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Outstanding Safety Recommendations

This page displays a list of all outstanding safety recommendations.  This means that a recommendation has been assigned to an organisation and has not been implemented.

Keywords: Recipient: Mode: Status:

Safety Recommendation 023/17
Issued To KiwiRail on 23 Aug 17
KiwiRail's records of random drug and alcohol tests for the three years from 2013 to 2015 showed that 95% of the positive results had related to employees working in its safety-critical infrastructure maintenance and train operations areas. KiwiRail's practice of randomly testing 10% of its workforce annually means that an individual is potentially tested once every 10 years, which is consistent with the rail protection officer not having been randomly tested in the previous 10 years.

Random testing is more useful than post-incident testing, as it is designed to act as a deterrent and prevent accidents and incidents instead of finding out after the event. The more likely staff are to be tested, the bigger the deterrent.

Comparative rail companies in New Zealand and Australia are testing at higher ratios, with some achieving a 50% testing programme within a 12-month period.

The Commission recommends to the Chief Executive of KiwiRail that he address KiwiRail?s low-ratio random testing programme.
Implementation Status: Open
Reply: We confirm that KiwiRail is increasing its random drug and alcohol testing regime from 10% per annum to 20% per annum. This change will take effect from 01 October 2017.

As further requested, KiwiRail undertakes to confirm with the Commission once the change is fully implemented including confirmation of the implementation date, a description of how it was implemented, and evidence to demonstrate full implementation.

Safety Recommendation 019/17
Issued To CAA on 28 Jun 17
The medical practitioners associated with the care of the instructor, and many of the others spoken to during the course of the investigation, were unaware of their obligations under the Civil Aviation Act to inform the CAA about a licence holder who has a known or suspected medical condition that may affect their ability to conduct their duties safely. Despite the efforts of the CAA, this lack of awareness of the Civil Aviation Act appears to be wider than just among those involved with this case.

On 28 June 2017 the Commission recommended to the Director of Civil Aviation that he improve the mechanisms for informing medical practitioners of the requirement to report to the CAA any health issues with a CAA licence holder that may interfere with that person?s ability to exercise the privileges of their licence safely.
Implementation Status: Open
Reply: Notwithstanding past and ongoing effort to educate medical practitioners about their duty to report to the CAA any health issues with a CAA licence holder that may interfere with that person's ability to exercise the privileges of their licence safety it is acknowledged this activity needs to be ongoing and the results of the Commission's investigation highlight this need. Accordingly this recommendation is accepted and the work will continue on an ongoing basis. As this educational work will need to be enduring in its nature and will be undertaken on an ongoing basis it is not practicable to specify a final implementation date. In conducting this ongoing work will we however review the manner in which we have sought to educate medical practitioners in the past and look to identify additional pathways that may be complimentary to those previously used. This review will be completed by 1 December 2017.

Safety Recommendation 020/17
Issued To CAA on 28 Jun 17
Section 27C(1) of the Civil Aviation Act requires medical practitioners to inform the Director if they believe a person is a licence holder and is aware, or has reasonable grounds to suspect, that the licence holder has a medical condition that may interfere with the safe exercise of the privileges to which the licence holder's medical certificate relates.

The Civil Aviation Act defines a medical practitioner as a health practitioner who is registered as a practitioner of the profession of medicine. This does not recognise that other health professionals (as defined in the Health Practitioners Competence Assurance Act 2003) may be providing care to a licence holder. Other health professionals, such as psychologists, could know, or become aware of, a CAA licence holder having a medical condition that may interfere with the safe exercise of the privileges of their licence.

On 28 June 2017 the Commission recommended the Director of Civil Aviation consider measures to ensure that other appropriate health practitioners, not included under the current definition in the Civil Aviation Authority Act, notify the Director when they are aware, or have reasonable grounds to suspect, that the holder of a CAA licence has a medical condition that may interfere with the privileges to which their medical certificate relates.
Implementation Status: Open
Reply: We recognise the basis for this recommendation and the outcomes the Commission is seeking to achieve. We are supportive of these. However changes to the Civil Aviation Act 1990 (the Act) would be required to support any effective measures aimed at implementing the recommendation. The Act is administered by the Ministry of Transport. As such, any recommendation for a change to the content of the Act should be made to the Secretary for Transport.

Safety Recommendation 021/17
Issued To CAA on 28 Jun 17
The medical examiner did not, and saw no reason to, contact the instructor's GP as part of the medical assessment process. Had he done so, it is likely that he would have learned of the instructor's recent illness and initiated a more formalised review of the instructor's fitness to fly. A procedural requirement for medical examiners to consult GPs would help to ensure that they are fully informed about applicants' health.

On 28 June 2017 the Commission recommended to the Director of Civil Aviation that he review the medical application process:
- to ensure that it promotes a positive reporting culture for applicants
- that is more robust in identifying potentially serious health issues that may interfere with the safe exercise of the privileges to which applicants' medical certificates relate
- to ensure that the system supports medical examiners exercising their discretion to consult medical practitioners when assessing applications for medical certificates.
Implementation Status: Open
Reply: By way of context to the CAA's response, it should be noted that consistent with developments overseas, the CAA has recently consulted with stakeholders regarding the appropriate medical certification standard for the holders of a private pilot licence. The international trend is for a reduction in the standard of any aviation medical certificate or even the removal of the requirement for such a certificate altogether. This reflects a view that the regulatory burden that has been imposed in the past is unreasonable given the very small number of accidents with a medical cause factor. It is important to note, however, that if such a change were to occur in New Zealand it would be very unlikely to apply to the medical certification of pilots conducting hire or reward activity. Therefore, the preceding context does not reduce the validity of the Commission's recommendations as they might apply to the holders of the aviation documents required for the performance of hire or reward operations.

The CAA accepts the first element of this recommendation and will do what it can to promote a "positive reporting culture" for medical certificate applicants to the degree it can do so while still acting decisively to protect the public interest when it has reasonable cause for concern about matters of potential aeromedical significance. The CAA will review current processes in line with this recommendation by 1 December 2017.

The CAA accepts the second element of this recommendation as it applies to the holders of aviation documents utilised for professional purposes. The CAA will review current processes in line with this recommendation by 1 December 2017.

The CAA considers that the third element of the recommendation is unworkable in that it would currently be unlawful in terms of the Civil Aviation Act for the Director to require an applicant, as a precondition to the issue of a medical certificate, to provide information from their GP or other medical practitioner, or to authorise the CAA to access that information, in the absence of reasonable cause in a specific case for requesting that information. In addition, the CAA considers that the provisions of S27C (3) of the Civil Aviation Act which requires medical practitioners to inform the Director if they have reasonable grounds to believe that a licence holder has a medical condition that may interfere with the safe exercise of the privileges of the licence they hold does not provide sufficient authority for the GP to share all medical information regarding a licence holder patient with a Medical Examiner. Any effective system in support of medical examiners in the manner anticipated by this element of the recommendation would require changes to the Civil Aviation Act. Given the above and the fact that the Ministry of Transport administers the Civil Aviation Act, the CAA recommends that the Commission consider making a recommendation to the Secretary for Transport for amendment of the Civil Aviation Act requiring GPs to provide, on request from a Medical Examiner, medical information regarding a patient who holds, or is seeking, aviation medical certification.

Safety Recommendation 022/17
Issued To MoH on 28 Jun 17
There is the potential for applicants for medical certificates to attempt to circumvent the medical assessment process by inaccurately representing their state of health through the misreporting of their treatment, including undisclosed medications and possible multiple GPs and other health professionals. This risk is shared by other transport modes that require a person to hold a medical certificate or make a declaration on their health status. A national health database would provide one means of addressing this risk.

On 28 June 2017 the Commission recommended to the Chief Executive of the Ministry of Health that he consider adding the following functions to the national electronic health record database under development:

- that a person's occupation be added to the record to allow monitoring of individuals who hold transport-related documents that require periodic medical checks, and who have potentially adverse health conditions or medications, so that the appropriate authority can be alerted to possible public safety risks
- a mechanism to draw the attention of all health practitioners to their obligation to notify the appropriate transport authority when a person or patient has a health condition or need for medication that could pose a threat to public safety in that individual's occupation.
Implementation Status: Open
Reply: The National Electronic Health Record Business Case project is a significant project that is working though a Treasury Better Business Case (BBC) process. This process is for agencies that have significant proposals that will have a whole of life cost of more than $25 million.

The BBC process has a number of stages and at this point we are close to completing stage 2 of 4. At the completion of stage 4 we expect that we will begin to implement the solution for the National Electronic Health Record, timing for the duration of the implementation phase is yet to be determined. With our current timeline, we expect this to begin no earlier than late 2018 pending approval from Cabinet and successfully delivering the business case process and large scale procurements required.

With these timings in mind, we recognise that there is a requirement to hold the occupation for an individual and to be able to undertake reporting and processes related to the occupation should potentially adverse health and/or medications be identified. At this stage we cannot commit that the functionality that has been suggested will be implemented and will not be in a position to do so until the Business Case process is completed. However, while we cannot yet confirm the details of this type of functionality, we can and will take this into account during our deliberations and include in our business case documentation the advantages of having this type of functionality tied into the Electronic Health Record once established.

Safety Recommendation 009/17
Issued To CAA on 28 Jun 17
A safety issue identified during the inquiry was the widespread practice of allowing passengers to leave and return to helicopters parked on snow while the rotors are turning. Frequently the pilot will also disembark to guide the passengers while they move under the main rotor disc. There is a serious risk to people on the ground if a helicopter has settled into fresh snow or it breaks through an apparently hard surface crust. Should this happen the clearance between the rotor disc and people walking beneath could reduce sufficiently for someone to be struck by the rotor blades.

On 25 May 2017 the Commission recommended that the Director of Civil Aviation ensure that helicopter operators who conduct snow landings address in their safety management systems the hazard of passenger disembarkation and embarkation during those landings while the rotors are turning.
Implementation Status: Open
Reply: In accordance with the provisions of Civil Aviation Rules Part 119: Air Operator - Certification, helicopter operators have until 1 February 2021 to introduce a Safety Management System. Given that timeline, the Director accepts the recommendation and will ensure that when operators' Safety Management Systems are certificated all significantr aviation risks are identified and managed.

Safety Recommendation 017/17
Issued To KiwiRail on 26 Jun 17
The approval process authorised one person to carry out the rail protection duties for two separate worksites within a protected work area throughout a 52.5-hour track occupation period without appointing a relief rail protection officer. The rail protection officer had worked relatively long hours during the week leading up to the incident and had had no days completely free of work. His working hours had provided limited opportunity for recovery from any fatigue or sleep loss that may have built up, and particularly sleep loss that he experienced on the first night of the planned work.

On 28 June 2017 the Commission recommended that the Chief Executive of KiwiRail review the company's Fitness for Work Policy to ensure that the workloads of personnel undertaking safety-critical work, including staff not on a roster, are managed effectively and that the risk of their suffering from the effects of fatigue is mitigated.
Implementation Status: Open
Reply: KiwiRail confirms that it accepts the intent of recommendation 017/17 and it will now scope the required compliance requirements and undertake the actions required to allow closure of the recommendation. Starting at the corporate level, this will require the implementation of a business-wide policy that will ensure that management control measures are developed and adopted across the business to ensure that personnel performing safety-critical functions have their workloads managed to ensure they don?t potentially suffer the effects of fatigue, which could contribute towards unsafe actions, behaviours or decisions being made.

Safety Recommendation 018/17
Issued To Skydive Taupo on 26 Jun 17
Skydive Taupo did not equip its parachute drop pilots with lifejackets and was not required to do so, because its flights from Taupo aerodrome, which used the Taupo aerodrome parachute landing area, remained within gliding distance of land at all times. This accident illustrated how that scenario downplayed the possibility of a pilot having to ditch an aeroplane, or bale out and drift to a water landing.

Therefore the Commission is recommending that the Chief Executive of Skydive Taupo investigate options for equipping their parachute drop pilots with effective flotation devices.
Implementation Status: Open
Reply: I confirm I intend to implement the final recommendation in relation to equipping drop pilots with an effective flotation device. A Quality Action Request has been raised through the Skydive Taupo Ltd Quality Assurance system to address this. Once the suitable flotation equipment has been confirmed and made fit for purpose, pilot training will be introduced and conducted regarding water landing procedures. The recommendation will be fully implemented by the 31st of August 2017.

Safety Recommendation 014/17
Issued To MNZ on 27 Apr 17
On 27 April 2017 the Commission recommended that the Director of Maritime New Zealand work with surveyors and designers of fishing vessels to ensure that fishing vessels have effective means of escape from all compartments for all reasonably foreseeable emergency situations.
Implementation Status: Open
Reply: Maritime New Zealand will work with surveyors and designers of fishing vessels to ensure that fishing vessels have effective means of escape from all compartments for all reasonably foreseeable emergency situations.

Maritime NZ holds regular seminars with surveyors where safety matters are raised and discussed. Guidance for surveyors and designers of fishing vessels will be developed in consultation with surveyors. The guidance will be available on the MNZ website and surveyors will be notified when it is available. We anticipate this will be completed by June 2018. This matter will also be raised at the next surveyor seminar. We will also ensure owners and operators are made aware of the issue.

I will send copies of the safety bulletin and guidance for surveyors to you when the documents have been completed.

Safety Recommendation 001/17
Issued To NZTA on 24 Mar 17
The Commission recommends that the Chief Executive of the NZ Transport Agency ensure that in their safety cases the access provider of, and operators using, the National Rail System consider fire in rail vehicles as a risk to the safety of their operations, and must demonstrate that they have mitigated that risk as far as reasonably practicable
Implementation Status: Open
Reply: The Transport Agency confirms that it will implement this recommendation. As it may involve significant work for some operators, the Transport Agency will need to carry out detailed planning to be able to provide the Commission with a definitive timeline. Likely actions include:
- The Transport Agency notifying affected operators
- Safety case variations being requested and approved (if required)
- Conducting a safety assessment of system changes associated with the recommendation, to test that the safety risk is being managed so far as reasonably practicable.

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