Inquiries & Recommendations

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Amend section 2(b) of Special Federal Aviation Regulation No. 73 -Robinson R-22/R-44 Special Training and Experience Requirements to make it clear that dual instruction in the “effects of low-G maneuvers” is limited to discussion only, and to reiterate that deliberate in-flight reduced G conditions are prohibited.

During this incident, 2 successive train control handovers were conducted in a fashion that did not detect the presence of all train movements, and on each occasion the trainee, then the incoming controller, assumed the responsibility for the desk before they had acquired full situational awareness of the status of all movements within their area. The area of train control would benefit from some form of external review of processes to identify if these practices were confined to this one event or symptomatic of a wider systemic issue.

Arrange for the training of staff employed as train crew on passenger trains to include sufficient event management training to ensure they are competent to respond appropriately to foreseeable events which could adversely affect passenger safety.

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, the need for additional information to be included in all rotorcraft flight manuals, to assist pilots in avoiding Vortex Ring State.

Develop a regime to ensure that locomotive driving and idling wheelset axle weights are maintained within tolerance

Ensure that operators are reminded of the requirement to have the equipment used approved by the Ministry of Transport.

Direct the Meteorological Service to provide Aerodrome Forecasts, using the best available information.

Re-emphasise, to each of the Company's pilots, the potential for the pilot flying to be distracted from the routine operation of the aircraft during the execution of an emergency procedure or even a relatively minor system abnormality procedure, particularly if an unexpected need to give assistance with the procedure develops.

Improve the effectiveness of detecting and reporting procedures for potential obstructions to rail traffic to ensure that such obstructions are removed or secured expeditiously.

Require airline inspectors charged with the supervision of the introduction of new airlines, to ensure that Line Training Captains demonstrate by flight test that they are competent for the duties required of them, particularly if they have not had training as flying instructors.

initiates appropriate regulatory action, such as an airworthiness directive, to require where possible the relocation of ELTs to a less vulnerable location than the nose section, on all helicopters.

On 1 February 2016 the Commission recommended that the chief executive of Auckland International Airport Limited, in conjunction with the chief executive of Airways, measure and recalibrate luminous intensity settings for the taxiway centreline lights, runway centreline and runway edge lights and reconfigure the associated control tower setting selections so that controllers may select the respective light intensities recommended by ICAO for various levels of ambient lighting.