Inquiries & Recommendations

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On 30 July 2026, the Commission recommended that the Chief Executive of KiwiRail review the procedures that apply to track workers carrying out work within tunnels, to ensure they are clear and unambiguous as to the requirement to advise train control before entering a tunnel.

On 30 July 2026, the Commission recommended that the Chief Executive of KiwiRail take action to improve communication to ensure it includes the correct methods of communicating safety-critical information when using mobile phones.

On 26 August 2026, the Commission recommended that Pratt & Whitney Canada, as the engine manufacturer for the PW127M engine, take action to ensure the engine quality assurance procedures during engine overhaul are able to identify pre-existing fatigue and ensure the continued airworthiness of the subject engine.

On 26 August 2026, the Commission recommended to the Chief Executive Officer of Air New Zealand that Air New Zealand review the Findings and Safety Issues contained within this report to identify further enhancements to crew evacuation training, training realism, passenger safety briefings, safety cards and evacuation commands with the objective of improving crew and passenger preparedness for emergency evacuations.

On 30 July 2026, the Commission recommended that the chief executive of KiwiRail review and improve the protection planning process to ensure all associated risks controls are applied and the practicality of the protection is considered when selecting the worksite protection method.

On 30 July 2026, the Commission recommended that the chief executive of KiwiRail implement procedures to formally audit worksite rail protection measures being used by RPOs to ensure they are complying with protection requirements.

On 25 June 2026, the Commission recommended that the chief executive of Lyttelton Port Company take reasonably practicable steps to verify that on-board systems with the potential to compromise dry dock safety are isolated and made safe prior to entering the dry dock, and that they maintain awareness of the status of these systems during the vessel’s time in the dry dock.

On 25 June 2026, the Commission recommended that the chief executive of Lyttelton Port Company modify its process and documentation to address how the overlapping responsibilities of parties conducting business in its dry dock are going to be managed.

6.3 On 25 June 2026, the Commission recommended that the managing director of Australian Longline PTY Limited review its safety management system and standard operating procedures to ensure it requires appropriate approval for proposed modifications to all safety-critical systems before conducting the work.

On 30 April 2026, the Commission recommended that the Chief Executive of KiwiRail Holdings Limited ensure that all structural-asset inspections and audit procedures are in full compliance with KiwiRail’s quality management system and standards, particularly with regard to riverbed-profile monitoring.

On 30 April 2026, the Commission recommended that the Chief Executive of KiwiRail Holdings Limited review the Trigger Action Response Plans for all high-risk assets to ensure they contain adequate responses to mitigate the risks specific to that asset.

On 30 April 2026, the Commission recommended that the Chief Executive of KiwiRail Holdings Limited develop and document KiwiRail’s risk-based asset management and maintenance system for flood and scour risk to rail bridges across the rail network.