KEY POINTS:
Previous engine stallings of vessels similar to a passenger boat that hit a rock wall in Milford Sound were not properly investigated, the Transport Accident Investigation Commission has found.
In October 2006, the passenger vessel Milford Sovereign was on a cruise in the sound with nine crew and 181 passengers on board.
During the trip the boat stopped to view penguins but stalled and struck a rock wall.
A short time later the boat tried again to stop but when the master put the engines astern they both stalled again.
The boat nearly collided with a nearby vessel.
No one was injured and the damage to the boat was minor.
The commission found that previous engine stalling of vessels similar to the Milford Sovereign had not been effectively investigated.
"A chance to prevent the latent stalling issue in the Milford Sovereign during its design and construction had been lost," said the report.
A loss of directional control of the Milford Sovereign had meant the safe ship management system was less vigorous than it could have been.
"Had the system at the time been more robust it should have identified the engine stalling problem and required that measures were taken to mitigate it."
The commission has recommended Maritime New Zealand takes action to address the risk of stalling.
Maritime New Zealand said it was investigating technical options to mitigate the risk of engines stalling.
- NZPA