Chief Executive's Report
Over the 2000/2001 year the Commission launched 47 investigations and finalised 36 reports on accidents and incidents of significance to aviation, rail, and marine transport safety in New Zealand. It promulgated 112 safety recommendations. This work was undertaken by a small group of dedicated staff for a total cost of $1.588 million, 0.1 % over our income of $1.586 million.
The report titles and numbers of safety recommendations listed in this annual report hide the solid grind of thorough research, analysis, and scientific argument behind each investigation, and the numbers certainly do not reflect the complexity of causal factors and the lives lost, or lives at risk if action is not taken to implement recommendations. To better illustrate the circumstances, dangers, and, ultimately, the opportunities for better safety, a few reports and the resulting recommendations finalised in the year are described in more detail in the section "Examples of investigations and their safety recommendations". These reports included investigations into the collision in fog of the passenger ferries Quickcat and Quickcat II on 31 May 2000 in Auckland Harbour, the collision of 2 freight trains at Waipahi on 20 October 1999, and the longstanding deadly problem in aviation: wirestrike, in this case at West Arm, Lake Manapouri on 28 March 2000. The Commission is pleased with the positive responses many of its recommendations have received and hopes that any decisions not to implement its recommendations are backed by appropriate cost-benefit analysis.
An important step promised last year has materialised: the TAIC has introduced a system to record the known status of safety recommendations developed since October 2000. Consistent with its legislation, the TAIC is not responsible for auditing acceptance of its safety recommendations but relies on reports from recipients or the safety authorities to show that the intent of the safety recommendation has been implemented. The system had it origins in a suggestion by a parliamentary Transport Select Committee, and was only possible as a result of the support of the Minister of Transport and the co-operation of the Ministry of Transport and the Safety Authorities. This process will give everyone more confidence that action really been taken, or if it has not been taken, the assurance that there were sound reasons. It will also help the TAIC frame better, and hopefully fewer, recommendations in future. We look forward to being able to comment on the implementation status of our safety recommendations in next year's annual report.
To maximise the safety message, the TAIC website is being redesigned to make it easier to search and retrieve information. Key changes are to include a searchable database of about 500 investigations undertaken by the Commission (and some earlier ones undertaken by the Office of Air Accidents Investigation) and some 1400 related safety recommendations. Data will include the details of the accident/incident investigation launched, the abstract of the report (unless the investigation was terminated without a report), the full text of any safety recommendations, recipient's replies, and implementation status. Back issues of the more popular occurrence reports will also be made available in electronic file format. The data collection and publication project has been a major undertaking, which started in earnest in August 2000. Completion depends on competing demands for our scarce resources, but we aim to have the work published on our website by 30 December 2001.
Timeliness is important for getting the safety message out to all those who can learn from our reports and who can implement recommendations. While the TAIC has a typically good record for reporting promptly, we did start the year with a significant backlog of rail accident and incident reports. This backlog has now been largely eliminated. Bringing the rail investigation workload under control was only possible when the Government increased our funding in June 1999. The 2 years taken to bring the rail investigation workload under control reflects the length of time taken to recruit an investigator (2 rounds of recruitment were necessary, due to the unattractive starting salary) and train him to the stage where he is now paying dividends for transport safety.
Looking at the facts of accident investigation and the expertise required to conduct sound investigations, we are alert to a very real future risk to staff retention. The departure of one rail or marine investigator doubles the workload of the remaining investigator, leaving no expert coverage when the remaining investigator is absent for training, ill health, or leave. The situation is slightly better in aviation: we have 3 investigators, so each would have to shoulder a 50% increase in workload. With such small staff numbers and limited resources, succession planning is impossible.
We are pleased that staff turnover has been minimal this year: our receptionist, Lucy Clyde, left to join Archives New Zealand, and we welcome Jane Terry to replace her.
We were devastated when Tom Middleton, an aviation assessor and well-known display flying pilot, died in an aircraft accident in December 2000. We have appointed Pat Scotter to take over that work. Charlie Oxley, rail assessor since 1993, has decided to retire, and in recognition of the heavy workload we have appointed 2 assessors to replace him: Alan McMaster and Bill Jones.
The safety recommendation implementation system and making 10 years' worth of safety lessons available on the internet will be major public achievements for the Commission and complement the work conducted by the staff, Assessors, and Commissioners in investigating the causes and circumstances of individual accidents and incidents. We look forward to continuing this vital work for transport safety for the future.
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