Inquiries & Recommendations

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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.

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