Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The Road Accident Investigation Study Team be reconvened as soon as practicable, with representatives of New Zealand Rail Ltd, to review the traffic engineering aspects of the State Highway 1/Kimberly Road intersection and the adjacent railway crossing on Kimberly Road, to determine what practical steps could be taken to reduce the likelihood of accidents.

Prepare a programme to educate builders and prospective builders on: • The need for craftsmanship, access to precision machinery and recognition of jobs which are beyond the builder's skills; • The need to evaluate any proposed changes to drawings to ensure there are no adverse consequences from incorporation of such modifications; • The need for sufficient manpower at critical stages of construction.

The CO2 fixed fire-fighting system installed in the engine room of the PeeJay V was not fully effective in extinguishing the fire because the space it was protecting was not, and could not, be fully closed down. When the CO2 system was triggered it did suppress the fire, but only for a few minutes. The reason for this was there was four ways for fresh air to enter the engine room after the CO2 had been injected into the compartment. The construction of the engine room did not allow the compartment to be fully sealed, which rendered the CO2 fixed fire-fighting system ineffective.

Examine the CAA auditing process and determine if it needs to be enhanced by periodically, or with reasonable justification, requiring general aviation document holders involved in air transport operations to demonstrate, to the auditors, how in practice they follow, and maintain, an appropriate safety management system.

Issue an interim instruction that, unless overriding considerations prevail, in the event of any system abnormality occurring during an instrument approach in instrument meteorological conditions the Captain shall discontinue the approach and climb to or maintain a safe altitude until the appropriate procedures relating to the abnormality have been completed correctly.

On 25 June 2020 the Commission recommended that the Managing Director of IMS New Zealand ensure that all Cloudburst monsoon buckets with hook-and-loop fasteners are modified to incorporate improvements in the fastener design.

On 23 August 2018 the Commission is therefore recommending that the Chief Executive Officer of Airways review the current practices of aerodrome control at Hamilton to ensure that the level of ATC service is consistent with CAA rules and the aerodrome safety system.

Ensure that the contents of all current and any future service bulletins where safe operation of engine types may be affected be promulgated by the best means possible to all known owners of the type of engine affected.

He require pilots engaged in air transport operations into confined airstrips to demonstrate the missed approach procedure with the aircraft in which they intend to operate, ballasted to the authorised mass and most adverse C of G position for that airstrip, and require that such demonstrations be used for checking in accordance with Regulation 76 and 77.

Liaise with Maritime Management Services and review the Safety Management Policy Manual for the Te Waka o Kapanga critically to ensure it contains all of the relevant safety information from the Company Operations Manual necessary to comply with the New Zealand Ship Safety Management Code.

Promote through boating education and safety bulletins and boat notices, the fitment of passive radar reflectors to small vessels, particularly those constructed of poor radar reflective materials.

On 14 December 2012 the Commission recommended to the Director of Civil Aviation that he liaise with Transport Canada to make other National Aviation Authorities aware of this incident and of the desirability of Dash 8 flight simulators closely representing the actual forces required for a landing gear alternate extension.