Inquiries & Recommendations

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On 30 April 2023, the Commission recommended that Maritime New Zealand require KiwiRail to provide evidence to Maritime New Zealand’s satisfaction that safety-critical rubber expansion joints onboard all vessels within KiwiRail’s Interislander fleet are fit for purpose taking into account the manufacturer’s guidance, namely: • they should be no older than eight months from the date of manufacture when installed • they are inspected annually including visual, tactile and hardness measurements • regardless of inspection findings, safety-critical REJs should be replaced after five years.

The Commission recommended that KiwiRail install a more effective engineering solution to prevent rail movements entering the Picton rail linkspan without authorisation.

The Commission recommended that KiwiRail ensure that safe working procedures are in place to manage site-specific risks associated with staff undertaking shunting activities.

The Commission recommended that the Secretary of Transport review and revise Civil Aviation Rule Part 91 to mandate the wearing of pilot restraint harnesses during critical phases of commercial balloon flights. (001/23)

The Commission recommended that Swire Shipping (NZ) Limited review their safety management system to ensure that safety leadership is developed at all levels within the organisation to help develop a strong safety culture. 006/23.

The Commission recommended that Maritime New Zealand develop and disseminate clear guidance to highlight the inherent risks associated with the telescopic accommodation ladders

The Commission recommended that the Civil Aviation Authority of New Zealand address the growing gap between New Zealand’s minimum performance requirements and technical standards for NVIS and helicopter air ambulance operations and current international best practices.

Crew resource management competency is not yet an effective safety measure for helicopters operating under CAR Part 135. On 22 February 2023 the Commission recommended that the Civil Aviation Authority of New Zealand address this safety issue.

The Commission recommended that the Ministry of Transport revisit its decision with respect to recommendation 004/11 and take steps to mitigate the increase in the risk of competence-based accidents in the recreational maritime transport sector.

The Commission recommended that the Ministry of Transport undertake research to determine the merits of a regulatory system for the recreational maritime sector, in line with overseas best practice, and how such a system may incorporate licensing, registration and boat design standards to improve the safety of New Zealand’s recreational maritime sector.

On 7 December 2022 the Commission recommended that KiwiRail review its permit-to-enter process by working with road-controlling authorities, and those requiring permits to enter, to ensure that provision is made for the practicable requirements of non-static or short-term work at multiple locations within the rail corridor.

On 7 December 2022 the Commission recommended that KiwiRail review its permit-to-enter process to ensure that any associated costs and requirements are not prohibitive to the completion of safety-critical work, and that the charging of fees for permits to enter is in accordance with the Railways Act 2005.