Inquiries & Recommendations

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Instigate regular training of his drivers, paying particular attention to unexpected events so that they can react automatically.

liaise with the Auckland Regional Council and Maritime Safety Authority and install appropriate lights on all the unlit beacons in Papakura Channel

Keep the ban on the use of the viewing platform in force until: a review of all aspects of the design, inspection and maintenance of the safety rails is completed; all remedial action is taken; and the safety management of passengers is reviewed, including an assessment of the need to provide signage, the languages in which any such signage is displayed; the supervision of children, particularly unaccompanied children; and the introduction of a safety briefing by the train Manager as the train departs.

revise Engineering Rules and supporting procedures and training to: 1. include requirements for multiple work groups within Conditional Stop Board Protection 2. define procedures to be followed when protecting multiple work groups, such procedures to include repeat-back requirements similar to those used in issuing track warrants, and an auditable Site Control Sheet to be held by the person in charge covering all approved work groups within the protection 3. structure the Site Control Sheet to allow such key information as:

Include in an advisory circular to Maritime Rule 90 [Pilotage (Appointment of Pilots and Pilotage)] minimum standards that a monitoring and currency system for pilot exempt masters must meet.

Establish the main ferry routes within Auckland enclosed water limits and arrange to have them marked on the appropriate charts with an appropriate warning for other harbour users that ferries regularly ply those routes.

Conduct a review, in consultation with RCCNZ, to ensure that maritime rescue plans are in place and put into practice where appropriate, for areas of increased water-based activity nationwide.

engineering standards consistent with world standard practice are identified and adhered to manufacturers’ inspection, repair and maintenance instructions are documented and followed safety critical components are identified and documented.

Approach the local air traffic service provider and local User Group to discuss the justification and acceptability of developing standardised procedures for the co-ordination of aircraft flying through Kawarau Gorge.

Consider introducing a procedure whereby the ground-crew check with the pilot that a glider's airbrakes are locked prior to attaching the cable.

They discuss the circumstances of this accident with the Rangitikei District Council to determine the most effective way of warning local citizens and others of this particular hazard.

Take immediate steps to control the weld repair of safety critical components to recognised standards to ensure the integrity of the original installation is retained.