Install a fire detection system in the engine room of the "Sweet Georgia" and ensure that the poor electrical installation standards identified in this report are rectified.
Issue date:Consider introducing more frequent inspections of the lateral load guides on the B767 in-hold loading equipment, or other appropriate measures, to ensure that any damage caused to these devices in the course of loading operations is detected and rectified promptly.
Issue date:On 2 August 2016 the Commission recommended that before allowing cruise ships to use Tory Channel in future, the Chief Executive of the Marlborough District Council review its harbour risk assessment for the safe navigation of ships through Tory Channel, and in doing so consider the safe navigation of cruise ships through Tory Channel as a separate risk. The new risk assessment should consider, but not be limited to, the following factors: - the limited number of piloted ships using Tory Channel make it difficult for harbour pilots to maintain currency
Issue date:Introduce the requirement for commercial vessels to be fitted with automatic identification system (AIS) or equivalent when carrying passengers outside of inshore limits.
Issue date:Make it clear to ATS staff that the controller with whom the pilot first makes contact should confirm that the pilot was aware of relevant hazardous weather reports, or the manual of Air Traffic Services should be amended to reflect the current policy in conjunction with a similar amendment to the NZAIP Planning Manual.
Issue date:Use the circumstances of this accident as educational material for single pilot IFR operators and pilots in the management of instrument approaches.
Issue date:Advise all operators of passenger trains of the circumstances of this accident with the recommendation that they: review the adequacy and security of handrails, guard-rails, and gates in areas where passengers may move; ensure that staff who inspect and maintain handrails; guard-rails, and gates are aware of the purpose of and the design intentions for the equipment; and review their passenger management polices in respect of safety briefings, signage, and passenger supervision to reduce the possibility of falls, impacts with trackside objects, or injuries from other causes.
Issue date:No-one in Hawke's Bay Regional Council or the Port Authority and none of the pilots themselves realised that the procedures for outward pilotage were in error. The pilotage areas marked on the navigational charts and contained in nautical publications did not align with the Maritime Rules and the Regional Council’s Navigation Safety Bylaws.
Issue date:Evaluate the information gained from the Taharoa wave rider buoy. If there is significant difference in the sea conditions between the Taharoa and Manukau or if the Taharoa wave rider buoy data is not available to POAL, he shall urgently take steps to place a wave rider buoy or other suitable measuring equipment close to the bar.
Issue date:On 25 October 2017 the Commission recommended to the Director of Civil Aviation that he use the key lessons arising from this report to remind aircraft operators and pilots of the importance of ensuring that aircraft occupants fasten and properly adjust their seatbelts at all times.
Issue date:instruct PA34 Seneca operators to ensure that all the requirements of DCA/PA34/22 have been complied with, including the on-going requirement for a placard on the lower nose landing gear housing.
Issue date:Emphasise to aircraft owners and operators the necessity of determining the location of such antennae and providing suitable masking to prevent any paint being applied to them.
Issue date: