Inquiries & Recommendations

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attend a bridge resource management course.

Considers amending the Tranz Rail Rules and Regulations to encourage the proactive use of train whistles when approaching level crossings at night.

On 26 September 2019 the Commission recommended to the owner of the Dong Won 701 that they assess the overall fire safety of each vessel in their fleet and ensure that the risks and consequences of fire are reduced to as low as possible, including ensuring that crews are appropriately trained and practised in responding to fires.

urgently undertake a comprehensive risk anaysis of all aspects of the operation of the 'Southern Winds'. This assessment should include the method and chain of command of the shore management team.

Introduce procedures into the leave programmes for track staff, including length gangers and track maintainers, to ensure adequate qualified staff remain on duty or on call to meet operating contingencies during holiday periods and that the names of such staff are advised to train control.

surveys the fixed container lashing points and makes repairs as necessary.

Review the action taken in respect of the Office of Air Accidents Investigation's recommendation that unserviceable flight instruments be removed or covered over so that inadvertent reference cannot be made to them in flight.

Develop educational material to raise awareness of the rules prohibiting cellphone use on IFR flights.

Further explore whether Rescue Coordination Centre should be responsible for tasking and coordinating all SAR aviation assets, as is done overseas.

Ensure each pilot in his company confirm in writing that the/she had read and understood the contents of the company's Operations Manual(s).

The Commission has determined that the current format of the CAA's audit and surveillance programme might not be effective for determining the true level of industry compliance with Civil Aviation Rules. The Commission recommends that the Director of Civil Aviation addresses this safety issue.

Institute a schedule of routine inspections for the equipment once it has been approved.