Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Control the conditions for cab riders to avoid familiarity resulting in a delegated control function.

introduce the formalised crew resource management procedures recommended in safety recommendation number 001/99, and ensure that such procedures include remote-control operators operating main line shunts.

By the most appropriate means ensures that all skippers and crew members within the safe ship management system are advised and instructed on the importance to safety of good "housekeeping" within the engine room spaces and that all repairs and modifications should be carried out using appropriate materials to the satisfaction of a safe ship management surveyor.

The train driver in this instance had several weeks earlier received a radio call about a divergent path to bypass a disabled passenger train at Otahuhu. However, on this occasion he did not receive a similar radio call warning him that his train was not going to follow the usual path. The circumstances of this latest accident provide further evidence that additional advice to train drivers about conditions that are likely to affect their trains can help to prevent accidents.

The development of Project Kupe system has the potential to reduce the risk of collision on the network but, due to resource and funding restraints without a cost/safety benefit analysis being undertaken, the project has extended out by 2½ years and has still not been approved. The Commission recommends the New Zealand Transport Agency takes action to address the safety issue (004/09).

Implements procedures to assure compliance with the rules for securing detached wagons left on the main line.

install a protection device on the Onehunga industrial line near Owen’s Siding to prevent uncontrolled wagon movements in a westerly direction beyond that point.

Ensure authorised line speed and signal sighting distances provide a safe stopping distance in the event of an Intermediate signal being misread at locations such as Plimmerton where level crossings and conflicting passenger movements create a potential hazard.

develop, in conjunction with Christchurch Tramway Limited, formalised procedures to be followed before any work is undertaken which conflicts with the requirements of the Christchurch Tramway Limited safety system.

Implement a credible system of Mu-meter monitoring on a regular basis, of runway surfaces at all aerodromes used for air transport operations and with a runway length of 1200 metres or more as per ICAO recommendation in Annex 14 to the Convention on International Civil Aviation paragraph 2.6.1 or otherwise.

Adopt the ICAO definition of runway incursion and the ICAO Runway Incursion Severity Classification model, use a consistent process to investigate runway incursions and ensure that other involved parties are promptly advised of an incursion notified by any one of them, and calculate annual runway incursion rates for certified aerodromes.

Ensure that all company pilots attend a bridge resource management course and adopt the principles as part of company operational policy and procedure.