Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

On 25 October 2017 the Commission recommended to the Director of Civil Aviation that he use the key lessons arising from this report to remind aircraft operators and pilots of the importance of ensuring that aircraft occupants fasten and properly adjust their seatbelts at all times.

instruct PA34 Seneca operators to ensure that all the requirements of DCA/PA34/22 have been complied with, including the on-going requirement for a placard on the lower nose landing gear housing.

Emphasise to aircraft owners and operators the necessity of determining the location of such antennae and providing suitable masking to prevent any paint being applied to them.

(a) distribute the Commission's Report 05-125 to all heritage operators with gangway-connected rolling stock, and (b) direct mainline heritage operators to crack test the non-alliance buffers on all their operational passengers carriages and guards' vans on an annual basis.

Publish educational material to remind IFR pilots about their mutual separation responsibilites in uncontrolled airspace, particularly when carrying out instrument approaches to the same aerodrome.

Enhance existing air brake and handbrake procedures to include: • a minima number of handbrakes to be applied proportional to the number of unattended wagons • a brake effectiveness test to be carried out before locomotives are separated from an unattended rake of wagons • operating personnel required to communicate with each other at defined stages before wagons are left unattended on a main line • consolidate instructions pertaining to the operation of hand brakes and air brakes applicable at train separation

The driving compartments on Trains 6250 and 6247 were damaged during the collision sequence to such an extent that had the drivers not vacated their driving positions before impact it was likely that they would have been at least seriously injured.

Reconsiders his decision to continue to approve a person to act as maintenance controller for an operator when that person is also employed by the maintenance service provider contracted to carry out aircraft maintenance for the operator.

On 27 September 2017, the Commission recommended that the general director of the Panama Maritime Authority seek improvements in the operator’s implementation of its safety management system on board its vessels, including the underlying safety culture

Introduce a requirement of cockpit voice recorders to be fitted and maintained in a serviceable state in appropriate New Zealand registered aircraft.

Improve the resilience of the track warrant system to accommodate deviations from standard patterns, taking particular account of the need for: • an improved method of providing an LE with a continuous and conspicuous visual display of his track warrant limit. • introducing a system to identify the position of trains in track warrant territory which would increase the situational awareness of LEs as they approached the limit of their track warrant, and limit the possible consequence of any overrun which may occur.

Use this accident scenario as a topic for pilot re-currency training or LOFT in simulators to enhance pilot awareness and CRM skills. The training should introduce similar errors for pilots to discover. The training should also ensure pilots treat all warnings, such as a stick shaker, as real warnings and make sure they respond appropriately until the threat has passed.