Confirm the ability of existing equipment, operators and procedures to detect all cracks over 2 mm deep in the position on the axle where this failure originated, using prepared test pieces as necessary to ensure this can be achieved consistently.
Issue date:Inform the safe ship management company of matters potentially affecting the validity of the safe ship management certificate
Issue date:Review Ansett's practice of setting MDA once established on the approach, with a view to implementing a procedure which will not set the MDA before it is safe to descend to that altitude.
Issue date:Ensure that where fitted to HRVs, seat belts must be worn by the driver and all passengers when driving on track, except in situations where movements are at slow speed and it is necessary to frequently stop and get in and out of the vehicle.
Issue date:The stop block installed at Melling was a solid concrete block with a limited ability to absorb impact forces. It was physically shifted in the first collision, and even further in the second. The second impact also split the concrete block near ground level and allowed it to rotate backward under the train. The train rode up and over the stop block as a consequence, sustaining substantial damage.
Issue date:Require that the Airways Corporation put in place plans for the mandatory replacement of controllers after an accident, or alternatively to close aerodromes or declare them uncontrolled after an accident for which the controller was providing air traffic service, until such time as the controller can be replaced.
Issue date:On 27 May 2021 the Commission recommended that the Director of Civil Aviation publish an educational article raising awareness of the importance of pilot type training being sufficiently comprehensive to mitigate any risks presented by particular helicopter characteristics
Issue date:That no further permission be granted for operations from the Rotomahana Block Airstrip, until the thistles have been removed.
Issue date:On 22 February 2024, the Commission recommended that KiwiRail ensure its Permit to Enter system enables safety-critical work at level crossings to occur in a timely manner and supports the maintenance of level crossings by road controlling authorities.
Issue date:The cylinder failed at below its normal working pressure because severe external corrosion had reduced the wall thickness from 4.81 mm to 1.45 mm (about 30% of its original thickness). The failed nitrogen cylinder and several other pressure cylinders within the stored energy system were not fit for purpose and should not have been in service. There is an urgent need for consistent and proper standards to be developed at a global level for maintaining, inspecting, testing and, where necessary, replacing high-pressure cylinders associated with stored energy systems on board ships.
Issue date:Maritime New Zealand receives some information via its general enquiries contact point and also via its maritime officers’ engagement with the community. However, there would be some added benefit if there were a similar process to that operated by the Civil Aviation Authority for people to report safety and security concerns. On 23 May 2018 the Commission recommended that the Director of Maritime New Zealand develop, implement and advertise a process where members of the public and the maritime community can submit reports on maritime-safety-related concerns.
Issue date:Review training and local procedures to encourage controllers to issue reporting instructions for aircraft that may pose a conflict as they pass either overhead or through local terminal areas.
Issue date: