Inquiries & Recommendations

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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

At the time of the grounding there was uncertainty between Maritime New Zealand and the owner of the Anatoki on what was a suitable level of crewing for a ship of that size and tonnage. The relationship between New Zealand and international standards for crewing ships is unclear and appears complex. The Commission recommends the Director of Maritime New Zealand resolves the correct level of crewing for the Anatoki and clarifies for industry the relationship between New Zealand and international crewing standards. (018/12)

Encourage Locomotive Engineers to draw attention to any timetables which could not be achieved within normal running speeds.

15.2.8. The Commission recommends that Standards New Zealand submit the Transport Accident Investigation Commission’s report MO-2013-203 DEV Aratere, Loss of propeller, Cook Strait, 5 November 2013 to the ISO Secretariat for its information and to consider whether the current standards for manufacturing large-diameter marine propellers are appropriate for modern, high-efficiency propellers that operate closer to cavitation margins

Improve methods of identifying rail siding operators and ensure that all identified operators are licensed or exempted as appropriate.

Through the approval process for New Zealand port and harbour safety management systems, encourage port companies and administrations responsible for navigational safety in ports with a high or complex traffic flow to consider establishing vessel traffic management services to one of 3 levels contained in IMO resolution A.857(20)

Specify maximum operating parameters for each of the vessels operating in Milford Sound, or put in place guidelines and procedures to assist masters to decide on the maximum safe operating weather conditions.

He redraft paragraph 3.3.1 on page MET 3-2 of the Aeronautical Information Publication to clarify whether or not the General Aviation Weather is intended for use by pilots planning VFR air transport operations.

Ensuring the completeness of a train following a train parting or similar event is a safety-critical procedure for protecting against wagons being inadvertently left behind and creating the potential for a high speed collision in track warrant territory. The Commission believes that the circumstances where the procedure for ensuring the completeness of the train was so easily by-passed on this occasion is a safety issue. The Commission recommends that the New Zealand Transport Agency addresses that safety issue.