Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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

The Commission recommended that MacGregor Germany GmbH & Co, the manufacturer of the mooring winch, ensure that other operators using the same type of winch are aware that the transverse bar should be removed after the winch has been installed on the vessel to increase the safe operation of the mooring winch.

Forward this report to Panama, the Flag State for the Taharoa Express, and invite its comment on how it will address the safety issues with the ship's international safety management system identified in this report, particularly in relation to compliance with statutory standards contained in SOLAS and New Zealand Maritime Rules, communications, identifying critical systems on board, inspection of the ship's structure and interoperability with port operations.

Ensure that crewing levels on the company vessels are sufficient to allow the master to operate the bridge with at least one other crew member during manoeuvring situations and have enough crew to safely conduct mooring and unmooring operations.

On 18 November 2020 the Commission recommended that Rakiura Charters Limited ensure that its Maritime Transport Operator Plan assesses all risks associated with its operations and ensure that adequate guidance is available for skippers to make decisions on when it is safe to sail.

Advises all current users of the AlliedSignal (Lycoming) LTS101 engine to inspect and check tighten each 'B' nut that secures the Pr and Pg accumulators to their respective pressure line, inspect and check tighten the 'B' nut that secures the Py line to the over speed governor, and to report to the manufacturer any instances of loose fittings.

Address the safety issue whereby in the event of an accident or incident, the emergency back-up radios are not capable of being used for communicating with either the rescue authorities or the boat’s home base.