Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On 25 August 2016 the Commission recommended to the Chief Executive of the NZ Transport Agency that he liaise with KiwiRail and relevant road controlling authorities to assess and confirm which provincial level crossings have significant safety issues that do not align with the NZ Transport Agency's Traffic Control Devices Manual - Part 9 - Level Crossings, then work with the authorities to ensure that safety improvements are prioritised and implemented.

Ensures Maritime Management Services are fulfilling the requirements of a safe ship management provider under the New Zealand Ship Safety Management Code.

The controllers were unaware of the activation of the STCA, which remained illuminated for about 30 seconds before the 2 aircraft crossed. The STCA is potentially a controller’s last defence for averting a collision and needs to be acknowledged in every case. The lack of response in this incident may indicate that either the STCA activation indications were not effective or controllers had become desensitised to the indications due to a high number of 'nuisance' alerts, or a combination of both.

As part of the review of the train control diagram format, introduces a formalised system to ensure that plotted track occupation limits are subject to a specific checking procedure.

The profile (specifically the rate of change in gradient) of the Beach Road level crossing at Paekakariki on the State Highway 1 side has been formed in such a way that those super-low-floor buses like the one involved in the Beach Road level crossing accident (or of similar design) are at risk of becoming stuck with their back ends foul of the railway tracks when they stop, as they are required to, at the stop sign before turning right to State Highway 1. In other words the same or a similar accident could happen again.

Submit for approval a rule change to special visual flight rules, in particular the application of the 1500 feet cloud ceiling, to remove any ambiguities that may exist.

Inspect all air transport operators of single-engine aircraft to establish their means of ensuring compliance with Civil Aviation Rule 135.87, "Flights over water".

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.