Inquiries & Recommendations

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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.

Carry out an LTSA investigation, or initiate a specific audit, of Train Control operations, such investigation or audit to include: • the resources available to meet the workload demand • the suitability of the roster system • the maximum shift desirable • the adequacy of arrangements for meals and other breaks during shifts • the adequacy of the current training system • the suitability of staff trained under any other system • the effectiveness of the safety observation and compliance monitoring system • the suitability and control of the work environment

Improves the training of freight handling staff to a standard which will ensure the safe handling of wagons.

The Commission recommends that the Chief Executive of KiwiRail ensure that where KiwiRail makes significant modifications to vessels, appropriate oversight is in place. Oversight includes keeping comprehensive records to demonstrate that components are safe and reliable and comply with the appropriate standards

Rail workers are not required to give permission for rail medical officers to access medical records held by their private practitioners, which means the rail medical officers would not necessarily have access to all relevant medical information in order to determine their fitness for safety-critical duties.

Require Safe Ship Management companies to include in their contracts or agreements with clients, a clear understanding of the operators' responsibility to report "major alterations" or "major repairs" as required by Rule Part 21 [Safe Ship Management] [original text referred to Part 20 in error].

Consider adopting the technique of applying full power before brakes release, where runway surface scorching is not a consideration.