Inquiries & Recommendations

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as a matter of urgency make the use of signal blocking command “control tags” mandatory on signals controlling the entry of trains into sections occupied by HRVs, track maintenance gangs or other track users.

On 25 September 2024, the Commission recommended that Transdev Wellington and Auckland One Rail implement regular checks of the onboard radios (both in-cab main radios and in-cab back-up portable radios) in their passenger trains to ensure they can communicate with train control.

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

Consider publicising the precautions to be taken by pilots when taxiing aircraft in conditions or poor visibility.

Ensure that the provision of a tour commentary by the Master is properly identified as a possible hazard and noted in the hazard register of each vessel. A suitable section should be inserted into the safe ship management documentation noting the potential hazard of a Master giving a tour commentary. Masters should be directed in the operations manual that if a situation arises where giving a tour commentary poses a risk to the vessel, then the commentary should be stopped or delegated to one of the crew.

Adopt a policy whereby the use of the safety lap seat belts, already fitted in the front passenger seats, is mandatory.

ensure that for any future commercial maritime venture that he may undertake, safe ship management manuals contain appropriate policies and guidelines to address: • safety briefings for passengers and crew • navigation standards • the management of fatigue, and • the consumption of alcohol on board.

The fire on board the Kokopo Chief was caused by radiated heat from an incandescent reflector lamp fitted in a cargo light igniting the timber cargo. While it is widely known that incandescent reflector lamps produce heat, the findings of this investigation offer valuable information to ship designers, owners and operators to consider when selecting the means of lighting in cargo holds and other parts of their ships. There are equivalent lighting options, such as LED lamps, that do not produce the same high temperatures.