Inquiries & Recommendations

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Arrange a meeting with the RNZAF and ACNZ to review the RNZAF's understanding of the observance of the airspeed restrictions in controlled airspace.

Forward this report to Panama, the Flag State for the Taharoa Express, and work with it on how it is going to address the issue concerning the past and current loading procedure for the Taharoa Express, which results in the ship sailing with the iron sand cargo above its transportable moisture limit, without a formal assessment having been conducted to determine whether the cargo is capable of liquefaction under normal load and transit conditions, and without determining whether the Flag State Panama should grant an exemption for sailing with its cargo above transportable moisture limit.

A blanket or other means of keeping warm be available for each passenger on flight involving landing at exposed or remote locations.

The company allocate staff to provide positive supervision of embarking and disembarking passengers on open apron areas.

Change the system for reporting fire alarms to ensure both the fire zone and the corresponding space are identified

On 15 May 2025, the Commission recommended that Maritime New Zealand collaborate with other states to submit joint papers to the IMO (through the appropriate sub-committee) recommending the IMO: b. amend the ISM Code (or through another mechanism) to ensure ship owners remain accountable for the safe operation of their ships, notwithstanding the use of ship management companies to operate their fleets. [024/25]

Review the status of the Flight Safety Co-ordinator to ensure that officer has a balanced input from the company's management, operations, and engineering staff on which to base an accident prevention programme.

Provide an air compressor for refilling breathing apparatus bottles to each of the company vessels fitted with self-contained breathing apparatus.

Promulgate a recommendation to all operators of Cessna A188 aircraft, advising the installation of diagonal bracing of the seat legs and a larger diameter seat locating pin.

Remind pilots of the actions for an engine failure after take-off as contained in the Civil Aviation Authority’s Flight Instructor’s Guide, and the benefit, if time permits, of changing fuel tank selection should a sudden, total and unexplained power loss occur.

They review the wording of clauses 3.8.4 and 3.8.5 of section L4 of the Working Timetable with a view to explaining clearly the situation which arose in this incident i.e. the need to reset the alarms if sequential berthing on the main line and loop occur at Eltham, and the crossing alarms cancel after the passage of the northbound train.

The number of defects that are causing incidents and accidents in New Zealand pilotage waters is of concern. It is an indication that New Zealand port and harbour authorities cannot totally rely on the International Safety Management system to ensure that vessels transiting New Zealand ports are operated safely and efficiently. Minor technical defects and human performance issues are often lead indicators of deeper systemic safety issues on board a vessel.