Inquiries & Recommendations

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That the LTSA review its road safety strategies to determine the best means of educating drivers on the dangers associated with driver fatigue and the most effective means of publicising ways of avoiding driver fatigue.

Review the design and operation of the signalling and integrated level crossing protection at Trentham for up trains, with a view to reducing the possibility of a stopping train with correct route setting and signal clearance receiving an initial red indication on Signal 29 after departing from Heretaunga.

Reviews the adequacy of existing incident reporting procedures to identify recurring problems and initiate appropriate follow up action.

Consider whether an Airworthiness Directive is necessary to require such modification action.

Ensure that exemptions are only granted when LTSA is satisfied that operating methods meet approved criteria.

define safety critical areas for standard voyage for vessels within the company's fleet. Institute and implement contingency plans for abnormal procedures such as, but not limited to, integrated bridge system and steering system partial and complete failures within areas.

Ensure persons in charge of obstructed sections are aware of, and comply with, the requirement to use fixed signals where available inside work limits to provide additional protection for staff working under conditional stop board protection conditions.

Review passenger service timetables to ensure the elapse times take into account, the speeds necessary for Locomotive Engineers to arrive at crew changeover positions on time.

Due to the high level of commercial and pleasure boating activity in the Great Barrier Island and Eastern Coromandel areas, as part of MSA's upgrading of coastal VHF coverage, ... produce a Marine Notice (Boats) and an MSA Circular Letter to surveyors reminding mariners and surveyors of the importance of checking and maintaining the quality and accessibility of life-saving and signalling appliances on all boats at all times, and that this be included as a requirement in the relevant rules.

Address the safety issue whereby crew who hold certificates of equivalency that allow them to crew small coastal vessels are not required to have undergone bridge resource management training.

The modern computerised Tranzlog vigilance system is capable of increased alertness monitoring beyond that currently exploited. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue whereby for about 5 years after the technology had become available that could reduce the risk of fatigue related occurrences; the rail industry has not exploited this opportunity (002/09).

There is insufficient data available on the New Zealand coast to make any meaningful analysis of shipping routes, density of ship traffic or potential areas of shipping convergence that might warrant the introduction of local ship routing systems. The Commission recommends that the Director of Maritime New Zealand begin to collate national data on shipping movements around the New Zealand coast that will in future enable Maritime New Zealand and local government authorities to monitor the potential need to introduce ship routing of some form.