Inquiries & Recommendations

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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.

Implement the requirements of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] Section 4 [Watchkeeping] for all vessels under the SGS M&I Safe Ship Management system. [This safety recommendation was subsequently found to be equally applicable to two other occurrences. Refer to reports 04-207 (grounding of fishing vessel "Poseidon" on 15 April 2004) and 04-209 (collision of fishing vessel "Joanne" with motor tanker "Hellas Constellation" on 19 May 2004).]

require all operators of the Piper PA 23-250 Aztec aeroplanes that are subject to AD DCA/PA-23/155A, to replace the gear selector lever with the new improved version, part number 761213, as soon as practicable.

On 30 July 2015 the Commission recommends to the Chief Executive of the NZ Transport Agency that from a regulatory perspective he take the necessary steps to ensure that the relevant Safety Case(s) and resultant safety system(s) (including any lease or access agreements made under those systems) expressly articulate which party or parties is responsible for controlling and protecting pedestrians as they cross the boundaries between railway stations and the rail corridor.

The present severe weather warning system described by Rail Operating Rules and Procedures Section 1, Rule 6(b) does not require feedback from area managers to the network control manager on receipt of severe weather alerts, which creates an open loop information flow and prevents the network control manager from maintaining an overview of severe weather actions being taken across the entire network. Network control managers spoken to did not see maintaining an overview of actions during severe weather as their responsibility.