Inquiries & Recommendations

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Take the steps necessary to ensure that all dumb barges with no persons on board that are used commercially for the carriage of cargo are brought within the safety framework of the Maritime Rules with regard to the issuance of load lines and the provision of stability information.

Review the company’s procedure manuals with the purpose of ensuring that there is sufficient information available for personnel responsible for making critical decisions to make informed judgements. Wherever possible, foreseeable risks should be addressed and contingency plans put in place and practised.

Promote the bridge resource management concepts by requiring pilots to use them at every opportunity.

On 26 February 2014 the Commission recommended that the Director of Civil Aviation continue to support the international work underway to improve the crash survivability of ELTs and to include GPS information in the data transmitted by such devices.

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

undertake a cost benefit analysis with a view to drafting an amendment to Maritime Rule Part 23, Operational Procedures and Training, for the Minister’s consideration to change the content and method of promulgation of the contents of “the instructions to be followed in the event of an emergency” for restricted limit passenger vessels. The amendment to include, at least, verbal advice of life jacket donning instructions so as to enable passengers to safely don the lifejackets carried on board

Require the fitting of an inclined footplate in front of each passenger seat, having first assessed what the optimum angle for such a footplate is.

Conduct a review of engine room watch keeping practices on board all company ships, and then issue instructions on the correct procedures to follow, particularly in relation to alarm monitoring

During the Picton berthing occurrence the master was captive to the propeller pitch controls and could not totally oversee the second officer who was under training, nor could he totally monitor the progress of the ship as it backed into the berth.

In controlled airspace where separation is not provided between aircraft operating under VFR, a VFR aircraft that is instructed to follow another aircraft is not explicitly required to advise ATC promptly if visual contact is lost with the relevant traffic.

review Toll Rail’s compliance monitoring of locomotive engineers to confirm that the increased monitoring as defined in the safety action of 21 February 2006 has been implemented and is effective.

On 7 December 2022 the Commission recommended that KiwiRail review its permit-to-enter process to ensure that any associated costs and requirements are not prohibitive to the completion of safety-critical work, and that the charging of fees for permits to enter is in accordance with the Railways Act 2005.