New Zealand accident investigators release updated report on 2024 ferry grounding near South Island

Management oversight of safety-critical project

TAIC said the operator had installed a new steering system, focusing mainly on physical installation of the equipment, treating it as a like-for-like replacement, which it wasn’t. However, the change management process was not robust, so operational differences between the old and new systems were not fully identified before the vessel returned to service. Also, sea trials, evaluation, and training did not adequately test or address those differences.

Safety audit and assurance checks were not being properly carried out, so shoreside management lacked visibility of day-to-day practice on the bridge drifting away from ideal. Safe navigation procedures were described in the operator’s safety management system and were available for the bridge team, but implementation was inconsistent. Hazard controls intended to prevent exactly this type of occurrence – such as challenge and verification, role definition, and good communication – were operating but not effectively enough at the time of the grounding.

Bridge team coordination

TAIC also found that the bridge team had not received training on two safety-critical operational differences: first, that to transfer steering control from one command console to another, rudder command settings on both consoles had to be aligned within two degrees; and second, that a force takeover function could override this requirement.