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Annual Reports 2001 - 2002

Chief Commissioner's Overview

Last year I advised that Deputy Chief Commissioner Phillipa Muir would be leaving the Commission because her second term was to expire in September 2001. This year fellow Commissioner Norman Macfarlane and I warmly welcome our new Deputy Chief Commissioner, Pauline Winter, who brings a wealth of experience from both the private sector (including a number of years in the construction industry) and public sector. Pauline is a management consultant and also trustee of the Auckland Energy Consumers Trust, and the Pacific Island Business Development Trust. Pauline is currently a board member of the Legal Services Agency and a Trustee of the Auckland Mayoralty Foundation. She was recently the Chief Executive Officer of Workbridge Inc, which specialised in providing jobs and training for people with disabilities throughout New Zealand.

The New Zealand Transport Accident Investigation Commission seeks a strengthening of its existing statutory independence by arguing that the Transport Accident Investigation Commission ought to be completely separated from the transport regulatory entities, being the Ministry of Transport, Civil Aviation Authority, Land Transport Safety Authority and the Maritime Safety Authority. The Commission has a sound professional relationship with the Ministry of Transport. Accordingly, this is the appropriate time to make out the case for more independence than currently applies in the existing statutory and operational environment. The case for clearer independence is founded in principle. A well-known international investigation of a major transport accident in the Baltic sea illustrates the fundamental importance of full independence and unmistakable competency in investigation capability of the relevant state agency.

The overseas accident I refer to is the 1994 sinking of the roll-on roll-off passenger vessel Estonia with the loss of 851 lives. The lessons of the Estonia accident have been discussed at 2 annual meetings of the International Transportation Safety Association the Chief Executive and I attended in New Zealand, 2001 and Helsinki, 2002.

The Estonia had a false bow (a "bow visor") and a draw bridge structure for loading and offloading freight and vehicles through the front of the ship. Before sailing, the bow visor was swung down and locked closed, and together with a watertight door formed by the raised drawbridge, kept the sea out. In 1994, while encountering heavy seas in the Baltic, during a voyage from Estonia to Sweden, the bow visor locking devices failed because they were of inadequate design and the visor fell off, allowing the watertight door to lower. The sea poured into the vessel. The bow visor problems had been encountered earlier by a number of similar ships. In some cases they were not notified to the authorities, in others the authorities did not act on the reports. Tragically those incidents did not lead to any systematic inspection and requirements for reinforcement of the bow visor locks on the Estonia. The first lesson, therefore, is the investigative agency's recommendations following incidents ought to be respected. Fortunately, with the new safety recommendation tracking regime now in use, New Zealand has learned this lesson.

The vessel was Estonian flagged, carrying mostly Swedish passengers. The ship sank in a Finnish Search and Rescue region, so the investigation was conducted by a Joint Investigation Board involving the representatives of 3 countries, Estonia, Finland and Sweden. The investigation was dogged with controversy and hampered by a turnover in investigating staff and even allegations of forgeries. Due to its temporary warrant, the Joint Investigation Commission ceased to exist after the final report was submitted to the various governments. After this the parties concerned had no one to whom to turn and as a result subsequent queries went unanswered and there was intense speculation over causes and conspiracies. There were a number of questions about the approach and work of the investigators. In an attempt to defuse the concerns, the government of Sweden funded a symposium on the Estonia sinking. None of the original investigating organisations were invited to this symposium. The symposium was held and resulted in the organisers recommending to the Swedish government that the investigation be reopened. I understand that the government will not reopen the investigation because there is nothing new to be learned from further investigation, but the controversy continues. The second lesson, therefore, is the relevant state agency or international group must have unchallengeable skilled human resources available with the capacity to produce authoritative investigative reports.

The Estonia sinking and investigation demonstrated an incomplete investigation process at two levels. On one level, information about previous similar occurrences was not independently investigated. Had the previous incidents been properly investigated, the causes of the disaster would have probably been identified and hopefully eliminated. 851 people would not have died in the Baltic Sea. Learning lessons is the sole purpose of independent accident and incident investigation. Learning is the reason for the existence of Transport Accident Investigation Commission. The second failure was the chaotic investigation into the Estonia: it was a mistaken response. The investigation process was not conducted by a permanent independent investigation agency, and staff turnover was high.

In summary, the sinking of the Estonia demonstrated investigation failure before the tragedy and investigation failure after the tragedy. In his report, the Chief Executive will touch on other risks associated with failed responses to a major accident, including the critical process of informing survivors and the families of deceased victims, and the public.

Bow visor problems are not unknown in New Zealand. In March 1998, the fast ferry Condor 10 was proceeding out of Wellington Harbour into a moderate southerly swell, when the vessel encountered two short steep waves of approximately 4.5 m in height1. The resultant slamming displaced the bow visor and caused substantial damage to the surrounding hull structure.

The TAIC was able to investigate the accident and identified a number of safety concerns including:

     

  • the level of type-rating training for the crew of high speed craft  
  • the quality of route assessment
  • the adequacy of route information provided for the master
  • the interpretation of the "worst expected conditions".

The TAIC made safety recommendations to a wide range of organisations, domestic and international, to minimise the potential of future accidents of this type, any of which could have had fatal consequences. This accident and the safety recommendations is typical of many investigations and demonstrates the need for the Commission to be able to respond completely and thoroughly. The Commission also investigates a range of incidents, which, although of a lower public concern, result in equally important messages for preventing major accidents in future.

In addition to safety recommendations arising from individual accidents and incidents, the Commission has taken a wider view of preventing accidents by suggestions for improvements in transport safety. For example, the Commission has for some years asked state transport agencies to require rail operators to improve the scope of incident notifications. A June 2002 report by consultants Halliburton KBR confirms that rail incidents are underreported.

The Commission attempts eternal vigilance concerning its ability to investigate. The Commission is funded by vote: Transport, the same resource pool which funds the Ministry of Transport and the transport regulators. The fact of potential conflict of interest between a funder and an independent investigator ought to be recognised: on one hand, the Ministry is responsible for the allocation of the Commission's budgetary resources, which are in some cases appropriated out of the Ministry's own allocation and on the other hand, the Ministry is under a legal obligation to recognise the statutory independence of the Commission. Conflicts of interest may occur particularly, as the Ministry is managing and in some cases drafting transport regulations, and the government is increasing its direct involvement in transport operations through ownership of operators such as Air New Zealand.

The Commission recognises unqualified accountability for the resources it expends. In last years' Transport and Industrial Relations Parliamentary Committee's review of TAIC, the Committee advocated that the TAIC should attempt to achieve more financial and operational independence from the Ministry of Transport and the Commission agrees that this must happen.

These issues must be managed wisely otherwise there could be adverse consequences for transport safety. The improved financial and operational independence advocated by the Transport and Industrial Relations Select Committee in its most recent review of TAIC is important. Any effort which might detract from complete and independent credible investigative performance could increase risks for the Minister of Transport and also the State. The risks could include: 

  • inability for TAIC to respond comprehensively to accidents  
  • increased conflicts of interest within the state transport entities  
  • missed investigations of incidents which might later be found to be precursors of major or high profile accidents.

These types of events have lead to major controversies for governments overseas and which have then generated much pain and hasty change. I know that New Zealand will learn from others and not wait to experience the same pain ourselves. The fact that New Zealand has a less than enviable safety record in parts of its transport system may indicate the need for more widespread investigations for safety.

The Commission has been contributing information and opinion to the Ministry of Transport review of accident investigation which was announced in July 2000. Mindful of the conflict of interest issues identified earlier and the Ministry's key role in the transport sector and in the review, the Commission looks forward to the results with great interest. The review may resolve a number of critical issues facing the Commission, including its independence, its capability for investigating a major accident, the span of investigations, and the duplication of roles between TAIC and regulators.

We all operate in an unforgiving environment where a major disaster that is not investigated comprehensively and independently by the State will probably provoke a later more comprehensive further investigation designed to identify the failings on the part of (and perhaps allocate blame to) the State. In the view of the Commissioners, the Commission ought to achieve a level of independence similar to that of the Office of the Auditor General. TAIC's counterpart agencies in Canada and USA have direct state funding without any intermediary body. The Transport Accident Investigation Commission submits that the same model ought to be considered for New Zealand. In closing my overview, may I share with you a compelling statement made in 1974, when the US congress made the National Transportation Safety Board independent of the US Department of Transport: 

Proper conduct of the responsibilities assigned to this Board requires vigorous investigation of accidents involving transportation modes regulated by other agencies of government; demands continual review, appraisal, and assessment of the operating practices and regulations of all such agencies; and calls for the making of conclusions and recommendations that may be critical of or adverse to any such agency or its officials. No federal agency can perform such functions unless it is totally separate and independent from any other agency of the United States.

Hon W P Jeffries
Chief Commissioner


1. TAIC report 98-204, available from TAIC's web site www.taic.org.nz

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