Circulate to all heritage and narrow gauge railway operators the lessons learned from this investigation and require an assessment of risk focused on passenger safety, be undertaken by each operator with the results being submitted to Land Transport Safety Authority for approval.
Issue date:It develops detailed education material for all pilots and air traffic controllers covering the hazard so illicit drug use especially THC*. (*THC is the abbreviated term for 9^ Tetra Hydro Cannabinol, the principal active metanolite of marijuana or hashish.)
Issue date:Ensure that the duly appointed harbourmaster for the Port of Gisborne is employed on terms and conditions which enable him or her to properly fulfil the statutory function of the position at all material times.
Issue date:Investigate fully the cause for the interruption of the transmission from the controller to the pilot of SAV 17R on 124.3 MHz.
Issue date:The practice of issuing Track Warrants prior to their immediate need, be reviewed to minimise the potential for the suppression of the Warrant's details by more recent events affecting the Locomotive Engineer.
Issue date:initiate changes to the Track Warrant computer System to introduce a cross check function in the Clause 3 "to location" field when train controllers are issuing previously prepared track warrants.
Issue date:The operator's system for planned maintenance and repair neither accurately record the history of inspection and repair, nor ensured the proper functioning of the controllable pitch propellers and their control systems, which were critical to the safe operation of the ship. The operator's planned maintenance and repair system should be comprehensively audited to ensure it meets the outcomes required by the ISM Code. (027/10)
Issue date:On 26 March 2025, the Commission recommended that KiwiRail review and improve the maintenance and inspection of safety-critical components of the carriage-coupler system to ensure they remain safe to operate.
Issue date:Improve the effectiveness of ‘see and avoid’ as a way to avoid mid-air collisions through the promotion of the skills required, including the need to actively listen to radio calls.
Issue date:Review the planned criteria for the marking of overhead wires and structures, to give increased priority to large spans, like West Arm.
Issue date:Require all ferry operators offering scheduled ferry services within Auckland enclosed water limits to submit for approval to the council a detailed route operational plan for all scheduled ferry routes, then coordinate between operators to ensure that such passage plans as far as practical avoid ferries meeting on opposing tracks. The approved route operational plans should be required to form part of operators' safe ship management system.
Issue date:withdraw from service and investigate the braking systems of all wagons that exhibit an abnormally high incidence of brake block burn-out.
Issue date: