The Department of Conservation has undertaken a sweep of actions to address "organisational deficiencies", primarily in its Whanganui District offices, highlighted by a near-fatal jet boat crash with a kayaker.
The November 18, 2020 crash on the Whanganui River left the kayaker with a broken collarbone, broken shoulder, six broken ribs, and a concussion.
An investigation resulted in all department field work in the Whanganui District stopping for 90 days from 23 April 2021, because "the significant volume of critical issues ... at any time could lead to another serious incident".
Last month, the ranger who was skippering the jet boat, Wanihi Butler, was ordered to pay $10,400 in reparations.
The investigation report, released under the Official Information Act and published online identified a range of issues including health and safety, leadership, and communication.
The report simultaneously said district staff were "highly committed ... and are willing to go above and beyond to get the job done" and that "a negative culture" had been allowed to "flourish and perpetuate to the point where some staff have a negative and resentful attitude with a lack of teamwork and respect".
It ultimately concluded issues went "deeper" than the singular crash and there were "organisation deficiencies" with opportunities to improve "operational excellence".
Visibility was poor on the river the morning of the crash, and rain "started to fall heavily" before the collision, which happened about 10am.
Butler was driving a jet boat named Wawahia toward Mangapurua Landing, deep in the Whanganui National Park, where routine track maintenance was happening.
The ranger was only certified to drive Wawahia's sister boat, the Paparoa, which his team leader was riding in, 15 minutes upstream.
The kayaker had forgotten his lifejacket and was kayaking on the "true left bank of the river", when he should have been on the true right, as per maritime laws. He started to paddle toward the jet boat because he "wrongly assumed that they were bringing him a spare life jacket".
He was also wearing dark clothes that blended in with the river.
At the same time, Butler, who had not checked the weather forecast, removed his "tinted safety glasses" that had fogged up "to clear them with his fingers to improve his visibility on the river, and looked down", the report said.
When he "returned his vision to the helm", Butler and another department member on board "heard a thump on the starboard (right) side of the jet boat". Butler had not expected to see a kayaker on the true left-hand side of the river "at that location and at the early time of day".
The colleague did not see the kayaker either, as they were "hunched over sheltering from the rain" instead of acting as a look-out to assist Butler.
After the crash, Butler was in a "panicked state" and tried to radio through to the district office but could not because of poor coverage.
The kayaker, who "was hurt, in a lot of discomfort, struggling to breathe, bleeding from his mouth and ... experiencing blurred vision" was eventually taken to the Department's Pipiriki Office and later taken to hospital by helicopter.
It was a ranger in the district office, some 77km away, who called emergency services.
The report stated the team leader stayed working upstream and was unaware of what happened until the end of the day.
The investigation team "found it unusual" the team leader did not check in to see why Butler and his colleague failed to turn up at the Mangapurua Landing site.
Butler told investigators he was "unaware of any safety plans for the boats, or the controls associated with known hazards", which included stopping the vessel in rainfall or poor visibility until it cleared.
However, a workbook showed he had completed training around a safe plan, with an assessment showing he had knowledge of it too.
No department staff had considered whether their work could have been delayed until the weather improved or if the contractor needed to be taken out by boat.
Also, "it was found that the second boat was not needed".
Jet boats were the primary mode of transportation around the river, but the investigation team could not find jet boat management within emergency procedures. "There was no evidence that the emergency procedures were referred to, known, or followed."
However, it was noted "on the day, due to the experience of the team, they managed the incident incredibly well despite the lack of an adequate plan".
Whanganui's Dublin Street Bridge. Photo / Bevan Conley
Stopping work to address 'organisational deficiencies'
Through interviews as part of the investigation it became known there were "several unreported incidents" in the district, including a "trailer accident, speeding incidents, driving without warrants, missing equipment and PPE [personal protective equipment]".
"There appears to be a culture of hiding incidents," the report stated. "The investigation team believes that staff are self-managing incidents and not raising issues due to the lack of active supervision to ensure best practice, combined with fear of reprisal."
Investigators were "not confident" about staff commitment to health and safety procedures.
Staff induction and office culture were also singled out. In the Pipiriki office specifically, it was noted by the operations manager that there was "limited capability around reading, writing and computer skills".
Investigators said this impacted on the office ability "to follow process, deliver on procedures, documentation and paperwork, including a safety culture".
There was a "common theme" of personal skipper logbooks not being used, despite it being a requirement of being a boat skipper, as well as vessel logbooks being incomplete.
The report said many interviewees mentioned a lack of supervision of staff at Pipiriki. "Senior staff often take the place of active supervision and were looked at for leadership, because of their role in the community and experience, even though it was not their role to be supervisors".
Investigators believed there was a "culture of apathy of staff, and a lack of motivation to follow correct processes and systems".
It also became clear the department had "no formal process to manage vessel modifications". This was brought to light because among issues relating to the Wawahia jet boat, it's clear perspex wind defectors were removed after being damaged and replaced by others made from another material, which "unfortunately restricted the driver's forward visibility".
"Currently the department's national fleet manager who receives inquiries defers any modifications to the department's independent BOCC [Boat Operator Certification Co-ordinator]," the report said.
"There needs to be a formal documented process and guideline nationally within the department."
Overall, a "full stop" of work was recommended by the investigation team, which central North Island operations director Damian Coutts agreed to.
"These issues are multifaceted, and none are a quick fix," he said.
Coutts' support for a district-wide stop-work included the fact Butler was based in the Whanganui office, and the risk of supervision issues at the Taumarunui site if it only focused on Pipiriki.
Coutts thought having a daily supervisor or management presence would be key to resetting the culture of "it is okay not to follow the DoC processes".
He was concerned with how work was allocated within the district, noting staff were travelling up to three hours to do some jobs when Tongariro District staff were based only about half an hour away.
In a separate letter for the Official Information Act response, dated 23 December 2021, Coutts said work in response to the report's 16 recommendations was "either complete, or underway where work is of an ongoing nature".
He said no work resumed until he was satisfied.
"The end result is the department has changed what it does, and how it acts/responds at a local, district and national level. Shining the light on deeply ingrained patterns of behaviour has made us a stronger, more professional organisation."
