Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Require Pesbo S.A. to re-design its future synchronous lifeboat release equipment so that it fully complies with the provisions of the LSA Code, and is able to be engaged and checked before the lifeboat is attached to the davit falls.

Ensure that all of the requirements specified by the manufacturer for LTS101 engine maintenance, including the performance trend monitoring procedures, are being carried out.

Embarks on a programme for bridge resource management training for ships officers in their employ.

A culture of poor adherence to safety standards existed on board the Pantas No.1, which possibly extends up through the operator and owner given the design deficiencies for fencing off openings, and the examples of unsafe behaviour exhibited by more than one member of the crew, indicating that this operator might require close regulatory supervision.

Advise that the fire extinguishers which are provided are available to any person in an emergency.

Widen the application of procedures currently in place for radio communications between LEs and gangers working with track maintenance machines under conditional stop board protection conditions to also include track gangs when working under the same conditions.

Ensure that all crews serving on the company’s ferries are aware that, when investigating a suspected or indicated fire within an enclosed space, opening the access may rapidly exacerbate the fire endangering the crew, passengers and the vessel. The procedure in the operations manual should include a caution and a reminder that where a fixed fire fighting system is installed for the engine spaces, its use should be considered as a possible safer alternative to opening the space, especially in vessels with twin-engine spaces.

Prepare and use a comprehensive pilotage passage plan. The plan should be readily understandable and have sufficient detail to inform visiting ship’s masters of procedures and operating criteria, in order that they are able to safety navigate the port. Such a plan should be given to and explained to masters before commencing any transit.

Review the desirability of requiring the LEs of passenger trains to assess stopping requirements at stations, on a location by location basis, to ensure that there is no potential conflict with safe train operation, and take appropriate steps where such conflict exists.

The fire on board the Kokopo Chief was caused by radiated heat from an incandescent reflector lamp fitted in a cargo light igniting the timber cargo. While it is widely known that incandescent reflector lamps produce heat, the findings of this investigation offer valuable information to ship designers, owners and operators to consider when selecting the means of lighting in cargo holds and other parts of their ships. There are equivalent lighting options, such as LED lamps, that do not produce the same high temperatures.

Give priority to completing workplace operating plans for both NZRL and the Port of Wellington Ltd covering the operational restraints necessary to ensure controlled integrated operation of both companies on Port of Wellington Ltd property, and that such plans are reviewed, updated and compliance checked to continually maintain a safe operational and work environment.

On 15 May 2024, the Commission recommended that the Director of Civil Aviation revise the rule, notes and guidance provided for CAR Part 12: Accidents, Incidents, and Statistics to make it clear that a door opening in flight is a safety issue and to take steps to address door-opening-in-flight occurrences that are not being promptly reported to the CAA.