Inquiries & Recommendations

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Investigate the practicability of using the radio altimeter to give back-up warning during non-precision instrument approaches.

Institute independent inspections of the Airways Corporation's operations where in the opinion of one of the pilots a collision was likely to have occurred if avoiding action has not been taken, irrespective of the cause attributed by the Airways Corporation.

They consider having the validity of the suggested changes to the seat design evaluated.

Ensure that before the Airways Corporation agrees to provide Air Traffic Control at any air show a realistic evaluation of the workload on the ATS Controllers is conducted and the appropriate arrangements made to ensure no individual controller will be overloaded.

Immediately advise all New Zealand Partenavia P68 operators about the potential for inadvertent tank-to-tank fuel transfer; and to ensure ease of movement of the cockpit fuel selector knobs. On receipt of the pending Vulcanair P68 service bulletin require operators to implement the actions recommended, to obtain the necessary synchronisation between the cockpit fuel selector knobs and wing fuel selector valves.

develop training procedures to strengthen the focus to Mis 60 and wrong line running procedures.

The current track and mechanical code standards and maintenance tolerances are not compatible and there remains a high risk of derailments caused by dynamic interaction.

Review the adequacy of existing Codes and procedures and amend as necessary to ensure they include unambiguous guidelines as to: • When, how, and where to measure rail temperatures. • A check list of conditions which identify clearly track which may be prone to buckling. • How to interpret the results of rail temperature measurements, and apply them to the immediate actions to be taken in respect of track which may be prone to buckling in order to ensure train safety when critical conditions are identified. • The follow-up actions to be taken to ensure on-going safety.

He introduces and ensures effective Bridge Resource Management (BRM) techniques on all vessels under his management.

The Commission considers that clearly defining procedures outlining responsibilities for monitoring, intervening or cancelling train operations during severe/adverse weather events is a safety issue and recommends the Director of Land Transport New Zealand addresses this safety issue.

Review the procedures for incident reporting to ensure that incidents such as the loss of a gangway are immediately reported to allow the necessary timely notification to the Land Transport Safety Authority.

On 30 April 2023, the Commission recommended that Maritime New Zealand require KiwiRail to provide evidence to Maritime New Zealand’s satisfaction that safety-critical rubber expansion joints onboard all vessels within KiwiRail’s Interislander fleet are fit for purpose taking into account the manufacturer’s guidance, namely: • they should be no older than eight months from the date of manufacture when installed • they are inspected annually including visual, tactile and hardness measurements • regardless of inspection findings, safety-critical REJs should be replaced after five years.