Inquiries & Recommendations

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ensure that company pilots do not attempt tasks of aircraft maintenance that are beyond the scope of approved pilot maintenance.

On 30 April 2025, the Commission recommended that Yugen Kaisha Chokyu take steps to ensure the effectiveness of its safety management practices with respect to voyage planning and navigation, and take steps to ensure the safe navigation of vessels in its fleet.

Take steps to identify and correct the repetitive non-compliance with Tranz Rail's rules and procedures for safe operation identified during the investigation of this accident.

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.