Inquiries & Recommendations

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Communication between members of work gangs in noisy environments can be seriously hampered by noise and the ear defenders worn by crew to protect against that noise, often making visual contact the sole method available for communicating. The uptake by the rail industry of technological advances such as radio equipment integrated into safety equipment has been progressed but has been slow.

The watertight doors on the Oceanic Discoverer had an unexplained design or maintenance peculiarity where the door would begin to self-close even when in the local-control mode. This peculiarity was observed on one other vessel that the Commission visited. The Commission therefore recommends that the watertight door manufacturer investigate this safety issue, provides a solution, and promulgates that solution through the International Association of Classification Societies (IACS) and any other way it can. (027/11)

Review procedures for compliance monitoring of shunting staff to place more emphasis on an increased level of "unannounced" observation of staff during normal duties and less emphasis on "arranged" monitoring by training staff.

In conjunction with the Safe Ship Management Company. prepare procedures covering maintenance on board company vessels with particular regard to hot work involving the use of welding or cutting equipment.

Investigate the feasibility of installing a ramp control facility in place of the existing gate allocation advisory service.

Consider reviewing their procedures for stream landing with Harvard aircraft so that such events are carried out on grass vectors wherever practicable.

Consider upgrading the first aid training of guards and locomotive engineers to the standard necessary for them to obtain certificates from a recognised first aid organisation

He require the [recommendations 018/90, 019/90, and 020/90) as airworthiness requirements for all imported aircraft.

Take the necessary steps to ensure that company pilots operating under VFR use all the resources available to them for accurate navigation.

Investigate train operations and route management on the Stratford to Okahukura Line, and other routes through remote areas; such investigation to include: • the performance of the train control radio system • the suitability of, and compliance with procedures, for tracking the progress of trains en-route • the procedures when en-route track warrant clause 10 radio check calls are not acknowledged by train control • the effectiveness of any existing emergency response plan • crew arrangements and rostering and initiate the action necessary to address any deficiencies found.

Take action to address the following safety issue - the engines on 3 Real Journey vessels operating in Milford Sound and Doubtful Sound that manoeuvre close to the shoreline and other features during the normal daily operation were prone to stalling when placed from ahead to astern at speeds over 7 knots, which raises some doubt as to their fitness for purpose. The operational procedures that the operator has put in place to mitigate the risk of stalling have not addressed the core design issue concerning the original drive train.

The Commission recommended that Yugen Kaisha Chokyu take steps to ensure the effectiveness of its safety management practices with respect to voyage planning and navigation, and take steps to ensure the safe navigation of vessels in its fleet.