Inquiries & Recommendations

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Publish advisory information about the torque gauge oil line system on the Hughes 369 helicopter type, so that operators and pilots may better understand the significance of the system, and what the appropriate pilot response should be to an abnormal torque gauge indication in flight.

Conduct an audit of, and modify as necessary, the existing flight monitoring system and associated procedures to ensure controllers are made aware of aircraft on conflicting tracks, particularly those aircraft flying in opposite directions on the same track.

Obtain a copy of and implement on board all vessels operated by his company the "Safety Guidelines for Small Commercial Fishing Vessels" as issued by FishSAFE organisation with particular reference to the more pertinent sections on fatigue management and the fitting of a watchkeeping alarm.

introduce a system to ensure road knowledge certification is for a limited, finite time and that subsequent recertification requires a defined criteria of route usage by individual LEs to remain current.

On date the Commission recommended to the Director of Civil Aviation that he monitor the progress of the investigations by Air Nelson and Bombardier Aerospace into the causes of excessive wear in Q300 nose landing gear door actuators (part number 2011-4504) and liaise with Transport Canada in order to produce acceptable corrective actions

The pilot on this occasion did not make what would have been an appropriate urgency or distress call when faced with a strong smell of fuel and the single engine indicating reduced performance. The Commission has commented in previous reports on the need for pilots to declare the appropriate level of urgency using the standard phraseology for the situation.

Require proof of a basic knowledge of the sequence of spin recovery as a prerequisite to the issue of any pilot certificate.

The need to encourage good aviation practice to help ensure pilots know how to perform an effective visual scan and how to actively listen to radio calls.

Take immediate steps to promulgate information on the prediction and avoidance of low level turbulence to its members. [This recommendation was also repeated in report 92-001]

It is a safety issue that there appears to be a disparity between the operating limits and designation of the Coastguard vessels and the types of extra curricular work the vessels are engaged in and the qualification requirements of the skippers of Coastguard vessels.

On 27 July 2016 the Commission gave notice to the Director of Civil Aviation that a recommendation has been made to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan