Inquiries & Recommendations

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Install a suitable restraint to minimise the risk of passengers falling from the trolley, before reinstating the carriage of passengers on motor trolleys.

Stress to all operators carrying out air transport operations, the importance of their pilots making sound command decisions appropriate to these operations, and the need to have a management system for ongoing supervision and monitoring of their staff.

Revise the GAP booklet "Winter Flying" to emphasise that hard ice will not be removed by brushing.

Consider using the PIANC guidelines when reviewing company policy and procedures.

On 27 October 2021 the Commission recommended that the Secretary for Local Government provide leadership to, and work with local authorities to ensure that traffic management plans identify any rail crossings within the vicinity of the proposed work and that the rail access providers have been consulted to ensure that any additional safety requirements in relation to the road/rail interface are met.

On 22 August 2023, the Commission recommended that Lyttelton Port Company Limited reviews the medical screening of stevedores to ensure it provides adequate assurance of medical fitness for their duties and responsibilities.

Review the capabilities of each of the personnel involved in the loading process to ensure they meet the required standards, are cognisant of their duties, and have sufficient resources and training to distribute and secure the load correctly.

The protection person was a user of cannabis. Although it could not be established scientifically that his performance was impaired by cannabis at the time of the incident, he did have a detectable level of THC-acid in his urine when he was tested after the incident.

Engineers be made aware of the accident circumstances to stress the desirability of identifying the cause of an apparent, recurrent, engine problem before authorising a test flight.

He require the RNZAC rules for formation flying to be reviewed by an independent panel of pilots familiar with formation flying.

A safety issue identified during the inquiry was the widespread practice of allowing passengers to leave and return to helicopters parked on snow while the rotors are turning. Frequently the pilot will also disembark to guide the passengers while they move under the main rotor disc. There is a serious risk to people on the ground if a helicopter has settled into fresh snow or it breaks through an apparently hard surface crust. Should this happen the clearance between the rotor disc and people walking beneath could reduce sufficiently for someone to be struck by the rotor blades.

Introduce measures to ensure that where two trolleys/HRVs, operating under Rule 198 and Rule 199, are authorised to occupy a particular section of track at a common time each must be given full particulars of the other's position and progress before the second is authorised to "on-track" and that where contact cannot be made with the first, adequate steps are taken to safeguard its progress before the second is permitted to "on-track".