Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Liaise with the owner of the Ngawihi Airstrip to improve the wind indicating system at the airstrip.

That copies of all exercise ECG tracing should be submitted to the PMO and not simply a report.

On 14 May 2025, the Commission recommended that the Ministry of Transport and the Civil Aviation Authority of New Zealand, in consultation with stakeholders, work to fully integrate drones into the aviation system and develop appropriate rules and standards, to reflect technology developments and relevant international best practices.

Present this report to the National Pleasure Boat Safety Forum with a view that the Forum determine the feasibility of private boats being registered, marked accordingly and required to meet minimum standards of seaworthiness.

The rules-based system adopted by the rail industry in New Zealand is overly complex and relies heavily on employees’ knowledge of it. The training and assessment programme for ensuring compliance did not in this case result in a safe operation. The lessons about rule complexity learned from the Glenbrook inquiry, and the similarities to the New Zealand railway rules system, suggest that the rule complexity issue might be widespread throughout the New Zealand rail system.

Use a more continuous compliance monitoring regime to ensure that newly-appointed staff are consistently using work practices which do not place them, or others, at unacceptable risk before they are certified for shunting duties.

On 22 February 2024, the Commission recommended that KiwiRail risk assess any regular propelling movements, including assessment of the locomotive cab ergonomic environment, to ensure the risks to both road and rail users are managed.

in conjunction with the Safe Ship Management Company review the 'Southern Winds' Safe Ship Management operations manual to promote best operating practices for the intended use of the boat.

In consultation with the Safe Ship Management provider, amend the emergency fire procedures for each of the groups’ ferries to better reflect the characteristics of each vessel, the use of available equipment on board and the safest possible method of fire fighting in the differing areas on board especially enclosed spaces.

Make full use of all available meteorological information to identify those elements, such as the spread between the ambient air and dew point temperatures, that may cause the flight conditions to become marginal or unsuitable.

That this jet boat fitted with a canopy did not have the path of emergency exit from the passenger compartment clearly marked and explained to the passengers during the safety briefing.

That individuals with risk factors for cardiovascular disease in particular be followed up on a regular basis according to age