Inquiries & Recommendations

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On 27 September 2023, the Commission recommended that KiwiRail adequately address the risk posed by disconnecting level-crossing protections, whether planned or unplanned.

On 27 September 2023, the Commission recommended that the Civil Aviation Authority of New Zealand, in consultation with stakeholders, resolve the ambiguity around night Visual Flight Rules and guidance to ensure they are fit for purpose.

On 27 September 2023 the Commission recommended that the Taupo Gliding Club develop and implement a system approved by GNZ that ensures instructors can positively verify that pilots have an appropriate level of competency to ridge soar on Mount Tauhara and safely conduct training flights on the ridge.

On 27 September 2023, the Commission recommended that the Civil Aviation Authority of New Zealand, in consultation with stakeholders, establish and clarify instrument currency requirements for night Visual Flight Rules flying.

On 27 September 2023, the Commission recommended that KiwiRail work with road controlling authorities to develop processes for notification, risk assessment and traffic management measures for unplanned level-crossing disconnections.

On 27 September 2023, the Commission recommended that Maritime New Zealand and WorkSafe (until 1 July 2024) ensure that their regulatory activity includes a proactive role (such as monitoring and assessment) in the safety of the stevedoring industry.

On 27 September 2023 the Commission recommended that Gliding New Zealand review how gliding club instructors are trained, and clubs are audited, and then take corrective action to ensure that all new instructors are consistently trained to the standards set out in the Manual of Approved Procedures (MOAP)

On 22 August 2023, the Commission recommended that Lyttelton Port Company Limited prioritises a review of their safety management system to ensure that: • documented procedures are consistent and reflect all critical aspects of the work as done • all risks are identified, and administrative risk controls are only used when more effective risk controls are not reasonably practicable • adherence to administrative risk controls is effectively managed • supervisory oversight is effective and not compromised by competing operational demands

On 22 August 2023, the Commission recommended that Maritime New Zealand works with industry stakeholders to improve safety standards for stevedoring operations through: • implementing an Approved Code of Practice for managing health and safety risks associated with stevedoring activity • establishing minimum training standards for stevedores • establishing a programme to facilitate continuous improvement of stevedoring safety standards, including the sharing of safety information amongst industry stakeholders.

On 22 August 2023, the Commission recommended that Lyttelton Port Company Limited reviews the medical screening of stevedores to ensure it provides adequate assurance of medical fitness for their duties and responsibilities.

On 22 August 2023, the Commission recommended that Wallace Investments Limited prioritise a review of their safety management system to ensure that: • the responsibility for safety of each stevedoring role is clearly defined, unambiguous, and understood by all personnel • procedures for work activity adequately cover scenarios with increased risk • all risks are identified, and administrative risk controls are only used when more effective risk controls are not reasonably practicable • adherence to administrative risk controls is effectively managed.

On 26 July 2023, the Commission recommended that Maritime New Zealand alert all Recognised Surveyors: • to the importance of conducting and documenting inspections of a vessel’s complete fuel system during surveys; and • to check vessels they are surveying have undergone a recent complete inspection of the fuel system.