Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Review Ansett New Zealand's use of configuration procedures designed to obviate unwanted GPWS warnings.

Put in place an inspection regime to check for load stress cracks in rudderstocks made from high-strength steel of tensile strength exceeding 400 MPa or yield strength exceeding 200 MPa that were manufactured to comply with the 1996 rules.

Establish an inspection procedure and criteria for acceptance or rejection of individual DMU driveshafts in service with the assistance of the universal joint manufacturer.

Review company procedures for flights through Kawarau Gorge, including the need for specified minimum flight altitudes and visibility requirements, which permit safe manoeuvring within the geographical constraints of the gorge.

On 22 August 2023, the Commission recommended that Lyttelton Port Company Limited prioritises a review of their safety management system to ensure that: • documented procedures are consistent and reflect all critical aspects of the work as done • all risks are identified, and administrative risk controls are only used when more effective risk controls are not reasonably practicable • adherence to administrative risk controls is effectively managed • supervisory oversight is effective and not compromised by competing operational demands

On 27 September 2023, the Commission recommended that the Civil Aviation Authority of New Zealand, in consultation with stakeholders, establish and clarify instrument currency requirements for night Visual Flight Rules flying.

Amend existing code instructions and training procedures for the operation of remote control locomotives to ensure they include: • a definition of what constitutes "adequate" when describing "range of vision" with particular regard to speed and the need to stop in a distance related to the clear distance seen ahead. • unambiguous guidelines as to the best position for operators on the leading vehicle, taking account of curved track and limitations imposed by positioning themselves on the trailing end.

increase the amount of information available in the existing site photography book to include street maps etc so that it becomes the major reference manual for train controllers in emergency situations and ensure that such books are made available on all train control desks

The terms of reference for Project Kupe do not currently include further development into full positive train control capability. The Commission recommends the New Zealand Transport Agency takes action to ensure that any project to enhance train control functionality results in a progressive move to achieving positive train control (005/09).

Consider ways of educating pilots on a safe VFR procedure for negotiating localised cloud areas when the planned route involves crossing high ground.

Supply a means whereby a towline can be severed in an emergency aboard the barges owned by his company.

Implement a system for recording and tracking in-use and spare critical components that enables the history of any critical component to be monitored and traced.