Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

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.

Ensure that the following initial training and certification, new entrant controllers do not commence training on another train control desk until they have completed at least 6 months duty on their first train control desk.

review the network protection at operationally critical locations such as but not limited to North and South Junctions.

Encourage the use of parachutes in their sport.

Ensure competent inspection of aircraft under construction is available by: • Selecting inspectors/designated persons who are not only sufficiently knowledgeable, but who have sufficient strength of personality to ensure proper standards of construction are met; • Stipulating the test pieces continue to be preserved for inspection when the Regulations are changed; • Ensuring an inspector/designated person is present when structures are enclosed.

Include a section in the SGS M&I Safe Ship Management manual on the signs, symptoms and effects of fatigue and practical methods of managing fatigue. [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).]

check all generator units similar to AL2073 to ensure that the cooling airflow is adequate and unrestricted within the generator enclosure around all parts of the diesel engine and the alternator housing, and that ther is no build up of diesel oil or dust particles.

Develop the restricted radar course to include other forms of electronic navigational aids, such as global position systems and echo sounders. [This SR was also applicable to investigation 04-204 restricted limit passenger vessel "Freedom III", grounding, Lake Manapouri, 24 February 2004]