Inquiries & Recommendations

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audit safety observation procedures to ensure defined frequencies are achieved, and ensure particular attention is given to newly certified staff.

Remind pilots of their responsibility after an aircraft accident to preserve the accident scene, to have the continued airworthiness of the aircraft assessed, and to notify the Director of any change in their medical condition.

Fit watchkeeping alarms to the wheelhouse of all vessels operated by his company.

Emphasise to all his pilots the need to follow the standardised checklist procedures and that they should not continue past a checklist item until it has been completed.

Ensure that helicopter pilots are included in any briefing held about winding exercises or other operations in which they will be involved.

The use of performance impairing substances is known to have a detrimental effect on the ability of people to safely operate in critical transport environments. The Commission recommends that the Secretary for Transport promotes the introduction of a drug and alcohol detection and deterrence regime for persons employed in safety critical transport roles

Establish quality assurance procedures within Real Journeys to ensure safety critical operational defects are properly addressed.

participate with Hamilton City Council in a review of Norton Road level crossing in Hamilton to include, but not limited to, the design, layout, signage, road markings, warning devices and the alignment of the road approaches and exit's to ensure these are appropriate and take steps to rectify any shortcomings identified.

Incorporate in the company safety management system, instructions to masters requiring them to operate the bridge with at least one other crew member during manoeuvring situations.

On 24 April 2024 the Commission recommended that KiwiRail review its adverse weather response system and processes to ensure they are effective in maintaining a safe rail network.

Ontrack’s system for ensuring staff competency and currency with rules and operating procedures has not been audited for 2 years, and in spite of the person-in-charge of the accident site at Ohinewai holding current Ontrack certification for his duties, he had not been properly inducted into a new work environment, he was not following documented procedures, and he together with other crew in similar roles was routinely violating documented procedures for work site protection.

Critically review policy for train control rosters with respect to allowable numbers of consecutive shifts and hours worked to ensure: · mini rosters are controlled within defined criteria compatible with the principles used in compiling base rosters. · defined criteria are met before offering additional shifts to train controllers. · actual hours are monitored and immediate corrective action taken when factors increase rostered shifts beyond acceptable limits.