Inquiries & Recommendations

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Ensure that the duly appointed harbourmaster for the Port of Gisborne is employed on terms and conditions which enable him or her to properly fulfil the statutory function of the position at all material times.

Investigate fully the cause for the interruption of the transmission from the controller to the pilot of SAV 17R on 124.3 MHz.

The practice of issuing Track Warrants prior to their immediate need, be reviewed to minimise the potential for the suppression of the Warrant's details by more recent events affecting the Locomotive Engineer.

initiate changes to the Track Warrant computer System to introduce a cross check function in the Clause 3 "to location" field when train controllers are issuing previously prepared track warrants.

The operator's system for planned maintenance and repair neither accurately record the history of inspection and repair, nor ensured the proper functioning of the controllable pitch propellers and their control systems, which were critical to the safe operation of the ship. The operator's planned maintenance and repair system should be comprehensively audited to ensure it meets the outcomes required by the ISM Code. (027/10)

On 26 March 2025, the Commission recommended that KiwiRail review and improve the maintenance and inspection of safety-critical components of the carriage-coupler system to ensure they remain safe to operate.

Improve the effectiveness of ‘see and avoid’ as a way to avoid mid-air collisions through the promotion of the skills required, including the need to actively listen to radio calls.

Review the planned criteria for the marking of overhead wires and structures, to give increased priority to large spans, like West Arm.

Require all ferry operators offering scheduled ferry services within Auckland enclosed water limits to submit for approval to the council a detailed route operational plan for all scheduled ferry routes, then coordinate between operators to ensure that such passage plans as far as practical avoid ferries meeting on opposing tracks. The approved route operational plans should be required to form part of operators' safe ship management system.

withdraw from service and investigate the braking systems of all wagons that exhibit an abnormally high incidence of brake block burn-out.

Critically evaluate the track maintenance regime for the entire rail network to ensure that track standards are maintained appropriate for the line classification and speed category, and where sections of track are identified as being at risk, put in place appropriate defences until corrective action has been taken.

Take immediate steps to ensure all staff are made aware that where the wearing of a version of approved high visibility gear when working on or adjacent to any operating line is part of a "Site Safety Plan" the wearing of such gear is mandatory and not elective.