Inquiries & Recommendations

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Issue standards and procedures to ensure that the design, construction and repair of type 14 brake beams ensures that they are fabricated to standards to avoid excessive stresses due to the cyclic loadings envisaged, particularly those due to possible resonance.

On 21 February 2020, the Commission recommended that the Director of Maritime New Zealand continue to develop its fatal accident database to improve the quality of the data so that the maritime sector is better able to understand the risks of alcohol and drug use in recreational boating accidents.

Introduce a procedure for endorsing Track Warrants with the time and train number associated with radio calls made to establish the whereabouts of opposing trains prior to crossings, and ensure it is audited.

develop educational material for CAA airworthiness personnel and licensed maintenance engineers to raise awareness of the need for them to recognise and respond to documented inadequate identification of critical lifed components when checking aircraft maintenance documents.

He require owner to level the threshold of runway 08 at Tiraora Lodge airstrip.

Liaise with the lifeboat davit manufacturer to establish the reason for limiting the winch capacity to the lifeboat plus 2 persons, and bring the installations on all company vessels fitted with them up to SOLAS compliance standards.

On 29 September 2016 the Commission recommended that the operator of the Captain M. J. Souza: review its internal auditing procedures to ensure that auditors make realistic assessments based on actual practices observed on board; and seek verification that documented procedures are being followed by the crew and they are appropriate for the task. Audit findings should be recorded together with any safety actions taken as a result of the audit.

Ensure all operating staff understand the principles of crew resource management and that all train crew ... attend formal crew resource management training by 31 December 2004. [This SR repeats or is similar to SR 006/01 (investigation 00-106), and 001/99 (investigation 98-107)]

[the LTSA, MSA and OSH] Immediately bring the potential problem of substandard connections between stacked bases to the attention of appropriate Australian transport safety agencies.

Introduce procedures governing the issue of track warrants to require a Locomotive Engineer taking control of the train after a crew change to have to "accept" an open track warrant with the same "double check" procedures associated with the issue of new track warrants.

He foster courses in formation flying conducted by pilots experienced in formation flying, from the RNZAF or elsewhere.

Operators of the AS 350B helicopter be advised of the circumstances of the accident involving ZK-HWW.