Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Develop and introduce appropriate specifications for the supply of locomotive sand that include quality assurance procedures to ensure the sand is fit for purpose.

Require Tranz Rail's safety system to include procedures which ensure compliance by other rail services operators with the requirements of Company Procedure C/024 "Private Rail Vehicle Interoperability Standards" and any other appropriate standards covering other rail service operators using Tranz Rail's railway line.

KiwiRail’s predecessors determined that the Wellington rail electric multiple unit commuter service was not a single-person operation. Irrespective of whether these trains were a "single-person" or a "two-person" operation, as a consequence, the radio system fitted to these trains did not have selcall capability and could not send an alert to train control automatically when there was a rapid drop in brake pipe pressure such as when the driver makes an emergency brake application.

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.

Consider the fitting of more efficient rudders, to increase the wind speed within which the vessels can safely manoeuvre or to provide additional manoeuvrability in extreme conditions.

On 27 September 2023 the Commission recommended that Gliding New Zealand review how gliding club instructors are trained, and clubs are audited, and then take corrective action to ensure that all new instructors are consistently trained to the standards set out in the Manual of Approved Procedures (MOAP)