Inquiries & Recommendations

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On 25 March 2026, the Commission recommended that KiwiRail effectively implement the decision-support system for its vessels’ engineering departments and regularly exercise it to ensure crew familiarisation and its effectiveness.

On 25 February 2026, the Commission recommended that Airbus revise its standard documentation about operating the thrust levers in the Flight Crew Operating Manual and the Flight Crews Techniques Manual, to ensure that pilots are fully aware of the risk of unintentional thrust lever positioning so they can be more prepared to operate the thrust levers and correctly select their intended settings.

On 30 July 2026, the Commission recommended that the Chief Executive of KiwiRail review the procedures that apply to track workers carrying out work within tunnels, to ensure they are clear and unambiguous as to the requirement to advise train control before entering a tunnel.

On 30 July 2026, the Commission recommended that the Chief Executive of KiwiRail take action to improve communication to ensure it includes the correct methods of communicating safety-critical information when using mobile phones.

On 30 July 2026, the Commission recommended that the chief executive of KiwiRail review and improve the protection planning process to ensure all associated risks controls are applied and the practicality of the protection is considered when selecting the worksite protection method.

On 30 July 2026, the Commission recommended that the chief executive of KiwiRail implement procedures to formally audit worksite rail protection measures being used by RPOs to ensure they are complying with protection requirements.

On 26 August 2026, the Commission recommended that Pratt & Whitney Canada, as the engine manufacturer for the PW127M engine, take action to ensure the engine quality assurance procedures during engine overhaul are able to identify pre-existing fatigue and ensure the continued airworthiness of the subject engine.

On 26 August 2026, the Commission recommended to the Chief Executive Officer of Air New Zealand that Air New Zealand review the Findings and Safety Issues contained within this report to identify further enhancements to crew evacuation training, training realism, passenger safety briefings, safety cards and evacuation commands with the objective of improving crew and passenger preparedness for emergency evacuations.

On 27 August 2026, the Commission recommended that Air New Zealand continue to work with De Havilland Canada for the provision of a technical solution that enables the flight management system to calculate a smooth descent flight profile through transition, thereby avoiding a procedural work-around that increases the likelihood of flight crew error.

On 27 August 2026, the Commission recommended that the Civil Aviation Authority promotes, through the appropriate International Civil Aviation Organization forum the need to extend the current CVR recording requirements to include all transport aircraft currently required to have a recorder fitted.