Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

in conjunction with the Chief Executive of Toll NZ Consolidated Limited, implement an integrated fault recording and management process for the Auckland suburban rail passenger vehicles that incorporates, but not limited to, the features of the existing Fleet Management Protocols and 54D Book recording systems.

KiwiRail provided a draft document that demonstrated its proposed risk-ranking system for assessing the slip hazard risk along the rail corridor. It included a method for assessing potential groundwater conditions, slope stability, soil type, surface cover, slope alterations and rail traffic and outlined a framework to come up with a risk rating. The proposed rollout of this system was over the next 2 financial years but this had not been confirmed at the time of writing.

The minimum requirement for a Milford rating be agreed and promulgated.

Confirm the ability of existing equipment, operators and procedures to detect all cracks over 2 mm deep in the position on the axle where this failure originated, using prepared test pieces as necessary to ensure this can be achieved consistently.

Inform the safe ship management company of matters potentially affecting the validity of the safe ship management certificate

Review Ansett's practice of setting MDA once established on the approach, with a view to implementing a procedure which will not set the MDA before it is safe to descend to that altitude.

Ensure that where fitted to HRVs, seat belts must be worn by the driver and all passengers when driving on track, except in situations where movements are at slow speed and it is necessary to frequently stop and get in and out of the vehicle.

The stop block installed at Melling was a solid concrete block with a limited ability to absorb impact forces. It was physically shifted in the first collision, and even further in the second. The second impact also split the concrete block near ground level and allowed it to rotate backward under the train. The train rode up and over the stop block as a consequence, sustaining substantial damage.

Require that the Airways Corporation put in place plans for the mandatory replacement of controllers after an accident, or alternatively to close aerodromes or declare them uncontrolled after an accident for which the controller was providing air traffic service, until such time as the controller can be replaced.

On 27 May 2021 the Commission recommended that the Director of Civil Aviation publish an educational article raising awareness of the importance of pilot type training being sufficiently comprehensive to mitigate any risks presented by particular helicopter characteristics

That no further permission be granted for operations from the Rotomahana Block Airstrip, until the thistles have been removed.

On 22 February 2024, the Commission recommended that KiwiRail ensure its Permit to Enter system enables safety-critical work at level crossings to occur in a timely manner and supports the maintenance of level crossings by road controlling authorities.