Inquiries & Recommendations

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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.

Remind pilots and operators of the correct meaning of the "Urgency" and "Distress" messages. The correct use of pro-words together with information about what actions will be taken by ATS on receipt of distress or emergency messages should be covered. The fact that a message can be easily cancelled, if the situation of the aircraft improves, should also be emphasised.

Emphasise the need for loading foremen to be particularly vigilant while loading is taking place in an environment of disruptions or other factors which minimise the time available for loading or require the supervision of the loading of more than one aircraft at a time.

Remove the present substantial concrete gate posts on the extended centre line of runway 05 and replace them with a light weight frangible structure to reduce the hazard to overrunning aircraft.

On 26 February 2025, the Commission recommended that Next Generation Critical Communications lead the establishment of a common communication platform for emergency services, to support the sharing of inter-agency communications to remove delays and improve the flow of information during an emergency response.

Promote ongoing understanding of ‘simultaneous operations’, including a published definition and how the practice relates to parallel runway operations at unattended aerodromes.

Draft an amendment to Maritime Rule 34[Medical Standards] for the Minister’s consideration, to require medical practitioners to consider if there is evidence of any such sleep disorders or fatigue when conducting their examinations