Inquiries & Recommendations

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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.

They undertake a study of the distance between mainline and loop tracks at crossing loops to determine the risk of recurrence and accordingly whether a programme should be instituted to increase the distance between the mainline and the loops at stations where passenger trains pass freight trains.

reinforce with track users that they request relevant train movement information from the train controller when seeking on-track authorisation, where this information would assist them with the planning of their track occupation.

Review the relevance and accuracy of the RFS information given on each landing chart in the NZAIP.

develop and implement a support programme for newly qualified entrants to jobs in safety-critical areas, such as the shunting environment, focusing on ongoing safety awareness, on-the-job training and ability to perform tasks to include such initiatives as peer review, mentoring and supervisory observation

Arrange that during peak periods ATC be notified if no gates are available for arriving aircraft which normally use the Eastern Apron.

put in place control measures to ensure: • Mini Rosters are controlled within separate defined criteria compatible with the principles used in compiling base rosters • The principles of rostering are applied to the overlapping weeks of consecutive rostered fortnights • defined criteria are met before offering extra shifts to LEs • actual hours are monitored and immediate corrective action taken when late running or other factors increase rostered shifts to defined unacceptable levels.