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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 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.

Safety Recommendation 002/17
Issued To NZTA on 24 Feb 17
The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder, ensure that they have identified and assessed the risk of fire in a rail vehicle. The Chief Executive should ensure that they have, as far as reasonably practicable, minimised the risk and have measures in place to deal with the outbreak of, and reactions to, fire events.
Implementation Status: Open
Reply: The Transport Agency confirms it will implement these recommendations. This will occur through our risk based assessment programme. The programme has a 12-18 month cycle to assess all current rail operators, although the Transport Agency will prioritise those that present a greater risk.

The Transport Agency believes that the enduring requirement of fire risk identification and mitigation and assurance is important. We do however note that the priority of rail risks may change over time and it considers that it is essential that the scope and focus of assessments adapts to the current risks and environment identified through the Transport Agency's risk based approach. For that reason it may prove difficult to eventually close these recommendations because of their on-going nature. However, when the Transport Agency has carried out the initial work in respect of all rail operators, we will engage with the Commission to discuss our perspective on how we can continue to gain assurance of the safety outcomes in question.

Safety Recommendation 003/17
Issued To NZTA on 24 Feb 17
The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder operating on the National Rail System, ensure that systems are in place that record in detail the maintenance history of safety-critical rail vehicle parts and that any tests on replacement parts are appropriate to simulate in-service conditions.
Implementation Status: Open
Reply: The Transport Agency confirms it will implement these recommendations. This will occur through our risk based assessment programme. The programme has a 12-18 month cycle to assess all current rail operators, although the Transport Agency will prioritise those that present a greater risk.

The Transport Agency believes that the enduring requirement of fire risk identification and mitigation and assurance is important. We do however note that the priority of rail risks may change over time and it considers that it is essential that the scope and focus of assessments adapts to the current risks and environment identified through the Transport Agency's risk based approach. For that reason it may prove difficult to eventually close these recommendations because of their on-going nature. However, when the Transport Agency has carried out the initial work in respect of all rail operators, we will engage with the Commission to discuss our perspective on how we can continue to gain assurance of the safety outcomes in question.

Safety Recommendation 004/17
Issued To NRSS on 24 Feb 17
The Commission recommends that the National Rail Safety System Executive adopt or develop a New Zealand Fire Standard that incorporates, but is not limited to:
- minimising sources of fire ignition
- restricting fire propagation
- the use of fire-resistant materials
- the provision of appropriate firefighting equipment
- ventilation systems to protect crew and passengers from harmful smoke and gases
- the installation of fixed fire protection systems
- the ability to self-rescue or relocate the train in the event of a fire in a tunnel or similar hazardous location.
Implementation Status: Open
Reply: The NRSS Executive noted that the request to ?adopt or develop? would not be within the scope of the NRSS Executive to undertake, but does recognise that such matters are required to be considered for the operating environment. Therefore the NRSS Executive can propose, through relevant NRSS documentation, the consideration of relevant international standards for the interoperability environment.
These standards would also incorporate, but not be limited to those specific areas as identified by the Commission, due to the systems approaches that will be required to sustain the Commission?s recommendations. The NRSS Executive noted in particular, that rail fire safety is a complex issue and one that requires a system?s approach across all aspects including infrastructure, rolling stock and operations to achieve and sustain safe outcomes.

Safety Recommendation 007/17
Issued To FAA on 23 Feb 17
On 23 February 2017 the Commission recommended to the Administrator of the FAA that he:
- extend the limitations and requirements of FAA AD 95-26-04 that currently apply to the R22, in regard to operating in strong winds and turbulence, to the R44 and R66 models; and
- extend those limitations and requirements so that they apply to all R22, R44 and R66 pilots regardless of their experience levels.
Implementation Status: Open
Reply:

Safety Recommendation 008/17
Issued To CAA on 23 Feb 17
On 23 February 2017 the Commission:
- gave notice to the Director of Civil Aviation that recommendation 007/17 had been made to the Administrator of the FAA, which recommended the FAA extend the limitations and requirements of FAA AD 95-26-04 to the R44 and R66, and to all Robinson pilots regardless of their experience levels
- recommended to the Director of Civil Aviation that until such time as recommendation 007/17 is actioned by the FAA, he extend the limitations and requirements of FAA AD 95-26-04 to R44 and R66 helicopters in New Zealand, and to all pilots of Robinson helicopters in New Zealand regardless of their experience.
Implementation Status: Open
Reply: The Director will consider whether the action sought by the Commission meets the legislative threshold that must be satisfied for the issue of an Airworthiness Directive. In doing this he will take into consideration the fact there have been no 'mast bump'accidents in NZ during the past two years. In addition, at the time of providing this response, the CAA has a team in the US working with the FAA Rotorcraft Directorate and the Robinons Helicopter Company on possible amendments to the Limitations sections of the Pilot Operating Handbooks of the Robinson series aircraft and improvements to safety awareness training. It may be that this work will provide an outcome that will meet the intent of the Commission?s recommendation.

Safety Recommendation 014/15
Issued To KiwiRail on 02 Nov 16
The Commission recommends that the Chief Executive of KiwiRail ensure that where KiwiRail makes significant modifications to vessels, appropriate oversight is in place. Oversight includes keeping comprehensive records to demonstrate that components are safe and reliable and comply with the appropriate standards
Implementation Status: Open
Reply: We have already implemented your recommendation by ensuring that all significant modifications to vessels are now always undertaken under the oversight of KiwiRail's Project Management Office which has its own strong project management disciplines including good records? management and strong governance.

Safety Recommendation 020/16
Issued To Talleys on 29 Sep 16
On 29 September 2016 the Commission recommended that the operator of the Captain M. J. Souza: review its internal auditing procedures to ensure that auditors make realistic assessments based on actual practices observed on board; and seek verification that documented procedures are being followed by the crew and they are appropriate for the task. Audit findings should be recorded together with any safety actions taken as a result of the audit.
Implementation Status: Open
Reply: Since August 2014 we have implemented a programme to improve the Health and Safety culture on this vessel. This started wit an internal review of our Health and Safety Systems (ashore and on board) governing the Capt M J Souza and following that review, we have taken several steps to improve Health and Safety outcomes which include:

1. Heightened oversight of the documented H & S procedures on the vessel at turnarounds by the vessel manager and operations manager including debriefing key staff on the vessel on H & S compliance and addressing any new hazards that may have been identified during the trip;

2. Implementation of a revised assurance process on the vessel and ashore to provide evidence to shore based management that Talley?s H&S protocols in fact being applied on board the vessel;

3. We have provided additional third party H & S training to the officers and crew of the vessel to ensure that they are aware of Talley's health and safety procedures, the hazards associated with their tasks and that they are operating safely;

4. Addressed and improved communication structures between senior management and senior vessel staff;

5. Setting out company expectations regarding H & S aboard the vessel and the consequences of departure from these expectations;

Further, when the vessel returns to NZ after its current Pacific Season in December 2016, we have identified an independent Health and Safety expert who will take a trip on the vessel to audit its compliance and to report to management on the H&S culture on the vessel, their compliance with the Talley's H&S programme and thereafter, if appropriate to put in place an effective change management programme.

Safety Recommendation 018/16
Issued To NZTA on 25 Aug 16
On 25 August 2016 the Commission recommended to the Chief Executive of the NZ Transport Agency that he liaise with KiwiRail and relevant road controlling authorities to assess and confirm which provincial level crossings have significant safety issues that do not align with the NZ Transport Agency's Traffic Control Devices Manual - Part 9 - Level Crossings, then work with the authorities to ensure that safety improvements are prioritised and implemented.
Implementation Status: Open
Reply: The Transport Agency, in its capacity as rail safety regulator, will formally write to the appropriate entities, including KiwiRail and advise them of the recommendation 018/16 and request that they advise the Agency of how they plan to:
1. Review the level crossings in their areas to establish if there are safety issues that need addressing - in alignment with the NZ Transport Agency?s Traffic control devices manual - Part 9 - Level Crossings
2. Ensure safety improvements are prioritised and implemented.
We will ensure the Commission is kept informed of the progress made relating to this recommendation.

Safety Recommendation 019/16
Issued To CAA on 24 Aug 16
On 24 August 2016 the Commission recommended that the Director of Civil Aviation provide a clear statement to relevant sectors of the aviation industry on whether stock clearing is a permitted activity. If the Director decides it is a permitted activity under a particular Civil Aviation Rule part, he should provide clear guidance on the conduct of the activity.
Implementation Status: Open
Reply: In our response to the Commission's draft report, 11 August 2016, we explained there is no CAA rule provision for stock clearing; therefore, the Director cannot provide clear guidance on the conduct of the activity in the context of existing CA Rules.

However, the CAA recognises that an operation to a remote airstrip presents a risk to air transport in that the landing area may have visible hazards, including the presence of stock, which could affect the safety of a landing. Whilst there are no existing provisions in the rules to descend below 500 feet (aside for take-off/landing or a baulked landing/discontinued approach), the Director will agree to pursue a means to enable air transport operators to overfly a remote airstrip below 500 feet for the purposes of ensuring the landing area is visibly free from hazards.

The CAA remains focused on safety management based on risk mitigation. The CAA believes the alternative safety action will address the safety issue raised by the Commission and we will advise when the work has been completed.

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