Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Until the responsibilities for the maintenance of sighting distances at public road level crossings have been clarified, it is important for the safety of rail users and road users that there are effective programmes to control vegetation growth around public road level crossings.

The medical practitioners associated with the care of the instructor, and many of the others spoken to during the course of the investigation, were unaware of their obligations under the Civil Aviation Act to inform the CAA about a licence holder who has a known or suspected medical condition that may affect their ability to conduct their duties safely. Despite the efforts of the CAA, this lack of awareness of the Civil Aviation Act appears to be wider than just among those involved with this case.

Remind pilots that an active listen-out and lookout are critical requirements around the runway environment.

On 30 April 2025, the Commission recommended that KiwiRail take all necessary steps to ensure that contractors operating under its rail licence carry out track work protection in accordance with KiwiRail’s safety case and safety system, particularly with respect to: a. supervision of trainee RPOs b. training of supervising RPOs.

Fit a suitable fire detection system in the engine-rooms of all company vessels.

Produce an Operations Manual to cover all aspects of the company and craft operation and establish a procedure to ensure all staff are familiar with its contents.

take steps to minimise the quantity of airborne dist particles being circulated in the generator enclosure of similar AL passenger cars.

Continue the training of deckhands employed by his company to a level where they can competently assist or relieve the master as necessary.

The Commission recommends that the National Rail Safety System Executive adopt or develop a New Zealand Fire Standard that incorporates, but is not limited to: - minimising sources of fire ignition - restricting fire propagation - the use of fire-resistant materials - the provision of appropriate firefighting equipment - ventilation systems to protect crew and passengers from harmful smoke and gases - the installation of fixed fire protection systems - the ability to self-rescue or relocate the train in the event of a fire in a tunnel or similar hazardous location.

Investigate the practicability of introducing an intermediate speed aspect for the signals 12L and 6L at Te Kauwhata and other similar locations.

Review the requirements for the installation of Flight Data Recorders in aircraft to recognise the latest ICAO recommendations on this subject.

Maintain the requirement that the signal station operator informs masters of transiting ships of any unlit or temporarily lit beacons and also include a reminder to advise the signal station should any other beacons be discovered extinguished.