Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Review the Operations Specifications and the associated Operations Manuals of each helicopter operator licensed to conducted scenic air transport operations to ensure any Civil Aviation Regulation is referred to only by its number and if necessary specific paragraph or ..[see recommendation 010/91].

Amends the Tranz Rail Rules and Regulations on the setting of locomotive headlights by LEs to require the headlights to be on full beam when trains are approaching level crossings at night.

In conjunction with the Safe Ship Management Company include a section in the Safe Ship Management manual on the signs, symptoms and effects of fatigue and practical methods of managing fatigue.

Dismantle and inspect for fatigue cracks as a matter of urgency all axles under the three axle bogies currently in service on the Silver Fern. Reassembly of uncracked axles should include action to prevent corrosion at the tapered gap between the axle and inner bearing.

Adopts and promulgates to crews a procedure that, where the release of a company agent after departure would preclude the use of the departure aerodrome for the return of the aircraft, this action is not taken until current weather and other operational information on the destination and alternate aerodromes has been received by the crew.

He require operators to produce detailed studies of potential downdraught or wind-eddy situations in the vicinity of airstrips that they use or intend to use for air transport operations in the Marlborough Sounds.

critically review the need to ensure that all bridge watchkeepers on New Zealand registered commercial vessels are appropriately qualified.

The nitrogen cylinders that formed part of the stored energy system on board the Emerald Princess were stowed in a harsh marine environment and had significant external corrosion. The nitrogen cylinders were inspected annually by the manufacturer’s authorised technician. The most recent inspection was two weeks prior to the accident. On each occasion the cylinders were judged to be in satisfactory working condition.

Reviews its rules for assigning limiting speed/wave height criteria for high speed craft, ensuring that due regard is given to the effect of different wave periods on such craft, and ensuring that for each craft, its speed/wave height table is accompanied by a clear and concise statement as to any other factors an operator must take account of when using the table.

Develop with industry a communication and education strategy to implement fatigue management guidelines taking into account the outcomes and recommendations from the fatigue management study currently being conducted by the MSA. [This safety recommendation was subsequently found to be equally applicable to two other occurrences. Refer to reports 04-207 (grounding of fishing vessel "Poseidon" on 15 April 2004) and 04-209 (collision of fishing vessel "Joanne" with motor tanker "Hellas Constellation" on 19 May 2004).]

Circulate to all heritage and narrow gauge railway operators the lessons learned from this investigation and require an assessment of risk focused on passenger safety, be undertaken by each operator with the results being submitted to Land Transport Safety Authority for approval.

It develops detailed education material for all pilots and air traffic controllers covering the hazard so illicit drug use especially THC*. (*THC is the abbreviated term for 9^ Tetra Hydro Cannabinol, the principal active metanolite of marijuana or hashish.)