Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Include mountain flying in the training syllabus for Private Pilot and Commercial Pilot Licences (Aeroplane), as is the case for helicopter licences. [Repeated as part of SR 023/02 (investigation 02-001) on 19 July 02.]

A working bridge watch navigational and alarm system should have been fitted to the Anatoki to mitigate the known risk of one-man bridge operations. Had one been fitted the mate might have been alerted in time to prevent the grounding. The Commission recommends the Director of Maritime New Zealand requires New Zealand-registered coastal vessels operating under one-man-bridge-operation to have a bridge watch navigational and alarm system to mitigate the known risk of sole watchkeepers falling asleep or becoming distracted from monitoring the progress of their vessels. (019/12)

distribute the Commission's report 06-112 to all tramway operators so that the lessons learned from this investigation are understood and recommend they take such actions as appropriate to prevent similar incidents.

Install a fire detection system in the engine room of the "Sweet Georgia" and ensure that the poor electrical installation standards identified in this report are rectified.

Consider introducing more frequent inspections of the lateral load guides on the B767 in-hold loading equipment, or other appropriate measures, to ensure that any damage caused to these devices in the course of loading operations is detected and rectified promptly.

On 2 August 2016 the Commission recommended that before allowing cruise ships to use Tory Channel in future, the Chief Executive of the Marlborough District Council review its harbour risk assessment for the safe navigation of ships through Tory Channel, and in doing so consider the safe navigation of cruise ships through Tory Channel as a separate risk. The new risk assessment should consider, but not be limited to, the following factors: - the limited number of piloted ships using Tory Channel make it difficult for harbour pilots to maintain currency

Introduce the requirement for commercial vessels to be fitted with automatic identification system (AIS) or equivalent when carrying passengers outside of inshore limits.

Make it clear to ATS staff that the controller with whom the pilot first makes contact should confirm that the pilot was aware of relevant hazardous weather reports, or the manual of Air Traffic Services should be amended to reflect the current policy in conjunction with a similar amendment to the NZAIP Planning Manual.

Use the circumstances of this accident as educational material for single pilot IFR operators and pilots in the management of instrument approaches.

Advise all operators of passenger trains of the circumstances of this accident with the recommendation that they: review the adequacy and security of handrails, guard-rails, and gates in areas where passengers may move; ensure that staff who inspect and maintain handrails; guard-rails, and gates are aware of the purpose of and the design intentions for the equipment; and review their passenger management polices in respect of safety briefings, signage, and passenger supervision to reduce the possibility of falls, impacts with trackside objects, or injuries from other causes.

No-one in Hawke's Bay Regional Council or the Port Authority and none of the pilots themselves realised that the procedures for outward pilotage were in error. The pilotage areas marked on the navigational charts and contained in nautical publications did not align with the Maritime Rules and the Regional Council’s Navigation Safety Bylaws.

Evaluate the information gained from the Taharoa wave rider buoy. If there is significant difference in the sea conditions between the Taharoa and Manukau or if the Taharoa wave rider buoy data is not available to POAL, he shall urgently take steps to place a wave rider buoy or other suitable measuring equipment close to the bar.