Inquiries & Recommendations

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On 22 August 2023, the Commission recommended that Wallace Investments Limited prioritise a review of their safety management system to ensure that: • the responsibility for safety of each stevedoring role is clearly defined, unambiguous, and understood by all personnel • procedures for work activity adequately cover scenarios with increased risk • all risks are identified, and administrative risk controls are only used when more effective risk controls are not reasonably practicable • adherence to administrative risk controls is effectively managed.

Make sufficient radios available for staff required to carry out isolation, hand operation and power restoration of motorised points to communicate effectively with Train Control.

On 27 September 2023, the Commission recommended that Maritime New Zealand and WorkSafe (until 1 July 2024) ensure that their regulatory activity includes a proactive role (such as monitoring and assessment) in the safety of the stevedoring industry.

KiwiRail is aware of 264 other public level crossings in New Zealand that have the same or similar issues with stacking distances for long road vehicles as that encountered at the Beach Road level crossing at Paekakariki. The Commission recommends to the Chief Executive of the NZ Transport Agency that as a matter of urgency he address this safety issue.

advise all owners of New Zealand fishing boats by the most appropriate means, of the safety benefits of voluntarily attending FishSAFE workshops and the availability of the "Safety Guidelines for Small Commercial Fishing Boats" on the FishSAFE website.

In approving the change in airworthiness category, the CAA did not review all the required documentation and so missed the opportunity to ensure the aeroplane was fit for the purpose. The Commission recommends that the Director takes the necessary action that ensures there is a thorough and coordinated oversight when accepting aircraft modifications and approving changes in category, especially for specialised operations like parachuting

Liaise with Marlborough District Council to urgently review the use of Vickerman Street level crossing and take such steps as are necessary to prohibit the use of the level crossing by vehicles exceeding 9m in length.

Reassess the Tranz Rail irregularity follow-up policy to ensure that it is positioned sufficiently towards a corrective action culture as distinct from a punishment culture so that prompt reporting of irregularities is encouraged.

Takes action, in conjunction with certificated instrument flight procedure service organisations, to eliminate the use of similar procedure titles for different instrument approaches to the same runway.

The Commission recommends the New Zealand Transport Agency takes action to address the safety issue whereby locomotive engineer medical tests procedures that could increase the likelihood of detecting sleep and other associated disorders do not currently include the use of modern diagnostic monitoring systems (003/09).

They review the adequacy of the road and rail layout, the warning devices, the view lines, and the passive signs pertaining to the Bell Crossing Street level crossing, and reach agreement with transit New Zealand and NZRL over what practical steps could be taken to reduce the likelihood of accidents.

The Commission recommended to the Director of MNZ that they engage with operators working under Maritime Rules Part 82 to identify jet boat systems which carry the risk of single point failure that would result in a total loss of control of the jet boat, and discuss possible measures that could be taken to reduce the risk to passengers and crew to as low as reasonably practicable.