Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

decide what role check calls have during controlled on track time for HRVs, track maintenance gangs and other track users and issue clear instructions covering any permitted use

Issue a Safety Notice warning pilots of the potential damage resulting from such an occurrence and requiring an engineer's inspection if an attempt is made to start with the clutch engaged.

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

Amend Police Standard Operating Procedures to include early engagement of the Police dive squad in maritime responses, when appropriate, to take advantage of their expertise and knowledge in water rescue.

On board the Rena, the master and crew were not following the navigation and watchkeeping standards and procedures set down in the Rena's safety management system for at least the six coastal voyages leading up to the grounding. With respect to port state control records, other vessels managed by CIEL also had a higher than average rate of deficiencies than the average for the Asia-Pacific region.

Emphasise that the minimum altitude that the route can be used legally is 3500 feet amsl.

Carry out an investigation, and take any necessary action, to ensure the design requirement for an IRU not to be faulted by an external failure, such as a shorted or open circuited data bus, is met.

Support the submission of papers to the IMO through an appropriate IMO forum for their consideration to raise awareness about the importance of: • doffing and deflation procedures • the potential hazard of inflating when obstructed overhead.

On 2 August 2016 the Commission recommended that the Director of Maritime New Zealand review Port Marlborough New Zealand Limited's Port Safety Management System and ensure that it has appropriate procedures in place to meet the requirements of its Pilot Training and Proficiency Plan and that the plan meets the intent of Maritime Rules Part 90: Pilotage.

Ensure the proposed NPRM on CARs Part 61 Pilot Licences and Ratings raises the minimum aircraft type-specific experience and competency requirements, especially for multi-engine aircraft, before an instructor is able to instruct on that type.

Promote the lessons learnt from this incident, in particular the value of good CRM training and the use of resources.

review training requirements, particularly English competency levels, for crews who fly to international destinations.