Inquiries & Recommendations

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arrange for an independent risk assessment by suitably qualifed personnel to evaluate the appropriateness, security and reliability of the current means by which oil is fed to the turbocharger on DMU auxiliary mtors.

"On date the Commission recommended to the Director of Civil Aviation that he urge Transport Canada to: - note the instances of false verification of landing gear position reported for the Q300 and some related aeroplanes and the potential for a false indication to cause an accident, and - require Bombardier Aerospace to take action to improve the reliability and dependability of the down-lock verification system"

Review the information on the Christchurch Visual Terminal Chart in relation to the upper and lower limits of the northern boundary of the eastern segment of the Christchurch TMA to make it clear that the one arc defines a boundary of two areas with different lower levels.

Develop a separate track warrant theory recertification examination for train controllers, which covers all relevant track warrant rules and regulations and other instructions included in reference manuals and books.

In addition to the precautions already outlined by Aerospatiale in Service Letters relating to "preparation for flight after parking in falling snow" it is recommended that before flight pilots ensure that the whole upper area of the AS 350B cabin and engine cowling assembly, including the rotor head cover, are cleared of all deposits of snow or ice which could constitute a hazard to engine operation if ingested.

in consultation with the Safe Ship Management Company ensure that the 'Southern Winds' meets the requirements of all Maritime Rules applicable to the vessel.

Ensures Bridge Resource Management principles are being practised within the COSCO fleet.

The Commission considers it is a safety issue that the practice of conducting routine track inspections at night, and the lack of clear guidelines for the conduct of special track inspections of the Johnsonville Line is not in line with sound engineering practices. The Commission recommends the Director of Land Transport New Zealand addresses this safety issue.

On 22 February 2022, the Commission recommends that the Director of Civil Aviation undertake prompt steps to mandate the wearing of pilot restraint harnesses during critical phases of balloon flight.

Promulgate in the Local Unit Orders at each aerodrome, specific procedures to be followed in the event of loss of communications.

On 7 December 2022 the Commission recommended that KiwiRail review its permit-to-enter process by working with road-controlling authorities, and those requiring permits to enter, to ensure that provision is made for the practicable requirements of non-static or short-term work at multiple locations within the rail corridor.

require all enclosed compartments containing combustion engines on new or modified rail vehicles to be fitted with fire detection and where appropriate a fire suppression system. Existing rail vehicles that fall into this category should be made to comply within a time specified by the Director.