Inquiries & Recommendations

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fit an appropriate fire detection and suppression system to the diesel engines on the ADL and ADK class passenger cars.

Amend the requirements [arising from recommendation 007/92: review the minimum flight times specified for issue of a CPL-H] accordingly.

Immediately prohibit the issue of conditional track warrants to the locomotive engineers of trains which are awaiting a crew change.

Take steps to improve the effectiveness of Tranz Rail’s track warrant compliance monitoring regime in identifying repeated non-compliances at an early stage, and initiating appropriate follow-up action.

Require the Airways Corporation to ensure that, before new procedures are implemented, they are incorporated in the Manual of Air Traffic Services.

The Commission has determined that there is evidence that the purpose of approved seats and berths and the value of seat belts in helicopters are not understood or are disregarded, and that in some operations there could be a culture of non-compliance with Civil Aviation Rules relating to passenger restraint. The Commission recommends that the Director of Civil Aviation addresses this safety issue.

Research what additional training for pilots should be carried out, with regard to the physical and psychological conditions that lead to errors of judgement and violation of rules and procedures, to better equip them to make sound command decisions, prior to being permitted to engage in air transport operations.

Evaluate all company vessels and where practicable fit fixed fire smothering systems in the engine-rooms.

confirm with Toll Rail, that the underframe equipment on the DMU fleet is currently at an acceptable standard of cleanliness and that the established inspection and maintenance procedures are appropriate to maintain those standards.

Require Airways to enhance the Auckland International Airport AIP arrival and departure information so the words "normal operations" are not selected for use in ATS communications when any non-normal operations are in effect.

It is a safety issue that the Coastguard did not have a process requiring its crews to undertake pre-departure planning when tasked to an incident thus increasing the risk of an accident occurring en-route to the incident area. It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc ensures all Coastguard crews conduct an appropriate pre-departure plan , that includes a risk assessment, and that the plan is reassessed at appropriate times as the rescue scenario unfolds.

That attention by drawn, once again, to the insidious hazard of low strung wires, to any aircraft which has descended to low level in an area with which the pilot is unfamiliar, or where the pilot has not positively confirmed that no wire hazard exists.