Inquiries & Recommendations

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Arrange for Piper Service Bulletin SB 893 "Nose Gear Centering Attach Bolt" to be amended, so that the instruction step 6©, which is to check for installation of placard p/n 582-943, is performed each time the SB is referred to.

Advise members that these aircraft should be flown only by experienced pilots.

Take steps to ensure that before introducing operational innovations such as the Otira Tunnel ventilation system that adequate structured risk assessments are carried out, and recorded, to achieve the intent of the company safety system.

Take the appropriate steps to ensure the main undercarriage axle part and serial number remains accessible visually after all protective processes have been completed.

determine maximum allowable speeds for all shunt movements when operating in sidings, regardless of whether or not discharging or loading of wagons is taking place, and include such information in the relevant yard and siding instructions and agreements.

All new operators of high speed craft, and all operators of new high speed craft be made to comply with Chapter 18 of the HSC Code.

Ensure that the rubber door seals used on the bi-parting doors of passenger cars are of a material type and profile that allows trapped limbs to be freed with minimal discomfort to the person caught between the doors

The track protection matrix contained in the Rail Operating Rules and Procedures is not clear on requirements for work site protection in some cases, the rail recovery unit being one example.

The KiwiRail medical assessment process did not ensure that the employee being assessed completed the online medical questionnaire themselves. There is some evidence that the system could potentially allow managers or others to complete the questionnaire on the employees’ behalf. On 23 August 2018 the Commission recommended that the Chief Executive of KiwiRail improve the health assessment system to ensure that the periodic medical check system captures data directly from the subject.

Educate pilots on the benefits of transmitting AIREPs, and amend the AIP to better reflect the objectives of the AIREP

Promulgate as soon as practicable, by NOTAM or otherwise, a warning to pilots that the information on approach plates, which relates to spot heights and lights, may be incomplete an in particular the highest ground in the immediate area of the spot height may not be depicted.

Review Flightline's Rolls-Royce Allison 250-C20B engine trouble-shooting procedures, and ensure comprehensive fault diagnosis is carried out when a repeated component change does not rectify a known problem.