Inquiries & Recommendations

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After the engine controls, and the engines and propellers are set for optimum performance, should the engines on any of the company’s vessels continue to be susceptible to stalling, determine the course of action that might best prevent further incidences of stalling.

The formation team leader consider including in the briefing prior to formation flying a discussion on the action to take if a pilot, particularly the person flying in the number 4 position, became disoriented.

Initiate a training regime for the crew of the 'Southern Winds' to include, but not be limited to, electronic navigation aids and blind pilotage.

The Commission has determined that some helicopter operations are offered in mountainous terrain by pilots who have insufficient knowledge, experience or currency for those operations. Ensuring that their pilots have adequate role training and supervision can be problematic for smaller scale operators. The Commission recommends that the Director of Civil Aviation addresses this safety issue.

Require Pesbo S.A. to provide a modification for existing synchronous lifeboat release equipment to address the deficiencies identified in this report.

On 25 September 2024, the Commission recommended that KiwiRail implement risk controls with respect to signal 308 to ensure that the hazards that have been identified are adequately mitigated.

On 24 April 2024 the Commission recommended that KiwiRail satisfy itself that all waterways within the rail corridor, including those owned by third parties, have effective and up-to-date maintenance programmes to ensure that the waterways can function as designed.

Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all rail operators includes a policy for managing the risks associated with substance induced performance impairment. Such a policy should: · be focused on education · include all levels of staff and be collaborative between them · include major contractors working for the licence holder

On 27 September 2023, the Commission recommended that KiwiRail work with road controlling authorities to develop processes for notification, risk assessment and traffic management measures for unplanned level-crossing disconnections.

Introduce changes to the existing staff training and promotion process, to ensure that prospective guards complete a predetermined length of time in a passenger operators’ role, before progressing on to training and certification as a guard

The port company should ensure that a berth allocated to a visiting vessel is suitable. A prerequisite for achieving that is port companies having an understanding of the loads capable of being generated by vessels with large windage areas and whether the port infrastructure is capable of withstanding them.

Include in future publications for special maritime events advice on the effects of wake produced by large concentrations of craft. Such advice should include the information contained in relevant marine notices.