Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure each hang glider be made aware of the desirability of using ballast to achieve optimum controllability of the glider if its sail area relative to the pilot's weight, decreased the wing loading below the advised minimum.

Work with lifejacket industry stakeholders and commercial operators to identify and implement effective safety measures that mitigate the risks associated with incorrectly re-arming and re-packing inflatable life jackets.

The Commission recommends that the Chief Executive of KiwiRail takes all appropriate steps to ensure that all rail vehicles travelling on the controlled rail network are electronically visible to train control.

Standardise and enforce relief arrangements for LE's involved in serious operating irregularities.

incorporate into existing procedures a requirement that the limits of wrong line running be defined by controlled facing signals. At locations where facing signals are not provided, these limits should be defined by appropriate permanent notice boards.

On 26 February 2025, the Commission recommended to the Director of Civil Aviation at the Civil Aviation Authority of New Zealand that they promote, through the appropriate International Civil Aviation Organization (ICAO) forum, consideration for the requirement and implementation for Vortex Ring State alerting systems to be installed in new helicopters.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

On 26 February 2025, the Commission recommended that the Chief Executive of the Ministry of Business, Innovation and Employment and Next Generation Critical Communications collaboratively conduct a review of the emergency 111 system with sector stakeholders, to remove unnecessary delays and improve New Zealand’s emergency response efficiency.

Better search and rescue efficiencies and a safer coastguard operation could be achieved if the design and type of vessels assigned to individual coastguard units are compatible with the conditions they are more likely to operate in and easily integrate with other search and rescue resources available locally and nationally.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

Work with lifejacket industry stakeholders to develop guidelines on the information that should be covered in safety briefings on lifejacket use, including doffing, deflation and hazards.

Review the maintenance procedure to ensure as far as practicable that the amplifier/fault protection unit in the nose wheel steering system is replaced before it fails in service.