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
• radio communications used for safety-critical tasks are consistent and reliable.
