Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

Compile a set of emergency response plans for each of his company's vessels and ensure each crew is familiar with the plans for their vessel.

Introduce a system for producing, circulating and keeping on board fleet safety and operational memoranda. The above system should be aimed at informing all crew of such matters.

In conjunction with New Zealand Railways Corporation critically review current track and mechanical code standards and maintenance tolerances to ensure they are compatible and minimise the potential for derailments caused by dynamic interaction.

Consider the carriage of a second pilot to act as lookout on these operations.

Require Airways New Zealand to improve its method of promulgation to controllers of safety-related information and to demonstrate that the content was understood and applied by controllers.

develop educational material to ensure that helicopter pilots understand the significance of a rotor overspeed event, and what action should be taken.

That the integrity of locomotive event recorders and radios during a train collision, derailment or rollover be strengthened to an extent that the capability be maintained to transmit an emergency radio selcall to train control.

This accident was the result of fine clay particles within the engine fuel system causing a momentary reduction in engine power. Fuel contamination is a greater risk for operators that conduct refuelling in the field or at remote locations.

Facilitate making information about the electricity network infrastructure available to pilots to aid their situational awareness, and to publicise the details of any agreed service.

He ensure each emergency exit has a readily identifiable and effective handle on the inside of the aircraft.