Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Use this report to re-emphasise to pilots and operators the hazards of icing, in particular tailplane icing and freezing rain.

Carry out a risk assessment of the Master’s workload on each of the company’s vessels with a view to reviewing the minimum crewing documents to ensure that adequate support is provided for the Master.

Implement the requirements of Maritime Rule 31C [Crewing and Watchkeeping - Fishing Vessels] for all vessels operated by his company and update the Safe Ship Management manuals as necessary.

Ensure MMS's resources are adequate for present and predicted workloads.

Produce educational material reminding operators of the importance of ensuring that procedures developed by the operator do not conflict with the mandatory provisions of the Aircraft Flight Manual.

Reviews the training, knowledge, and experience of Track and Structures Managers, Gangers, and those required to act in such positions, in respect to their ability to identify and understand the track related factors contributing to derailments and to make timely and safe decisions regarding the track geometry improvement required, and speed to be applied, before the track is reopened for traffic.

Draw the pilots' attention to their duty to ensure that their passengers use the safety harness provided.

It is important that KiwiRail addresses the above recommendation, which is aimed at addressing the safety issues examined in this report. The NZ Transport Agency has various powers under the Railways Act 2005 to monitor and ensure KiwiRail's performance and compliance. The Commission recommends that the Chief Executive of the NZ Transport Agency take all appropriate steps to ensure that KiwiRail addresses the above recommendation.

Establish procedures, with safeguards, for maintenance work in Train Control offices to ensure that Train Control Officers are not unreasonably hampered in the execution of their duties.

On 25 February 2016 the Commission recommended that the chief executive of KiwiRail ensure that the bridge resource management policy and procedures outlined in its safety management system remain relevant and effective for all crews on all ships in the fleet, all of the time.

Ensure that the supervision of on-the-job training of train controllers in training or trainee train controllers only be undertaken by qualified staff who have a current certification for that train control desk.

Review the company policy on driver working hours to reduce the possibility of drivers operating fatigued.