Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Develop a documented procedure for fitting the wear liners to the bolster wear pocket.

Ensure the review of the design of the safety rails considers if a secondary safeguard is required where the concertina weather protection is not provided.

On 25 February 2016 the Commission recommended to the Director of Civil Aviation that he review all modifications to the cockpit lighting on BK117 helicopters for night vision use, to ensure they do not unduly increase the risk of a similar incident occurring. If they do introduce an unacceptable level of risk, changes to the installation, such as a low-fuel-level aural warning or brighter LED caution lights, should be required.

Contact the School Trustees Association to facilitate the distribution of advice to all New Zealand Schools on the hazards associated with playing adjacent to active railway tracks.

Produce a manual of procedures and guidelines for those MSA-approved authorised persons to follow when assessing, approving or auditing commercial jet boat operators' activities and safe operational plans.

prohibit staff members from riding motor cycles for any time they are required to maintain safe line of sight for a propelling movement when shunting sidings.

Amend the Offshore Operations Manual to detail the measures to be taken after a runway situation occurred with a winch. In particular to stress that the winch not be used again until the fault has been rectified by an aircraft maintenance engineer.

Instruct Emirates to educate all its pilots to always strictly apply normal checking procedures, to thoroughly scrutinize all the available flight information, particularly ATIS broadcasts, and to always acknowledge receipt of the ATIS.

Educate licensed aircraft engineers who are holders of an Inspection Authorisation, particularly those maintaining ex-military aircraft, on airworthiness directives and the requirement for the aircraft to conform to its type certificate.

During pre-flight briefing for these operations, you stress the importance of not departing from the planned task without a re-briefing.

Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all operators operating on the principal lines, loops and sidings of the national rail network includes a requirement for a train control voice-recording facility and a train control radio log capable of being downloaded for analytical purposes.

ensure that adequate appropriately trained staff are available to enable relief for vacancies amongst train controllers as a result of sickness etc to be undertaken without calling on staff rostered for or already on mandatory rest periods between shifts.