Inquiries & Recommendations

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Ensure that the current review of safe ship management, and, the amendments to Maritime Rules Part 21 and Part 46 results in: -Safe ship management companies discharging their responsibilities to ensure their client vessels comply fully with the required standards -Maritime New Zealand discharging its own responsibilities for the oversight of the maritime industry standards in accordance with the Maritime Transport Act 1994 -Owners of vessels discharging their responsibilities to ensure their vessels remain in compliance with the rules at all times.

Investigate the establishment of providing sufficient liaison with Air Traffic Control to ensure that aircraft captains be directed not to enter the Eastern Apron to the north of taxiway D unless the gate they have been allocated is free.

That distraction of jet boat drivers when driving at high speeds that require a high degree of concentration had not been identified as a risk to the operation and was the main factor contributing to this accident. This could be an issue to address across the industry.

Ensure for operations into airstrips, that a pilot's ability has been checked in each aircraft type which the company requires him or her to operate into that strip.

Include an article in the Seafood New Zealand magazine featuring this report, the intent of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] together with its advisory circular and the work of the Maritime Safety Authority convened FISHgroup and fishSAFE initiatives.

include within existing inspection procedures for bogie side frames a requirement that staff, as far as each level of inspection allows, check for cracks with particular emphasis on the pedestal roof/tension member area.

Critically examine the requirements for duplicate inspections of aircraft control systems, with a view to including helicopter tail rotor drive trains as part of the duplicate inspection regime.

The training system for drivers of the push/pull sets on the Auckland rail network did not use standard training techniques, did not teach standard best practice methods for train operations, and did not include appropriate standards for minder drivers to achieve before being certified to teach trainee drivers.

Ensures that any necessary track geometry improvements required following derailments which show obvious signs of likely track related factors are carried out based on an understanding of the detailed site measurements taken following the derailment and take appropriate account of the latest track evaluation car data available.

Review the Operations Specifications and the associated Operations Manuals of each helicopter operator licensed to conducted scenic air transport operations to ensure any reference to dispensations for lower minimum height to be flown in adverse weather be reviewed in relation to the terrain and the overall consideration of passenger safety.

Until such time as improved safety measures can be introduced they erect conspicuous warnings signs to encourage the closer supervision children playing in the railway/fountain environment.

On 27 May 2021 the Commission recommended that Pegasus Fishing enhance its training system so as to upskill deckhands in watchkeeping practices that meet the minimum requirements of Maritime Rules Part 31 and adequately reduce the risk of accidents and incidents resulting from poor watchkeeping practices.