Inquiries & Recommendations

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ensure that where a train control shift is extended beyond 8 hours a mandatory break of at least 15 minutes is available to the train controller as close as practicable to the start of the shift extension.

At the time of this incident KiwiRail’s safety system could not ensure that infrastructure staff were competent to perform their roles, and could not ensure that the appropriate safety observations and revalidations of current staff competency had been undertaken.

The adequacy of existing restraint systems installed in aerial work helicopters for the use of shooters be considered as a matter of urgency.

draft an amendment to Rule Part 40C.60 Design, Construction and Equipment - Non-Passenger Solas] for the consideration of the Minister to include an additional requirement that ships towing in pilotage operations must be fitted with either a towing hook that has a positive means of quick release or a towing winch that has means of rapidly paying out when under load, either of which must be controllable from the conning positions and at the hook or winch.

in conjunction with the operating companies and using Signalling and Interlocking diagrams as the standard, institute a policy for the agreement and adoption of appropriate siding names connected directly to the controlled network on the diagram

Undertake a hazard identification audit of his operation, with special regard to the particular risks associated with operating from a launching ramp close to a bridge, where strong river currents may be experienced.

Ensure that waivers of the wake turbulence separation standards are: (i) restricted to VMC, by day only; and (ii) specifically acknowledged by pilots with words such as "ACCEPT WAIVER"; and (iii) not permitted under certain circumstances, for example: when a light aircraft: (a) will take-off behind a heavy or medium aircraft from a point on the runway more than 150 m beyond where the heavy or medium aircraft started its take-off roll; or

correct inconsistencies identified in the Foul Time Rule 918 and Rail Operating Code relating to safety buffer, clearance of occupations and safeguarding positions when circumstances alter.

It is advisable that the responsibilities of the various authorities involved in responding to a shipboard fire are clearly documented and understood by all parties involved. The FENZ Ship Fire Procedure did not accurately reflect the obligations of the master and the harbourmaster, which under different circumstances with different people involved could be problematic.

On 15 May 2025, the Commission recommended that Maritime New Zealand work with the Ministry of Transport to continue to develop and then implement a more comprehensive maritime incident response strategy that includes a risk assessment to identify areas most susceptible to very serious marine casualties, particularly mass fatality events, and strengthen the long-term salvage and rescue capability in those areas.

participate with Selwyn District Council and New Zealand Railways Corporation in a review of Browns Road level crossing at Dunsandel to ensure that the design, layout, signage and warning devices, together with the alignment of the road approaches, are appropriate and take steps to rectify any shortcomings identified.

He installs, although not required under SOLAS, an ARPA to one of the radar sets on each vessel under his management.