Train drivers becoming distracted and forgetting the aspect of warning signals their train has recently passed is a known risk to the rail industry. The signal alert device that was installed in train cabs to help drivers remember the aspect of the last signal their train had passed was not used by the driver on this occasion and was not widely used by other drivers because, once activated, the alarm sounded for 6 seconds and could not be cancelled and the sound was easily confused with other in-cab alarms.
Issue date:amend Rule 905, Compulsory Stop Protection, to allow the site protector to give authority to the driver of a rail vehicle to pass the compulsory STOP board and proceed to a location short of the worksite. Where circumstances change, the site protector must be contacted to authorise all subsequent rail vehicle movements within the work area.
Issue date:Review the adequacy of the current protection rules applicable to track workers.
Issue date:On 13 December 2018 the Commission recommended that the Chief Executive of the NZ Transport Agency work with licensed rail access providers and road controlling authorities to ensure that they meet their responsibilities for maintaining sighting distances at public road level crossings.
Issue date:Develop a standard for auto tow systems to meet and require each system to be approved by the Club Safety Officer.
Issue date:Require operators of aerodromes that have taxiways joining a runway at an oblique angle to prescribe the procedures and conditions, including the environmenatal conditions, under which the taxiways may be used to enter the runway.
Issue date:This incident highlighted a number of individual failures in the system for managing aircraft separation within the Auckland Terminal sector, the busiest sector within the New Zealand air traffic control system. Together with the findings of the NOSS, this indicates that a deeper systemic issue within the overall management of the sector may exist.
Issue date:The operating handle of the watertight door protruded into the doorway when it was in its opening position which was why the door could not be opened when the engineer was trapped. The Commission recommends that the manufacturer assess the design and/or installation of the doors such that this safety issue is resolved. The solution should be promulgated through the International Association of Classification Societies (IACS) and any other way it can.
Issue date:Initiate instructions to flight attendants that: are specific for each aircraft type which they operate, enhance the concept of a sterile flight deck during critical phases of a flight, clarify the need for them to be seated as soon as practicable after the signal to do so is given.
Issue date:Explore the practicality of connecting the radio altimeter output into the DFDR.
Issue date:He introduce a mandatory system of two-tier entry into safe ship management where operators are issued with Provisional Safe Ship Management Certificates pending full compliance with the New Zealand Ship Safety Management Code. Provisional Certificates should only be issued for a specified period and for ships where: • the requirements under the present Certificate of Survey system are met or exceeded; and • operating crew hold qualifications required by the relevant manning regulations.
Issue date:In conjunction with the safe ship management company, investigate the forward visibility from the steering position of the Triptych, with special reference to passengers on the foredeck and put in place operating procedures to ensure that the skipper’s visibility it not obstructed while the vessel is underway. Such measures should be included in the safe ship manual.
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