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Annual Report 2003 - 2004

Chief Executive's Report

Probably the most significant investigation (in terms of public interest the demands on the Commission's resources and complexity) launched in the year was that into the double-fatality accident involving the Convair 580 near Paraparaumu in October 2003. The wreckage recovery process cost approximately $120,000, 3 times the total annual budget for air accident investigation direct costs. A successful funding bid in 2002/03 ensured sufficient additional resources to enable us to continue operations without seeking supplementary funding and contributed (in the form of an additional investigator of air accidents) to the speed and thoroughness of whole process of wreckage recovery and examination. The final report on the accident is expected to be published in the 2004/05 year.

It is impossible to measure objectively the contribution of each investigation to transport safety in terms of the prevention of future accidents. Sometimes the Commission's recommendations have global application. One important example is provided by the report the Commission published this year about the Boeing 747 tail-strike during take-off at Auckland International Airport on 12 March 2003 (report 03-003). This investigation found that inadequate cross checking of critical aircraft data led to take-off at low speed. A very real potential for a major accident existed as the aircraft struggled into the air with its main undercarriage only a few metres from the grass at the edge of the runway. Had any other event occurred to disturb take-off (for example the wheels ploughing into the grass) there was insufficient margin in the take-off speed. Rather than just the tail scrape, which did occur, loss of control and a major accident could have occurred. 389 people were on board.

Another important recommendation arose out of the derailment of an express freight train, near Te Wera, in July 2002 (report 02-116). This investigation involved extensive work determining the likely degree and effect of substances that impair human performance. In this case alcohol was directly involved. However, the effect of any performance impairing substances, legal or illegal, is of concern for the potential to cause accidents - in any mode of transport. The safety recommendation is focused on the elimination of the use of performance impairing substances within the rail industry. Draft rail transport law has been amended to address substance-induced performance impairment.

An important marine transport safety recommendation arose following the collision of the passenger freight ferry Aratere with a moored fishing vessel, San Domenico, in Wellington Harbour in July 2003. This investigation and resulting safety recommendation highlighted the problems of fatigue and medication affecting staff working in safety-critical roles. The recommendation also provides for educational material to inform and educate staff of the methods to ensure safe working practices.

While the Commission's statutory duty is to investigate occurrences, which the Commission believes that the circumstances have, or are likely to have, significant implications for transport safety, or may allow the Commission to establish findings or make recommendations, which may increase transport safety3, it is often impossible to tell whether a notified event is of significance unless investigated. The forthcoming capability review may go some way toward reducing the risk that the Commission is not investigating as wide a range of occurrences as it should.

An important procedural change in reporting safety recommendation status occurred with an improvement in efficiency and public availability of tracking data. The Commission now collects the implementation information directly from the recipient of the SR, rather than have the regulators do this. Another major advance was to publish the implementation status of safety recommendations on its web site.

Timeliness of air and marine investigations continued to be good, meeting the target of completing 90% of investigations within 9 months. Timeliness of rail investigations undertaken by the Commission is poor, due to the combination of high caseload, the Te Wera derailment (which involved lengthy discussions with the operator and regulator over substance-induced impairment policies and research on other countries. handling of the same issues), and turnover of TAIC rail investigation staff. We were expecting steady improvement and to meet the target in 2004/2005, however, a recent 6-week illness of our most senior investigator, and a spate of rail incidents in the last 2 months, has put attainment of even that long-term goal at risk.

In pursuit of its statutory duties the Commission's expenditure for 2003/04 of $ 2.174 million4, closely matching a budget of $2.159 million. Total revenue including other income was $2.205 million. The net result was a surplus of $0.031 million. The additional resource was a welcome and significant increase enabling the Commission to hire 2 additional investigators and undertake work deferred to save costs in previous years. The lengthy search for the additional investigators contributed to a net surplus in salaries of $94k and organisational development of $69k. This was largely offset by the direct investigation costs $127k higher than budgeted associated with the wreckage recovery of the Convair aircraft off Paraparaumu (investigation 03-006) and the wreckage recovery and engineering work associated with a helicopter accident near Mokoreta, Southland (investigation 04-003).

In the coming year we look forward to contributing to the Secretary for Transport's review of the Commission's capabilities.

John Britton
Chief Executive

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3. s13 (1) (b) of the TAIC Act
4. All figures exclude GST.