Inquiries & Recommendations

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Review the qualifications structure and the seagoing limits so as to ensure that the intent of the Commission's recommendation 028/05 is upheld.

Require Safety Officers in charge of auto tow operations to ensure each pilot is familiar with the procedure to be implemented in the event of a rope break and

Review the desirability of allowing the vehicles defined in part viii, clause 27 of the New Zealand Railways Corporation (General) Regulations 1982 to continue to have unrestricted access over level crossings and to impose any conditions considered necessary to improve the safety of such operations.

Equip each of his aircraft with adequate means of securing baggage and cargo.

Train drivers becoming distracted and forgetting the aspect of warning signals their train has recently passed is a known risk to the rail industry. The signal alert device that was installed in train cabs to help drivers remember the aspect of the last signal their train had passed was not used by the driver on this occasion and was not widely used by other drivers because, once activated, the alarm sounded for 6 seconds and could not be cancelled and the sound was easily confused with other in-cab alarms.

amend Rule 905, Compulsory Stop Protection, to allow the site protector to give authority to the driver of a rail vehicle to pass the compulsory STOP board and proceed to a location short of the worksite. Where circumstances change, the site protector must be contacted to authorise all subsequent rail vehicle movements within the work area.

Review the adequacy of the current protection rules applicable to track workers.

On 13 December 2018 the Commission recommended that the Chief Executive of the NZ Transport Agency work with licensed rail access providers and road controlling authorities to ensure that they meet their responsibilities for maintaining sighting distances at public road level crossings.

Develop a standard for auto tow systems to meet and require each system to be approved by the Club Safety Officer.

Require operators of aerodromes that have taxiways joining a runway at an oblique angle to prescribe the procedures and conditions, including the environmenatal conditions, under which the taxiways may be used to enter the runway.

This incident highlighted a number of individual failures in the system for managing aircraft separation within the Auckland Terminal sector, the busiest sector within the New Zealand air traffic control system. Together with the findings of the NOSS, this indicates that a deeper systemic issue within the overall management of the sector may exist.

The operating handle of the watertight door protruded into the doorway when it was in its opening position which was why the door could not be opened when the engineer was trapped. The Commission recommends that the manufacturer assess the design and/or installation of the doors such that this safety issue is resolved. The solution should be promulgated through the International Association of Classification Societies (IACS) and any other way it can.