Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

develop a system for recording and tracking both new and reconditioned key components used on bogies.

Review the terminology used by approach controllers, in RTF with pilots, when they wish to restrict an aircraft's descent on the DME arc to an altitude greater than the minimum depicted on the applicable VOR/DME chart.

Continue to counsel controllers to apply caution and conservative judgement to the specific situation of an arriving and departing aircraft, especially where the arriving aircraft is of higher performance.

Ensure that crewing levels on all company ships are sufficient to enable the ship to be operated safely in all circumstances. Consideration should be given to effective management of on- and off-duty staff.

Require all commercial jet boat operators to have a system for recording and tracking in-use and spare critical components that enables the history of any critical component to be monitored and traced.

Address with the commercial jet boat industry that in spite of the requirements under Maritime Rules Part 80 and other safety initiatives taken by Maritime New Zealand that the issue of delivering meaningful pre-trip safety briefings to passengers, particularly where understanding of the English language is an issue, still remains.

Introduce a documented system of regular peer reviews to ensure the standard of tug handling remains consistent.

Liaise with Coromandel Ferry Services and review the Safety Management Policy Manual for the Te Waka o Kapanga critically and ensure it contains the relevant operational and safety instruction necessary to comply with the New Zealand Ship Safety Management Code.

liaise with Auckland International Airport Limited to change the characteristics of the airport light to a special mark under the International Association of Lighthouse Authorities system of buoyage and beaconage.

ensure that company pilots do not attempt tasks of aircraft maintenance that are beyond the scope of approved pilot maintenance.

On 30 April 2025, the Commission recommended that Yugen Kaisha Chokyu take steps to ensure the effectiveness of its safety management practices with respect to voyage planning and navigation, and take steps to ensure the safe navigation of vessels in its fleet.

Take steps to identify and correct the repetitive non-compliance with Tranz Rail's rules and procedures for safe operation identified during the investigation of this accident.