Inquiries & Recommendations

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On 26 February 2025, the Commission recommended that the Director of Civil Aviation at the Civil Aviation Authority of New Zealand use the lessons from this report to raise awareness for helicopter pilots of the risks associated with inadvertently entering flight conditions that are conducive to Vortex Ring State.

Reinforce the training and increase the compliance monitoring of RCO's to ensure they are positioned and operate in such a manner that a combination of: "range of vision" normal operating distractions shunting speed maintain an acceptable factor of safety with respect to possible collision.

Prepare medical guidelines for Locomotive Engineers (and other operating staff as appropriate) concerning fitness for duty.

Ensure the New Zealand airworthiness directive schedule specifies applicable airworthiness directives called up in the ex-military type certificates data sheets.

On 25 October 2023, the Commission recommended that Waka Kotahi reviews the operation of long-hood leading locomotives by all rail participants to ensure sufficient risk controls are in place

liase with Lloyds Register of Shipping to review the cargo securing manual to clarify the lashing required when containers are loaded more than one high in the main vehicle deck.

Review the adequacy of similar integrated workplace operating plans for NZRL and other port authorities or other similar operating complexes where the size of operation and/or scope of activities are such that unacceptable operational conflict may exist, and initiate action where necessary to ensure a safe operational and work environment.

Clarifies the responsibilities of the tug masters with respect to tug and towline maintenance, with emphasis on the need for on-going thorough inspections of the towline.

Amend section 2(b) of Special Federal Aviation Regulation No. 73 -Robinson R-22/R-44 Special Training and Experience Requirements to make it clear that dual instruction in the “effects of low-G maneuvers” is limited to discussion only, and to reiterate that deliberate in-flight reduced G conditions are prohibited.

During this incident, 2 successive train control handovers were conducted in a fashion that did not detect the presence of all train movements, and on each occasion the trainee, then the incoming controller, assumed the responsibility for the desk before they had acquired full situational awareness of the status of all movements within their area. The area of train control would benefit from some form of external review of processes to identify if these practices were confined to this one event or symptomatic of a wider systemic issue.

Arrange for the training of staff employed as train crew on passenger trains to include sufficient event management training to ensure they are competent to respond appropriately to foreseeable events which could adversely affect passenger safety.

On 26 February 2025, the Commission recommended to the Director of Civil Aviation at the Civil Aviation Authority of New Zealand that they promote, through the appropriate International Civil Aviation Organization (ICAO) forum, the need for additional information to be included in all rotorcraft flight manuals, to assist pilots in avoiding Vortex Ring State.