Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Take immediate steps to ensure the continued serviceability of the flight recorders fitted to their aircraft.

Reconsider the issues involved with regard to the appropriate restraint of airborne deer shooters, with a view to ensuring that the equipment used for their restraint incorporates safety features guarding against inadvertent release.

On 28 May 2025, the Commission recommended that KiwiRail review its national project management structure to ensure there is sufficient oversight of and ongoing support for all project staff at all levels to maintain safe working conditions and manageable workloads.

Introduce operating procedures for Tranz Rail staff and customers who move wagons without using rail mounted vehicles, or load or unload wagons, which ensure: only approved equipment is used, and only by appropriately certified staff; equipment for moving wagons is applied at approved positions, and that these positions are clearly defined to staff concerned; that any damage causing deformation to safety critical components such as handgrips which could compromise fitness for purpose is identified promptly and the wagons removed from service.

Introduce formalised crew resource management training for Train Control Operators, Signalmen and LEs based on the training available in the aviation and marine industries. [SR repeated as SR 006/01 in investigation 00-106]

ensure that existing fatigue management training programmes include, but are not limited to, issues such as sleep practices, lifestyle, family commitments and the use of drugs including alcohol and stimulants etc.

Arrange for liaison at local level throughout New Zealand, to ensure that controllers and the drivers of potential rescue vehicles are equipped with the same maps, preferably overprinted with an easy reference grid.

Review the organisation links between ATS staff responsible for out of the ordinary Air Traffic Control situations to ensure they provide for the optimum flow of essential information between the individuals involved.

Transit New Zealand develop a code of practice for the design of intersections with closely adjacent railway crossings, taking into account the combined risk of accident that the two hazards present.

On 14 December 2017, the Commission recommended to the Director of Civil Aviation that he consult with the original equipment manufacturer when considering a modification or supplemental type certificate which, if approved, could result in any aircraft being used in a way that is significantly different from that which the manufacturer originally modelled and used as the basis for determining component fatigue lives and the aircraft maintenance programme

Individually identify all driveshafts on the DMU fleet so that their maintenance and service history can be recorded and tracked.

Several deaths of crew in the inshore and coastal fishing fleet, including the 2 seafarers lost in this accident, have been attributed, at least in part, to the absence of an effective anchor watch, in spite of the various marine notices and other literature on the topic of keeping anchor watches.