Inquiries & Recommendations

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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.

Gets the calibration of the automatic weather station on Great Mercury Island checked, and ensures that it reports relative to magnetic north.

acts, in concert with the FAA as the type certification authority, to amend the Aircraft Flight Manuals of the Metro and associated types to include a limitation and caution that the autopilot and yaw damper must be disconnected while in-flight fuel balancing is done. In addition, the AFM should contain a procedure for in-flight fuel balancing.

The daily bulletin was not clear to the Auckland signal box controller on the location of the work site within Tamaki Station and it was not user friendly to signal box controllers because it gave locations expressed in kilometres rather than points or signal names; the language typically used by signal box controllers. The Commission recommends the chief executive of the New Zealand Transport Agency ensures that the daily bulletins that convey critical information to rail participants is presented in a clear and unambiguous way