Inquiries & Recommendations

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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.

On 15 May 2025, the Commission recommended that the owner of the Shiling review the performance of ship management companies engaged to operate its ships against international and domestic requirements, to enable it to be satisfied that the ships are seaworthy for every voyage.

Review the policy and procedures for issuing exemptions from compliance with the rules to ensure that safety critical standards are not compromised.

Soundsair be subject to an Audit by the Air Transport Division with a minimum delay, unless such action had already been taken or the company was no longer operating.

Promote resource management concepts throughout the operational staff of the port.

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.