Inquiries & Recommendations

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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.

Install blue edge lighting or blue reflectors around the perimeter of the "Skycare" apron.

Evaluate the publicity material available for educating school children on the hazards associated with playing or trespassing near railway tracks.

reinforce the principles of Crew Resource Management in regard to clear and concise communication to all levels of infrastructure staff.

Devise a suitable stop-go decision making system in the form of either establishing a minimum speed to be attained by a known distance into the take-off run, or by physically marking the anticipated lift-off point.

Consider the use of 30 flap for all take-offs.

In conjunction with the Maritime Safety Authority, determine and put in place measures to ensure that the company vessels comply fully with the provisions of Maritime Rules Part 31C).

Fit trim tab indicators.

KiwiRail's Risk Management Policy for "continuity of core services" did not give proper consideration to the safety of passengers and crew when a core service such as train control failed, causing the widespread stoppage of an entire metropolitan passenger rail system. On 29 October 2014 the Commission recommended that the Chief Executive of KiwiRail revise the risk rating assessment matrix in its Risk Management Policy to reflect the fact that train control is a safety-critical service, and to consider the safety of people in crowds when assessing and mitigating the risks.