Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Include in the policy manuals instructions to ship’s staff on how the company expects the principles of effective bridge resource management should be complied with.

Establish the service stresses being developed in the driven axle of the three axle bogie, and from this determine the related fatigue crack growth rates and implement an inspection regime to detect such cracks and remove any axle from service before it fails.

The Authority issue an Advisory Circular to bring to the attention of aerodrome operators, matters pertaining to helicopter operations that they ought to consider in preparing expositions.

Liaise with an [operator of the vessel in accident report 97-202/203] and review the Safety Management Policy Manual for their vessel critically and ensure it contains the relevant operational and safety instruction necessary to comply with the New Zealand Ship Safety Management Code.

Include in procedures for departing from stations a confirmation check by the Tranz Metro Driver that the doors are closed, by referring to the door-closed light on the console in the EMU cab

Advises all secondary school boards of the circumstances of the Henderson accident and suggests that boards in the vicinity of a rail corridor, which may have similar problems, raise the issue of potential hazards in the rail environment with students and co-operate with Tranz Rail, local authorities, and other affected local groups to develop and implement specific local action plans to minimise or eliminate hazards.

Ensures standards and inspection procedures are in place to prevent the use of strops and other restraining devices which are below desirable standards.

The training syllabus for the New Zealand Commercial Pilot Licence (Aeroplane) be amended to include "Mountainous-terrain flight training" and the extent of training required be similar to that already specified in the case of Commercial Pilot Licence Helicopter, and the requirement be applicable prior to the validation or conversion of foreign Pilot Licences to equivalent New Zealand Pilot Licence[s]. [Repeated as part of SR 023/02 (investigation 02-001) on 19 July 02.]

On 23 May 2018 the Commission recommended that the Director of Maritime New Zealand use an appropriate mechanism to make it mandatory for crotch straps to be fitted to lifejackets required on board commercial vessels that operate out of bar harbours and off exposed coastlines

Define the person (or persons) upon whom the responsibility for the inspection of safety equipment and safety features on carriages rests.

Revise immediately, the information in the NZAIP Planning Manual page AGA 0-29 Section 9 and in Civil Aviation Information Circulars GEN A19 and A20.

Expedite the implementation of his plans for obtaining the appropriate staff numbers to achieve their planned safety audits in the appropriate time scales.