Inquiries & Recommendations

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The Spherical Thrust Bearings remained in service in an unserviceable state despite inspections by various engineers and the pilot over the preceeding 18 months. This may indicate that the documented inspection procedures for the bearings are not being followed correctly or that the procedures need to be examined for their adequacy.

ATC, having cleared an aircraft to make a non-standard circuit, is not prevented from concurrently clearing a following aircraft to join the circuit by the standard overhead joining procedure, even though that could lead to a head-on traffic conflict.

define criteria for clinical parameters, such as peak aortic velocity, that would limit the risk of sudden incapacitation in pilots with mild heart valve disease to within acceptable limits, and establish appropriate medical surveillance criteria.

Implement a formal system that: • notifies surveyors of current and emerging changes to maritime rules for the construction, maintenance, and surveying of vessels • clarifies, where needed, the intent and application of maritime rules and other relevant standards

An additional statement made in paragraph 2.1 to the effect that if communications are interrupted after approach clearance is received, the approach profile is to be flown irrespective of any previous height limitation.

The Commission has determined that there is no requirement for the carriage or wearing of life jackets on a flight during which, in the event of a forced landing, a water landing was likely or preferable. The Commission recommends that the Director of Civil Aviation addresses this safety issue.

uses the most prudent and practical method available to them to disseminate information to owners of PC3 engines regarding modifications to the connecting block assemblies.

Short breaks be planned at hourly intervals on this type of operation.

The Commission recommends that Pacific International Line disseminate the findings and lessons arising from this report to its fleet and audit the navigational practices of its fleet for compliance with the COLREGS at all times.

Include an article in the Seafood New Zealand magazine featuring this report, the intent of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] together with its advisory circular and the work of the Maritime Safety Authority convened Fishing Industry Safety and Health Advisory Group (FISHgroup).

quantify lengths of CWR that have an unknown neutral temperature and ensure they are assessed, and protected where appropriate until destressing can be arranged. [SR repeated in report 02-104: 3 separate track buckle occurrences on the South Island coal route during the summer of 2001/2002.]

modify the side shroud panels of the DMU ADC cars to improve access to the auxilary engines.