take note of staff perceptions and experiences revealed by interviews carried out during this investigation and put processes in place, including regular personal familiarisation with operating practices, to improve corporate safety culture and its understanding at field level.
Issue date:Renegotiate the pilots' contract with NZALPA to remove the condition which is intended to prevent the company from installing CVRs in their aircraft.
Issue date:Require controllers to desist from issuing clearances by visual separation where only one pilot has sighted the other aircraft, unless that pilot is behind the lateral axis of the other aircraft.
Issue date:Revise the Fog and Poor Visibility section of the Quality Procedures Manual to clearly identify the responsibilities of the skippers under the collision regulations with particular regard to safe speed.
Issue date:Review its medical Standards and Certification (Civil Aviation Rule Par 67) to consider the advisability of urine screening for THC* to be included as a discretionary component of all medical examinations if the medical examiner suspects the applicant of illicit drug use. (*THC is the abbreviated term for 9^ Tetra Hydro Cannabinol, the principal active metanolite of marijuana or hashish.)
Issue date:The modification of ZK-EUF by the engineering company was not in keeping with required engineering practices and the supporting documentation was both incomplete and inaccurate. The Commission recommends the Director takes the necessary action that ensures that high engineering standards are maintained by this and other aircraft maintenance organisations
Issue date:Review controller training and checking standards to ensure flight progress strips continue to compliment the functions of the radar display and provide an adequate means by which to control aircraft should there be a radar failure of some sort.
Issue date:Document, in the appropriate manuals, the airspeeds and aircraft configuration recommended for VFR flight in conditions of reduced visibility.
Issue date:Communication between members of work gangs in noisy environments can be seriously hampered by noise and the ear defenders worn by crew to protect against that noise, often making visual contact the sole method available for communicating. The uptake by the rail industry of technological advances such as radio equipment integrated into safety equipment has been progressed but has been slow.
Issue date:The watertight doors on the Oceanic Discoverer had an unexplained design or maintenance peculiarity where the door would begin to self-close even when in the local-control mode. This peculiarity was observed on one other vessel that the Commission visited. The Commission therefore recommends that the watertight door manufacturer investigate this safety issue, provides a solution, and promulgates that solution through the International Association of Classification Societies (IACS) and any other way it can. (027/11)
Issue date:Review procedures for compliance monitoring of shunting staff to place more emphasis on an increased level of "unannounced" observation of staff during normal duties and less emphasis on "arranged" monitoring by training staff.
Issue date: