Inquiries & Recommendations

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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.)

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.