Chief Executive's Report
The Commission’s investigators initiated 47 investigations and completed reports into 41 accidents and incidents during the year. All reports and accompanying safety recommendations are available in hard copy by subscription, or can be downloaded free of charge from the Commission’s web site, www.taic.org.nz. A further 7 accident and incident investigations were ceased over the year without proceeding to final report stage. These investigations were discontinued because it was determined that the occurrences causing the investigations did not meet the test of section 13 of the TAIC Act; they were not occurrences likely to be of significance to transport safety. The Commission’s investigation and report output statistics are provided on page 56. Variances in numbers of investigations launched compared with target and with previous years are due to the uncertainty inherent in predicting the number and complexity of accidents and incidents to be investigated.
Of the investigations finalised during the year, 68% were completed within 9 months. We were not able to meet the timeliness target of completing 90% of marine and aviation investigations within 9 months because of 2 complex investigations, and having to devote resources to training new investigative staff as previewed in last year’s report.
Particularly complex or difficult investigations included the grounding of the bulk log carrier Jody F Millennium at Gisborne in February 2002, the grounding of the bulk carrier Tai Ping in Bluff Harbour in October 2002, the fatal derailment of a freight train at Te Wera in July 2002 (investigation still under way), 3 derailments due to heat buckles between December 2001 and January 2002, and the collision of 2 passenger units in Wellington in August 2002. It is a credit to the team of investigators and administration staff that we have managed to complete as many investigations as we did. The 6 June 2003 accident involving the Piper Chieftain near Christchurch demanded significant resources and was handled within the Commission’s capabilities.
The other tangible result of TAIC’s work over the year was production of 47 safety recommendations (SRs). We were also able to confirm that 60 SRs (many from previous years) had been implemented. The statistics are summarised on page 41. A description of the process, and comment on some SRs which have been open (that is have not yet been implemented) occurs on page 27. The Commission’s tracking of the implementation of SRs, as advocated by a number of parties and supported by the Minister, is a logical, business-like feedback process that can only improve SR quality and implementation, and thus TAIC’s effectiveness at preventing similar accidents in future.
In the aviation industry, key SRs (including marking overhead wires and requiring mountainous terrain flying training) will probably be implemented through changes to aviation Rules. TAIC cannot be more specific about whether the Rules will satisfy the Commission’s SRs until the detail of each of the Rules is known. SRs dealing with shortcomings in the Rules affecting flying in mountains have arisen from 3 air accidents – the first in 1993 – investigated by the Commission which together have claimed 21 lives. We hope that appropriate Rules will be implemented in time to prevent more accidents.
The top maritime safety issues, from the Commission’s perspective, revolve around seafarer fatigue, increasingly large ships fitting into ports, and certification of watchkeepers and skippers of pleasure craft. These are covered in more detail in subsequent sections of this report.
The Commission applauds the Maritime Safety Authority for its work to identify and reduce substance-induced performance impairment amongst mariners, a problem that is probably under-represented in the Commission’s reports only due to the lack of testing of crews promptly after an accident or incident. It is also important that there should be wider public understanding that performance can, and is, impaired by a wider range of substances than just recreational drugs (including alcohol). Overthe- counter medicines, prescribed medicines, fumes and other apparently innocuous substances can impair performance sufficiently to cause an accident. This is why the Commission prefers to use the term “substance induced performance impairment policy” (SIPIP) or “hazardous substances policy” (HSP) rather than, for example, the simplistic and emotive term “drugs and alcohol policy”.
The Chief Commissioner has, in his overview, referred to the definitions of rail accident and incident, event recorders on passenger units and train control recordings. The Commission’s other SRs include the need for fatigue prevention measures for train controllers and improved compliance with train control procedures.
Producing the above reports and SRs, for the immediate imperative of preventing future accidents and saving lives resulted in expenditure for 2002/03 of $1.776 million1, closely matching a budget of $1.770 million. The original Crown revenue of $1.550 million was increased by supplementary Crown revenue of $0.032 million to enable the Commission to obtain readiness capability in victim and media communications, primarily for high profile accidents. Total revenue including other income was $1.784 million. The net result was a surplus of $0.004 million. As identified in last year’s report, the Commission is in a very exposed position due to its small size, which makes succession planning very difficult. Another difficulty posed by its small size is that associated with investigating larger than typical accidents. The Minister has responded to these problems by increasing TAIC’s funding next year to $2.172 million, and a $0.94 million capital injection. This will enable the Commission to hire an additional 2 investigators (one aviation, one rail) and undertake work deferred to save costs in previous years. This is a most important and very welcome addition to our capacity.
The 2002/03 year continued many of the challenges of the previous year, however, the additional resources provided for the Commission has reduced the exposure to major staff losses and will improve our capability to deal with rail and aviation accidents.
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1. all figures exclude GST