Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

Dependent on action taken, in 062/93 above, give consideration to requiring an inspection of fuel pump drive shaft internal/external splines in affected Chandler Evans fuel pump assembled installed on the LTS 101 gas turbine engines to ensure that spline wear will not compromise the integrity of the fuel pump drive before the assembly is withdrawn from service for overhaul.

Use this accident to educate pilots on fuel management techniques, including the use of dip sticks, and engine failure checklists for multi-engine aircraft.

Clarify the level of rescue and fire fighting protection required for the categories of domestic aerodromes described in the NZAIP, and its relationship to the categories of rescue fire services listed on the landing charts.

Note the failures of the regulatory system to detect shortcomings in the maintenance of infrastructure (as presented in the Commission’s report 05-116: collapse of the Nuhaka Bridge under a work train) and shortcomings in the construction and commissioning process for newly modified rolling stock (as presented in this report), and;

Ensure that the pilot not flying has a responsibility during any approach to land to monitor the aircraft's speed, height, distance to go and configuration of air brakes and spoilers to advise the pilot flying if any of these factors are not within the limits.