Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Use only authentic or approved parts when replacing worn or damaged critical components, or use parts reconditioned, either to the manufacturer’s specifications or to the approval of an appropriate surveyor.

Review the Operations Specifications and the associated Operations Manuals of each helicopter operator licensed to conducted scenic air transport operations to ensure any minimum height dispensations are reviewed in relation to the requirement for the pilot to have an optimum chance of conducting a successful forced landing in the event of an engine power loss.

Revise Rail Operating Code Section 2, Part 9 to give clear guidelines to all staff involved in the hand operation of motorised points,

There is no standard system of hand signals across the rail industry for use when directing operations involving cranes and other lifting devices, such as on the rail recovery unit.

The post-mortem toxicology results for the pilot in the Carterton hot air balloon showed that he had a positive result for tetrahydrocannabinol (a constituent of cannabis). It was likely that this was due to 2 factors: first, the pilot smoking cannabis shortly before the accident flight; and, second, residual tetrahydrocannabinol, from ingesting cannabis over a longer term, redistributing in the pilot’s blood after his death.

Identify on each jet boat all components that are critical to the safe operation of the boat, and have a documented inspection and maintenance system in place that covers those critical components. The inspection and maintenance system should complement rather than replace any existing system of daily checks.

re-evaluate the safety management certificate issued to the Pacific Princess to ensure that the International Safety Management code is being fully complied with. In the event of there being a change of management of the vessel, pass on this safety recommendation to the new administration issuing the certificate.

Critically review the designing, building and commissioning into service of Aratere, with a view to developing procedures and guidelines for use with future new buildings.

Create an auditable system for the inventory, care and maintenance of the shore mooring lines and associated spares, to ensure that the equipment is in a serviceable condition at all times.

Correct the calculations in the risk assessment, and focusing on its objectives, re-evaluate the level of risk and safety of the Kakariki transiting Otago Harbour.

implement a revised signalling system controlling northbound trains approaching Te Maunga to provide enhanced advance warning to the LE of a train routed to the Mount Maunganui Branch, and develop and action a priority list of any similar locations where an enhanced advance warning would reduce an unacceptable risk of high speed entry to a medium speed route.

On 8 December 2021, the Commission recommended that KiwiRail, in the development of a formal SFAIRP policy, consider incorporating wider factors of engineering judgement, incident history and local knowledge. (011/21)