Inquiries & Recommendations

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On 25 September 2024, the Commission recommended that NZ Transport Agency Waka Kotahi work with rail operators to assess the benefits of all rail operators on the Auckland rail network using a common engineering safety system to improve the safety of all users of that network.

critically review the existing communication and traffic management system for Manukau Harbour and upgrade it to ensure harbour users are aware of other traffic movements.

The Commission recommended that the Civil Aviation Authority of New Zealand address the growing gap between New Zealand’s minimum performance requirements and technical standards for NVIS and helicopter air ambulance operations and current international best practices.

On 27 September 2023, the Commission recommended that KiwiRail adequately address the risk posed by disconnecting level-crossing protections, whether planned or unplanned.

Put in place procedures to reinforce the need for effective bridge resources management on board the company's ships. This should include the requirement that the full bridge team are on the bridge before departure, and that administrative work is separated from the navigation function of the ship's officers.

Advise all recipients of its synchronous lifeboat release equipment of the type supplied to the Aratere, of this incident and of the potential for the equipment to be incorrectly engaged when recovering a lifeboat.

Harmonise the provisions relating to separation after loss of communications in the Manual of Air Traffic Services and the Flight Guide.

Advise all member Classification Societies of this incident, the contents of this report and the need for vigilance on the part of class surveyors and owners’ superintendents when inspecting welds and/or their associated parts during the construction and subsequent surveys of vessels.

review the Rail Operating Code with a view to clarifying those instances where staff to be relieved from duties when involved in an operating occurrence.

limit the number of preferential trainers to two, supplemented by others for operational needs in specialist subjects, undertaking OJT of trainee train controllers or retraining train controllers to a subsequent desk.

change the procedures for introducing rule and regulation amendments to ensure staff are fully conversant with such changes prior to introduction, and that effective introduction is monitored.

The operator did not have adequate systems available for the pilot to determine the actual all-up weight and balance of the helicopter for the firefighting operation, or to ensure that incidents such as the previous loss of a window were recorded, notified to the CAA and investigated. The use of a prohibited door configuration suggested inadequate awareness of and adherence to flight manual limitations, which often differ between otherwise similar variants of an aircraft.