Inquiries & Recommendations

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Remind pilots of the actions for an engine failure after take-off as contained in the Civil Aviation Authority’s Flight Instructor’s Guide, and the benefit, if time permits, of changing fuel tank selection should a sudden, total and unexplained power loss occur.

They review the wording of clauses 3.8.4 and 3.8.5 of section L4 of the Working Timetable with a view to explaining clearly the situation which arose in this incident i.e. the need to reset the alarms if sequential berthing on the main line and loop occur at Eltham, and the crossing alarms cancel after the passage of the northbound train.

The number of defects that are causing incidents and accidents in New Zealand pilotage waters is of concern. It is an indication that New Zealand port and harbour authorities cannot totally rely on the International Safety Management system to ensure that vessels transiting New Zealand ports are operated safely and efficiently. Minor technical defects and human performance issues are often lead indicators of deeper systemic safety issues on board a vessel.

Consider adopting the Swiss Air Force take-off technique, and monitor the actual performance achieved against the performances graphs which form part of the Swiss pilots manual.

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 and follow a routine maintenance programme to ensure that all existing fencing is kept in sound condition to optimise the safety potential of the structures.

More attention be paid to cardiovascular risk factors in asymptomatic individuals, in order to identify individuals with significant vascular disease, before the risk of pilot incapacitation becomes excessive.

Implements a system of regular structured meetings of all pilots and tug masters operating in the port, to foster good communication and a shared concept of operational requirements. Such a system should supplement, rather than replace, the informal communication which exists between pilots and tug masters.

They place a large dark board behind the flashing lights of the crossing alarms on the eastern side of the crossing in order to improve the visibility of the lights when the sun is setting.

On 25 October 2023, the Commission recommended that KiwiRail undertakes a review of its non-technical skills training to ensure it provides adequate training on how to work together to manage threats.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

Implement a requirement for Recognised Surveyors to record in their survey report the servicing and expiry details for life-saving appliances onboard the vessel, to reduce the risk of appliances that are not fit for purpose remaining in service.