Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On 27 September 2023, the Commission recommended that the Civil Aviation Authority of New Zealand, in consultation with stakeholders, resolve the ambiguity around night Visual Flight Rules and guidance to ensure they are fit for purpose.

On 8 December 2021, the Commission recommended that KiwiRail carry out an analysis of how it could best incorporate engineering control measures into both its current and future operations to minimise the risks that human factors play in effective protection for track workers. (009/21)

ensure that the alertness management training programme includes provision for ongoing refresher training

They implement the appropriate measures to ensure the attention of the public is drawn to the particular hazard of trespass on the railway in the area.

Review the charted area in which the Te Waka o Kapanga operates, combine this with the experience and local knowledge of the area staff , and produce a set of guidelines to show into which areas skippers may go, and any restrictions on such areas including recommended minimum passing distances off known dangers.

Includes in the International Safety Management system for the T.A. Explorer, the requirement for masters to plan each passage from berth to berth.

Following the accident, the Commission had some difficulty accessing sufficient information about the Easy Rider, a vessel that was still actively in the system. Maritime New Zealand was not able to find the older part of the ship file. Consequently the Commission had to rely on records from other vessels in order to make a reasonable assessment of the Easy Rider's stability.

That the LTSA review its road safety strategies to determine the best means of educating drivers on the dangers associated with driver fatigue and the most effective means of publicising ways of avoiding driver fatigue.

Review the design and operation of the signalling and integrated level crossing protection at Trentham for up trains, with a view to reducing the possibility of a stopping train with correct route setting and signal clearance receiving an initial red indication on Signal 29 after departing from Heretaunga.

Reviews the adequacy of existing incident reporting procedures to identify recurring problems and initiate appropriate follow up action.

Consider whether an Airworthiness Directive is necessary to require such modification action.

Ensure that exemptions are only granted when LTSA is satisfied that operating methods meet approved criteria.