Inquiries & Recommendations

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In conjunction with Survey Nelson Limited, amend the ship safety manual to reflect: · a policy to ensure that all persons on board wear a lifejacket when crossing the bar outbound and inbound regardless of the prevailing conditions on the bar. · operating limits set separately for the Uawa River bar and outer fishing grounds, based on observed conditions, the capabilities of the Osprey and his own local knowledge and experience.

Draft an amendment to Maritime Rule 40A [Design, Construction and Equipment - Passenger Ships Solas] for the Minister’s consideration, that new restricted limit passenger ships with enclosed engine room spaces should be fitted with a fire detection system and a fixed fire extinguishing system in the engine spaces.

Consider the use of protective helmets and suitable protective clothing for all personnel on board, when conducting operations of this nature.

On 10 April 2017 the Commission recommended to the Director of Maritime New Zealand that he inform all New Zealand surveyors and port state control officers about the circumstances of this accident and advise them to pay special attention to any corroded nitrogen cylinders or other pressure vessels when conducting their Class or Flag State surveys, particularly when inspecting pressure vessels stored in an open marine environment.

Recommend the fitting of steering limit stops in the installation manual for all HJ-212 jet units, and other model jet units as appropriate.

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.

complete a review of accident and incident notification procedues to ensure notifications, especially those requiring immediate action, are processed in a timely manner.

Make the fitting of bilge alarms mandatory in all vessels.

It be a requirement that air transport operators' Operations Manuals and Training Manuals detail their operational and training procedures, minimum experience levels and en route meteorological minima for their Milford Sound operations.

Develop a process which, subsequent to a derailment, requires an inspection by qualified wagon maintenance staff of those portions of the train which have not derailed, before the train is authorised to move

The trainee controller having to refresh his knowledge in double-line automatic signalling rules at the same time as undergoing desk certification complicated the desk certification process, requiring more handovers during a shift. There would be some safety benefits in KiwiRail’s training system for train controllers in specifying a maximum period for which new and returning train controllers can be away from using critical systems such as double-line automatic signalling before requiring refreshing in these systems.

He make all sea staff in his employment aware of the effect the light illuminating the forecastle can have on the ability of other vessels to distinguish the sidelights of their ship at night.