Inquiries & Recommendations

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Produce educational material discussing the ramifications of a double engine failure in a twin-engine aeroplane, with emphasis on the need for pilots to have an appreciation of the glide performance of the type(s) they are operating and the advisability of staying familiar with their basic forced landing training.

Develop guidelines for the use of the third pilot, for the times one is carried.

introduce self-appraisal techniques to assist train controllers in establishing their fitness to commence duty and provide adequate relief measures to ensure that train controllers do not feel obligated to commence duty if they do not consider they meet the required fitness standards.

The safety management system on board the Oceanic Discoverer did not adequately address the issue of watertight door maintenance, which could be an indicator that other aspects of the safety system need improving It is recommended to the Director of the Australian Maritime Safety Authority that he oversees a special audit of the Safety Management System on board the Oceanic Discoverer with at least a focus on the planned maintenance system and how it addresses the identification and maintenance of safety critical machinery and components. (028/11)

amend the Engineering Rules to ensure adequate warning of temporary speed restrictions is given to Les in a practical, effective and auditable manner until such time as the appropriate warning boards have been erected.

Ensure all other axles on the Silver Ferns are similarly treated when next in the workshop, and that all spare axles are similarly treated before installation.

On 26 February 2014 the Commission recommended that the Director of Civil Aviation review FAA SFAR 73 in the context of the New Zealand aviation system and adopt relevant improvements that would likely enhance operational safety of Robinson aircraft in New Zealand.

On 30 April 2025, the Commission recommended that KiwiRail utilise engineering controls on track worksites to mitigate the risk of human error by track workers carrying out safety-critical tasks.

There was no means of preventing the uncontrolled escape of fuel from the fuel tank vents when the boat was inverted and these vents were located above the emergency exit from the passenger compartment.

modify either the gunwale or the passenger seats to prevent passengers sliding into the gap under the gunwale.

Includes in the Route Operation Manual for Condor 10, or any other high speed craft operated by it, relevant information to assist masters in passing through the Wellington Harbour entrance in safety.

include in the 12-monthly inspection, additional tests to measure and record engine compression and crankcase pressure.