Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Alert the civil aviation authorities of other countries where these aircraft are operated, to the potential hazards.

Develop without delay procedures whereby CAA may approve suitable check pilots to conduct Regulation 76 checks.

Arranges for appropriate publication of the circumstances surrounding this accident for safety educational purposes to alert pilots to the pressures inherent in scheduled and "semi-scheduled" VFR Air Transport flights relevant to en route decision making.

Evaluate and quantify the traffic on the Dart River and put in place a policy that will prevent conflict between and within the various user groups.

Introduce a system for a formal hand-over of company vessels from Master to company and back to Master. The system's purpose is to ensure that both the Master and the company are aware of aspects of operation, safety and maintenance for the vessel before the vessel departs the wharf and upon its return. The work record book could form part of the system.

Publish educational material such as a "Vector" article on the topic of the need for pilots and engineers to be aware of mechanical deterioration of items such as this door latch mechanism to ensure that timely remedial action is taken before failure occurs.

Include in the policy manuals instructions to ship’s staff on how the company expects the principles of effective bridge resource management should be complied with.

Establish the service stresses being developed in the driven axle of the three axle bogie, and from this determine the related fatigue crack growth rates and implement an inspection regime to detect such cracks and remove any axle from service before it fails.

The Authority issue an Advisory Circular to bring to the attention of aerodrome operators, matters pertaining to helicopter operations that they ought to consider in preparing expositions.

Liaise with an [operator of the vessel in accident report 97-202/203] and review the Safety Management Policy Manual for their vessel critically and ensure it contains the relevant operational and safety instruction necessary to comply with the New Zealand Ship Safety Management Code.

Include in procedures for departing from stations a confirmation check by the Tranz Metro Driver that the doors are closed, by referring to the door-closed light on the console in the EMU cab

Advises all secondary school boards of the circumstances of the Henderson accident and suggests that boards in the vicinity of a rail corridor, which may have similar problems, raise the issue of potential hazards in the rail environment with students and co-operate with Tranz Rail, local authorities, and other affected local groups to develop and implement specific local action plans to minimise or eliminate hazards.