Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder operating on the National Rail System, ensure that systems are in place that record in detail the maintenance history of safety-critical rail vehicle parts and that any tests on replacement parts are appropriate to simulate in-service conditions.

Continue to take steps to assess the safety culture among operating staff involved with Track Warrant Control and introduce programmes and procedures to improve it if deficiencies are noted.

The Commission recommends to the Chief Executive of the NZ Transport Agency that he requires the Executive of the National Rail System Standard to develop standards to ensure that all rail participants meet a consistently high level of crew resource management, and communication that includes the use of standard rail phraseology (002/12).

Liaise with the Air Transport Division of the Ministry of Transport to have a more informative and accurate depiction and description of the areas adjacent to the taxiways to the "Skycare" apron and the purpose of these areas included in the NZAIP and the associated flight guide charts.

Consider requiring early re-certification under appropriate civil aviation rules (which embody the management system approach to safety) of those general aviation air transport operators, which, in his assessment, appear to be at risk because of a poor safety culture, poor attitudes, or poor systems or practices, and ensures that there are no undue delays in the certification of other operators.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan