On 27 March 2024 the Commission recommended that KiwiRail review and improve the training given to track workers, to include identification of the risks associated with: 1. operating a HRV unsupervised when travelling to worksites 2. a HRV cab being a safety-critical area, to enable them to operate a HRV safely
Issue date:Promote the benefits of bridge resource management throughout the navigating officers in the fleet.
Issue date:On 23 August 2017, the Commission recommended that Maritime New Zealand issue guidance and advice to operators and surveyors about the need to take a risk-based approach when determining the level of surveyor oversight required for changes to critical systems, regardless of whether or not the changes are considered major modifications.
Issue date:Do not use the locomotive and carriage consist on days when there is a build-up of wet leaf litter on the rails, but instead use the articulated train which has traction on all wheels.
Issue date:Improve the training programme for tug masters. It addition to the material the programme already contains, it should include: · a more comprehensive training manual · more prescriptive descriptions of the tasks that a tug master must be able to accomplish competently, including emergency and non standard situations · how that competence shall be assessed · information on the handling characteristics of each of the Port Company tugs · general information regarding the safe operation of a tug · an in-depth description of risks that may be encountered during a towage operation.
Issue date:In conjunction with the engine control manufacturer, ensure that each of the company’s vessels is configured for optimum operation by checking their engine control systems.
Issue date:undertake a comprehensive zero-based revision of the TWC Regulations (and their associated practices) to ensure that adequate defences are in place to combat foreseeable risks arising out of human error.
Issue date:ensure inspection requirements included in rail service operation safety systems clearly define: • the type of inspections required • the frequency of each inspection • the persons who can carry out each inspection.
Issue date:Liaise with Transit New Zealand to urgently review the use of Vickerman Street level crossing and take such steps as are necessary to prohibit the use of the level crossing by vehicles exceeding 9m in length.
Issue date:Install an emergency sanding system to provide an alternative method of enhancing the wheel/rail adhesion should the normal sanding system fail to work effectively.
Issue date:Paraparaumu and Feilding mid-air collisions have shown that despite pilots making appropriate radio transmissions, they have failed to actively listen and respond appropriately to the transmissions of others and take action to avoid a collision. The Commission also notes that limitations with the concept of see-and-avoid probably contributed to the Paraparaumu and Fielding mid-air collisions as well as the near miss above New Plymouth.
Issue date:In conjunction with the safe ship management company include in the safe ship management manuals throughout the fleet a prepared safety briefing to be made immediately before or immediately after sailing on all company vessels to comply with the requirements of Maritime Rules Part 23 section 27
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