Inquiries & Recommendations

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include within existing inspection procedures for bogie side frames a requirement that staff, as far as each level of inspection allows, check for cracks with particular emphasis on the pedestal roof/tension member area.

Critically examine the requirements for duplicate inspections of aircraft control systems, with a view to including helicopter tail rotor drive trains as part of the duplicate inspection regime.

The training system for drivers of the push/pull sets on the Auckland rail network did not use standard training techniques, did not teach standard best practice methods for train operations, and did not include appropriate standards for minder drivers to achieve before being certified to teach trainee drivers.

Ensures that any necessary track geometry improvements required following derailments which show obvious signs of likely track related factors are carried out based on an understanding of the detailed site measurements taken following the derailment and take appropriate account of the latest track evaluation car data available.

Review the Operations Specifications and the associated Operations Manuals of each helicopter operator licensed to conducted scenic air transport operations to ensure any reference to dispensations for lower minimum height to be flown in adverse weather be reviewed in relation to the terrain and the overall consideration of passenger safety.

Until such time as improved safety measures can be introduced they erect conspicuous warnings signs to encourage the closer supervision children playing in the railway/fountain environment.

On 27 May 2021 the Commission recommended that Pegasus Fishing enhance its training system so as to upskill deckhands in watchkeeping practices that meet the minimum requirements of Maritime Rules Part 31 and adequately reduce the risk of accidents and incidents resulting from poor watchkeeping practices.

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.