Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Introduce operating procedures for Tranz Rail staff and customers who move wagons without using rail mounted vehicles, or load or unload wagons, which ensure: only approved equipment is used, and only by appropriately certified staff; equipment for moving wagons is applied at approved positions, and that these positions are clearly defined to staff concerned; that any damage causing deformation to safety critical components such as handgrips which could compromise fitness for purpose is identified promptly and the wagons removed from service.

Introduce formalised crew resource management training for Train Control Operators, Signalmen and LEs based on the training available in the aviation and marine industries. [SR repeated as SR 006/01 in investigation 00-106]

ensure that existing fatigue management training programmes include, but are not limited to, issues such as sleep practices, lifestyle, family commitments and the use of drugs including alcohol and stimulants etc.

Arrange for liaison at local level throughout New Zealand, to ensure that controllers and the drivers of potential rescue vehicles are equipped with the same maps, preferably overprinted with an easy reference grid.

Review the organisation links between ATS staff responsible for out of the ordinary Air Traffic Control situations to ensure they provide for the optimum flow of essential information between the individuals involved.

Transit New Zealand develop a code of practice for the design of intersections with closely adjacent railway crossings, taking into account the combined risk of accident that the two hazards present.

On 14 December 2017, the Commission recommended to the Director of Civil Aviation that he consult with the original equipment manufacturer when considering a modification or supplemental type certificate which, if approved, could result in any aircraft being used in a way that is significantly different from that which the manufacturer originally modelled and used as the basis for determining component fatigue lives and the aircraft maintenance programme

Individually identify all driveshafts on the DMU fleet so that their maintenance and service history can be recorded and tracked.

Several deaths of crew in the inshore and coastal fishing fleet, including the 2 seafarers lost in this accident, have been attributed, at least in part, to the absence of an effective anchor watch, in spite of the various marine notices and other literature on the topic of keeping anchor watches.

On 15 May 2025, the Commission recommended that Maritime New Zealand collaborate with other states to submit joint papers to the IMO (through the appropriate sub-committee) recommending the IMO: c. introduce the requirement for a continuous synopsis record for the repair and maintenance of ships’ critical equipment and systems remain on board throughout a vessel’s life. [025/25]

Review the suitability of procedures for disseminating the requirements of standards to those responsible for compliance, and take such steps as are necessary to ensure that the relevant Tranz Rail persons are aware of and capable of carrying out their responsibility within the system to achieve the intent of such standards.

Circulate a summary of this report to industry to highlight the safety benefits of using resources, both inside and outside the cockpit, to manage emergency situations.