Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Address the safety issue whereby the risk assessment for the Port of Taharoa that was in its draft form, after 4 years of development, did not follow the recognised methodology to classify and apply the appropriate measures to mitigate the risks. The safety management system that the risk assessment underpins must be regarded as fragile until an expert independent total review of it is made.

Develop guidelines for the track inspectors to determine when timber sleepers are no longer suitable for continued service.

The Commission recommends that the Chief Executive of the NZ Transport Agency ensure that in their safety cases the access provider of, and operators using, the National Rail System consider fire in rail vehicles as a risk to the safety of their operations, and must demonstrate that they have mitigated that risk as far as reasonably practicable

Assists the Marlborough District Council to the extent necessary to ensure a navigational light beacon is established on Anatakupu Island, or on such suitable alternative site as might be identified, to improve the directional awareness of masters transiting French Pass in a north-easterly direction and to maintain the safety of navigation through French Pass.

The Mercer PDA is near a busy international and domestic airport and close to the tracks flown by aircraft flying from Auckland to Tauranga, which alone elevates the risk of midair collisions if air traffic controllers lose awareness of aircraft operating in and around the PDA, or if aircraft deviate outside the PDA.

Emphasise to all Tranz Rail staff involved in passenger operations the importance of the existing procedures that provide for the safety of passengers when boarding or alighting from trains, and implements compliance monitoring to ensure the procedures are adhered to.

Require the owners of Pterodactyl Ascender II + 2 aircraft to remove the second seat and associated structure.

carry out a review to validate the permanent 25 km/h speed restriction currently in effect for eastbound trains when travelling through Tunnel 1 on the Midland Line

On 26 June 2025, the Commission recommended that Shanhaiguan Shipbuilding Industry Co Ltd implement quality assurance practices to ensure all rudder pintle assemblies are effectively installed.

Publish criteria for staff involved in occurrence investigation which ensures locomotive event recorder extraction follows serious operating incidences such as signal overruns.

On 6 April 2020 the Commission recommended that the Chief Executive of KiwiRail identify cyclic track conditions on the national rail network and develop a standard that prioritises actions to be taken in order to reduce the likelihood of a derailment.

Continue to implement good crew resource management on all of their tugs.