Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Develop some educational material on go-around procedures where involuntary overtaking may occur, and promulgate this to pilots and controllers.

Extend the requirement for the carriage of flight data recorders to all multi-engined aircraft used principally for air transport operations.

Devise regulatory requirements for air traffic service standards, incorporating such a requirement.

Pilots in command be advised of the need to consider full the consequences of a repetition of an engine fault before conducting a test flight following a reported engine malfunction.

Liaise with the owner of the Ngawihi Airstrip to improve the wind indicating system at the airstrip.

That copies of all exercise ECG tracing should be submitted to the PMO and not simply a report.

On 14 May 2025, the Commission recommended that the Ministry of Transport and the Civil Aviation Authority of New Zealand, in consultation with stakeholders, work to fully integrate drones into the aviation system and develop appropriate rules and standards, to reflect technology developments and relevant international best practices.

Present this report to the National Pleasure Boat Safety Forum with a view that the Forum determine the feasibility of private boats being registered, marked accordingly and required to meet minimum standards of seaworthiness.

The rules-based system adopted by the rail industry in New Zealand is overly complex and relies heavily on employees’ knowledge of it. The training and assessment programme for ensuring compliance did not in this case result in a safe operation. The lessons about rule complexity learned from the Glenbrook inquiry, and the similarities to the New Zealand railway rules system, suggest that the rule complexity issue might be widespread throughout the New Zealand rail system.

Use a more continuous compliance monitoring regime to ensure that newly-appointed staff are consistently using work practices which do not place them, or others, at unacceptable risk before they are certified for shunting duties.

On 22 February 2024, the Commission recommended that KiwiRail risk assess any regular propelling movements, including assessment of the locomotive cab ergonomic environment, to ensure the risks to both road and rail users are managed.

in conjunction with the Safe Ship Management Company review the 'Southern Winds' Safe Ship Management operations manual to promote best operating practices for the intended use of the boat.