Inquiries & Recommendations

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Introduce a system of driver review where junior drivers are periodically assessed by a senior driver and senior drivers by their peers. From time to time, such reviews should be undertaken when river conditions are near safe operating limits.

That the requirement for the carriage of flight data recorders be extended to include a basic FDR or CVR (where the aircraft is operated with more than one pilot) on all multi-engine aircraft used principally for Air transport Operations with seats for nine or more passengers. (A similar Recommendation was previously issued following and accident on 8 August, 1989 involving Britten Norman Islander ZK-EVK near Blue Duck Glacier, Upper Dart Valley).

conduct a risk assessment for LPG carriers transiting Manukau harbour and form a set of rules and guidelines governing their movement within harbour limits.

The Commission recommends that the Chief Executive of KiwiRail ensures that appropriate protocols and/or arrangements are in place, and are being applied, to properly manage and coordinate routine and unplanned track infrastructure activity so that train controllers are able to perform their safety critical function without becoming unduly distracted or burdened.

Shunting locomotives which travel along main lines or regularly pass over level crossings on public roads be fitted with event recorders.

The Commission recommends that the Civil Aviation Authority amend its policies and procedures for issuing certificates of airworthiness for imported second-hand aircraft to ensure that the appropriate audit and assurance processes are in place and the procedures are consistently applied.

He inspect the various types of aircraft used for air transport operations and identify each door which a passenger might use as an exit in an emergency.

Introduce a documented policy where the crews of company vessels, including the pilot vessels and tugs, routinely verify the operation of the channel beacons in any area transited at night, with logbook entries to record results.

On 28 October 2015 the Commission recommended that the Chief Executive of Maritime New Zealand review the Dream Weaver operation with a view to ensuring that the Dream Weaver is fit for its intended purpose and that the operator’s safety management system, or the succeeding MOSS system, is operating as it should.

Publish an alert bulletin warning all Robinson R22 operators of the potential damage from such an occurrence and requirement an engineer's inspection if an attempt is made to start with the clutch engaged.

It is a safety issue that the Coastguard did not extend the training in the concept of crew resource management to all members of the crew so that the crews could work cohesively as a team to maintain situational awareness, monitor the plan, anticipate dangerous situations, acquire timely information and avoid pre-occupation with minor problems.

In spite of the education material produced by the Civil Aviation Authority on hand-starting aircraft, the understanding of the risks associated with that activity were not well recognised by this operator and might not be with other operators in that sector of the industry.