Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

On 24 September 2020, the Commission recommended that KiwiRail undertake a review of the New Zealand Rail Operating Rules and Procedures to ensure that appropriate guidance is provided for those involved in the operation of work trains.

Inquiries into this and previous incidents involving air traffic controllers have relied on radar and radiotelephone recordings, and the statements made by the air traffic controllers. However, verbal communications between controllers in the same work space is critical and integral element of the process for controlling aircraft but are currently not recorded. Without controller-station local area recordings, investigations will not always be able to identify all the contributing factors to an incident or accident and therefore valuable learnings might be lost.

On 26 April 2017 a recommendation was made to the Director of Civil Aviation that, as a matter of urgency, he use this interim report, the service letter from Eurocopter (Service Letter No. 1727-25-05) and any other pertinent material to remind the aviation industry of the lessons learned from accidents involving sling loads, in particular the use of monsoon buckets during firefighting operations

The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder, ensure that they have identified and assessed the risk of fire in a rail vehicle. The Chief Executive should ensure that they have, as far as reasonably practicable, minimised the risk and have measures in place to deal with the outbreak of, and reactions to, fire events.

Future editions of the Road Code draw attention to need for drivers to ensure that the sound level in their car is moderate enough to enable them to hear the warning devices of emergency vehicles, trains and other cars.

[the LTSA, MSA and OSH] Bring the problem of substandard connections between stacked bases to the attention of safety agencies in other countries where it is considered the use of dissimilar interlocking systems could result in similar substandard practices.

On 26 July 2023, the Commission recommended that Maritime New Zealand alert all Recognised Surveyors: • to the importance of conducting and documenting inspections of a vessel’s complete fuel system during surveys; and • to check vessels they are surveying have undergone a recent complete inspection of the fuel system.

remove or alter the extended plate to the left of the accelerator to prevent the driver’s forefoot from catching on it.

Review the desirability of incorporating such changes to improve the survivability of accidents which may occur to aircraft with the existing seat design.