Inquiries & Recommendations

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Advise all member Classification Societies of this incident in order that where synchronous [lifeboat] release equipment of the same type is fitted on ships classed by them, their surveyors and all relevant ship operators are made aware of the potential for improper engagement of the equipment.

Ensure that managers and users of aerodromes, in particular for unattended aerodromes, understand and fulfil their responsibilities for ensuring safe operations. This includes: a. Facilitating a coordinated approach with WorkSafe New Zealand, LGNZ and NZ Airports Association, among others, b. Providing training and support to aerodrome operational and management personnel, and c. Identifying and encouraging aerodrome user group’s contributions towards aerodrome safety.

Require Airways to ensure that ATIS broadcasts at all applicable airports, regardless of the means of format and transmission of ATIS, have clear word and sentence structures, are unambiguous, never imply that things are normal when they are not, contain no permanent information and conform as closely as possible to ICAO recommended standards.

Rail Standards for New Trains The National Rail System Standards (6) (Engineering and Interoperability) is the only standard within the National Rail System set that defines braking performance. However, it does not address the performance in low adhesion conditions of modern metropolitan passenger trains that are fitted with computer controlled brake and wheel slide protection systems. The current National Rail System Standard (6) does not require any more from a braking system than for a train to be able to stop within a specified distance in dry conditions.

Require companies engaged in aerial work activities to demonstrate their capability in a different sample of their specialist tasks during consecutive audit inspections.

Reviews the LTS101 engine periodic inspection requirements regarding the GP turbine rotor shroud sealing rings to establish if there is a need for these sealing rings to be replaced or measured as part of the scheduled maintenance.

as part of the current review of Maritime Rule Part 90 resolve any ambiguities that may exist between the regulatory and port specific requirements for the issuance and continued currency of pilotage exemption certificates to ensure a standardised application.

Investigate system deficiencies disclosed by air miss incidents having an element of pilot error, with a view to devising systems that are error tolerant.

Review the requirements for the restraint of first aid kits to ensure they will be securely held but still accessible in a survivable accident.

Institute a requirement in the Certificate of Airworthiness inspection of refurbished aircraft that all flight instruments shall have been overhauled or are within their approved "shelf" life if the aircraft has not been operated for a significant period before the refurbishing was completed.

Until more effective protection for the public is provided at the Heretaunga Street pedestrian level crossing area in Hastings they restrict the speed of trains in that area to 40 km/h.

Conduct a cost/benefit analysis of the establishment of an automated monitoring system of the beacon lights in selected critical areas, such as major bends in the channel, of Otago Harbour, and if feasible establish a monitoring system.