Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

Include an article in the Seafood New Zealand magazine featuring this report, the intent of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] together with its advisory circular and the work of the Maritime Safety Authority convened FISHgroup and fishSAFE initiatives.

provide clearer guidelines to operating staff defining the actions to be taken when safety critical components of a train consist become defective while in operation. The guidelines should include when advise is to be south, the position of the person from whom it is to be sought, and the action to be taken if that person cannot be contacted.

The Commission recommends that the Director of Civil Aviation review the parachute accident and incident reporting system under Civil Aviation Rule Part 12 and Advisory Circular AC12-1, in conjunction with the Part 115 and Part 149 organisations’ requirements, to provide a more effective national resource to manage the sector’s safety.

Remind captains of the desirability of keeping the other crew members informed of their intentions at all times.

The push/pull train sets were signed off as fit for purpose and commissioned to the Auckland passenger train network when they did not comply with the National Rail System Standard with regard to maximum allowable stopping distance as a complete train, and it has not yet been proven that they do so under all conditions of loading and track condition.

Member States are required to undergo five-yearly independent evaluations of their seafarer training systems. However, those evaluations remain confidential between the IMO, the auditing States and the States being assessed. According to Regulation I/10, member States are required to verify for themselves the effectiveness of other States' maritime education, training and certification systems before recognising certificates issued by those States. However, this can only be realistically achieved through a full systemic audit of the seafarer training system.

On 13 March 2025, the Commission recommended that Pegasus Fishing Limited review their safety management system and take steps to ensure safe navigational watchkeeping principles are observed during all phases of the fishing operation.