Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Air traffic control is a highly safety-critical function of the aviation system, yet the process by which Airways ensured that workplace practices were in accordance with documented procedures was not effective, as shown by the non-compliance with written and agreed roster requirements.

Redevelop the current emergency response training programme for train controllers and network control managers, in conjunction with appropriate external agencies, to include but not limited to: · responding to emergency notifications · dealing with potentially distraught people reporting emergencies · procedures for ensuring emergency sites are identified and confirmed · the use of maps and map grid references when establishing such sites · procedures for contacting emergency services

Review New Zealand Rail Limited's fencing policy with a view to establishing a sound fence for sufficient distance with side of island platforms to make the authorised access more attractive than bypassing a fence.

Include in Advisory Circulars detailed mountain-flying training guidance information, to assist operators who conduct routine commercial operations into mountainous areas, such as Fiordland or similar regions, to meet the Civil Aviation Rules requirement to establish a training programme that ensures each of their pilots is trained and competent to fly in such areas.

In relation to the weather conditions in the area at the time of this accident, emphasises compliance with applicable VFR minima regarding flight visibility and clearance from cloud.

bring to the attention of the appropriate IMO committee the final version of this report and make a recommendation to the committee that it: consider reviewing the requirements for rescue boats to include a dedicated seating or bracing arrangement designed to minimise injury to the operating crew in the event of mishap or heavy weather operation.

Investigate the practicability of "delethalising" the level crossing environment progressively be removing obsolete substantial obstructions, and relocating signal stanchions, equipment housings and other essential structures, sited within 500m of track distance from any level crossing, so that they were at least 5 m from the trackside and investigate the practicality of improving the frangibility of warning light/barrier masts so that they minimised the damage inflicted on vehicles which collided with rail vehicles.

ensure that Safe Ship Management surveyors are aware of the requirements of the Maritime Rules and that the vessels they inspect and certify meet the requirements of those rules.

Various aircraft paint schemes have shown to have little benefit in improving the conspicuity of aircraft for the wide range of weather, environmental and geographical conditions likely to be encountered. Similarly the current minimum aircraft lighting requirements are not always effective in attracting the attention of pilots in bright conditions. However, more modern high intensity strobe lighting can increase the ability for an aircraft to be detected in most lighting conditions and could improve the reliability of ‘see-and-avoid’ as a primary means of preventing mid-air collisions.

On 27 September 2021, the Commission made a recommendation to South Port that they ensure South Port’s safety management system develops measures to make certain that pilot training and proficiency requirements are being met as per the South Port Pilot and Tugmaster Training Manual and as required by Maritime Rule Part 90: Pilotage.

Require Robinson Helicopter Company to amend its flight manuals to include the use of "Warning" for those operating conditions and practices that involve a risk of personal injury or loss of life.

undertake random audits of vessels which have a safety management certificate issued by your company in order to check that the requirements of the International Safety Management code, with respect to on-board communication, are being complied with in practice.