Inquiries & Recommendations

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Introduce a system where each set of bags has an identification mark that can be used to trace their movement and repair.

Notwithstanding the fault in the mimic screen, the signallers had a surprising lack of familiarity with the physical layout of the yard they were controlling, particularly as one of the signallers had some 13 years’ experience in the Wellington signal box. The fact that no-one was aware that the mimic screen was not representative of the actual yard layout is an issue.

the river VHF radio channel is available solely for radio traffic necessary for the safe operation of jet boats on the river. This channel should be monitored by all operators and their boats and used for the passing of safety information, including the disposition of private jet boats on the river. A separate VHF radio channel should be utilised for routine radio traffic of the commercial operators.

On 25 October 2017 the Commission recommended that the Director of Civil Aviation include the safety issue of helicopter operational culture in its current ‘sector risk profile’ review.

The Commission recommended that the Maritime and Port Authority of Singapore investigate and, if necessary, review their audit processes to see if they can be further developed to identify weaknesses in the safety management system and their practical implementation on-board vessels under their flag.

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

Submit a copy of Commission’s report 01-211, together with the Maritime Safety Authority final report into the same incident, to the Maritime Safety Committee of IMO to support the work and initiatives now being conducted by both the Marine Accident Investigation Branch and the Maritime and Coastguard Agency of the United Kingdom, regarding the safety of lifeboats and lifeboat drills. Any review conducted by IMO should consider reported accidents worldwide, with particular emphasis on lifeboat/rescue boat launch and recovery systems.

The training provided by Polynesian Airlines to their security officers include safety procedures for working around aircraft on the ground and knowledge of the relevant parts of the Airline's traffic Safety Manual.

Require that where a secondary electrically driven submersible bilge pump is fitted, it meets the requirements as prescribed in Maritime Rule Part 40D 28(6).

Reviews the procedures for converting used rolling stock purchased overseas to ensure: variations within the stock purchased are recognised and provided for, each modification required for safe operation on Tranz Rail systems is identified, the modifications required are designed, and installation managed, to ensure controlled implementation.

Amend all Company Manuals which refer to the operation of the actuators in the lateral load guides on the B767 in-hold loading equipment to ensure they describe the correct method of operation of the guides i.e. that they are operated manually instead of the automatic operation detailed at present.

On 27 March 2024 the Commission recommended that KiwiRail provide Gangers with the necessary resources to enable them to supervise and train track workers safely and effectively while also completing work tasks