Inquiries & Recommendations

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Amend the Offshore Operations Manual to detail the measures to be taken after a runway situation occurred with a winch. In particular to stress that the winch not be used again until the fault has been rectified by an aircraft maintenance engineer.

Instruct Emirates to educate all its pilots to always strictly apply normal checking procedures, to thoroughly scrutinize all the available flight information, particularly ATIS broadcasts, and to always acknowledge receipt of the ATIS.

Educate licensed aircraft engineers who are holders of an Inspection Authorisation, particularly those maintaining ex-military aircraft, on airworthiness directives and the requirement for the aircraft to conform to its type certificate.

During pre-flight briefing for these operations, you stress the importance of not departing from the planned task without a re-briefing.

Either invoke Section 6F (1) of the Transport Services Licensing Act 1989 or, alternatively, procure changes to legislation or, alternatively, by any other process you judge suitable, ensure that the approved safety system for all operators operating on the principal lines, loops and sidings of the national rail network includes a requirement for a train control voice-recording facility and a train control radio log capable of being downloaded for analytical purposes.

ensure that adequate appropriately trained staff are available to enable relief for vacancies amongst train controllers as a result of sickness etc to be undertaken without calling on staff rostered for or already on mandatory rest periods between shifts.

Review the Operations Specifications and the associated Operations Manuals of each helicopter operator licensed to conducted scenic air transport operations to ensure any minimum height dispensations are given in specific detail.

instigate a programme of training and practice to reinforce bridge resource management techniques amongst members of bridge navigation teams on board the company's vessels.

Re-emphasises to pilots involved in single pilot VFR Air Transport that in the event of adverse weather or abnormal circumstances being encountered, management assistance and support from suitably qualified and experienced company personnel may be obtained by discussion prior to flight, or by RTF contact during flight.

In conjunction with Fullers Group Limited, ensure that all crews serving on the company’s ferries are aware that, when investigating a suspected or indicated fire within an enclosed space, opening the access may rapidly exacerbate the fire endangering the crew, passengers and the vessel. The procedure in the operations manual should include a caution and a reminder that where a fixed fire fighting system is installed for the engine spaces, its use should be considered as a possible safer alternative to opening the space, especially in vessels with twin-engine spaces.

Instigate regular monitoring and logging of the critical operating oil pressures and flows of the controllable pitch propeller system under repeatable standardised operating conditions. Ensure that data collected is understood by the engineers and is sufficient to give warning of a possible failure in the unit. The maintenance system of the vessel should include the action to be taken if the values obtained deviate from those specified by the manufacturer.

Issue standards and procedures to ensure that safety straps effectively restrain loose brake rodding gear clear of all obstructions within the permitted tolerances associated with rolling stock / track interaction.