Inquiries & Recommendations

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KiwiRail's Risk Management Policy for "continuity of core services" did not give proper consideration to the safety of passengers and crew when a core service such as train control failed, causing the widespread stoppage of an entire metropolitan passenger rail system. On 29 October 2014 the Commission recommended that the Chief Executive of KiwiRail revise the risk rating assessment matrix in its Risk Management Policy to reflect the fact that train control is a safety-critical service, and to consider the safety of people in crowds when assessing and mitigating the risks.

Conduct a programme of education for aircraft operators, airport operators, and pilots to increase their familiarity with emergency communications and their understanding of the need for a prompt declaration if assistance was required, particularly if the actual status of the aircraft was in doubt.

Include in an advisory circular to Maritime Rule Part 90A [Pilots' Qualifications] the minimum standards that a monitoring and currency system for maritime pilots must meet.

When railway crossing alarms are disabled, a temporary road traffic speed restriction and suitable warning signs, accompanied by suitable hazard lighting during the hours of darkness, be placed on the approaches to the crossing.

They review with the subcontracting cable suppliers whether there is a need to impose a life or additional inspections on their winch cables to ensure the sacrificial wear between strands does not jeopardise the safety of winch operations.

Ensure that Maritime New Zealand has an adequate system for monitoring the performance of marine surveyors.

Educate pilots of the requirement to make a radio call when becoming visual on an instrument approach.

Require the Airways Corporation to ensure that its staff comply with the requirements of the Manual of Air Traffic Services.

There is a heightened risk of trains colliding within the approaches to Wellington Station because limited available space makes the track layout congested. The existing layout means there are fewer safety overlaps designed into this area and fewer fail-safe back-up systems in place in the event of a driver failing to stop at a red light. Any increases in commuter train services into and out of Wellington through this tight track layout increases the pressure on this bottleneck area, and in turn increases the underlying risk of relying on train drivers to stop at red lights.

Consider introducing a procedure whereby the ground-crew check with the pilot that a glider's airbrakes are locked prior to attaching the cable.

They discuss the circumstances of this accident with the Rangitikei District Council to determine the most effective way of warning local citizens and others of this particular hazard.

Take immediate steps to control the weld repair of safety critical components to recognised standards to ensure the integrity of the original installation is retained.