Inquiries & Recommendations

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Mandate and enforce a traffic management system for vessels transiting Tory Channel that is unambiguous and takes account of the different types and speeds of vessels typically using the passage. When designing the system, consider defining the area of restricted navigation, determine when the inward-bound vessel is clear of the entrance and make the reporting points near the entry to the zone at each end

Require MSA-approved authorised persons to have undergone safety audit training.

That exercise ECGs may only be submitted to the PMO if they are recorded after the patient has discontinued antihypertensive medication for an appropriate period, so that a true maximal heart test can be achieved.

It is probable that if an aid to navigation of some type had been installed on Astrolabe Reef, the Rena grounding would have been prevented. However, there are many such isolated dangers to navigation around the coast of New Zealand. Installing and maintaining physical navigational aids on remote hazards is costly. Virtual aids to navigation are potentially a cost-effective means of marking such isolated dangers.

Redraft the instructions currently in Section 5, clause 1.8, of the Operations Code, to make it clearer under what conditions "absolute necessity" applies when considering the option to signal the movement from a position on the ground.

Use the lessons from this report to educate pilots on some of the common factors in mid-air collisions, and in particular the requirement to know and apply CARs and to address any non-compliance, as appropriate.

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