Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The level of compliance monitoring of Ontrack does not appear to be appropriate given the size and complexity of its safety system and the safety issues raised in this report.

Explore the practicability of encouraging the principal of each school in New Zealand to alert their pupils to the potential hazards associated with the railway environment, not only as trespassers, but also as intending passengers or occupants of a railway platform.

Investigate the role of a sole pilot and provide sufficient assistance for that pilot, including regular relief pilot(s) and a system of peer support.

Change the written procedures regarding the closing of watertight doors to reflect the intent of Maritime Rule Part 23 [Operational Procedures and Training]

introduce appropriate and practicable speed restrictions through Tyrees Cut and other similar areas of concern on the river.

On 8 July 2022 the Commission recommended that Pacific International Lines take further steps to ensure that the safety precautions prescribed in its Safety and Emergency Manual are implemented effectively on board its vessels.

Ensure Train Managers are trained to inspect the safety features of the passenger areas of three trains and be required to make such an inspection prior to the departure of each passenger service from the terminal stations.

Undertake a review of the current safety management system relating to the installation, maintenance and operation of CWR track, and take appropriate steps to address those failings in the system which were identified as contributory to Edendale, prior to the 1995-96 summer season. As part of this review, particular attention should be paid to: • The adequacy of standards and procedures relating to the installation and maintenance of CWR track. • The compliance with standards and procedures relating to the installation and maintenance of CWR track.

Forward this report to the International Maritime Organization and invite the appropriate committee to note the contents of the report with a view to any future amendments to the Code of Safe Practice for Solid Bulk Cargoes and the Code of Practice for the Safe Loading and Unloading of Bulk Cargoes.

In conjunction with the other commercial operators on the Dart River system formulate a procedure to ensure that: information concerning the presence and intentions of private jet boaters on the river system is promulgated to all commercial operators at the earliest possible time.

Skydive Taupo did not equip its parachute drop pilots with lifejackets and was not required to do so, because its flights from Taupō aerodrome, which used the Taupō aerodrome parachute landing area, remained within gliding distance of land at all times. This accident illustrated how that scenario downplayed the possibility of a pilot having to ditch an aeroplane, or bale out and drift to a water landing. Therefore the Commission is recommending that the Chief Executive of Skydive Taupo investigate options for equipping their parachute drop pilots with effective flotation devices.

On 25 October 2023, the Commission recommended that the Director of Civil Aviation at the Civil Aviation Authority of New Zealand review the suitability of hook and loop retaining straps as a means of securing emergency locator transmitters to airframes.