Inquiries & Recommendations

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On 25 October 2023, the Commission recommended that KiwiRail undertakes a review of its non-technical skills training to ensure it provides adequate training on how to work together to manage threats.

On 25 September 2024, the Commission recommended that KiwiRail review the trigger settings of its rainfall-monitoring equipment and weather risk matrix to ensure they can identify and respond to moderate or heavy rainfall that occurs within a short time period.

On 25 March 2026, the Commission recommended that the Director of Maritime New Zealand work with New Zealand commercial jet boating stakeholders to review and improve the requirements prescribed to commercial jet boat operators to ensure that safety measures on board are adequate to protect passengers from injury.

On 24 March 2026, the Commission recommended that the chief executive of KiwiRail take immediate steps to improve the safety culture of their staff at Port Otago rail yard to increase compliance with KiwiRail’s Operating Rules and Procedures and reduce at-risk behaviours.

On 24 March 2026, the Commission recommended that the chief executive of KiwiRail take steps to ensure that when the emergency stop button is applied on its remote-control packs, there is an emergency alert automatically sent through to train control.

On 25 February 2026, the Commission recommended that the Ministry of Transport, when monitoring NZTA’s regulatory performance, ensures that NZTA is fulfilling its safety oversight role effectively, including NZTA’s response to the increase in KiwiRail’s signal passed at danger incidents.

On 25 February 2026, the Commission recommended that NZTA, when monitoring KiwiRail’s performance against their safety objectives, including monitoring of key performance indicators, ensures that the safety risk of KiwiRail’s high signal passed at danger ratio is being well managed and controlled, including in non-metro areas.

On 25 February 2026, the Commission recommended that KiwiRail utilise engineering safety controls in areas of its rail network where none currently exist, to mitigate the risk of human error by locomotive engineers and reduce signal passed at danger incidents.

On 24 March 2026, the Commission recommended that the chief executive of KiwiRail review and improve KiwiRail’s training on the air-brake operation system and include the associated risks of not following the required procedures.

On 25 March 2026, the Commission recommended that Maritime New Zealand actively promulgate IMO MSC.1/Circ.1533, ‘Revised guidelines on evacuation analysis for new and existing passenger ships’ and issue associated guidelines to all passenger ferry operators, and strongly encourage them to conduct and regularly review Escape, Evacuation and Rescue Analyses (EERAs) consistent with these guidelines, regardless of vessel construction date.

On 25 March 2026, the Commission recommended Maritime New Zealand work with the Ministry of Transport and collaborate with other stakeholders to continue to develop, and then implement, a wider maritime incident response strategy assessment to identify areas most susceptible to very serious marine casualties, particularly mass fatality events, and strengthen the salvage and rescue capability in those areas.

On 25 March 2026, the Commission recommended that Maritime New Zealand prioritise the review of its Maritime Incident Readiness and Response Strategy (MIRRS) to ensure it is consistent with international conventions, resolutions and guidance, and incorporates the following: • an updated national maritime risk assessment • specific Cook Strait response plans • an across-stakeholder exercise programme.