Inquiries & Recommendations

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Research what additional training for pilots should be carried out, with regard to the physical and psychological conditions that lead to errors of judgement and violation of rules and procedures, to better equip them to make sound command decisions, prior to being permitted to engage in air transport operations.

Evaluate all company vessels and where practicable fit fixed fire smothering systems in the engine-rooms.

confirm with Toll Rail, that the underframe equipment on the DMU fleet is currently at an acceptable standard of cleanliness and that the established inspection and maintenance procedures are appropriate to maintain those standards.

Require Airways to enhance the Auckland International Airport AIP arrival and departure information so the words "normal operations" are not selected for use in ATS communications when any non-normal operations are in effect.

It is a safety issue that the Coastguard did not have a process requiring its crews to undertake pre-departure planning when tasked to an incident thus increasing the risk of an accident occurring en-route to the incident area. It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc ensures all Coastguard crews conduct an appropriate pre-departure plan , that includes a risk assessment, and that the plan is reassessed at appropriate times as the rescue scenario unfolds.

That attention by drawn, once again, to the insidious hazard of low strung wires, to any aircraft which has descended to low level in an area with which the pilot is unfamiliar, or where the pilot has not positively confirmed that no wire hazard exists.

Locomotive operating instructions do not address the effects of power braking on train stopping distances, particularly in situations requiring emergency brake applications.

Review and improve the process which is intended to correlate amendments to the associated manuals when the Company makes a decision to modify equipment, to ensure any consequential amendments in the standard operating procedures are detailed in writing as soon as the modifications are embodied.

Investigate, possibly in conjunction with the Milford Sound Development Authority, the installation of a remote automatic weather station in the outer part of Milford Sound to give operators contemporaneous weather conditions.

Reinforce with all train controllers the need to monitor actual running times against the scheduled time to complete a track section, and immediately contact the locomotive engineer and his manager when a fast run is identified.

Work with SAR coordination authorities to identify SAR assets that are likely to be routinely called on to act as on-scene coordinators and develop a joint training program that will ensure that they work to the same framework and use the same terminology as the coordinating authorities.

On 25 September 2024, the Commission recommended that Transdev Wellington and Auckland One Rail take action to fit automatic alert systems to emergency brake activations on its passenger train services, to alert train control to an emergency at the earliest possibility.