Inquiries & Recommendations

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Review the NAIAD Instruction Manual and expand it to include full fitting instructions for the bags, and guidelines for the user regarding repair or replacement of wearable parts.

On 26 February 2025, the Commission recommended that Kawasaki Heavy Industries revise the Kawasaki BK117 B-2 Flight Manual to include specific data for Vortex Ring State to assist pilots in avoiding this phenomenon.

In conjunction with the safe ship management company, amend the safe ship management manual, section on emergency management procedures throughout the fleet to ensure in the event of an emergency that at least one member of the crew to be positioned on each passenger deck so as to be able to assist passengers.

The near collision occurred at a convergence of several busy metro passenger lines and there was no automatic protection applied to preventing such a collision in the event of a driver failing to stop at Signal 38. Equivalent signals protecting other lines into Wellington station have been fitted with signal trips that automatically apply a train's brakes in the event of it overrunning the signal. A signal trip fitted to Signal 38 would have automatically applied the passenger train brakes in this case.

install a voice recording system in all major signal boxes under the same conditions and purposes as operating in the national train control centre

complete, as a matter of priority, the tasks that the CAA is required to do to progress the proposed amendments to CA Rule Part 141 (Aviation Training Organisations – Certification) and to CA Rule Part 61 (Pilot Licences and Ratings).

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

On 25 September 2024, the Commission recommended that KiwiRail review the route knowledge training for locomotive engineers to ensure infrequent driving of the route and prolonged absences are identified so that locomotive engineers have the route knowledge to travel safely.

Instruct his pilots to perform a tactile check before take-off, when conditions dictate, to ensure that critical surfaces are free of contaminants such as frost and ice.

In conjunction with Fullers Group Limited, amend the emergency fire procedures for each of the groups’ ferries to better reflect the characteristics of each vessel, the use of available equipment on board and the safest possible method of fire fighting in the differing areas on board especially enclosed spaces.

Use this report to re-emphasise to pilots and operators the hazards of icing, in particular tailplane icing and freezing rain.

Carry out a risk assessment of the Master’s workload on each of the company’s vessels with a view to reviewing the minimum crewing documents to ensure that adequate support is provided for the Master.