Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

complete a review of accident and incident notification procedues to ensure notifications, especially those requiring immediate action, are processed in a timely manner.

Make the fitting of bilge alarms mandatory in all vessels.

It be a requirement that air transport operators' Operations Manuals and Training Manuals detail their operational and training procedures, minimum experience levels and en route meteorological minima for their Milford Sound operations.

Develop a process which, subsequent to a derailment, requires an inspection by qualified wagon maintenance staff of those portions of the train which have not derailed, before the train is authorised to move

The trainee controller having to refresh his knowledge in double-line automatic signalling rules at the same time as undergoing desk certification complicated the desk certification process, requiring more handovers during a shift. There would be some safety benefits in KiwiRail’s training system for train controllers in specifying a maximum period for which new and returning train controllers can be away from using critical systems such as double-line automatic signalling before requiring refreshing in these systems.

He make all sea staff in his employment aware of the effect the light illuminating the forecastle can have on the ability of other vessels to distinguish the sidelights of their ship at night.

You review the flight test requirements for Private Pilot Licence (Helicopter) and Flight Instructor Rating - Helicopter in general and for type ratings on the R22 aircraft in particular to ensure applicants are aware of the hazards of inducing low "g" flight condition in helicopters with teetering rotor systems, and understand the appropriate recovery technique should such a condition be encountered, and are aware of any specific operating hazards which are detailed in the relevant aircraft's Flight Manual.

Append a warning note to the Nelson Aerodrome VFG/IFG Chart to the effect that "Gate 5" the north-eastern end of the main apron may be used from time to time for high-power engine runs by medium-weight turboprop aircraft.

The Department of Port Administration of the American Samoa Government investigate installation of additional floodlighting on the eastern side of the apron, so that access to aircraft left side doors, lockers and service points is not in shadow.

take note of staff perceptions and experiences revealed by interviews carried out during this investigation and put processes in place, including regular personal familiarisation with operating practices, to improve corporate safety culture and its understanding at field level.

Renegotiate the pilots' contract with NZALPA to remove the condition which is intended to prevent the company from installing CVRs in their aircraft.