Inquiries & Recommendations

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4.2 On 27 July 1988, following a separate accident it was recommended to the Director of Civil Aviation that he: Require aircraft maintenance engineers to render inoperable or remove any unserviceable equipment in an aircraft which if used may endanger the safety of flight. Consider requiring or recommending the fitting of carbon monoxide detection discs where there is a potential for contamination of an occupied area with this gas.

Incorporate any manufacturer’s recommended maintenance schedule in the Shotover Jet inspection and maintenance system.

Require his Rules Rewrite Team to review the requirements for gaining an approval to conduct an air show to: • Assign a CAA Officer to ensure the Organiser of any air show complies with the approval throughout the running of the event.

Provide road vehicle access, or alternative transport arrangements, to the northern portal of the Rimutaka Tunnel which gives emergency services the ability to respond at the northern portal in a manner similar to that achievable at the southern portal at Maymorn.

Provision be made for continuous weather information to be available from key areas such as the McKinnon Pass and the Upper Hollyford Valley to ensure that the normal VFR weather minima could be observed while transiting the passes.

They advise each roading authority in New Zealand that they should consult with NZRL before revising lane markings on the approaches to level crossings.

Consolidate and clarify procedures to avoid conflicting movements in the Auckland Freight Centre and include procedures for the dispatch of trains.

On 25 October 2023, the Commission recommended that KiwiRail undertakes a review of its non-technical skills training to ensure it provides adequate training on how to work together to manage threats.

On 25 September 2024, the Commission recommended that KiwiRail review the trigger settings of its rainfall-monitoring equipment and weather risk matrix to ensure they can identify and respond to moderate or heavy rainfall that occurs within a short time period.

On 24 March 2026, the Commission recommended that the chief executive of KiwiRail take immediate steps to improve the safety culture of their staff at Port Otago rail yard to increase compliance with KiwiRail’s Operating Rules and Procedures and reduce at-risk behaviours.

On 24 March 2026, the Commission recommended that the chief executive of KiwiRail take steps to ensure that when the emergency stop button is applied on its remote-control packs, there is an emergency alert automatically sent through to train control.

On 25 February 2026, the Commission recommended that NZTA, when monitoring KiwiRail’s performance against their safety objectives, including monitoring of key performance indicators, ensures that the safety risk of KiwiRail’s high signal passed at danger ratio is being well managed and controlled, including in non-metro areas.