Inquiries & Recommendations

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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.

Ensure that operators include in their expositions relevant operational material for night VFR flights.

None of KiwiRail's staff involved with loading and securing the wagon body was sufficiently familiar with the KiwiRail Freight Handling Code to realise that the securing arrangement was not compliant with the Code. KiwiRail had a responsibility to ensure that staff was trained and competent in all tasks being undertaken. It had to ensure that the loading and stowage of goods on railway wagons were carried out by people with the appropriate training and certification.

He review the present provision in CASO 20 Part 9 with a view to requiring operators to obtain specific permission for air transport operations at low level irrespective of whether or not they are planned over populous areas.