Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

conduct a full audit of the Auckland train control radio system to ensure it meets required standards for communication between train controllers and locomotive engineers, including Tranz Metro services

Install halogen bulbs in all purple loop points indicator lights at Track Warrant Stations.

introduce a signals qualification into the certification process for second persons to assist with the identifying and understanding of signal indications, particularly when acting as the eyes of the LE in long hood running situations.

revise the operation of the vigilance device system to provide a better defence against short duration microsleeps.

Explore the practicability of requiring harnesses with an upper restrain facility to be available for each passenger in aeroplanes with an authorised maximum all up weight of less than 2250 kg.

Ensure that the flight paths and procedures of all operators who commonly conduct scenic flights in this area were harmonised without delay.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

Require Safe Ship Management companies to include in vessel operation manuals clear, unequivocal directions to masters and operators that accidents should be reported directly to the head office of the Maritime Safety Authority at the earliest possible opportunity.

Ensure appropriate provision is made to give effect to the requirement for military pilots participating in an air display to have clearance from the RNZAF Display Director before commencing his display.

The response to the derailment was disjointed with both Ontrack and Toll Rail staff being unaware of their respective responsibilities with the result that critical notifications and actions were not taken immediately and some, such as notifying emergency services and an LPG expert, not being taken for several hours following the derailment.

review the procedures for the distribution of manufacturer's service bulletins and letters to ensure that all company vessels receive all applicable current and future documentation and the distribution and receipt are adequately recorded.

Forward this report to Panama, the Flag State for the Taharoa Express, and invite its comment on how it will address the safety issue where the stability computer on the ship was not capable of calculating the free surface effect of the free water in the cargo holds during the loading process, so that when the ship was forced to put to sea prematurely, the true stability of the ship could not be quickly and efficiently calculated.