Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure that all crews serving on the company’s ferries are aware that, when investigating a suspected or indicated fire within an enclosed space, opening the access may rapidly exacerbate the fire endangering the crew, passengers and the vessel. The procedure in the operations manual should include a caution and a reminder that where a fixed fire fighting system is installed for the engine spaces, its use should be considered as a possible safer alternative to opening the space, especially in vessels with twin-engine spaces.

Prepare and use a comprehensive pilotage passage plan. The plan should be readily understandable and have sufficient detail to inform visiting ship’s masters of procedures and operating criteria, in order that they are able to safety navigate the port. Such a plan should be given to and explained to masters before commencing any transit.

Review the desirability of requiring the LEs of passenger trains to assess stopping requirements at stations, on a location by location basis, to ensure that there is no potential conflict with safe train operation, and take appropriate steps where such conflict exists.

The fire on board the Kokopo Chief was caused by radiated heat from an incandescent reflector lamp fitted in a cargo light igniting the timber cargo. While it is widely known that incandescent reflector lamps produce heat, the findings of this investigation offer valuable information to ship designers, owners and operators to consider when selecting the means of lighting in cargo holds and other parts of their ships. There are equivalent lighting options, such as LED lamps, that do not produce the same high temperatures.

Give priority to completing workplace operating plans for both NZRL and the Port of Wellington Ltd covering the operational restraints necessary to ensure controlled integrated operation of both companies on Port of Wellington Ltd property, and that such plans are reviewed, updated and compliance checked to continually maintain a safe operational and work environment.

On 15 May 2024, the Commission recommended that the Director of Civil Aviation revise the rule, notes and guidance provided for CAR Part 12: Accidents, Incidents, and Statistics to make it clear that a door opening in flight is a safety issue and to take steps to address door-opening-in-flight occurrences that are not being promptly reported to the CAA.

Include in the tugs’ planned maintenance system, a regular check to ensure that the speed controls remain synchronised. A service history of any adjustments or modifications to the engines and control systems should be recorded.

Amend the engine starting sequence to include a check that the clutch light is "off" after selecting the master switch on.

Reviews the adequacy of compliance monitoring of wagon loading.

Introduce procedures to ensure that when the application of the rear handbrake is required by the Rules, the application is confirmed to the engine driver before an attempt is made to uncouple the engine from the train.

Require controllers to comply strictly with provisions of the Manual of Air Traffic Services.

A number of the passengers and crew on the Easy Rider had a large physique. There were only 3 adult and one child lifejackets on board to share among 9 passengers and crew. The 3 adult lifejackets were not large enough to be securely fitted to those passengers and crew whom had a large physique. The Maritime Rules make provision for the carriage of children’s lifejackets but are silent on the need for larger lifejackets to cater for people whom have a large physique. This is a safety issue.