Inquiries & Recommendations

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After the Commission publishes its final report, use this accident scenario in CAA educational material to refresh helicopter pilots, instructors and examiners knowledge about PTG underspeeds.

The Commission recommended that KiwiRail ensure that safe working procedures are in place to manage site-specific risks associated with staff undertaking shunting activities.

The Commission recommended that Maritime New Zealand develop and disseminate clear guidance to highlight the inherent risks associated with the telescopic accommodation ladders

He design and fit suitable handles for opening such doors from the inside in an emergency.

close the entry and exit points to the land alongside the South Island Main Trunk railway line immediately south of the Browns Road and State Highway 1 intersection to prevent unsafe use.

The wire pennants parted under tensile overload because they had all been significantly weakened by severe corrosion. Corrosion had gone undetected inside a plastic sheathing that the manufacturer of the lifting sling had placed around the wire pennants. The presence of the plastic sheathing encasing the wire rope meant that neither the crew nor the various surveyors tasked with inspecting the launching system could inspect and maintain the wire rope as required by SOLAS.

Establish a system, in conjunction with any operators for whom Airwork provide maintenance services, that ensures any follow up maintenance action necessary after any maintenance, is correctly recorded and carried out at the appropriate time.

reinforce with operating staff the need to remain on the train in situations that could put their own and the lives of passengers at risk.

The issue of serious harm resulting from the operation of watertight doors remains a safety issue that has not been resolved by the maritime industry worldwide, and some advice to mariners in its various forms, including that given by the International Maritime Organisation, could unintentionally exacerbate the issue.

The Commission has made an urgent recommendation to the Chief Executive of KiwiRail that he ensure that at the Wellington maintenance depot, and other maintenance depots under KiwiRail control: - maintenance is undertaken in accordance with good railway engineering practice - manufacturers' inspection, repair and maintenance instructions are documented and followed - safety-critical components are identified and documented - work instructions are issued for maintaining all equipment - work on safety-critical components is signed off by someone other than the maintainer

Develop and introduce appropriate specifications for the supply of locomotive sand that include quality assurance procedures to ensure the sand is fit for purpose.

Require Tranz Rail's safety system to include procedures which ensure compliance by other rail services operators with the requirements of Company Procedure C/024 "Private Rail Vehicle Interoperability Standards" and any other appropriate standards covering other rail service operators using Tranz Rail's railway line.