Inquiries & Recommendations

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Require better information to be displayed by aircraft operators to aid passengers and potential rescuers to locate onboard first aid kits and fire extinguishers.

Expedite the process of making rules for the carriage and use of TCAS by appropriate aircraft.

He require an examination of the key personnel of airline operators on their knowledge of their regulatory responsibilities and of any special hazards associated with their operation as part of the Quality Audit of Air Transport Operators.

The Commission recommends that the Secretary for Transport review and revise Civil Aviation Rule Parts 105, 115 and 149 for parachuting operations, in conjunction with the Part 149 organisations’ operating procedures and standards, to reduce the potentially adverse consequences of an unintended water landing.

Driver distraction has the potential to contribute to or cause serious accidents and incidents. In this case the driver of the passenger train was distracted by engaging in a non-operational conversation with the train manager, and failed to stop his train at a red signal. On 23 October 2013, the Commission recommended that the Chief Executive of KiwiRail takes the necessary action to reinforce to all staff the existing rule forbidding non-operational conversation with train drivers, and use some means of monitoring compliance with the rule.

Ensure that the" Esprit de Mer" meets the requirements of Maritime Rules Part 40A (Design, Construction and Equipment Passenger Ships which are not SOLAS Ships).

The responsibility for the safety and security of a vessel moored alongside a harbour wharf lies with both the vessel and the port operator. Notwithstanding that joint responsibility it remains an important function of a port to ensure that the wharf structure and mooring system is adequate for any vessel that intends to use it. Section 7 of this report draws attention to the work that PrimePort Timaru is currently undertaking, and the work it is planning to undertake, to improve the condition and reliability of its wharves, associated mooring systems and mooring procedures.

Conduct a cost benefit analysis into the requirement that applicants renewing their Local Launch Operator's certificate, who have not had practical electronic navigation aid training, should attend such a course before a new certificate is issued. [This SR was also applicable to investigation 04-204 restricted limit passenger vessel "Freedom III", grounding, Lake Manapouri, 24 February 2004]

Ensures that all safe ship management providers meet or exceed the same minimum standards.

Formally structure compliance monitoring for newly-appointed staff to include input from experienced shunting staff where appropriate.

Review the supervision of inexperienced controllers with a view to preventing the development of undesirable habits and unsatisfactory techniques.

He emphasise to pilots on low level cross country exercises a need to consider, during pre-flight briefings, the action to be taken in relation to unattended aerodromes close to the planned track in the event of a diversion due to weather.