Inquiries & Recommendations

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The wire pennants parted under tensile overload because they had all been significantly weakened by severe corrosion. Corrosion had gone undetected inside a plastic sheathing that the manufacturer of the lifting sling had placed around the wire pennants. The presence of the plastic sheathing encasing the wire rope meant that neither the crew nor the various surveyors tasked with inspecting the launching system could inspect and maintain the wire rope as required by SOLAS.

Amend NZCAR C3 to specify the direction in which dump levers are to be operated to dump the load.

Continuation training requirements be stipulated in Operator's Training Manuals.

Takes immediate steps to review the security of the main line adjacent to the Hutt Timber siding at Tokoroa and initiate action to protect the main line from any runaways which may occur.

Critically review the scheduling and manning level of all Pacifica ships, and ensure that the maritime rules for the prevention of fatigue can be complied with, and if not, take the necessary action that will enable crews to safely operate the company ships in compliance with the rules.

Require his Rules Rewrite Team to review the requirements for gaining an approval to conduct an air show to: • Ensure the CAA approval for the event is not given until agreement is obtained from the military that they will comply with the relevant civil requirements and the specific provisions for air traffic control during the event have been reviewed in detail.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

develop educational material for FAA airworthiness personnel to raise awareness of the need for them to recognise and respond to documented inadequate identification of critical lifed components when checking aircraft maintenance documents.

Advise all Hughes 369 operators to ensure that N2 governor (beep) switches, and other toggle switches, are securely fastened to prevent any abnormal movement.

Considers the use of key performance indicators to define trespass problems at high risk localities and assess the effectiveness of any improvements made to reduce risk.

Consider establishing a requirement for a minimum level of experience for controllers who perform solo duties.

Educate pilots about the objectives and application of operations under special visual flight rules.