Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

introduce a procedure for stabling of locomotives so that the person applying the handbrake is able to confirm application by visually checking contact between the brake blocks and wheels.

Arrange for the Gisborne pilot to attend a Bridge Resource Management course.

Auckland Trains The Commission is aware that new passenger trains have recently been introduced in Auckland. The Commission is not aware of any safety issues with the new trains but expects they would have been tested to comply with the same National Rail System standards as the Matangi trains in Wellington. Therefore, they may be exposed to the same lack of optimised brake performance risks in low adhesion conditions.

Include in the flight training programme for company helicopter pilots, slign load re-currency training as part their annual proficiency training programme.

Conduct a risk assessment of navigation in confined waters and upgrade the passage plans to make use of techniques such as monitored turns and critical decision points and foster the use of good bridge resource management to implement and monitor the passage plans

Operators' safety management systems should indentify risks to their operations and put in place processes to mitigate any identified risk. The share fishing system of remuneration has the potential to place significant commercial pressure on skippers, which could compromise good judgment when making decisions affecting the safety of their vessels and crew. This potentially serious safety issue should be addressed through operators' safety management systems with guidance from Maritime New Zealand in consultation with fishing industry organizations.

Review the procedures in use for releasing the chain from the aircraft if it should become snagged.

Identify all other private level crossings that the public are invited to use to ensure that: - the appropriate authority has been given for such use - the deed of grant contains appropriate conditions that ensure public safety - the appropriate signage for a public level crossing status is in place.

Amend Welair's Operations Manual to include a paragraph altering pilots to the hazards of operating into Awaroa in strong north-westerly wind conditions.

Consider fitting a fire-detection and fixed fire-extinguishing system to the vessel.

Review the existing understandings with the RNZAF in relation to the observance of airspeed restrictions in controlled airspace.

In conjunction with the safe ship management company, amend the safe ship management manuals throughout the fleet to contain in the training of crews the necessity in an emergency situation of making passengers aware of the crew’s presence and the need for them, as trained personnel, to provide guidance, help and support to passengers.