Inquiries & Recommendations

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Temporary speed restrictions are used to manage the safety of train operations when a general deterioration in track condition is identified. KiwiRail Network's codes and standards consider track geometry faults such as cant, twist, line, top and rate of change of cant deficiency separately when determining the appropriate speed value.

Ensure persons in charge of obstructed sections are aware of, and comply with, the requirement to use fixed signals where available inside work limits to provide additional protection for staff working under conditional stop board protection conditions.

Review passenger service timetables to ensure the elapse times take into account, the speeds necessary for Locomotive Engineers to arrive at crew changeover positions on time.

Due to the high level of commercial and pleasure boating activity in the Great Barrier Island and Eastern Coromandel areas, as part of MSA's upgrading of coastal VHF coverage, ... produce a Marine Notice (Boats) and an MSA Circular Letter to surveyors reminding mariners and surveyors of the importance of checking and maintaining the quality and accessibility of life-saving and signalling appliances on all boats at all times, and that this be included as a requirement in the relevant rules.

Address the safety issue whereby crew who hold certificates of equivalency that allow them to crew small coastal vessels are not required to have undergone bridge resource management training.

The modern computerised Tranzlog vigilance system is capable of increased alertness monitoring beyond that currently exploited. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue whereby for about 5 years after the technology had become available that could reduce the risk of fatigue related occurrences; the rail industry has not exploited this opportunity (002/09).

There is insufficient data available on the New Zealand coast to make any meaningful analysis of shipping routes, density of ship traffic or potential areas of shipping convergence that might warrant the introduction of local ship routing systems. The Commission recommends that the Director of Maritime New Zealand begin to collate national data on shipping movements around the New Zealand coast that will in future enable Maritime New Zealand and local government authorities to monitor the potential need to introduce ship routing of some form.

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.