Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure that the rubber door seals used on the bi-parting doors of passenger cars are of a material type and profile that allows trapped limbs to be freed with minimal discomfort to the person caught between the doors

The track protection matrix contained in the Rail Operating Rules and Procedures is not clear on requirements for work site protection in some cases, the rail recovery unit being one example.

The KiwiRail medical assessment process did not ensure that the employee being assessed completed the online medical questionnaire themselves. There is some evidence that the system could potentially allow managers or others to complete the questionnaire on the employees’ behalf. On 23 August 2018 the Commission recommended that the Chief Executive of KiwiRail improve the health assessment system to ensure that the periodic medical check system captures data directly from the subject.

Educate pilots on the benefits of transmitting AIREPs, and amend the AIP to better reflect the objectives of the AIREP

Promulgate as soon as practicable, by NOTAM or otherwise, a warning to pilots that the information on approach plates, which relates to spot heights and lights, may be incomplete an in particular the highest ground in the immediate area of the spot height may not be depicted.

Review Flightline's Rolls-Royce Allison 250-C20B engine trouble-shooting procedures, and ensure comprehensive fault diagnosis is carried out when a repeated component change does not rectify a known problem.

In conjunction with the relevant local Councils and New Zealand Rail Limited, examine the feasibility of restoring the pedestrian right of way which previously existed adjacent to State Highway 2, between Horokiwi Road and Petone Bridge.

ensure that following initial training and certification, new entrant train controllers do not commence training on another train control desk until they have completed at least 12 months duty on their first train control desk

Tranz Rail liaise with Buller Port Services to find a permanent solution to minimise the effect of the yard lights on vessels navigating in the port area without compromising the safety of personnel working in the rail operating yard.

Issue instructions for controllers to utilise adjacent PVD to provide additional information and thereby avoid continual scale changes on their own screen.

Establish installation and maintenance standards for driveshafts and instruct all relevant maintenance staff in their use.

Complete the recommendations of the independent report, New Zealand Aircraft Icing Hazards, in particular: a. ensure all IFR operators provide adequate written guidance for operations in adverse or hazardous weather conditions, b. Audit air operators to ensure they have clear and unambiguous procedures for avoiding not only turbulence and thunderstorms, but also severe icing conditions, and