Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

research information available on factors contributing to biological sleepiness in LEs, with particular regard to the possible adverse effect of continuous night shifts, and take steps to: • minimise the probability of biological sleepiness leading to microsleeps provide an effective defence against any microsleep which may occur leading to an unacceptable risk exposure.

The Commission recommended that Oceanic Fishing Limited have appropriate fatigue management policies and procedures in place and a method to audit these to ensure that they are being applied effectively on-board vessels in their fleet.

On 27 February 2025, the Commission recommended that Maritime New Zealand implement measures to raise awareness of the standards for the Certificate of Medical Fitness for seafarers and ensure that certificate holders understand their responsibilities to maintain certificate validity and report any impacting changes.

Require that all ships of over 500 GRT, that are not fitted with a voyage data recorder, that use the Marlborough Sounds on a regular basis be fitted with an automatic location communicator

Amend the Cessna 206 passenger safety information cards to show accurately how to operate the cargo doors and exit the aircraft, including when the flaps are extended.

The aviation community, including the regulator, Airways, aerodrome operators and aircraft operators, does not have a consistent approach to reducing the risk of simultaneous opposed circuits at aerodromes. Simultaneous opposed circuits can exist as a result of locally agreed procedures at uncontrolled aerodromes, and also at controlled aerodromes under some conditions.

Consider publicising the precautions to be taken by pilots when taxiing aircraft in conditions or poor visibility.

Ensure that the provision of a tour commentary by the Master is properly identified as a possible hazard and noted in the hazard register of each vessel. A suitable section should be inserted into the safe ship management documentation noting the potential hazard of a Master giving a tour commentary. Masters should be directed in the operations manual that if a situation arises where giving a tour commentary poses a risk to the vessel, then the commentary should be stopped or delegated to one of the crew.

Adopt a policy whereby the use of the safety lap seat belts, already fitted in the front passenger seats, is mandatory.

ensure that for any future commercial maritime venture that he may undertake, safe ship management manuals contain appropriate policies and guidelines to address: • safety briefings for passengers and crew • navigation standards • the management of fatigue, and • the consumption of alcohol on board.

The fire on board the Kokopo Chief was caused by radiated heat from an incandescent reflector lamp fitted in a cargo light igniting the timber cargo. While it is widely known that incandescent reflector lamps produce heat, the findings of this investigation offer valuable information to ship designers, owners and operators to consider when selecting the means of lighting in cargo holds and other parts of their ships. There are equivalent lighting options, such as LED lamps, that do not produce the same high temperatures.

Introduce restrictions on boats operating without motorised propulsion during future special maritime events where concentrations of spectator craft are expected.