Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

At the time of the grounding, Port Otago’s policies, procedures and compliance monitoring of pilotage operations fell short of meeting good industry standards for pilot training outlined in maritime rules, or fully achieving the principles of safety management systems outlined in the New Zealand Port and Harbour Marine Safety Code.

Design a modification to inhibit the starter switch unless the clutch is disengaged during ground starting.

Address with the commercial jet boat industry that in spite of the requirements under Maritime Rules Part 80 and other safety initiatives taken by Maritime New Zealand that the issue of accounting for passengers when multiple boats are involved during emergency response still remains.

Crew resource management competency is not yet an effective safety measure for helicopters operating under CAR Part 135. On 22 February 2023 the Commission recommended that the Civil Aviation Authority of New Zealand address this safety issue.

Establish procedures so that the pilot flying always reminds the pilot not flying about the appropriate technique for landing in a strong crosswind, each time such a landing is to be attempted.

Remind pilots and air traffic controllers to comply strictly with the rules for phonetic pronunciation, particularly of numerals, and to seek immediate clarification of any clearance or read-back affected by a crossed transmission.

Ensure that RFD, and other liferaft manufacturers: • provide painter securing instructions that reflect the use of a weak link as part of a float free system • issue clear and unequivocal installation instructions to accompany each liferaft • Maritime New Zealand to promote the use of manufacturers designed liferaft cradles where available.

Three of the 5 persons involved in this accident received serious head injuries and 2 of these died as an indirect result. There are a number of other activities where the benefit of wearing a helmet has been recognised: cycling, snow skiing, motorcycling, white-water kayaking and white-water rafting to name a few. Given the protection they can provide, it would seem that wearing them on a personal watercraft would be wise and there may be a case for it to be mandatory.

There are a number of reasonable measures that had not been taken to further reduce the risk of trains colliding within the approaches to Wellington Station, such as: - providing better recognition of signals - standard procedures for signalling trains through the area - better communication between train drivers and persons controlling the trains. This incident has shown that more work is required of KiwiRail to further reduce the likelihood of trains colliding within the Wellington Station area.

Issue a memorandum to the tug masters, to remind them of the requirements of the Safe Ship Management Certificate, particularly the carriage of additional persons.

On 26 April 2017 a recommendation was made to the Director of Civil Aviation that, as a matter of urgency, he use this interim report, the service letter from Eurocopter (Service Letter No. 1727-25-05) and any other pertinent material to remind the aviation industry of the lessons learned from accidents involving sling loads, in particular the use of monsoon buckets during firefighting operations

The Commission recommends that the Chief Executive of the NZ Transport Agency, when conducting safety assessments of each rail licence holder, ensure that they have identified and assessed the risk of fire in a rail vehicle. The Chief Executive should ensure that they have, as far as reasonably practicable, minimised the risk and have measures in place to deal with the outbreak of, and reactions to, fire events.