Chief Executive's Report
Over the year we launched 47 investigations and completed 45 reports into accidents and incidents. Of the investigations finalised in the year, 76% were completed within 9 months. Variances in numbers of investigations launched, in comparison to target and previous years, are due to the uncertainty inherent in predicting the number and complexity of accidents and incidents to be investigated. We were not able to meet the timeliness target of completing 90% of marine and aviation investigations within 9 months because of staff turnover (we had to recruit 2 new marine investigators), and several complex or difficult investigations in both modes. The Commission's investigation and report output statistics are provided on page 63.
Importantly, for the first time in the Commission's 12 year history, we are able to confirm the outcome for public safety in more concrete terms: that recipients have completed implementing 47 of TAIC's safety recommendations (13 aviation, 18 rail, and 16 marine) over the year. Tracking and confirming implementation of safety recommendations is a valuable development in transport safety, supported by the Minister and Parliament's Transport and Industrial Relations Committee. The statistics are summarised on page 52.
This visible contribution to public safety contrasts with previous years when the Commission could only report on what the recipients of the Commission's safety recommendations said that they intended to do. In line with human and organisational nature, action did not always match intention, and the Commission did not know whether a safety recommendation had been implemented, other than by investigating a subsequent accident. The implementation tracking system relies on the cooperation of the 3 regulatory agencies (CAA, MSA, and LTSA) and transport operators or other recipients of recommendations.
Our original Crown revenue of $1.550 million1 was increased by supplementary Crown revenue of $0.132 million. Total revenue including other income was $1.719 million. Total expenditure of $1.693 million exceeded forecast by $0.106 million. The net result was a surplus of $0.026 million.
The increase in expenditure was primarily required to attenuate staff recruitment and retention risks. Over the year staff turnover was 50%. Three of TAIC's 8 investigators left. Two of the investigators were headhunted to better paid positions, another left because the work was too demanding. The most significant departure was that of Chief Investigator of Accidents, Captain Tim Burfoot, who left to become Operations Manager at the Interisland Line. I am delighted to report that we were able to promote Captain John Mockett to the position, rather than having to look outside TAIC for a replacement. Another key appointment was Denise Steele, who replaced Office Manager Melanie Watts.
Given TAIC's small size, losing 3 investigators was a major crisis because:
- the departure of one investigator, in any mode, constitutes a loss of between half and a third of our investigative capability for accidents in that mode of transport
- there is an almost nonexistent pool of trained investigators from which to recruit. As a result we have to recruit people who have high level operational experience (for example aircraft pilots, masters of ships, and senior railway staff) and then train them as investigators
- recruitment can take many months
- any remaining investigator has to be diverted from investigations under way to help with on site training of the new investigator
- the new investigator is unavailable for significant periods because he or she has to attend off site training courses, some of which are overseas
- accidents do not wait for investigators to be trained, so the backlog caseload keeps building.
An independent survey confirmed that we need to pay more to attract and retain our investigators and this adjustment, together with recruitment costs, resulted in our personnel budget being exceeded by $0.113 million. We conducted our own advertising and recruitment programme as we felt this was the most efficient option, although we did contract out some specialist testing of applicants. The impact of staff losses will continue for some time while we catch up on outstanding work.
Clearly the Commission is in a very exposed position due to its small size, which makes any sort of succession planning impossible. Another difficulty posed by its small size is that associated with investigating larger than typical accidents.
The Commission's quality management system includes a comprehensive plan for investigating a major accident. An exercise, held to test the plan, has shown that the Commission lacks sufficient investigative and support staff to respond to accidents more demanding than those it encounters month to month. The Ministry of Transport has been alerted to this risk.
We have researched ways of conducting major accident investigations, relying on existing staff numbers and borrowing or hiring additional expertise. For example, it has been suggested that the regulators could supply investigators to make up the shortfall in TAIC's numbers. However, TAIC would have to rely on the regulator making enough staff available long enough to complete the investigation, and sufficient numbers of the regulator's investigators would swamp the 2 or 3 TAIC investigators. It would no longer be an independent TAIC investigation. We have concluded that the task is not possible with current staff numbers, even with offers of assistance from within New Zealand and overseas, if the Commission is to produce a credible report, free of conflicts of interest, within a reasonable time. Changes at TAIC and in the field of accident investigation mean that TAIC is unlikely to be able to undertake another Ansett Dash 8 type investigation as promptly as the original 1995 investigation.
An average of 13 years elapsed between the Tangiwai rail bridge disaster (123 deaths in 1953), the Wahine ferry sinking (51 deaths in 1968), and the Mount Erebus DC10 accident (257 deaths in 1979). It is now 23 years since the DC10 accident. Some may view the 23 year gap as evidence that there is no urgency for change, but we are concerned that the gap indicates time may run out before the question of resources is resolved, if TAIC is expected to conduct a major accident investigation.
Our mandate is to investigate occurrences of significance to transport safety, but we cannot tell if an occurrence is significant to transport safety unless we investigate it. This problem has been raised by the Select Committee several times. The proposition occurs that we are not investigating all the occurrences that we should under our legislation. Rather, TAIC investigates only the tip of the iceberg. In aviation, the Convention on International Civil Aviation overcomes this problem by advocating that the state's independent investigator is to investigate all aircraft accidents and serious incidents. A number of similar safety investigation agencies overseas are responsible for investigating all accidents and incidents in some modes of transport. TAIC would require more investigators to conduct a wider range of safety investigations. These investigators would be of great help in managing a major accident investigation, and (not least) will help prevent future aviation, rail and marine accidents. The opportunity could be taken to remove the duplication of roles that both TAIC and the regulators undertake for safety investigation, consistent with comments by the Transport and Industrial Relations Select Committee in its 2001/02 review of TAIC and the May 2001 Civil Aviation Performance Review.
If an investigation is conducted in an atmosphere of public trust and acceptance, the preventive aspects of the report are likely to receive greater emphasis than if the investigation is conducted in an atmosphere of controversy. Controversy often starts with concerns expressed by the accident victims - whether they are the survivors, or families of the dead and injured. The respect and concern shown to victims of an accident has a great impact on all work surrounding the aftermath of the accident, including the investigation into cause. It is not enough to carry out a thorough, scientific, effective and fair investigation. Victims must be helped to understand the purpose and process of the TAIC investigation.
Our analysis of accidents in New Zealand and overseas shows that an inadequate response has ramifications for the investigator, the transport system, and the government. Inadequate responses in the USA2 resulted in such bitter complaints from families of callous treatment and government insensitivity in their time of grief, that it caused the US to pass urgent special legislation, and in the Netherlands, arguably would have toppled the government3 had another controversy not done so first. We welcome and have contributed to reviews by other government agencies that are aimed at providing a coordinated response after an accident.
A significant beneficial development in the year was that TAIC received a government guarantee of up to a maximum amount of NZ$10 million, to cover urgent commitments in the initial stage of an investigation - for example deep water wreckage recovery. The guarantee will enable TAIC to gain immediate access to funds should an overseas contractor require a deposit or guarantee in advance of dispatching specialist recovery equipment to New Zealand.
The changing face of transport, both within New Zealand and overseas, means that TAIC must be alert to strategic issues affecting accident investigation and the effectiveness of its reports. Over the year, the Commission advocated improvements in a number of areas, for example:
- the establishment of confidential incident reporting systems, which are now seen by safety experts as beneficial to learning about accidents and incidents, and so preventing future accidents
- clearer standards for reporting rail incidents, more consistent with aviation and marine practice, reducing the scope for avoiding notifying TAIC of incidents
- requiring speed and other data to be recorded for all main line locomotives (including passenger units, many of which currently do not have such recorders)
- requiring recording of train control communications.
The Chief Commissioner's last overview commented on difficulties posed when the Commission gives evidence at inquests. The role of the Coroner is an important one, and each of New Zealand's 70 Coroners is independent. This year the Commission has put more effort into initiating communications with Coroners and explaining the statutory limitations on the evidence the Commission's investigators can give, with encouraging results. However, a central problem TAIC encounters at inquests remains to be resolved. If a party considers that the Commission's accident report adversely affects it, that party can use the inquest as a forum to attempt to discredit the Commission's report. TAIC cannot rebut misleading evidence and false arguments presented at the inquest because TAIC must keep sensitive information confidential to preserve the free flow of information to its investigators for solving the causes of accidents. The necessary restrictions on any TAIC response favours the party attempting to discredit the TAIC report, generating controversy and confusion over the TAIC report and the causes of the accident. This is not the fault of the Coroner, the parties to the inquest, or the news media. It is simply the almost inevitable product of overlap of two different independent approaches to investigating and preventing accidents. The end result can be inconsistent or produce conflicting findings that are unhelpful to transport safety, at a time when both TAIC and Coroners are concerned about scarce resources. Some resolution of this problem may be possible in the pending review of the Coroners' Act, or the review of accident investigation.
The 2001/02 year has provided many challenges for TAIC which we have overcome, thanks to the combined effort of the Commissioners and staff. I am particularly grateful for the extra effort "old hands" have put in to maintain operations over the year and to help train new staff.
1. all costs exclude GST
2. Generated by the TWA 800 and ValuJet accidents, as reported in Lloyd's Casualty Week August 9 1996.
3. Paper by Ken Johnson, then Executive Director of Transportation Safety Board of Canada, referring to the 1992 El Al Boeing 747 freighter which crashed into an apartment block in Amsterdam. Such controversy surrounded the accident that one report showed that 60% of Dutch voters believed that the inquiry into the accident failed to uncover the truth.
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