Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure that all Circuit Marker Posts marking the track circuit approaching the Facing Points Indicators in Track Warrant areas are maintained in position.

Direct the Tasman District Police to work with RCCNZ, other emergency response agencies and local authorities to develop a maritime rescue plan that includes the Kaikōura region.

Recommend to all air transport operators that they develop pro-active monitoring strategies such as occasionally using passengers to carry out spot, passive checks to report on the conduct of flights.

Alert owners/operators of LTS 101 series gas turbine engines to the circumstances of the accident to AS 350D ZK-HGV and the potentially serious consequences of complete power loss resulting from failure of the fuel pump drive.

Fit watchkeeping alarms independent of all other equipment in the wheelhouse of all vessels operated by his company and put in place a procedure to ensure that the watchkeeping alarms are operated whenever a navigational watch is undertaken.

On 25 August 2016 the Commission recommended to the Chief Executive of the NZ Transport Agency that he liaise with KiwiRail and relevant road controlling authorities to assess and confirm which provincial level crossings have significant safety issues that do not align with the NZ Transport Agency's Traffic Control Devices Manual - Part 9 - Level Crossings, then work with the authorities to ensure that safety improvements are prioritised and implemented.

Ensures Maritime Management Services are fulfilling the requirements of a safe ship management provider under the New Zealand Ship Safety Management Code.

The controllers were unaware of the activation of the STCA, which remained illuminated for about 30 seconds before the 2 aircraft crossed. The STCA is potentially a controller’s last defence for averting a collision and needs to be acknowledged in every case. The lack of response in this incident may indicate that either the STCA activation indications were not effective or controllers had become desensitised to the indications due to a high number of 'nuisance' alerts, or a combination of both.

As part of the review of the train control diagram format, introduces a formalised system to ensure that plotted track occupation limits are subject to a specific checking procedure.

The profile (specifically the rate of change in gradient) of the Beach Road level crossing at Paekakariki on the State Highway 1 side has been formed in such a way that those super-low-floor buses like the one involved in the Beach Road level crossing accident (or of similar design) are at risk of becoming stuck with their back ends foul of the railway tracks when they stop, as they are required to, at the stop sign before turning right to State Highway 1. In other words the same or a similar accident could happen again.

Submit for approval a rule change to special visual flight rules, in particular the application of the 1500 feet cloud ceiling, to remove any ambiguities that may exist.

Inspect all air transport operators of single-engine aircraft to establish their means of ensuring compliance with Civil Aviation Rule 135.87, "Flights over water".