Inquiries & Recommendations

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advise all operators of steam locomotives of the need to use borosilicate glass tubes in sight gauges, with all such gauges to have a safety screen in front of them.

Fit a device to the aft steering wheel to secure it against inadvertent operation. Such a device should be quick-release to allow instant helm control should it be required in an emergency.

The current requirements for communicating the status of main-line points at crossing stations within single-line automatic signalling territory results in a potential single point of failure where the consequences could be a high-speed rollover, derailment or collision.

Require a one time inspection of all aircraft which have a radio altimeter installed to determine whether the radio altimeter antennae are free from paint.

On 15 May 2024, the Commission recommended that the Secretary for Transport and the Director of Civil Aviation resolve the ambiguity in the definition of ‘crew members’ in commercial transport operations and take steps to clarify the use of the term in associated rules and Advisory Circulars.

He facilitate the ratification by the appropriate parties of the proposed new code for Road Signs and Markings for Railway Level Crossings and their agreement in regard to implementation.

Review the existing visual signals in use between tug and glider pilots and re-promulgate the list of standard signals to be used by the pilots of all clubs which are members of the Association in the form of a poster or other aid likely to be a constant reminder to all tug and glider pilots.

As the results of the Australian Ultralight Federation's wing tests were circulated to Resurgam owners in Australia and New Zealand, it was not considered necessary to make any additional recommendations.

There were 2 safety issues identified with the Wellington maintenance depot processes: - there were no individual task instructions on how each job was to be done - there was no check sheet associated with each task to record that important steps and checks for the task had been completed. Instead, the depot relied on the knowledge of the depot staff to complete each task satisfactorily. These shortcomings in maintenance control could be indicators of other safety issues within the wider maintenance system at the Wellington maintenance depot.

Schedule planned maintenance programmes for the examination of automatic air brake valve handles to ensure correct operation.

Include an article in the Seafood New Zealand magazine featuring the report into this tragic accident highlighting the part played by minimal stability and the consumption of cannabis.

Introduce procedures that define permanent, pre-determined call locations on routes under track warrant control, from where locomotive engineers must call train control to confirm their whereabouts; together with a requirement that if such calls are not acknowledged by train control, the train must stop at the next track warrant station or designated intermediate board until communication is established.