Inquiries & Recommendations

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Ensure that staff allocated driving duties of on-track maintenance vehicles are appropriately trained and certificated.

The interpretation of SIGMETs could be improved by the use of clearer reference to geographical regions, although the requirement to conform to ICAO Standards and Recommended Procedures is appreciated.

develop and introduce a more intensive audit and assessment procedure for new train controllers for their first 12 months in the position, culminating in a re-certification after that period before moving into the bi-annual re-certification process.

draft an amendment to Rule Part 40C.60(b) [Design, Construction and Equipment - Non-Passenger Solas] for the consideration of the Minister to clarify the intent of the rule with regard to the requirements for positive means of quick release mechanisms for ships towing from bollards

Draw attention of owners/operators to Textron Lycoming Commercial Service Letter 102 (dated 23 June 1992) to inform or remind them of the series of modifications and improvements that may be made to existing fuel pumps with particular reference to Chandler Evans Service Bulletin SB 73-98 "Improved internal spline lubrication resulting in reduced spline wear and extended pump service life".

Put in place procedures to ensure that the watchkeeping alarms fitted to all vessels operated by his company are used whenever a navigational watch is undertaken.

Require your pilots to compute required landing distances for the destination before loading their aircraft for lights terminating at an airstrip.

KiwiRail's records of random drug and alcohol tests for the three years from 2013 to 2015 showed that 95% of the positive results had related to employees working in its safety-critical infrastructure maintenance and train operations areas. KiwiRail's practice of randomly testing 10% of its workforce annually means that an individual is potentially tested once every 10 years, which is consistent with the rail protection officer not having been randomly tested in the previous 10 years.

Publish widely, including to foreign Civil Aviation Authorities where the PA31 type is operated, advisory material about the cause of this undercarriage failure-to-extend accident, to alert operators and pilots to a previously unknown deficiency, and to assist any future investigation of a similar occurrence.

Conduct a practical pre-contract audit of each international cargo handling contractor's ability to meet the requirements of the contract prior to entering into any future contract.

The Commission recommended that Talley’s introduces a system for managing contractors working on board. The system should include sign-off for each task, a job safety analysis for each task that may pose risks to the contractors or crew, and, where applicable, testing to ensure the repaired system is fit for purpose.

Review the appropriateness of the company operations manual landing procedure which requires a deviation from the PAPI glide path indication to achieve the required touchdown point versus the manufacturer's claim that the necessary landing distance safety margins can be achieved by maintaining the standard approach technique.