Inquiries & Recommendations

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Promote the inclusion of trouble checks in the procedures for dealing with a single engine failure in a twin piston engine aeroplane, where these do not form part of the Flight Manual procedures.

On 25 October 2023, the Commission recommended that KiwiRail reviews its second person training approach to ensure: • the document management of the training material is robust • the training material is fit for purpose and consistent with the training provided to other safety-critical roles • supervision during on-the-job training is adequate.

Require instructors to retain written documentation, regarding the progress of their various students training, for a period of one year beyond the successful completion of that training.

introduce a procedure to ensure train controllers who establish an abnormal history of serious operating incidents are removed from train control until the reasons for this are understood and addressed.

Investigate and improve the mooring system so that it is effective for the size and type of vessels expected to utilise the port. Such improvement should include the provision of sufficient adequately trained personnel to operate the system.

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.