Inquiries & Recommendations

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Introduce standards for design, inspection and repair of safety critical components which ensure they remain fit for purpose in the intended operating environment.

The Commission recommended that Maritime New Zealand ensure that as soon as reasonably practicable the owner of the Amaltal Enterprise install a new system that complies with current maritime rules and put in place additional measures to manage the risk created by the limitations of the current fire-extinguishing system until such time as the new system is installed.

The location of the Fruitvale Road level crossing close to the Fruitvale Road Station platform represents a risk to level-crossing users in the event of a platform overrun for whatever the reason. There is a delicate balance between the signalling ensuring the level crossing is protected in the event of a platform overrun and ensuring road users are not kept waiting for so long as to engender the known unsafe practice of road users ignoring signals and barriers and entering the level crossing ahead of passing trains.

Review the procedures for distribution of International Maritime Organization circulars to ensure all affected parties promptly receive International Maritime Organization documentation and the distribution and receipt is adequately recorded.

Address the safety issue whereby large commercial vessels above the internationally accepted size for the carriage of AIS are operating into and around busy New Zealand ports without AIS fitted, potentially compromising the effectiveness of traffic management systems and other measures to prevent collisions between vessels.

Advise all New Zealand operators of FU24 aircraft, of the potential for light growth to jam the ailerons of these aircraft.

On 24 April 2024 the Commission recommended that KiwiRail place greater emphasis on training rail personnel in reporting unusual weather conditions (in accordance with KiwiRail’s Operating Rules, Section 1 – General Rules, rule 6(b), to ensure they retain currency.

ensure that the northern view lines from the western side of Caverhill Road level crossing for traffic heading east are preserved by prohibiting the storage of rail vehicles on the backshunt at the north end of the crossing loop.

Ensure the operating instructions for all survival craft and their launching appliances on all company vessels are correct, easily understandable by the crew, and clearly understood by the crew. Instructions should include a note not to deviate from standard operating procedures before fully assessing the consequences of doing so.

The Tranz Metro maintenance policy was biased towards being reactive rather than proactive and did not include identifying and monitoring the performance of safety-critical components such as high-speed circuit breakers.

Require his pilots to comply with the Civil Aviation Safety Order or any other civil document governing the conduct of a particular air show in which military aircraft are involved or advise the organisers of any parts of such instructions with which he is not prepared to comply.

[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.