Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

while policy and any legislative changes are being developed, consult with industry to develop a communication and education strategy to ensure that masters, owners, operators, surveyors and inspectors are aware of the validity of the present qualifications and the minimum crewing requirements for all vessels and their relevant operating areas.

As a matter of urgency inspect his fleet of Convair 580 aircraft to ensure the cockpit voice recorders are correctly installed and are functioning as required.

Publish guidance material for all night VFR flying.

Instigate a programme of training and practice amongst members of bridge navigational teams, especially Masters, in ship handling and manoeuvring for their specific ships in simulated abnormal situations in safety critical areas for their standard voyages. Such situations should include but not be limited to, bad weather, engine failure, steering failure.

Take urgent steps to complete his review of the adequacy of CAA audit staff numbers for carrying out safety audits on operators in accordance with their stated policy.

Work with SAR coordinators and providers of SAR air assets across New Zealand to identify opportunities for the supply and, if necessary, the storage of fuel for extended SAR operations in remote areas, and maintain a database of identified stored fuel and fuel supply logistics.

The quality of crew resource management to achieve outcomes in this case, including the management of resources at different locations such as the train control centre, locomotive cabs and track work sites, sometimes using different communication methods, was of a poor standard, and previously published occurrence reports, as well as other, still open investigations, indicate that the standard of crew resource management across the rail industry is not adequate.

The existing track and structures inspection codes were prescriptive and did not embrace the risk assessment principles documented in the more recent Structures Inspection Manual W200 or required for rail systems under National Rail System Standard (NRSS) 4.

Develop some educational material on go-around procedures where involuntary overtaking may occur, and promulgate this to pilots and controllers.

Extend the requirement for the carriage of flight data recorders to all multi-engined aircraft used principally for air transport operations.

Devise regulatory requirements for air traffic service standards, incorporating such a requirement.

Pilots in command be advised of the need to consider full the consequences of a repetition of an engine fault before conducting a test flight following a reported engine malfunction.