Inquiries & Recommendations

Ngā ketuketutanga me ngā tūtohunga

Consider either recalling all old HJ-212 steering nozzles or producing a service bulletin warning users of possible failure and the consequences.

On 25 October 2017 the Commission recommended that the Director of Maritime New Zealand, use the Port and Harbour Marine Safety Code and its associated governance arrangements, or any other appropriate mechanism, to ensure that port authorities produce and publish passage plans for their respective pilotage districts that meet the port-specific requirements and guidelines contained in, Chapter V, Safety of Navigation, of the Annex to the International Convention for the Safety of Life at Sea and Resolution A.893(21) Guidelines for Voyage Planning.

Review and update company manuals and procedures to ensure they are correct and provide the best available guidance for pilots to detect, avoid and escape from adverse or hazardous conditions.

while formulating the company's Safety Management System, he gives priority to those sections which relate to procedures and practices for the critical shipboard operations of passage planning and navigation in confined waters.

liaise with emergency services to ensure that existing contact procedures are adequate and that the training and ongoing certification of train controllers reinforces such procedures.

Require regular inspections to determine that the "Do not paint" decals are in place and legible.

On 30 April 2025, the Commission recommended that Fulton Hogan: a. review and improve the procedures and guidelines for the supervision of trainee RPOs b. provides appropriate training to supervisor RPOs to enable them to perform this function effectively.

Take steps to promulgate the Railways Regulations to increase the awareness of the general public of their provisions.

install a protection device on the loop at Owens siding to prevent an uncontrolled wagon movement traveling in a westerly direction beyond that point.

Introduce the following directions into the harbour bylaws covering their ports, to emphasise the intent and principles of STCW and SOLAS: • all vessels, whether under pilotage or pilot exempt, shall have an agreed passage plan for transits within harbour limits • the number of crew members on the bridge shall be sufficient to safely carry out the agreed passage plan

The Commission recommended to the Director of Civil Aviation that he include the knowledge and training requirements of Special Federal Aviation Regulation No. 73, or an equivalent requirement, as a prerequisite for the issue of a Robinson R66 type rating.

The approval process authorised one person to carry out the rail protection duties for two separate worksites within a protected work area throughout a 52.5-hour track occupation period without appointing a relief rail protection officer. The rail protection officer had worked relatively long hours during the week leading up to the incident and had had no days completely free of work. His working hours had provided limited opportunity for recovery from any fatigue or sleep loss that may have built up, and particularly sleep loss that he experienced on the first night of the planned work.