This page displays a list of all outstanding safety recommendations. This means that a recommendation has been assigned to an organisation and has not been implemented.
Safety Recommendation
018/11
Issued To
NZTA
on 23 Jun 11
Temporary speed restrictions are used to manage the safety of train operations when a general deterioration in track condition is identified. KiwiRail Network?s codes and standards consider track geometry faults such as cant, twist, line, top and rate of change of cant deficiency separately when determining the appropriate speed value.
The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail to make changes to the codes and standards relating to imposing temporary speed restrictions. Multiple track faults within the same section of track should be considered collectively when determining if a temporary speed restriction needs to be imposed before track repairs are made. (018/11)
Implementation Status:
Open
Reply:
We intend to work closely with KiwiRail with an aim to implementing and closing this recommendation as soon as practicable.
Discussion on it will commence on publication of the final report and will be ongoing.
When implementation is effected and the appropriate evidence has been gathered, we will be liaising with TAIC with a view to closing this safety recommendation.
Safety Recommendation
012/11
Issued To
MNZ
on 25 May 11
It is a safety issue that the system for tasking a Coastguard rescue vessel does not always ensure that the people responsible for tasking or operating the vessel are in possession of sufficient information to make a prudent decision on whether the task should be undertaken. Further, a person independent of the crew should always involved in the decision process.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc. develops a nationwide standard that supports measured decisions based on the maximum available information when tasking coastguard vessels.
Implementation Status:
Open
Reply:
Accepted
Coastguard to develop and implement a nationwide standard that supports measured decisions based on the maximum available information when tasking coastguard assets. As the environment we operate in is dynamic we see the investment in the decision making skills of those in charge as, if not more, valuable than a system or process and will continue to pursue this as our primary outcome.
Training component is being addressed within the CRM for CRV Masters and the Duty Officer or nominated Ground Person as part of the current Training Development Project to be completed for implementation from July 2011.
Safety Recommendation
013/11
Issued To
MNZ
on 25 May 11
It is a safety issue that there are shortcomings in the standard of navigation training applied by Coastguard crews particularly for navigation at night and in poor weather conditions.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc. ensures that all Coastguard crews achieve a high standard of navigation skills for all Coastguard crews commensurate with the worst case scenario of conducting rescues at night and in bad weather.
Implementation Status:
Open
Reply:
Accepted
Coastguard volunteer (CoC) training will include high standard of navigation skills commensurate with worst case scenario of conducting weather at night and in bad weather.
This is being addressed as part of the mandatory competency level for Operational Crew as well as an advanced navigation skill set for Senior Crew, through a new course being designed as part of the current Training Development Project to be completed for implementation from July 2011.
Safety Recommendation
014/11
Issued To
MNZ
on 25 May 11
It is a safety issue that the Coastguard did not have a process requiring its crews to undertake pre-departure planning when tasked to an incident thus increasing the risk of an accident occurring en-route to the incident area.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc ensures all Coastguard crews conduct an appropriate pre-departure plan , that includes a risk assessment, and that the plan is reassessed at appropriate times as the rescue scenario unfolds.
Implementation Status:
Open
Reply:
Accepted
All Units have requirements as part of the Safe Ship Management System (MNZ) for standard operating procedures for pre-departure planning. Coastguard will develop and implement a National standard for pre-departure planning that includes a risk assessment process and reinforces the SAPP requirements laid out in the Coastguard Boat Book,
The application of pre-departure planning will be regularly reviewed as part of the Unit Capability Reports completed by Regional Operations Managers. It will also and incorporated into the CRM for CRV Masters as part of the current Training Development Project to be completed for implementation from July 2011.
Safety Recommendation
015/11
Issued To
MNZ
on 25 May 11
It is a safety issue that the Coastguard did not extend the training in the concept of crew resource management to all members of the crew so that the crews could work cohesively as a team to maintain situational awareness, monitor the plan, anticipate dangerous situations, acquire timely information and avoid pre-occupation with minor problems.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc incorporates in its training regime for all crew from the very early stages the concept and use of crew resource management as a means of achieving its goal of optimum safety and efficiency in the operation of its vessels.
Implementation Status:
Open
Reply:
Accepted
Coastguard will develop and implement training from the recruit stage to develop a culture that increases individual?s appreciation of the personal and team responsibility. This will improve the cohesiveness of the team to maintain situational awareness, monitor the plan, anticipate dangerous situations, acquire timely information and avoid pre-occupation with minor problems.
This will be addressed as part of CRM for all crew members as part of the current Training Development Project to be completed for implementation from July 2011. This will also be applied retrospectively to existing crew.
Safety Recommendation
016/11
Issued To
MNZ
on 25 May 11
It is a safety issue that there appears to be a disparity between the operating limits and designation of the Coastguard vessels and the types of extra curricular work the vessels are engaged in and the qualification requirements of the skippers of Coastguard vessels.
It is recommended that the Director of Maritime New Zealand considers some means of aligning the qualifications of Coastguard certificated skippers with the qualifications structure of Maritime New Zealand to ensure that the Coastguard certification better serves the needs of its skippers with respect to operating limits, designation of vessels and anticipated work to be undertaken.
Implementation Status:
Open
Reply:
Accepted
Current Coastguard training requirements exceed those required for a number of the MNZ Commercial qualifications so alignment is overdue and would be strongly supported by Coastguard.
Safety Recommendation
017/11
Issued To
MNZ
on 25 May 11
Better search and rescue efficiencies and a safer coastguard operation could be achieved if the design and type of vessels assigned to individual coastguard units are compatible with the conditions they are more likely to operate in and easily integrate with other search and rescue resources available locally and nationally.
It is recommended that the Chief Executive of The Royal New Zealand Coastguard Inc review the coastguard fleet with a view to achieving standardization of design, suitability for likely operating conditions and the best fit with other search and rescue resources both locally and nationally.
Implementation Status:
Open
Reply:
Accepted
Coastguard is responsible for the Coastguard Rescue Vessel fleet and is currently identifying funding to undertake the 'Vessel Standardisation Project' as identified in the 2020 Vision document:
Rescue Vessel fleet built to agreed plans and process
Classes of vessels agreed and replacement aligned with 'fit for purpose' identified through 'evaluation'.
Standard fit out to agreed National standard
Coastguard is also progressing a Coastal Evaluation Tool for use with current and future resourcing.
Safety Recommendation
001/11
Issued To
CAA
on 24 Feb 11
The pilot on this occasion did not make what would have been an appropriate urgency or distress call when faced with a strong smell of fuel and the single engine indicating reduced performance.
The Commission has commented in previous reports on the need for pilots to declare the appropriate level of urgency using the standard phraseology for the situation.
The Commission recommends that the Director of Civil Aviation promote to all pilots and operators, through the best means available, the need to use the appropriate phraseology to declare a level of urgency or distress that reflects the true nature of an emergency.
Implementation Status:
Open
Reply:
On 21 March 2011 the Civil Aviation Authority advised that in response to the recommendation it is intended that the 2012 series of AvKiwi safety seminars for pilots around New Zealand will focus on radio communications, including the need for pilots to declare the appropriate level of urgency using standard phraseology for the situation. However, while the use of correct phraseology in various situations will be promoted, the pilot-in-command still needs to make the appropriate decision in the first instance.
Safety Recommendation
002/11
Issued To
MNZ
on 22 Oct 10
When a speed uplifting is granted by local government organisations or by Maritime New Zealand, this is effectively a reversal of measures taken to mitigate a previously identified risk of accidents occurring between craft travelling at high speed and other recreational water activities.
In the case of the Kawarau River, it is a safety issue that few additional measures have been taken to mitigate the additional risks that the speed uplifting has created. This situation probably exists on the Kaituna River and therefore could also exist in other waterways where the speed restrictions have been uplifted.
A second safety issue is that there is an inconsistency between Maritime Rules Part 91 where speed upliftings applied for under Rule 91.21 require a risk assessment, and then if successful, public notification and notification in the Gazette, and speed upliftings enacted by navigation bylaws that are not subject to risk assessment, approval by the Director, and publication in the Gazette.
The Commission recommends that the Director of Maritime New Zealand and the Chief Executive of Local Government New Zealand address these 2 safety issues through the appropriate forum with local government organisations with a view to achieving an appropriate level of safety and consistency in safety standards on affected inland waterways.
Implementation Status:
Open
Reply:
Safety Recommendation
003/11
Issued To
MNZ
on 22 Oct 10
Maritime Rules Part 80 required commercial jet-boat drivers to undergo a minimum of 50 hours? training before being licensed to drive commercial jet-boats, but the Rule did not require the drivers to hold formal Maritime Documents requiring them to demonstrate an in-depth knowledge of the collision-prevention rules (Maritime Rules Part 22) and other maritime skills required of drivers of other types of commercial craft.
While acknowledging that some jet-boat operations do not require interactions with other craft (the Shotover Jet is one example), most commercial jet-boats operate on rivers and lakes where they must coexist with recreational and other commercial craft.
The Commission recommends to the Secretary of Transport that he liaise with the Director of Maritime New Zealand to address this safety issue, either by a change to the Maritime Rules or through some other appropriate forum.
Implementation Status:
Open
Reply:
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