Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

include an article in the Seafood New Zealand magazine featuring a summary of the report into this accident highlighting the benefits of owners and operators providing appropriate fire fighting equipment to enable a boat’s crew to effectively fight a fire on board.

Liaise with Port Otago Limited and combine the resources of all parties to reassess the risk level for the Kakariki transiting Otago Harbour and take whatever action is required to achieve a level of safety commensurate with prudent seamanship, and appropriate ship and port company operations.

Provide a library of collated technical information for builders and prospective builders.

The NOSS showed that the number of communication errors by both controllers and pilots, particularly for the Auckland Terminal sector, was unusually high by international standards. This increases the risk of communication errors contributing to a breakdown in safety standards. The Commission believes this is a safety issue that the Director needs to address with Airways and recommends that he satisfies himself that Airways' planned Strategic Safety Plan will reduce communication errors and the consequent risk.

while policy and any legislative changes are being developed, consult with industry to develop a communication and education strategy to ensure that masters, owners, operators, surveyors and inspectors are aware of the validity of the present qualifications and the minimum crewing requirements for all vessels and their relevant operating areas.

As a matter of urgency inspect his fleet of Convair 580 aircraft to ensure the cockpit voice recorders are correctly installed and are functioning as required.

Publish guidance material for all night VFR flying.

Instigate a programme of training and practice amongst members of bridge navigational teams, especially Masters, in ship handling and manoeuvring for their specific ships in simulated abnormal situations in safety critical areas for their standard voyages. Such situations should include but not be limited to, bad weather, engine failure, steering failure.

Take urgent steps to complete his review of the adequacy of CAA audit staff numbers for carrying out safety audits on operators in accordance with their stated policy.

Work with SAR coordinators and providers of SAR air assets across New Zealand to identify opportunities for the supply and, if necessary, the storage of fuel for extended SAR operations in remote areas, and maintain a database of identified stored fuel and fuel supply logistics.

The quality of crew resource management to achieve outcomes in this case, including the management of resources at different locations such as the train control centre, locomotive cabs and track work sites, sometimes using different communication methods, was of a poor standard, and previously published occurrence reports, as well as other, still open investigations, indicate that the standard of crew resource management across the rail industry is not adequate.

The existing track and structures inspection codes were prescriptive and did not embrace the risk assessment principles documented in the more recent Structures Inspection Manual W200 or required for rail systems under National Rail System Standard (NRSS) 4.