Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

The formation leader rely on his own judgement if he doubted a person's fitness to fly rather than seek a subjective reassurance from that person in front of his peers.

Evaluate the use of purpose manufactured ropes as soon as practicable.

Encourage operators of aerodromes to apply suitable technological measures to complement procedural defences against runway incursions.

Address the safety issue of emergency locator transmitters sometimes being installed in a way that affects their crash survivability.

Withdraw the Permit-to-Fly from Pterodactyl Ascender II + 2 microlight aircraft.

Establish an understanding with CAA/ACNZ on the need or otherwise for military aircraft to exceed the promulgated airspeed restrictions in controlled airspace.