Inquiries & Recommendations

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It is important that KiwiRail addresses the above recommendation, which is aimed at addressing the safety issues examined in this report. The NZ Transport Agency has various powers under the Railways Act 2005 to monitor and ensure KiwiRail's performance and compliance. The Commission recommends that the Chief Executive of the NZ Transport Agency take all appropriate steps to ensure that KiwiRail addresses the above recommendation.

Establish procedures, with safeguards, for maintenance work in Train Control offices to ensure that Train Control Officers are not unreasonably hampered in the execution of their duties.

On 25 February 2016 the Commission recommended that the chief executive of KiwiRail ensure that the bridge resource management policy and procedures outlined in its safety management system remain relevant and effective for all crews on all ships in the fleet, all of the time.

Ensure that the supervision of on-the-job training of train controllers in training or trainee train controllers only be undertaken by qualified staff who have a current certification for that train control desk.

Review the company policy on driver working hours to reduce the possibility of drivers operating fatigued.

research information available on factors contributing to biological sleepiness in LEs, with particular regard to the possible adverse effect of continuous night shifts, and take steps to: • minimise the probability of biological sleepiness leading to microsleeps provide an effective defence against any microsleep which may occur leading to an unacceptable risk exposure.

The Commission recommended that Oceanic Fishing Limited have appropriate fatigue management policies and procedures in place and a method to audit these to ensure that they are being applied effectively on-board vessels in their fleet.

On 27 February 2025, the Commission recommended that Maritime New Zealand implement measures to raise awareness of the standards for the Certificate of Medical Fitness for seafarers and ensure that certificate holders understand their responsibilities to maintain certificate validity and report any impacting changes.

Require that all ships of over 500 GRT, that are not fitted with a voyage data recorder, that use the Marlborough Sounds on a regular basis be fitted with an automatic location communicator

Amend the Cessna 206 passenger safety information cards to show accurately how to operate the cargo doors and exit the aircraft, including when the flaps are extended.

The aviation community, including the regulator, Airways, aerodrome operators and aircraft operators, does not have a consistent approach to reducing the risk of simultaneous opposed circuits at aerodromes. Simultaneous opposed circuits can exist as a result of locally agreed procedures at uncontrolled aerodromes, and also at controlled aerodromes under some conditions.

Investigate the allocation of a more remote area for parking VIP vehicles during peak traffic periods.