This page displays a list of safety recommendations that relate to the marine mode. You can use the filter tool to refine the results and to search for keywords within the text of each recommendation.
Urgent recommendations released publicly in advance of a final report are available here until release of a final report at which time they are incorporated into the database.
Urgent recommendations - Marine inquiry MO-2016-202 Cruise ship Azamara Quest, contact with Wheki Rock, Tory Channel, 27 January 2016, published 29 August 2016. Recommendations. Media Release.
Recommendations database (completed inquiries)
on 26 Feb 15
The wire pennants parted under tensile overload because they had all been significantly weakened by severe corrosion. Corrosion had gone undetected inside a plastic sheathing that the manufacturer of the lifting sling had placed around the wire pennants.
The presence of the plastic sheathing encasing the wire rope meant that neither the crew nor the various surveyors tasked with inspecting the launching system could inspect and maintain the wire rope as required by SOLAS.
Encasing steel wire in plastic sheathing when it is to be used in the marine environment has significant implications for maritime safety, especially when the wire must be regularly inspected and maintained in order to remain fit for purpose.
On 26 February 2015 the Commission recommended that the Director of Maritime New Zealand, through the port and flag state control programme, verify that wires that require regular inspection and maintenance by a ship?s crew and surveyors are readily accessible and easily maintained as required by Chapter VI of the International Life-Saving Appliance Code.
This recommendation will be incorporated into our PSC mentoring and oversight program. We anticipate this will be integrated into our standard PSC inspections by the end of 2015.
on 19 Nov 14
On board the Rena, the master and crew were not following the navigation and watchkeeping standards and procedures set down in the Rena's safety management system for at least the six coastal voyages leading up to the grounding.
With respect to port state control records, other vessels managed by CIEL also had a higher than average rate of deficiencies than the average for the Asia-Pacific region.
The Commission recommends that CIEL evaluate the effectiveness of its safety management system to ensure that the issues identified with that system as applied on board the Rena do not affect other vessels within its fleet.
1. We understand the first two paragraphs of recommendation 010/14 are given by way of introduction or summary of the conclusions in the report. However, you will also appreciate from our previous submissions, we do not agree with these two paragraphs.
2. The first two paragraphs are statements of facts and opinions and are not recommendations. It is not possible to implement anything asserted in the first two paragraphs as has been suggested.
3. CIEL strongly objects to the content and utility of these two paragraphs in the recommendation for the reasons [given].
. . .
11. With regard to the actual recommendation in the third paragraph CIEL had implemented such a review. This included an internal review of the safety management system and the performance of vessel audits, including navigational audits.
on 25 Sep 14
It is probable that if an aid to navigation of some type had been installed on Astrolabe Reef, the Rena grounding would have been prevented. However, there are many such isolated dangers to navigation around the coast of New Zealand. Installing and maintaining physical navigational aids on remote hazards is costly. Virtual aids to navigation are potentially a cost-effective means of marking such isolated dangers. However, these are still being trialled by the International Association of Marine Aids to Navigation and Lighthouse Authorities and no performance criteria have yet been set regarding their accuracy and intended use. The Commission noted during its inquiry that although the technology is relatively new and there is no regulatory framework in place, some port authorities are already beginning to use virtual aids to navigation. There is a potential safety issue around the use of aids to navigation that have not been fully tested.
The Commission recommends that the Director of Maritime New Zealand consider the use of virtual aids to navigation and monitor progress through the International Air Transport Association (IATA) of the development of performance criteria for them, but meanwhile work with regional councils and port companies to control the use of virtual aids to navigation until they have been fully assessed and appropriate performance criteria set by IATA and Maritime New Zealand.
The Director of Maritime New Zealand accepts this recommendation (noting that the references to IATA are erroneous and should be a reference to IALA) and notes that in its Statement of Intent 2014-2020 Maritime New Zealand has included a Review of Costal Navigation Safety as a key strategic review of the safety regulatory system. The Director of Maritime New Zealand initiated this review in August 2014 and the review will consider the use of navigation aids (including virtual aids) as part of its inquiry. The Terms of Reference for the review are attached and include timelines for key deliverables.
In addition The Director of Maritime New Zealand established (in 2012) a joint MNZ/Regional Council CEs' group to facilitate cross agency engagement and promotion of navigation safety matters. A significant initiative, led by Maritime New Zealand, in the first year of the establishment of the group has been the conduct of an environmental scan of the New Zealand Port and Harbour Marine Safety Code. The findings of that scan will inform the Coastal Navigation Safety Review and the cross-agency co-ordinated responses to the findings are expected to address the recommendations of the Commission.
on 16 Dec 13
Most of the Fullers vessels operate in enclosed or inshore limits, and in areas frequently plied by other ferries and recreational vessels. In the past 10 years there have been a number of incidents and accidents involving passenger ferries in the Auckland area, and on almost every occasion the passengers have not needed to enter life-rafts. Instead they have been transferred to other vessels in the vicinity.
Although passenger transfer is the more likely method for abandoning ship in the congested Hauraki Gulf, the crews do not practise transferring passengers from one vessel to another, nor do they practise bringing one vessel alongside another. The vessels in Fullers' fleet have subtly different heights of rubbing strips, and access and egress points. There would be merit in introducing this into the training schedule, and also merit in considering subtle design changes to better facilitate ship-to-ship passenger transfers.
On 16 December 2013 the Commission recommended to the Chief Executive of Auckland Council that he co-ordinates the ferry companies that operate large passenger ferries on the major Hauraki Gulf routes to adopt ferry design features and training programmes aimed at minimising the risk of a ship-to-ship transfer of passengers when the need arises to abandon a passenger ferry.
In response to this recommendation, Auckland Council agrees to coordinate the ferry companies that operate large passenger ferries on the major Hauraki Gulf routes to adopt ferry design features and training programmes aimed at minimising the risk of a ship to ship transfer of passengers when the need arises to abandon a passenger ferry.
Whilst the Council will work with the ferry operators in this regard, the Council has limited regulatory power to require ferry owners to comply. Maritime New Zealand is the regulatory body who have the necessary power to compel commercial operators to adopt the required design features. Maritime New Zealand has existing Maritime Rules which prescribe the regulations concerning the construction of vessels and the training of crew members.
The large passenger ferries are of varying ages and designs and it may not be economically viable to redesign some members of the existing fleet; however thought regarding passenger transfer should be considered during the design of future new builds.
Auckland Council will undertake to implement the recommendation so far as it is able to do so by 30 June 2014.
on 11 Oct 13
The post-mortem toxicology results for the pilot in the Carterton hot air balloon showed that he had a positive result for tetrahydrocannabinol (a constituent of cannabis). It was likely that this was due to 2 factors: first, the pilot smoking cannabis shortly before the accident flight; and, second, residual tetrahydrocannabinol, from ingesting cannabis over a longer term, redistributing in the pilot?s blood after his death.
The Commission found that the accident was caused by errors of judgement by the pilot. It also found that it could not exclude the possibility that the pilot's performance had been impaired as a result of ingesting cannabis.
This is not the first time that the Commission has inquired into occurrences where persons operating aircraft, vessels or rail vehicles, or where persons performing functions directly relevant to the operation of these, have tested positive for performance-impairing substances such as illicit drugs and alcohol. The Commission is increasingly seeing more occurrences where the use of performance-impairing substances is a feature.
Unless this safety issue is properly addressed, further occurrences where the use of performance-impairing substances is a contributing factor will occur. Legislative or regulatory reform in this area is necessary.
The Commission, therefore, recommends that the Secretary for Transport complete, as a matter of priority, all necessary work that will support the introduction of appropriate legislation or rules that will:
- prescribe allowable maximum levels for alcohol
- prohibit persons from operating an aircraft, vessel or rail vehicle if they are impaired by drugs
- require operators to implement drug and alcohol detection and deterrence regimes, including random testing
- prescribe post-occurrence testing requirements for drugs and alcohol.
This legislation or these rules should apply:
- across the aviation, maritime and rail transport modes
- to persons operating an aircraft or a marine craft for recreational purposes.
Below is the Ministry's response to the final recommendation, noting at this date that I have not seen the final report.
I wish to note that the determination of the need for legislation or rules is a matter for the Minister of Transport, rather than the Secretary for Transport. The Ministry's response to the recommendation is prepared with this in mind.
I also note that the inquiry's findings conclude that the accident was caused by errors of judgement by the pilot, but include the possibility that the pilot may not have been impaired. Before I respond to the recommendation I would like to take this opportunity to comment on relevant work in the transport sector.
Drug and alcohol impairment in the aviation, maritime and rail sectors
Alcohol and drug impairment in the transport sector is an issue that the Ministry takes very seriously. Impairment in driving is one of the largest causes of serious road crashes in New Zealand, contributing to about a third of all road deaths every year.
The impact of drug and alcohol impairment on the aviation, rail and maritime sectors has been an area of focus for the Ministry. Following the review of safety practices within the adventure and outdoors commercial sectors conducted by the previous Department of Labour, in August 2012 the Government agreed to amendments to aviation and maritime rules to improve safety in these sectors. These amendments are now in force and include a requirement for adventure activity operators to include a description of how they will manage the safety risks associated with drug or alcohol impairment in their relevant safety plans (Organisational Management Systems for aviation and Safe Operational Plans for maritime).
To assist maritime operators, Maritime New Zealand has produced safety guidelines for managing risks related to alcohol and other drugs for raft and jet boat operators. The Maritime Transport Amendment Bill 2013, which has had its third reading and will come into force in the next few weeks, will implement the internationally applicable alcohol limit for merchant seafarers established by the 2010 amendments to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1995 (STCW).
The Civil Aviation Authority has worked closely with adventure aviation operators to support the development and implementation of drug and alcohol management policies that include testing. A detailed advisory circular for adventure aviation operators outlines the expectations for drug and alcohol monitoring and management, and what acceptable policies should include.
Many transport operators, particularly those involved in transporting members of the public, already have drug and alcohol management policies in place in the workplace. Operators regard this as good business practice and meeting the duties of employers and employees set out in the Health and Safety in Employment Act 1992. Some operators that are involved in safety sensitive activities, such as Air New Zealand, Qantas, KiwiRail and Maersk Line have also introduced drug and alcohol policies involving testing regimes.
Statistics from the New Zealand Drug Detection Agency show that the number of workplace drug tests carried out in New Zealand increased 31 percent between 2011 and 2012, with an increase in alcohol tests of 32 percent over the same period. These results suggest that employers in safety sensitive areas, including transport, are taking workplace safety very seriously.
Drug testing on the road
The drug driving regime has been in force for just under four years. The Ministry has a project on its work programme to investigate developments in drug screening and testing technologies (and associated issues) that have occurred over this time. This work is due to take place during 2014.
Post accident testing
Aviation, maritime, and rail legislation does not currently provide for transport agencies, the Commission, or Police (except in relation to the STCW alcohol regime for international or large domestic vessels) to conduct toxicological tests following an accident. Only when a fatality occurs can a Coroner test for the presence and level of drugs and alcohol in the deceased as part of the post mortem investigation.
As a result there is a lack of New Zealand data to quantify the extent of alcohol and drug use in the aviation, maritime, and rail sectors, and its links to accidents and incidents. In comparison, the road sector's drug and random alcohol testing regime provides the necessary data to develop an understanding of the links between drug and alcohol use and accidents and incidents.
Compulsory post accident testing would provide valuable data on alcohol and drug use within the aviation, maritime and rail sectors in New Zealand. Aggregated data from the test results would inform future policy options, including the potential introduction of maximum limits and testing requirements, as noted in the Commission's recommendation.
In order to establish whether there is a case for a compulsory post accident drug and alcohol testing regime, the Ministry has commissioned the New Zealand Institute of Economic Research (NZIER) to investigate and report on:
- criteria to determine which accidents (and incidents) should be covered
- who should be tested
- the agency responsible for undertaking the testing
- the testing procedures to be used (with reference to current national and international standards) in order to safeguard the integrity and accuracy of the testing
- an offences and penalties regime for refusing to be tested or interfering with test results or samples
- the agency responsible for the data collection
- the cost of implementing a compulsory regime
- the legislative changes required to give effect to a compulsory regime.
Once we have the NZIER report, we will brief the Minister of Transport on the options. We expect to be able to do this in December 2013. The Minister may then need to take a paper to Cabinet regarding any further work.
Response to recommendation
This brings me to the Ministry response to your recommendation that the Ministry completes the work necessary to support the introduction of legislation or rules that will:
1. Prescribe allowable maximum levels for alcohol;
2. Prohibit persons from operating an aircraft, vessel or rail vehicle if they are impaired by drugs;
3. Require operators to implement drug and alcohol detection and deterrence regimes, including random testing; and
4. Prescribe post occurrence testing requirements for drugs and alcohol.
The completion of the first three parts of the recommendation is dependent on the fourth, prescribing post occurrence testing requirements for drugs and alcohol. As I have discussed earlier in this letter, the Ministry of Transport is already undertaking work, as a matter of priority, to determine the case for a compulsory post accident testing regime.
We will be able to confirm the next steps for post accident testing once the Minister has considered our advice. Of course we will keep the Commission informed of the progress of the post accident testing proposal, as well as any other work that relates to the Commission?s recommendation.
Finally, like the Commission, the Ministry also believes there should be zero tolerance of operator impairment where members of the public are being transported by sea, rail and air. We feel very deeply for the families of those who lost their lives in this accident.
on 22 Mar 13
The number of defects that are causing incidents and accidents in New Zealand pilotage waters is of concern. It is an indication that New Zealand port and harbour authorities cannot totally rely on the International Safety Management system to ensure that vessels transiting New Zealand ports are operated safely and efficiently. Minor technical defects and human performance issues are often lead indicators of deeper systemic safety issues on board a vessel. If the issues of mechanically unreliable vessels and substandard crew resource management on vessels operating into New Zealand ports are to be addressed, this will need to be done at a national level rather than individual ports dealing with the issues as they arise.
The Commission recommends that the Director of Maritime New Zealand consult port and harbour authorities and the New Zealand Maritime Pilots Association to develop a formal system for port and harbour authority employees to report vessel defects and crew performance issues. The purpose of the system should be to make information immediately available to maritime employees who can use the information to improve the safety of pilotage operations at subsequent ports. The purpose of the system should not be to replace the mandatory reporting of accidents and incidents, but instead to disseminate that information in a timely fashion to prevent similar accidents and incidents in the immediate future.
Maritime New Zealand has previously commented on the distribution of incident and accident notifications, and also on the monthly summaries, which are now posted on the Maritime New Zealand public website. TAIC was perhaps envisaging an arrangement whereby a pilot in one port who has a concern about a ship or becomes aware of an incident can immediately pass that information on to pilots and MNZ personnel at the next port of call so that appropriate action can be taken. Martime New Zealand understands that this is what already happens routinely and considers there is no need to formalise it. Maritime New Zealand's previous comment on this recommendations is set out below, and is reiterated in light of the above recommendation:
MNZ has online report system in place - this facilitates the notification of information including vessel defects and crew performance issues. The recent shift to a regional structure and the development of an intelligence and planning team has resulted in a more timely response to any information received. Furthermore, notifications received by MNZ are forwarded to the appropriate harbourmaster for their information as well as a monthly summary of all notifications. It is intended that these monthly summaries will in future be posted on MNZ's website making them more readily availably to Pilots, [this is now the case] Harbourmasters, Port Companies and any oter interested parties. Information sharing may also be supplemented by other available resources such as APCIS and Lloyds.
on 22 Mar 13
Vessels' machinery installations and their control systems are complex, and regardless of how well maintained they are there will always remain the possibility that some part fails for some reason. For a vessel like the Hanjin Bombay that has only one propulsion system, the risk of losing control of the vessel caused by a single-point failure is higher than that for other vessels that have greater levels of redundancy built in to their propulsion and power-management systems. These types of vessel rely heavily on tug services when operating in confined pilotage waters.
Port of Tauranga Limited's Port and Harbour Safety system policy on the level of tug service did not adequately manage the risk of single-point failures leading to the loss of control of a vessel. This is a safety issue that could also be relevant to other New Zealand ports.
The Maritime Transport Act 1994 currently restricts the Director's powers to audit port operators. However, the Commission notes that the Marine Legislation Bill currently before Parliament will introduce a new Part 3A to the Maritime Transport Act, which will provide clear authority for the Director to take action in relation to port operations.
The Commission recommends that, once the Marine Legislation Bill has been enacted and the new Part 3A of the Maritime Transport Act is in force, the Director address this safety issue with all port authorities, including Port of Tauranga Limited, when approving and auditing Port and Harbour Safety Management Systems.
MNZ already does raise such matters with all port and harbourmasters when approving and auditing port and harbour safety management systems (SMS's) under the voluntary New Zealand Port and Harbour Marine Safety Code (the Code). Maritime New Zealand will continue to do this.
The Code places responsibility on individual port companies and councils for preparing risk assessments and reviewing them on a regular basis, and for mitigating any risks identified in accordance with recognised risk management frameworks.
The amendments to the Maritime Transport Act will include provisions for the Minister to make rules prescribing standards for port and harbour safety and for the Director to impose conditions on the use and operation of any commercial port. These are intended to be reserve powers for use where there are significant safety, or environmental, issues.
on 13 Feb 13
Following the accident, the Commission had some difficulty accessing sufficient information about the Easy Rider, a vessel that was still actively in the system. Maritime New Zealand was not able to find the older part of the ship file. Consequently the Commission had to rely on records from other vessels in order to make a reasonable assessment of the Easy Rider's stability.
When the Easy Rider was converted for inshore trawling it was required to undergo a simplified stability assessment, which it did, but the records sourced from the safe ship management company included only partial details of the inclining test and stability calculation that had been carried out. There was no record of the stability advice letter said to have been sent to the owner. Such a letter would normally include recommendations on the loading of the vessel.
Because commercial vessels can frequently change ownership and their owners can switch between safe ship management providers, there is a need for Maritime New Zealand to maintain a central database of all important safety and operation records for the entire life of each vessel in the system.
The Commission recommends the Director of Maritime New Zealand develops and maintains a system for centralising important operating and safety records for every commercial vessel in the New Zealand maritime system, including a policy on the retention and disposal of records that would best ensure records are kept for an appropriate period after a vessel leaves the system.
MNZ currently has a centralised database for records relating to vessels. Since September 2008 this has included records relating to vessel name and type, inspections, audits, deficiencies, and corrective actions for vessels in the SSM system. Ownership is recorded at the time of issue and reissue of SSM certificates. In addition, information about each vessel is held by the Safe Ship Management Company responsible for carrying out functions for that vessel.
It is proposed that the current SSM framework will be replaced with the new Maritime Operator Safety System (MOSS). Going forward, this will mean that all key vessel information is held and managed by MNZ. The implementation work for MOSS includes consideration and assessment of how best to provide for the transition and management of information currently held by SSM companies.
on 13 Feb 13
The Commission recommends that the Director of Maritime New Zealand clarifies with industry the legal requirements around dual purpose use of vessels and the use of commercial vessels as pleasure craft, and ensures that safe ship management documents refer to the full requirements an owner must comply with before the vessel is used for another purpose.
The current legal position under the Maritime Transport Act is that a ship is operated commercially is a commercial ship at all times and therefore required to comply with the applicable provisions of the Maritime Transport Act and the Maritime Rules for commercial ships.
In the case of Easy Rider, the vessel was normally used or intended to be normally used as a fishing ship and was in fact embarking on a commercial fishing voyage when the accident occurred. It was therefore a commercial ship at the time of the accident.
MNZ is currently developing a new Maritime Operator Safety System (MOSS) which will include clarity over the application of the rule to the non-commerical use of a commercial ship.
on 13 Feb 13
A number of the passengers and crew on the Easy Rider had a large physique. There were only 3 adult and one child lifejackets on board to share among 9 passengers and crew. The 3 adult lifejackets were not large enough to be securely fitted to those passengers and crew whom had a large physique. The Maritime Rules make provision for the carriage of children?s lifejackets but are silent on the need for larger lifejackets to cater for people whom have a large physique. This is a safety issue.
Larger oversize approved life jackets are available in New Zealand, and at least one manufacturer will custom make a life jacket to suit.
Maritime Rules require that an approved life jacket be carried for every person on board every recreational and commercial vessel. While an approved life jacket is marked as complying with the appropriate standard, other life jackets are freely available for purchase that are not approved to the appropriate standard, yet they are often labelled as being approved to some other standard that is not accepted in New Zealand. An unwary purchaser, particularly a recreational boating person, could be misled into thinking they were purchasing a life jacket approved to New Zealand standards. This is another safety issue.
The Commission recommends that the Director of Maritime New Zealand addresses these 2 safety issues in any educational campaigns by making it clear that not all life jackets that can be purchased in New Zealand are approved and meet the requirements of New Zealand Maritime Rules, and that persons who have a large physique should purchase or be provided with a life jacket that is appropriate for their physique.
The Commission has identified two safety issues, namely a potential lack of awareness by the public of the importance of ensuring that life jackets are an appropriate size for the intended person (including those of larger physique); and the risk that a person wishing to purchase a lifejacket may be misled into believing that the lifejacket is approved when this is not the case.
Maritime Rules (Part 91 definition of PFD) provide that a personal flotation device (PFD), which includes a lifejacket, carried and used on board a recreational craft must be certified by a recognised authority as meeting NZ standard NZS 5823 series or a national or international standard that the Director is satisfied substantially complies with these standards.
The Director has made such determinations in respect of a number of such national and international standards. This includes Australian, US, ISO and EN standards. The Directors's determination in respect of these standards is available on the MNZ website, including advice on choosing the appropriate PFD.
MNZ also actively promotes and supports the correct use, size and fitting of life jackets at education seminars, boat shows, and through boating education programmes. MNZ also conducts ongoing campaigns in all forms of media (including the MNZ website) to emphasise the variety of valuable information on choosing the correct life jacket for all boating activities. These messages will continue to be promoted.