Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

Reviews Tranz Rail's high speed craft operation, and that of other operators of high speed craft in New Zealand, to ensure that they are complying with the relevant codes before a Permit to Operate is issued.

Include an article in the Seafood New Zealand magazine featuring this report, the intent of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] together with its advisory circular and the work of the Maritime Safety Authority-convened FISHgroup and FishSAFE initiatives.

Most of the Fullers vessels operate in enclosed or inshore limits, and in areas frequently plied by other ferries and recreational vessels. In the past 10 years there have been a number of incidents and accidents involving passenger ferries in the Auckland area, and on almost every occasion the passengers have not needed to enter life-rafts. Instead they have been transferred to other vessels in the vicinity.

NRSS 5 (Occurrence Management) refers to the Coordinated Incident Management System (CIMS) as if it only applies to a specific incident site and does not take into account that, for a larger or more complex emergency response, the incident command centre could be somewhere Page 32 | Report 09-103 else. NRSS 10 (Crisis Management), which is designed to work in parallel with NRSS 5, does not refer to the CIMS but refers to the civil defence model as being separate from the CIMS model, when instead it forms part of it.

Environment Southland manages navigational safety within the Fiordland region and is committed to undertaking and regulating marine operations for cruise ships within its area. The increasing frequency, scale and duration of cruise ship traffic through Fiordland will increase the risks. Milford Sound is not the only passage where blind pilotage can be a necessity.

Direct the Rescue Coordination Centre and New Zealand Police to work together to ensure that effective processes are in place that allow the Rescue Coordination Centre to coordinate maritime and/or aviation assets on behalf of Police when requested or deemed beneficial, fully utilising the strengths of both SAR coordinating authorities for efficient and well-coordinated search and rescue operations.

Urgently review the suitability of, and compliance with, procedures ensuring safe operation of multiple shunts between Wellington yard and the Ferry Terminal.