Inquiries & Recommendations

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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.

The most likely reason for the side frame failures is that they had reached the end of their fatigue lives. A lack of identifying marks and records of side frame age and maintenance history means that it will be difficult to predict the onset of fatigue cracking in bogie side frames. The presence of fatigue cracking initiating in the region of the radius, just beyond the wear plate of the side frames, is difficult to detect by normal visual inspections, and at the current rate of MPIs the entire inventory of bogie side frames will not be completed until 2020.

The Commission recommends that the chief executive of KiwiRail closely monitor the replacement of brake blocks on individual wagons to provide another predictive tool for preventing premature wheel-bearing failures.

Amend the requirements for vertical separation when specified rates of climb or descent are used, especially for low performance aircraft, to ensure that there is either an increase in the level of monitoring, or a greater buffer is applied for the procedure.

Require all military formation leaders/aircraft captains participating in an air show to attend the pre-display briefing conducted by the organisers.

In conjunction with the Safe Ship Management Company implement the requirements of Maritime Rule Part 31C [Crewing and Watchkeeping - Fishing Vessels] for all vessels operated by his company and update the safe ship management manuals as necessary.

Implement procedures to ensure that the requirements for persons in charge of obstructed sections to not obstruct the line until satisfied that any controlled signals governing the entry of trains into the work area are fixed at stop are complied with.