Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

When a speed uplifting is granted by local government organisations or by Maritime New Zealand, this is effectively a reversal of measures taken to mitigate a previously identified risk of accidents occurring between craft travelling at high speed and other recreational water activities.

Use this accident to educate pilots on appropriate landing and braking techniques, especially for remote and restricted length aerodromes.

Remind operators and maintainers of Piper PA34-200T Seneca aircraft of the requirement to adhere to aircraft towing limitations, and to regularly and thoroughly inspect the nose undercarriage assembly for correct alignment.

They take positive steps to encourage a safety culture among Locomotive Engineers and other operating staff in which events which are not understood, and apparent faults or errors are promptly reported, openly discussed and solutions disseminated.

On 21 May 2020 the Commission recommended that Shih Wei Navigation Company Limited (Taiwan) carry out a comprehensive safety assessment of vessels engaged in carrying and securing deck log cargo. The assessment is to result in appropriate procedures and guidance being contained in the safety management system and ensure that a safe system of work is established.

Fill in the drainage ditch which the aircraft passed through.

Direct the Meteorological Service to sponsor a study of the best way to present weather information to general aviation pilots and to implement the system which shows the best results.

The Commission recommends that the Chief Executive of the NZ Transport Agency takes all appropriate steps to ensure that KiwiRail addresses the above recommendations.

Submit for approval a rule change for flight under visual flight rules in uncontrolled airspace by medium and large air transport aircraft, making reference to aircraft size and manoeuvrability, to ensure adequate safety margins are retained.

The Paraparaumu and Feilding mid-air collisions both involved instructors who, because of their experience and training, should have been the most capable of the pilots to be able to recognise the potential for a mid-air collision and take avoiding action. It appears that in these cases the instructors might have been focusing more on instructing or examining the student pilots and less on ensuring the safety of their aircraft.

Establish procedures that ensure comprehensive, independent verification of all essential take off data, such as the TOW, reference speeds and thrust setting, is accomplished at key points before engines are started.

The training that the train crew had received was limited to conflict avoidance and did not provide them with the skills to deal with wider security scenarios. The action the train crew took on this occasion was appropriate. However, the crew was not trained in alternative options. In different circumstances the crew might need to take alternative action. Guidance on the options that might suit various scenarios would be useful to train crews.