
22:08of clear water
22:10How close
22:11was the captain
22:12to him
22:13calling for an
22:13abandon ship?
22:15Do you know that?
22:15The captain
22:17or the master
22:18obviously was
22:19preparing for
22:20that eventuality
22:21he held people
22:22at muster stations
22:23got them to
22:24muster stations
22:25early and held
22:25them at muster
22:26stations for
22:27three hours
22:27until they were
22:28safely within
22:28the port
22:30and he was
22:31clearly monitoring
22:32the situation
22:33at all times
22:33how close he came
22:34I don't know
22:35the answer to that
22:36But that had
22:36gone every step
22:37up to abandon
22:38a ship
22:38without doing it
22:39where there were
22:39other steps
22:40that he had
22:40done before that?
22:41No the lifeboats
22:42were prepared
22:43which was an
22:43entirely appropriate
22:44response
22:45Just one other
22:46thing
22:47the gearbox
22:47fault that
22:48happened later
22:48on
22:49going through
22:49the heads
22:50was that
22:50related
22:51was that
22:51caused by
22:52the earlier
22:52I know you
22:53can't look at
22:53cause
22:54but do you
22:54know if that
22:54was caused
22:55by the earlier
22:55power out
22:56there's really
22:57two unrelated
22:58things
22:58They were
22:58unrelated
23:00So 900 metres
23:01of clear water
23:02ahead
23:02what do you
23:03mean
23:03Behind
23:03sorry
23:04900 metres
23:05that's the
23:05navigable and
23:06safe area
23:07in which you
23:07can navigate
23:09or anchor
23:10without risk
23:12Okay
23:12how deep
23:13was the water
23:14I don't know
23:16Sorry
23:16just to be
23:17clear
23:17on that
23:18one sailing
23:19two power
23:20outing
23:21events
23:22happened
23:22that were
23:23completely
23:23unrelated
23:23to each
23:24other
23:24One was a
23:25power outage
23:25the other
23:26was a gear
23:27failure
23:27which lost
23:28the propulsion
23:28not
23:29electricity
23:30not power
23:34Any other
23:35questions?
23:35No thank you
23:36Asriel
23:37online
23:40Thank you
23:41Thank you
23:42Thank you
23:42Thank you
23:42Thank you
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