Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

The bridge operations on board the Leda Maersk fell short of achieving good industry practice in both planning and executing the passage under pilotage and bridge resource management.

There is recurring evidence indicating that standards of maintenance of rolling stock on the national rail network as demanded in Veolia's and KiwiRail's safety cases is lower than preferable and reasonable in that for example: - manufacturers' inspection, repair and maintenance instructions are not always documented and followed - safety critical components are not always identified and documented - work instructions for maintaining safety-critical equipment are not always issued and work on safety-critical components is not always signed off by someone other than the maintainer

On 23 May 2018 the Commission recommended that the Director of Maritime New Zealand continues to emphasise to recreational boat users the benefits of having crotch straps fitted to their lifejackets.

Currently KiwiRail does not have a fully developed, comprehensive fatigue risk management system to ensure that all relevant personnel perform at adequate levels of awareness. On 23 August 2018 the Commission recommended that the Chief Executive of KiwiRail ensure that a comprehensive fatigue risk management system is fully developed and implemented within the organisation.

In conjunction with the appropriate local authorities reviews the effectiveness of the current policy with respect to the provision and maintenance of fencing in areas such as North Auckland, the Hutt Valley and other similar suburban areas to minimise trespass at known high risk areas.

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.