Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Prepare and distribute a letter or bulletin to advise operators how to locate the part and serial number of B767 main undercarriage axles.

include an area familiarisation trip with an experienced train controller or similarly qualified person as part of the training and certification for any train control desk together with an unaccompanied field trip scheduled within an acceptable timeframe following certification as a follow up

Section 27C(1) of the Civil Aviation Act requires medical practitioners to inform the Director if they believe a person is a licence holder and is aware, or has reasonable grounds to suspect, that the licence holder has a medical condition that may interfere with the safe exercise of the privileges to which the licence holder's medical certificate relates.

Review the requirements for positioning of "crash" axes in light aircraft to improve the likelihood of them being accessible tot he pilot in the event of the cockpit area being distorted in a survivable accident.

Include this accident, and the safety messages highlighted by this report, as a case study to be included in the ongoing training of the operating groups concerned.

Take action to restrict movements through the crossover at the south end of Te Kauwhata, such that signal 59006 is not required to give a medium speed indication for a routing to the loop.

If using a suitable observer instead of a second pilot, seat the observer in the second pilot position.

Participate with the Land Transport Safety Authority, Toll NZ, Auckland and Waitakere City Councils in a review of all existing railway level crossings within the Auckland metropolitan area, to ensure that their design, layout, signage and warning devices are adequate for current road and rail traffic volumes and will be adequate to meet projected increases in rail traffic on the Auckland rail corridors.

Ensure that the harbour risk assessment fully addresses the operation of tourist vessels in the Fiordland area. Take note of the identified risks when developing, in compliance with the New Zealand Port and Harbour Marine Safety Code, the harbour safety management system and standard operating procedures for Milford Sound.

On 24 August 2016 the Commission recommended that the Director of Civil Aviation provide a clear statement to relevant sectors of the aviation industry on whether stock clearing is a permitted activity. If the Director decides it is a permitted activity under a particular Civil Aviation Rule part, he should provide clear guidance on the conduct of the activity.

Require the CAA to implement, as soon as practicable, a system which will ensure any instances of operator non-compliance and non-conformance which are identified by, or to, the Authority are corrected promptly or sanctions automatically follow.

Enhance existing air brake and handbrake procedures to include: • a minima number of handbrakes to be applied proportional to the number of unattended wagons • a brake effectiveness test to be carried out before locomotives are separated from an unattended rake of wagons • operating personnel required to communicate with each other at defined stages before wagons are left unattended on a main line • consolidate instructions pertaining to the operation of hand brakes and air brakes applicable at train separation