Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Delegate responsibility to one or more entities, for the remit, jurisdiction and resources to set standards for search and rescue (SAR) assets and the training of their SAR crews and enter into service level agreements with other agencies and operators for the provision of search and rescue assets.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

Initiate rule making to require information to be available and visible to passengers on air transport flights, such as on cards in seat pockets, that outlines the operating standards and how passengers can contact the operator or the CAA if they have any concerns about safety.

As a result of this accident they re-emphasise the consequences of flying alone and of ignoring the grading system applied to launch sites and pilot's ability.

Ensure all operating staff understand the principles of crew resource management and that all ... train controllers attend formal crew resource management training by 31 December 2004.

In consultation with the commercial jet boat industry, expand the section on Bilge Pumping in the Code of Practice for the safety of Commercial Jet Boats Operating on Rivers to reflect the following: Where practicable, bilge pumps should be activated automatically and the driver should be provided with an indicator which shows when each pump is operating; and where practicable, the overboard discharge(s) should be located in a position where the driver can observe the discharge.

Ensure that in all cases of a train parting, the whole train is inspected before any attempt is made to couple up and move off.

An engine that had been involved in a sudden stoppage incident overseas was put through a conformity inspection and released to service in New Zealand without the required inspections having been completed. The regulator's guidelines for inspecting used parts of unknown origin was not well defined, and the company's approved procedures developed from these guidelines were not adequate in this case.

They review the adequacy of the road and rail layout, the warning devices, the view lines, and the passive signs pertaining to the Bell Crossing Street level crossing, and reach agreement with transit New Zealand and NZRL over what practical steps could be taken to reduce the likelihood of accidents.

The Commission recommended to the Director of MNZ that they engage with operators working under Maritime Rules Part 82 to identify jet boat systems which carry the risk of single point failure that would result in a total loss of control of the jet boat, and discuss possible measures that could be taken to reduce the risk to passengers and crew to as low as reasonably practicable.

in conjunction with Toll NZ Consolidated Limited 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

When liaising with Central Hawkes Bay District Council regarding alternative proposals to overcome the problem associated with access from SH2 to Victoria Street that priority consideration be given to options that include improved view lines in the south-east quadrant of the Victoria Street level crossing, either at its present site or by relocating the crossing to the north.