Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Reviews the adequacy of the elements of the safety system which failed to prevent unsupervised unloading of wagons on a grade in circumstances where no physical protection from any resulting runaways was provided for the adjacent main line, and take appropriate steps to avoid a recurrence.

Renegotiate, as soon as practicable, the pilots' contract with Ansett New Zealand to remove the condition which is intended to prevent Ansett New Zealand from installing Cockpit Voice Recorders in their aircraft.

Review the use of language in such documents as MATS to ensure that ambiguities do not occur.

Circulate a memorandum to reiterate the following points: Masters and crew check their vessels in accordance with the new hand-over system. No-one relies on non-return valves as a stop for water flooding back into bilges. Bilge alarms are maintained and tested regularly and it is a danger to the vessel and her crew to disconnect them. Bilge pumps are not left running continuously on bilge spaces where there is no indication of the pump's running status unless the bilge is under constant surveillance.

On 26 February 2014 the Commission recommended to the Director of Civil Aviation that he apply stricter requirements upon holders of air operator certificates to take effective action to correct identified deficiencies, and that any serious safety issues that are identified with managerial oversight of airline operations always result in findings.

He promulgate a single advisory radio frequency for aircraft in the uncontrolled airspace between Auckland and Whenuapai Control Zones, including Mechanics Bay ATZ.

Promulgate to aircraft commanders the ramifications of legislation pertaining to civil aerodromes.

Consider placing on board all his vessels a copy of the publication "Bridge Team Management, A Practical Guide" published by The Nautical Institute, together with a circular outlining this accident and drawing attention to chapter six, "Teamwork" and chapter seven, "Navigating With a Pilot on Board".

Include a section in Local Unit Orders specifying the manner in which flight progress strips should be moved to represent the progress of the relevant aircraft.

On 27 October 2021 the Commission recommended that Waka Kotahi review its current auditing of agencies delegated to approve traffic management plans, to ensure that applicants developing traffic management plans identify any rail crossings within the vicinity of proposed work and that the rail access providers have been consulted to ensure that any additional safety requirements in relation to the road/rail interface are met

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.

Amend NZCAR C3 to specify the direction in which dump levers are to be operated to dump the load.