Inquiries & Recommendations

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Review procedures and contingencies for rostering Train Control Officers, with particular regard to defining maximum shift hours and maximum hours between breaks, and make appropriate provision for certified relief staff.

Shunters be advised not to ride on the leading footplate of locomotives as they pass over public level crossings unless they are required to pilot the train movement at low speed.

Educate pilots on the operation of the use of general aviation areas, in particular those areas within the Queenstown control zone.

Review the coverage and application of "Site Safety Plans" to ensure they incorporate the wearing of high visibility gear as a mandatory requirement when working on or adjacent to any operating line for Signal Maintainers carrying our regular lineside equipment inspections, and for other staff subjected to similar risk.

On 10 April 2017 the Commission recommended to the manufacturer that, as a matter of urgency, it contact all known ship owners that have the same or similar emergency launching and recovery systems installed on their vessels, informing them about the circumstances of this accident, and advising them to have the systems inspected immediately by a competent person to check whether the nitrogen cylinders and other pressure vessels associated with the systems are fit for purpose. Any nitrogen cylinders deemed unfit due to corrosion should be removed for further assessment

Review the "EMERGENCY" section of the IFG with a view to ensuring that the scope of the "communication failure" part of that section is sufficiently comprehensive to provide pilots with information and advice on actions to be taken in the event of a failure of communications from Air Traffic Control.

Take immediate steps to review the adequacy of the RFS service provided at Gisborne Aerodrome for the scheduled passenger service aircraft presently operating into Gisborne Aerodrome.

In conjunction with his safe ship management company amend his operations manual to include specific instructions on the use of the watch alarm by the skippers of his vessels.

Implements a system of familiarisation in tug operations for maritime pilots, as required.

Require operators of aerodromes where an air traffic service is provided and that have more than one taxiway available for entry to any runway to prescribe the procedures and conditions, including the environmental conditions, under which multiple taxiways may be used to enter the runway.

Review the Quick Reference Handbook for the B747-400 series regarding the procedure for Inertial Reference Unit (IRU) selection by the crew, after an EICAS IRS fault message is displayed, to determine if any change is necessary to ensure all three IRUs are not switched off unnecessarily.

In co-operation and consultation with the aviation industry, appropriate seatbelt modification or other restraint system be devised to provide an appropriate degree of shooter safety during hunting operations.