Inquiries & Recommendations

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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engines to ensure that spline wear will not compromise the integrity of the fuel pump drive before the assembly is withdrawn from service for overhaul.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.

Require his Rules Rewrite Team to review the requirements for gaining an approval to conduct an air show to: • Prohibit the simultaneous operation of display and non-display aircraft with any airspace designated for an air show.

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.

On 25 October 2023, the Commission recommended that KiwiRail integrates fully with the technology on the Auckland Metro network, to ensure the safe operation of rail within a complex system.

ensure that trainee train controllers view the operations of the various signalling systems on the Tranz Rail network during their initial training at the train control school

Liaise with Transit New Zealand, Tranz Rail Limited and the appropriate local authorities to initiate a review to define all public level crossings where the stacking distance for long road vehicles is insufficient to ensure safe entry to or exit from the crossing, and to ensure that appropriate action is taken, consistent with the frequency of use and the potential consequences of collision. [This safety recommendation also repeated as SR 036/02 in report 02-113, near collision between TranzCoastal and empty petrol tanker.]

inspect all stirrup connections at regular intervals and replace components that exhibit excess corrosion.

Publish advisory information about the torque gauge oil line system on the Hughes 369 helicopter type, so that operators and pilots may better understand the significance of the system, and what the appropriate pilot response should be to an abnormal torque gauge indication in flight.