Inquiries & Recommendations

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Introduce inspection and maintenance procedures to ensure that the event recorders where installed on locomotives are operative while travelling on main lines.

Undertake a risk analysis of critical voyage events to identify areas of significant risk and counter measures necessary to minimise the hazard to personnel, ship and harbour installations.

On 23 February 2018 the Commission recommended that the Directeur D’exploitation at Ponant review the procedures for the setting up, training in and ongoing support for ECDIS systems on all of its ships, and ensure that all comply with mandatory requirements and that the ships’ crews are fully conversant with good industry practice for the use of ECDIS.

Develop appropriate track maintenance standards and inspection procedures governing the relative heights of converging lines.

The continuation training and supervision of Polynesian Airlines of their security officers include measures to ensure that security officers concentrate on surveillance duties, rather than assisting loaders or passenger service officers in their tasks.

produce an Advisory Circular, to be used in conjunction with the Maritime Rules, that gives owners, operators, masters and crew guidance and advice on the causes, recognition, management and prevention of fatigue among seafarers.

KiwiRail’s change management process for upgrading the signal box display had not ensured that the mimic screen matched the physical track layout, and had not detected the absence of an interlock to prevent the signallers setting the points to a configuration over which it was not possible for rail traffic to travel.

Examine runway visual indications with the objective of providing additional visual reminders to pilots that a displaced threshold is in operation.

He publish flight safety advice to pilots explaining: • How features such as valleys, VFR lanes or edges of controlled airspace constrain aircraft onto similar courses and concentrate traffic density; • How similar performance aircraft may converge laterally or vertically where lookout is most difficult; • What steps to take to compensate for this difficulty; • That an essential part of visual collision avoidance is a low traffic density. Good airmanship includes consideration of when and where to fly, with this in mind.

Implements a track inspection regime of a standard and to a frequency that: • identifies and protects predictable weak spots • detects repeated non-standard practices and that the inspection requirements are formalised and adhered to.

Evaluate the hull and directional control characteristics of the Fiordland Navigator and, where appropriate, adopt for that ship the remedial actions for the Milford Sovereign.

Promote the early introduction of terrain awareness and warning systems for Part 135 aircraft, current and new, flown under single-pilot IFR in accordance with the criteria to be proscribed by the proposed new Rules.