Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

introduce check procedures for staff involved with the signalling of trains before authorising a train to continue after it has overrun a signal which reverted to Danger as it approached

The owner and the master on board the Anatoki were not effectively managing the standards of navigation and the drug and alcohol policy at the time of the grounding. The Commission recommends the Director of Maritime New Zealand audits Coastal Bulk Shipping 2007 Limited’s safe ship management system both ashore and on board the Anatoki to ensure that it meets the standards required by the New Zealand safety management system. (017/12)

[the LTSA, MSA and OSH] Liaise as necessary to immediately bring to the attention of the relevant sectors of the New Zealand land and sea transport industry the need to be alert to sub-standard connection of stacks of bases and replace such connections with a system which complies with appropriate standard.

The Commission recommends that the Director of Civil Aviation as a matter of urgency reviews the approvals granted for the FU24-954 aircraft with a view to amending the Flight Manual to allow more accurate determinations of aircraft centre of gravity. This review should also extend to other conversions of Fletcher and Cresco aircraft.

Consideration be given to providing a clip in an illuminated position near the Locomotive Engineer which would enable him to have the Track Warrant clearly visible without affecting his ability to maintain an adequate lookout ahead of the train.

Carry out specific training and educational programmes to make all yard operational staff fully aware of the requirements for loose shunting and institute a system to ensure compliance.

Urgently consult with industry and put in place temporary measures that will enable those operators who are having difficulty complying with the present manning requirements to continue operating, so long as the temporary measures are consistent with safe operation. These measures should be in place until the amendments to Part 31B - Crewing and Watchkeeping - Offshore, Coastal and Restricted (Non-Fishing Vessels) and Part 32 – Qualifications, come into force in 2004.

Conduct a special inspection of Santa Maria II and other vessels owned or operated by the owner to ensure that they fully comply with all relevant Maritime Rules with particular attention to ensure that all fire fighting equipment on board, especially fixed fire suppressant systems, comply with New Zealand regulations.

Consider re-commissioning the actuators in the lateral load guides on the B767 in-hold loading equipment.

Implement procedures to ensure tonnage limitations are not exceeded on shunting services.

It is possible that the Te Onetea Road level crossing is one that has been affected by changes in the allowable dimensions of long, low road vehicles. Unless the profiles of all level crossings are assessed against the current allowable dimensions for long, low vehicles, the potential risk of this type of accident occurring will remain high.

The Commission recommended that the Ministry of Transport undertake research to determine the merits of a regulatory system for the recreational maritime sector, in line with overseas best practice, and how such a system may incorporate licensing, registration and boat design standards to improve the safety of New Zealand’s recreational maritime sector.