Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Ensure that all employees who carry out safety-critical duties within the operations area receive formal training in fatigue awareness and management with priority being given to shift workers. Such courses should also be made available to staff members’ families and be completed by the end of 2004.

Introduce a certification system for part-time ticket assistants, including re-certification at similar intervals to other full-time operating staff, to ensure continued competency in their role in event management to safeguard passenger safety.

Participate with the Land Transport Safety Authority, Papakura District Council, Auckland and Waitakere City Councils in a review of all existing railway level crossings within the Auckland metropolitan area, to ensure that their design, layout, signage and warning devices are adequate for current road and rail traffic volumes and will be adequate to meet projected increases in rail traffic on the Auckland rail corridors.

Critically review the familiarisation and training programs for watchkeeping engineers to ensure that they fully cover all aspects of engine room watchkeeping.

They investigate the practicability of introducing an operating procedure that, when trains are to cross at Eltham, requires one train to stop outside the limits of the track circuits for the Bridge Street and London Street level crossing alarms until the other train has berthed and advised that the train is in the siding clear of the fouling boards.

Carry out a comprehensive risk assessment of the company’s marine operations and develop operating limitations and contingency plans to assist the Masters. Such plans should be included in the safe ship management documentation.

Tranz Rail Limited review the number, size, orientation and backing details of the flashing lights protecting Victoria Street level crossing to see if an improved indication can be given to westbound motorists on Victoria Street during early morning sun conditions and liaise with the Central Hawkes Bay District Council, as necessary, to achieve early implementation of any possible improvements arising from the review.

He require the "brace for impact" position to be included as part of the pre-flight passenger briefing by demonstration or by reference to a briefing aid.

On 25 October 2017 the Commission recommended to the Director of Civil Aviation that he use the key lessons arising from this report to remind aircraft operators and pilots of helicopter performance and environmental conditions that can lead to vortex ring state, and of the need to be alert to the potential for it to occur, even in apparently benign conditions.

Institute a requirement for the pilot to positively check engine power output as early as practicable in the take-off roll.

Ensure systems are in place to assess the competency of any appointed or acting Track and Structure Manager or Ganger concerned to make such decisions.

Communicate with the operator of Solander Fisheries and operators of other New Zealand registered unlimited area ships advising them of this accident and the need to ensure that these operators crew their vessels with suitably qualified crew in accordance with the requirements of the Maritime Rules.