Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Revise the syllabus for Local Launch Operator and other relevant marine qualifications to include a practical electronic navigation aid component similar to but shorter than the revised restricted radar course referred to in safety recommendation 037/04. [This SR was also applicable to investigation 04-204 restricted limit passenger vessel "Freedom III", grounding, Lake Manapouri, 24 February 2004]

The CAA said that it had put in place changes in policy and training for its inspectors by February 2014. Leading up to that date, and afterwards, CAA inspectors had overlooked significant non-compliances by the operator of the helicopter at Fox Glacier and they had not raised findings on matters of non-compliance with Civil Aviation rules.

Ensure that any new pilotage exemption certificates issued are subject to the existing size and area limitations currently applicable.

Revise and consolidate existing standing orders and instructions into a Beacon Hill Operations Manual. Instructions should include the role of the signal station in monitoring and enforcing the traffic management system, which should include a closed-loop style of communication.

implement Alertness Management courses to reach at least 90% of LEs by the end of 2001 and 100% by the end of 2002

Promulgates to operators the availability of the lower ILS minima intended and generally implemented by the rulemaking process, advising action to amend ILS approach charts, and what steps air transport operators may take to obtain approval to use lower minima prior to obtaining recertification under rule part 19.

Ensure that procedures for dealing with stalled trains are understood and adhered to by all operating staff.

Establish a policy that all staff undergoing training are properly supervised.

Investigate the need for and the feasibility of, introducing a suitable maintenance procedure to detect internal wear of winch cables before the cable's strength was reduced to an unacceptable stage.

Safety-critical rail workers are not required to declare prescribed medications they are taking when presenting for triggered health assessments. The driver had been prescribed a combination of medication that was known to cause performance impairment and behavioural changes, anxiety, agitated delirium and disorientation in more severe cases. The medicines also came with a warning to patients to not drive or operate heavy machinery until the effects became known.

The system for recording faults on Tranz Metro trains was not user-friendly, was not being followed all of the time and did not achieve its purpose of reporting faults and informing drivers.

The train controller had been identified by KiwiRail management as having concentration and focus issues in relation to tasks required for the safe execution of track occupation authorities following a track occupation irregularity during February 2012. This was 16 months before the track occupation irregularity covered in this report, and during that period the train controller went on to have two further operating irregularities while he remained in the role.