Inquiries & Recommendations

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Ensure that drivers include in the pre-trip safety briefing that passengers should use the footrests to brace themselves against the motion of the boat.

Put in place a system, to be available on request, to recover and make available as soon as practicable any relevant recorded radar information which might assist the Search and Rescue Co-ordination Centre to locate a missing aircraft.

Review the visibility of PW14 warning signs on each side of each railway crossing in your district and take any necessary action to reinstate the uninterrupted view requirements defined in the "Manual of Traffic signs and Markings.

Draft an Amendment, by the most appropriate means, to Maritime Rule Part 24B carriage of cargoes stowage and securing for the Minister’s consideration. The amendment to ensure that the rule includes reference to the appropriate International Standards Organization standard for lashing and securing arrangement on road vehicles for sea transportation on ro-ro ships - Part 2 Semi trailers, and if applicable the current New Zealand Standard covering lashing points on road vehicles for sea transportation on ro-ro ships.

Continue to stress the dangers involved in operating in conditions of turbulence in Microlight aircraft.

Instigate a programme of training and practice to reinforce bridge resource management techniques amongst members of bridge navigational teams on board the company’s vessels.

On 10 April 2017 the Commission recommended to the International Association of Classification Societies that it inform all of its members about the circumstances of this accident and advise them to alert their surveyors to pay special attention to any corroded nitrogen cylinders or other pressure vessels when conducting their Class or Flag State surveys, particularly when inspecting pressure vessels stored in an open marine environment.

Address with the port operator and the owner of the port safety management system the issue whereby the mandatory requirements of SOLAS and New Zealand Maritime Rules, including reference to guidelines such as the Code of Safe Practice for Solid Bulk Cargoes and the Code of Practice for the Safe Loading and Unloading of Bulk Cargoes, have not been incorporated into standard operating procedures, nor have they been followed.

Reviews the acceptability of the relocated spigots as a safe stowage for transition heads on QR and DQ locomotives.

Consider introducing training on the limitations of human performance and methods of handling excessive workload, as part of the flying training syllabus. • Require aircraft used for IFR air transport operations to be fitted with digital altimeters. • Apply the requirements for additional familiarisation flying after gaining a type rating, prescribed for air transport flights under IFR, to the pilots of any IFR flight carrying passengers

He regulate the traffic density at Milford Sound by restricting the maximum number of aeroplane departures within a period of time. A suggested figure is six departures in any fifteen minute period. This would give flexibility while allowing aircraft to fly to MacKinnon Pass and return to overhead Milford Sound without encountering dense traffic.

develop a safety defence system for track occupations in SLAS areas in line with systems that provide a similar level of safeguards in other signalling areas.