Inquiries & Recommendations

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The driving compartments on Trains 6250 and 6247 were damaged during the collision sequence to such an extent that had the drivers not vacated their driving positions before impact it was likely that they would have been at least seriously injured.

Reconsiders his decision to continue to approve a person to act as maintenance controller for an operator when that person is also employed by the maintenance service provider contracted to carry out aircraft maintenance for the operator.

On 27 September 2017, the Commission recommended that the general director of the Panama Maritime Authority seek improvements in the operator’s implementation of its safety management system on board its vessels, including the underlying safety culture

Introduce a requirement of cockpit voice recorders to be fitted and maintained in a serviceable state in appropriate New Zealand registered aircraft.

Improve the resilience of the track warrant system to accommodate deviations from standard patterns, taking particular account of the need for: • an improved method of providing an LE with a continuous and conspicuous visual display of his track warrant limit. • introducing a system to identify the position of trains in track warrant territory which would increase the situational awareness of LEs as they approached the limit of their track warrant, and limit the possible consequence of any overrun which may occur.

Use this accident scenario as a topic for pilot re-currency training or LOFT in simulators to enhance pilot awareness and CRM skills. The training should introduce similar errors for pilots to discover. The training should also ensure pilots treat all warnings, such as a stick shaker, as real warnings and make sure they respond appropriately until the threat has passed.

For resetting the alarms at Eltham, to obviate the need for the Locomotive Engineers to leave the cab to reset them.

Introduce a system of driver review where junior drivers are periodically assessed by a senior driver and senior drivers by their peers. From time to time, such reviews should be undertaken when river conditions are near safe operating limits.

That the requirement for the carriage of flight data recorders be extended to include a basic FDR or CVR (where the aircraft is operated with more than one pilot) on all multi-engine aircraft used principally for Air transport Operations with seats for nine or more passengers. (A similar Recommendation was previously issued following and accident on 8 August, 1989 involving Britten Norman Islander ZK-EVK near Blue Duck Glacier, Upper Dart Valley).

conduct a risk assessment for LPG carriers transiting Manukau harbour and form a set of rules and guidelines governing their movement within harbour limits.

The Commission recommends that the Chief Executive of KiwiRail ensures that appropriate protocols and/or arrangements are in place, and are being applied, to properly manage and coordinate routine and unplanned track infrastructure activity so that train controllers are able to perform their safety critical function without becoming unduly distracted or burdened.

Shunting locomotives which travel along main lines or regularly pass over level crossings on public roads be fitted with event recorders.