FinalreportMO-2016-205:Fatalfallfromheightonbulkcarrier,NewLegendPearl,3November2016TheTransportAccidentInvestigationCommissionisanindependentCrownentityestablishedtodeterminethecircumstancesandcausesofaccidentsandincidentswithaviewtoavoidingsimilaroccurrencesinthefuture.Accordinglyitisinappropriatethatreportsshouldbeusedtoassignfaultorblameordetermineliability,sinceneithertheinvestigationnorthereportingprocesshasbeenundertakenforthatpurpose.TheCommissionmaymakerecommendationstoimprovetransportsafety.Thecostofimplementinganyrecommendationmustalwaysbebalancedagainstitsbenefits.Suchanalysisisamatterfortheregulatorandtheindustry.Thesereportsmaybereprintedinwholeorinpartwithoutcharge,providingacknowledgementismadetotheTransportAccidentInvestigationCommission.FinalReportMarineinquiryMO-2016-205FatalfallfromheightonbulkcarrierNewLegendPearl3November2016Approvedforpublication:September2017TransportAccidentInvestigationCommissionAbouttheTransportAccidentInvestigationCommissionTheTransportAccidentInvestigationCommission(theCommission)isastandingcommissionofinquiryandanindependentCrownentityresponsibleforinquiringintomaritime,aviationandrailaccidentsandincidentsforNewZealand,andco-ordinatingandco-operatingwithotheraccidentinvestigationorganisationsoverseas.Theprincipalpurposeofitsinquiriesistodeterminethecircumstancesandcausesofoccurrenceswithaviewtoavoidingsimilaroccurrencesinthefuture.Itspurposeisnottoascribeblametoanypersonoragencyortopursue(ortoassistanagencytopursue)criminal,civilorregulatoryactionagainstapersonoragency.TheCommissioncarriesoutitspurposebyinformingmembersofthetransportsectorandthepublic,bothdomesticallyandinternationally,ofthelessonsthatcanbelearntfromtransportaccidentsandincidents.CommissionersChiefCommissionerJaneMearesDeputyChiefCommissionerPeterMcKenzie,QCCommissionerStephenDaviesHowardCommissionerRichardMarchantCommissionerPaulaRose,QSOKeyCommissionpersonnelChiefExecutiveLoisHutchinsonChiefInvestigatorofAccidentsCaptainTimBurfootInvestigatorinChargeCaptainJenniferCuttrissGeneralCounselCathrynBridgeEmailinquiries@taic.org.nzWebwww.taic.org.nzTelephone+6444733112(24hrs)or0800188926Fax+6444991510AddressLevel16,80TheTerrace,POBox10323,Wellington6143,NewZealandImportantnotesNatureofthefinalreportThisfinalreporthasnotbeenpreparedforthepurposeofsupportinganycriminal,civilorregulatoryactionagainstanypersonoragency.TheTransportAccidentInvestigationCommissionAct1990makesthisfinalreportinadmissibleasevidenceinanyproceedingswiththeexceptionofaCoroner’sinquest.OwnershipofreportThisreportremainstheintellectualpropertyoftheTransportAccidentInvestigationCommission.Thisreportmaybereprintedinwholeorinpartwithoutcharge,providedthatacknowledgementismadetotheTransportAccidentInvestigationCommission.CitationsandreferencingInformationderivedfrominterviewsduringtheCommission’sinquiryintotheoccurrenceisnotcitedinthisfinalreport.DocumentsthatwouldnormallybeaccessibletoindustryparticipantsonlyandnotdiscoverableundertheOfficialInformationAct1982havebeenreferencedasfootnotesonly.OtherdocumentsreferredtoduringtheCommission’sinquirythatarepubliclyavailablearecited.Photographs,diagramsandpicturesUnlessotherwisespecified,photographs,diagramsandpicturesincludedinthisfinalreportareprovidedby,andownedby,theCommission.VerbalprobabilityexpressionsTheexpressionslistedinthefollowingtableare...
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