Inquiries & Recommendations

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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.

On 10 April 2017 the Commission recommended to the Cruise Lines International Association that as a matter of urgency it contact members, informing them about the circumstances of this accident and warning them to have the systems inspected immediately by a competent person. Any corroded nitrogen cylinders or other associated pressure vessels should be removed for further assessment.

Co-operate with Transit New Zealand, the Tauranga District Council, and the Land Transport Safety Authority in a review of all level crossings in Mt. Maunganui.

Ensure that the lengths of track for which track inspectors are responsible, are such that appropriate inspections can reasonably be made in the time available.

Safety inspections performed by the Authority should take account of hazards to helicopters as well as to aeroplanes.