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Annual Report 2003 - 2004

Chief Commissioner's Overview

This last year the Commission launched 44 investigations (including resuming one investigation originally reported on in 20021), completed 42 investigations (some begun in the previous year), ending the year with 37 investigations in progress2. The Commission also issued 70 safety recommendations. The Commissioners met 11 times in the process.

Over the year we received evidence of 36 of the Commission's recommendations being fully implemented. A further 10 recommendations were probably implemented, and the Commission is at time of writing making inquiries to confirm this.

A significant and welcome advance for the Commission in the 2003/04 year was an increase in organisational capacity, with the addition of 2 investigators, one aviation and one rail, following an increase in resourcing by the Government. The positions were filled after an extensive search process, confirming the Commission's view that candidates having the necessary minimum of operational experience and personal attributes for training, as investigators are not readily available. The increase in numbers of investigators brought the total number to 9, comprising 4 air accident investigators, 3 rail accident investigators, and 2 marine accident investigators.

The recently completed Government Review of the Transport Sector, endorsed by Cabinet, decided to maintain the current roles and arrangements for transport accident investigation. The Minister has tasked the Secretary for Transport with working with TAIC on a number of matters over the coming months. The first of these is to review TAIC's capability with a view to making a budget bid for additional safety investigators and supporting resources during 2004/05. The Commission welcomes this because an increase in the number of investigators has significant benefits. These include improving prompt access to high-level expertise, improves timeliness of reports, reducing the dependency on just a few investigators for each mode of transport, and is an incremental step towards achieving sufficient numbers to be able to be confident that it has sufficient numbers to manage and direct the most critical of events: a major accident investigation.

The Commission welcomes the appointment of a Minister for Transport Safety and looks forward to working with that Minister and the Minister of Transport.

Operational issues will be covered in more detail in the Chief Executive's report. However, a very important recommendation made by the Commission over the year was the need for rail operators to implement a policy for managing the risks associated with substance induced performance impairment (safety recommendation 012/03). Discussion leading up to the recommendation also guided the Commission's submission on the Railways Bill, suggesting amendments to:

  • clearly identify the overall purpose or role of the regulator, rather than relying on the role being described in detailed task-oriented terms, and
  • make the criteria for the Director to vary a safety case less restrictive, so the rail system is more responsive to emerging issues and safety developments, rather than merely responding to operator non-compliance with legislation or Rules.

Drawing on its railway accident investigation experience over the last 10 years, the Commission, through submissions on the Railways Bill, sought improvement in a number of other areas of railway safety though new legislation, relating to the definition and recording of rail accidents and incidents, the recording of train control and locomotive event data.

The Commission publishes its reports with due regard for the concerns of all those affected by the investigation, and no one can be more directly affected by an accident than the victims. To this end the Commission supplies, under embargo, advance copies of its reports to give all those affected the opportunity to read and prepare themselves for public release of the report. The Commission also supplies copies under embargo to the news media so they have an opportunity for more careful reading of these often highly technical reports than might otherwise be the case in an attempt to break the story or meet a deadline. The Commission followed such a process when it released the report into the Air Adventures Ltd Piper Chieftain accident, in which 8 people died and 2 others were seriously injured (report 03-004). Unfortunately, one newspaper breached the embargo, which added to the stress and suffering of the victims, and has put the whole embargo process in jeopardy. The Commission has lodged a complaint with the Press Council, and is considering other options for managing the release of its reports. Unfortunately, none are likely to be as efficient as the embargo process. The Commission continues its membership of the International Transportation Safety Association (ITSA), an organisation whose other members are State investigation agencies from Australia, Canada, Finland, India, The Netherlands, Sweden, United Kingdom, and USA. ITSA was founded on the beliefs that:

  • Independent non-judicial investigations of transportation accidents contribute significantly to the safety of the travelling public and the environment
  • There is a need for an international organisation, that brings together accident investigation agencies in all modes of transportation
  • It would be beneficial to learn from the experiences of other countries and share safety information.

The mission of ITSA is: "To improve transport safety in each member country by learning from the experiences of others." As an indication of the standing of the Commission, at the most recent meeting of ITSA at Apeldoorn, in the Netherlands, I was honoured to be appointed Acting Chair for the meeting, and Chairman for the period July 2004 to March 2005.

Together with fellow Commissioner Norman Macfarlane I was honoured that the Minister extended my appointment for a further period from 1 July 2004 to 1 November 2004. The Commission has been a challenging and rewarding organisation to work for. Its success can be directly attributed to my fellow Commissioners Norman Macfarlane and Pauline Winter, and to the staff, headed by Chief Executive John Britton.

Hon W P Jeffries
Chief Commissioner

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1. Investigation 01-005 Bell UH-1H Iroquois ZK-HJH, tail rotor failure and in-flight break-up resulting in 3 fatalities, near Taumarunui, on 4 June 2001.
2. The 37 investigations includes 4 investigations where the Commission was assisting an overseas investigation agency.