Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

undertake a cost benefit analysis with a view to drafting an amendment to Maritime Rule Part 42A Safety Equipment – Life saving appliances, Performance, Maintenance and Servicing for the Minister’s consideration. The amendment to include a requirement for the provision of equipment to make crew members readily distinguishable from passengers in the event of an emergency.

Maritime Rules Part 80 required commercial jet-boat drivers to undergo a minimum of 50 hours training before being licensed to drive commercial jet-boats, but the Rule did not require the drivers to hold formal Maritime Documents requiring them to demonstrate an in-depth knowledge of the collision-prevention rules (Maritime Rules Part 22) and other maritime skills required of drivers of other types of commercial craft.

Take steps to identify and correct the repetitive non-compliance with Tranz Rail rules and procedures for safe operation identified during the investigation of this incident.

Civil Aviation Rule 91.525 requires a life jacket to be available for each person on board a single-engine aircraft being flown beyond the gliding distance from shore. The life jacket is to be stowed in a readily accessible position. The Commission has previously recommended to the Director of Civil Aviation that on all flights, if at any point a ditching is likely to have a better outcome than a forced landing on unfavourable terrain, life jackets should be carried. Helicopters descend at a much higher rate in autorotation than an aeroplane does when gliding.

Review the periodicity of distribution of publicity material to schools in the area of NZRL operations and its relevance to the present environment.

The automatic train status information presented to drivers in the driving cabs of Tranz Metro trains did not give the drivers adequate information about the status of critical on-board systems.