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Outstanding Safety Recommendations

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.

Keywords: Recipient: Mode: Status:

Safety Recommendation 014/15
Issued To KiwiRail on 02 Nov 16
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
Implementation Status: Open
Reply: We have already implemented your recommendation by ensuring that all significant modifications to vessels are now always undertaken under the oversight of KiwiRail's Project Management Office which has its own strong project management disciplines including good records? management and strong governance.

Safety Recommendation 020/16
Issued To Talleys on 29 Sep 16
On 29 September 2016 the Commission recommended that the operator of the Captain M. J. Souza: review its internal auditing procedures to ensure that auditors make realistic assessments based on actual practices observed on board; and seek verification that documented procedures are being followed by the crew and they are appropriate for the task. Audit findings should be recorded together with any safety actions taken as a result of the audit.
Implementation Status: Open
Reply: Since August 2014 we have implemented a programme to improve the Health and Safety culture on this vessel. This started wit an internal review of our Health and Safety Systems (ashore and on board) governing the Capt M J Souza and following that review, we have taken several steps to improve Health and Safety outcomes which include:

1. Heightened oversight of the documented H & S procedures on the vessel at turnarounds by the vessel manager and operations manager including debriefing key staff on the vessel on H & S compliance and addressing any new hazards that may have been identified during the trip;

2. Implementation of a revised assurance process on the vessel and ashore to provide evidence to shore based management that Talley?s H&S protocols in fact being applied on board the vessel;

3. We have provided additional third party H & S training to the officers and crew of the vessel to ensure that they are aware of Talley's health and safety procedures, the hazards associated with their tasks and that they are operating safely;

4. Addressed and improved communication structures between senior management and senior vessel staff;

5. Setting out company expectations regarding H & S aboard the vessel and the consequences of departure from these expectations;

Further, when the vessel returns to NZ after its current Pacific Season in December 2016, we have identified an independent Health and Safety expert who will take a trip on the vessel to audit its compliance and to report to management on the H&S culture on the vessel, their compliance with the Talley's H&S programme and thereafter, if appropriate to put in place an effective change management programme.

Safety Recommendation 018/16
Issued To NZTA on 25 Aug 16
On 25 August 2016 the Commission recommended to the Chief Executive of the NZ Transport Agency that he liaise with KiwiRail and relevant road controlling authorities to assess and confirm which provincial level crossings have significant safety issues that do not align with the NZ Transport Agency's Traffic Control Devices Manual - Part 9 - Level Crossings, then work with the authorities to ensure that safety improvements are prioritised and implemented.
Implementation Status: Open
Reply: The Transport Agency, in its capacity as rail safety regulator, will formally write to the appropriate entities, including KiwiRail and advise them of the recommendation 018/16 and request that they advise the Agency of how they plan to:
1. Review the level crossings in their areas to establish if there are safety issues that need addressing - in alignment with the NZ Transport Agency?s Traffic control devices manual - Part 9 - Level Crossings
2. Ensure safety improvements are prioritised and implemented.
We will ensure the Commission is kept informed of the progress made relating to this recommendation.

Safety Recommendation 019/16
Issued To CAA on 24 Aug 16
On 24 August 2016 the Commission recommended that the Director of Civil Aviation provide a clear statement to relevant sectors of the aviation industry on whether stock clearing is a permitted activity. If the Director decides it is a permitted activity under a particular Civil Aviation Rule part, he should provide clear guidance on the conduct of the activity.
Implementation Status: Open
Reply: In our response to the Commission's draft report, 11 August 2016, we explained there is no CAA rule provision for stock clearing; therefore, the Director cannot provide clear guidance on the conduct of the activity in the context of existing CA Rules.

However, the CAA recognises that an operation to a remote airstrip presents a risk to air transport in that the landing area may have visible hazards, including the presence of stock, which could affect the safety of a landing. Whilst there are no existing provisions in the rules to descend below 500 feet (aside for take-off/landing or a baulked landing/discontinued approach), the Director will agree to pursue a means to enable air transport operators to overfly a remote airstrip below 500 feet for the purposes of ensuring the landing area is visibly free from hazards.

The CAA remains focused on safety management based on risk mitigation. The CAA believes the alternative safety action will address the safety issue raised by the Commission and we will advise when the work has been completed.

Safety Recommendation 014/16
Issued To MoT on 27 Jul 16
On 27 July 2016 the Commission recommended to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.
Implementation Status: Open
Reply: The Ministry considers that such a recommendation is premature as the costs and benefits of such a recommendation have not been canvassed. The Ministry appreciates that the Commission may have been minded to make such a recommendation because of the lack of available data. The Ministry suggests that prior to making a recommendation, some more work should be undertaken to determine the benefits and costs of flight data and video recording in cockpits.

Safety Recommendation 015/16
Issued To CAA on 27 Jul 16
On 27 July 2016 the Commission gave notice to the Director of Civil Aviation that a recommendation has been made to the Secretary for Transport that he promote, through the appropriate ICAO forum, the need for cockpit video recorders and/or other forms of data capture in the cockpits of certain classes of helicopter to address this safety issue.
Implementation Status: Open
Reply: The Director has considered the recommendation and in view of the Secretary for Transport's response to the Commission on the matter of cockpit video recorders and/or other forms of data capture, the Director is prepared to accept the recommendation but with a caveat that reflects the Secretary's response, i.e, That the Director of Civil Aviation conduct a safety and cost benefit exercise of installing flight data and/or cockpit video in certain classes of helicopters.

In that regard the Director will initiate an issue assessment paper on recording devices for certain classes of helicopters. Given the timeframe of such a study is likely to be lengthy; the Director cannot provide a completion date at this stage.

Safety Recommendation 013/16
Issued To NZTA on 27 May 16
It is possible that the Te Onetea Road level crossing is one that has been affected by changes in the allowable dimensions of long, low road vehicles. Unless the profiles of all level crossings are assessed against the current allowable dimensions for long, low vehicles, the potential risk of this type of accident occurring will remain high.

The ALCAM survey measures the gradient of the road leading up to the level crossing, but does not measure the rate of change in gradient in order to record the profile or vertical alignment of the road for the purposes of ensuring that road-legal vehicles can use the level crossing safely without becoming stuck.

It is important that rail level crossings are compatible with road vehicles, and that road users are made aware of limitations on the use of at-risk level crossings, in much the same way that drivers of high vehicles are warned of low bridges and tunnels.

The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail and all road controlling authorities to ensure that rail level crossing assessments include a measure of the road profile and compatibility with the allowable dimensions for long and low road vehicles.
Implementation Status: Open
Reply: In relation to Recommendation 013/16, the Transport Agency is currently exploring options of how to best find a solution to addrss this safety recommendation.

We will inform the Commission once the Transport Agency has both determind and can detail the scope of what is required.

Safety Recommendation 012/16
Issued To NZTA on 27 May 16
A survey of the Te Onetea Road level crossing was carried out to the ALCAM standards on 20 March 2012. The sighting distances in both directions did not allow sufficient time for long vehicles to drive safely over the level crossing without being struck by a train. Therefore, a fully road-compliant long vehicle could not use the level crossing with the recommended margins for safety.

No action had been taken between the 2012 survey and the date of the accident, 27 February 2014, to mitigate the risk to road users and train vehicles. The Commission recommends that the Chief Executive of the NZ Transport Agency work with KiwiRail and Waikato District Council to address this safety issue.
Implementation Status: Open
Reply: In relation to Recommendation 012/16, the Agency intends to refer the sighting distance issue directly to the Waikato District Council and KiwiRail Holdings Ltd.

We will do this at the earliest opportunity and will report progress back to the Commission.

Safety Recommendation 010/16
Issued To KiwiRail on 25 Feb 16
On 25 February 2016 the Commission recommended that the chief executive of KiwiRail ensure that the bridge resource management policy and procedures outlined in its safety management system remain relevant and effective for all crews on all ships in the fleet, all of the time.
Implementation Status: Open
Reply: KiwiRail accepted the recommendation as proposed.

Safety Recommendation 002/16
Issued To CAA on 25 Feb 16
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.
Implementation Status: Open
Reply: On the basis that the FAA has twice rejected the inclusion of the Robinson R66 model in SFAR 73, the Director will not implement the recommendation, but will continue to monitor advice from Robinson Helicopters and the FAA with respect to the operation of R66 helicopters.

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