Inquiries & Recommendations

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Advise all member Classification Societies of this accident and that where a reduction in diameter was granted for rudderstocks made of high-strength steel, surveyors and ship operators should be aware of the possibility of load stress cracking. Vessels fitted with such rudderstocks should be inspected to check for such cracks.

For safety barriers in train gangways, ensure, if not already done, that: they can not be disconnected unintentionally or as a result of tampering and, the spacing and layout and strength of the barriers complies with or exceeds the standards specified in New Zealand Standard NZS/AS 1657-92 "Fixed platforms, walkways, stairways, and ladders - Design, construction, and installation". [This safety recommendation replaced safety recommendation 059/94 from the original investigation]

They undertake a study of the frequency and location of container door opening and other "out of gauge" incidents 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.

For future educational trips involving the transportation of a school party over water, any power-driven vessel supplied by, or on behalf of, the school should be one that is operated under a safe ship management system.

The Commission considers it a safety issue that the New Zealand rail network is not equipped with an integrated acousitc bearing monitoring system compatible with current international practice. The Commission recommends the Director of Land Transport New Zealand urgently addresses this safety issue.

draft an amendment to Maritime Rule 34 [Medical Standards] for the Minister’s consideration to · provide educational material for examining medical practitioners as to the difficulties of shift work, sleep disorders, fatigue, prescribed medications, and the impact these have with seafarers, particularly those engaged in safety critical tasks

The Commission recommends that the Chief Executive of KiwiRail ensures that train control management has: - appropriate risk management protocols in place to assess and manage all risks associated with the train control function (including risks associated with merging train control desks), and that all relevant train control personnel are aware of these protocols and comply with them; and - appropriate procedures in place to provide him and the Board of KiwiRail with assurance that train control is exercising an appropriate risk management approach to its operations.

direct that, where possible, the flying of stepped approach profiles be discontinued and replaced with constant angle approaches for non-precision instrument approaches.

Until the responsibilities for the maintenance of sighting distances at public road level crossings have been clarified, it is important for the safety of rail users and road users that there are effective programmes to control vegetation growth around public road level crossings.

Issue standards and procedures to ensure that the design, construction and repair of type 14 brake beams ensures that they are fabricated to standards to avoid excessive stresses due to the cyclic loadings envisaged, particularly those due to possible resonance.

On 21 February 2020, the Commission recommended that the Director of Maritime New Zealand continue to develop its fatal accident database to improve the quality of the data so that the maritime sector is better able to understand the risks of alcohol and drug use in recreational boating accidents.

Introduce a procedure for endorsing Track Warrants with the time and train number associated with radio calls made to establish the whereabouts of opposing trains prior to crossings, and ensure it is audited.