Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The cylinder failed at below its normal working pressure because severe external corrosion had reduced the wall thickness from 4.81 mm to 1.45 mm (about 30% of its original thickness). The failed nitrogen cylinder and several other pressure cylinders within the stored energy system were not fit for purpose and should not have been in service. There is an urgent need for consistent and proper standards to be developed at a global level for maintaining, inspecting, testing and, where necessary, replacing high-pressure cylinders associated with stored energy systems on board ships.

Maritime New Zealand receives some information via its general enquiries contact point and also via its maritime officers’ engagement with the community. However, there would be some added benefit if there were a similar process to that operated by the Civil Aviation Authority for people to report safety and security concerns. On 23 May 2018 the Commission recommended that the Director of Maritime New Zealand develop, implement and advertise a process where members of the public and the maritime community can submit reports on maritime-safety-related concerns.

Review training and local procedures to encourage controllers to issue reporting instructions for aircraft that may pose a conflict as they pass either overhead or through local terminal areas.

Investigate the watertight integrity of the company’s ships with a view to enhancing their ability to withstand flooding damage. Consider upgrading the ships’ stability data to enable the master of the ship to calculate by rapid and simple means the residual stability of the ship under varying conditions of service, including a damaged condition.

Cancel any approvals for human sling loads which were issued prior to the promulgation of CASO 20.

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.