Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Review the present system of annual re-examination of locomotive engineer's first aid ability with a view to extending it to apply to guards as well

On 23 February 2017 the Commission recommended to the Administrator of the FAA that he: - extend the limitations and requirements of FAA AD 95-26-04 that currently apply to the R22, in regard to operating in strong winds and turbulence, to the R44 and R66 models; and - extend those limitations and requirements so that they apply to all R22, R44 and R66 pilots regardless of their experience levels.

There is no requirement for operators of passenger trains to have effective communication between the locomotive engineer and the on-board person in chage of passenger operations that will facilitate good crew resource management and be effective in emergency situations.

Provide train controllers with documentation clearly defining and illustrating the boundaries of radio repeaters in use on the respective routes of the network.

The Commission considers that not having a weather proofing engineering review done of the Johnsonville Line is a safety issue and recommends the Director of Land Transport New Zealand addresses this safety issue.

Work with SAR coordination entities to ensure they have procedures for prompting the operator of air assets as to the maximum range of operation and opportunities for refueling for sustained SAR operations.

Initiate with the aircraft manufacturers an investigation into the practicality of enhancing the survivability of the aerials of any ELTs in passenger transport aircraft which are hard wired into aircraft.

[the LTSA, MSA and OSH] Bring the problem of substandard connections between stacked bases to the attention of safety agencies in other countries where is considered the use of dissimilar interlocking systems could result in similar substandard practices.

include an article in the Seafood New Zealand magazine featuring a summary of the report into this accident highlighting the benefits of owners and operators providing appropriate fire fighting equipment to enable a boat’s crew to effectively fight a fire on board.

Liaise with Port Otago Limited and combine the resources of all parties to reassess the risk level for the Kakariki transiting Otago Harbour and take whatever action is required to achieve a level of safety commensurate with prudent seamanship, and appropriate ship and port company operations.

Provide a library of collated technical information for builders and prospective builders.

The NOSS showed that the number of communication errors by both controllers and pilots, particularly for the Auckland Terminal sector, was unusually high by international standards. This increases the risk of communication errors contributing to a breakdown in safety standards. The Commission believes this is a safety issue that the Director needs to address with Airways and recommends that he satisfies himself that Airways' planned Strategic Safety Plan will reduce communication errors and the consequent risk.