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Annual Report 2004 - 2005

Chief Commissioner's Overview

The historic 1944 international meeting in Chicago, United States of America, attended by delegates from western countries, laid the foundations for the management of international civil aviation. Western Governments foresaw the likely expansion of post-war aviation and the need for Governments generally to establish particular institutions to investigate air accidents for safety, in a similar manner to the judicial oath: "without fear, favour, affection or ill will". Thus independent investigating Commissions or Boards were established and over the decades, these Commissions or Boards extended their mandate from civil aviation to include other transportation modes of rail and sea, and in some cases road and pipelines.

New Zealand met its obligations under the ensuing International Civil Aviation Organisation (ICAO) with the creation of the Transport Accident Investigation Commission (TAIC) mandated under the Transport Accident Investigation Commission Act 1990 to investigate the causes and circumstances of transport accidents in New Zealand.

In the last year, as Chief Commissioner of New Zealand's Transport Accident Investigation Commission, I chaired the International Transport Safety Association (ITSA, a group of some 10 similar Commissions and Boards including those from the United States, Canada, Australia and the Netherlands.

At the annual ITSA meeting held in Washington DC in March of this year, I along with the Deputy Chief Commissioner, Pauline Winter, viewed a reconstructed TWA300 Boeing 747 at the Washington Academy of the National Transportation Safety Board (NTSB). In 1996, this aircraft, after only a few minutes flight out of New York, appeared to blow up in mid-air. The American authorities at first thought that terrorists had fired a missile at the civilian airliner.

The NTSB pursued a painstaking scientifically based investigation involving recovery from the Atlantic of the aeroplane and its reconstruction, which established that the probable primary cause of the accident was an explosion of the Centre Wing Tank.

At the Washington meeting earlier this year the American investigators explained, with reference to the re-constructed plane, the actual chain of events, which led to the break-up of the fuselage. In identifying the cause of the accident the investigation excluded the terrorist theory and made safety recommendations on fuel tank flammability, fuel tank ignition sources, design and certification standards and maintenance and aging aircraft systems. Implementation of all safety recommendations should reduce the potential for a reoccurrence of this accident. Boeing aircraft, demonstrably, are comprehensively designed for safe operation and any discovered anomaly, as in this case, is meticulously analysed and immediately corrected.

Our own Commission's investigation into the Singapore Airline's tail-strike incident involving a fully laden Boeing 747-400 aircraft at Auckland International Airport in 2003 established the need for a design improvement in the aircraft's electronic equipment. Preparatory to take-off, the pilots made an elementary arithmetical mistake in entering data. As a result, the aircraft was underpowered when attempting to take off, causing a tail strike. The aircraft, despite being damaged, was able to complete the take off and reconfigure for an emergency landing, which was safely carried out without injury to any of the passengers or crew.

The subsequent investigation resulted in a recommendation to Boeing and Honeywell to adopt double-checking electronic equipment, which should avoid any repeat of human error in such calculations. The NTSB adopted the TAICs recommendation and referred the matter to the United States Federal Aviation Administration for implementation by Boeing and Honeywell. It is pleasing to have such international recognition for the quality of the Commission's investigations and recommendations.

These examples illustrate the value of independent, scientifically based investigations into the causes and circumstances of accidents, or incidents, which do not involve damage, injury or fatality (the "near misses"). By this feedback, the transport safety system is dynamically engaged in a process of truth-discovery about itself, which contributes to the transport system's continual development and improvement. Transport policy, at its best, is a "learning organisation".

The highlights of the year included the significant increase in funding of the Commission by the Government, due to the advocacy of the then Minister of Transport, Hon Pete Hodgson and his associate the Minister for Transport Safety Hon Harry Duynhoven and the continual improvement in the co-operative monitoring with the Ministry of Transport of the implementation of the Commission's recommendations as to safety improvements. Dialogue and goodwill are essential to the mission of continual development and improvement of transport safety in New Zealand.

In addition, two important statutes affecting the Commission were passed in December 2004 and came into effect on 25 January 2005. The first, the Public Finance Amendment Act, introduced tighter state sector management controls and will have positive input on the Commission's accountability document formats in future. The second, the Crown Entities Act, reinforced the status of the Commission as an independent Crown entity and emphasised its constitutional difference from the other entities in the transport sector, namely the Ministry of Transport (a public service department) and the three transport regulators (classified as Crown entities or individual statutory bodies) namely: the Civil Aviation Authority, the Maritime Safety Authority (now Maritime New Zealand) and the Land Transport Safety Authority (now Land Transport New Zealand).

Parliament's re-affirmed emphasis on the Commission's independence is important in an environment where Government has progressively moved away from a policy of fully privatised systems and again become a re-investor and principal owner and operator of New Zealand's transport infrastructure, particularly in the rail and air modes in which the Commission investigates accidents and incidents (along with marine). The inherent conflicts of interest that are thereby created have been identified to Ministers.

The review by the Ministry of Transport of the Commission's capabilities undertaken in 2004 following the government's Review of the Transport Sector was completed prior to the 2005/2006 Budget Bid.

The Commission's mandate remained unchanged following the reviews, although legislation was passed by Parliament extending the scope and responsibilities of the other transport entities. As a result of the Commission's deliberations on the impacts of its activities, a more proactive communications policy has been adopted towards the principal audiences for the Commission's outputs, particularly with respect to the media but also the general public. This is designed to dispel confusion that arises because of overlapping jurisdictions, such as that of coroners, and to raise the Commission's profile as New Zealand's independent investigator of aviation, rail and marine accidents. The Commission has welcomed the tabling of the Coroners Bill and has contributed supporting submissions to the Select Committee in conjunction with the Ministry of Transport. Overlaps in between the Commission's and some coroners' investigations have given rise to difficulties that the Bill will largely resolve, assuming it is passed by Parliament in substantially its present form.

During the year and in response to public representations, the Commissioners determined that it was inappropriate to publish certain information on TAICs website relating to investigations prior to its own formation in 1990. While it is entirely appropriate that New Zealanders be reminded that major accidents can occur in this country - and, indeed, have done in the past, it is not appropriate that the Commission publish investigative reports and evidence for which it was not, itself, responsible.

In February, an independent audit of the Commission's compliance with the ICAO Procedures and Standards for Investigations was carried out. An issue highlighted was the fact that the responsibility for compliance with ICAO Annex 13 (governing the procedures and standards) is, in New Zealand, delegated to the CAA, instead of the Commission as the country's independent investigator of aviation accidents and incidents. Whether the delegation ought to be made to the Commission rather than the CAA is a matter for representation to the Minister during the course of next year.

In a small organisation employing only 15 staff, where all of those staff are key, it was unfortunate that resignations were received from the Chief Executive and one of the 9 investigators. In New Zealand there is only a small pool of suitably qualified people capable of performing the exceptional duties of a transport accident investigator. It is essential for the future of the Commission that we maintain effective retention policies for our skilled human resources.

The Commission's thanks are extended to John Britton for his long and exemplary service and to ex-Commissioner Norman Macfarlane who acted as Chief Executive during the process of recruiting. The Commissioners also welcome Lois Hutchinson, as the new Chief Executive, Lois had already taken up the position at the time of writing.

Finally, the Commissioners wish to acknowledge the excellent support received during the year from both of the Ministers, Hon Hodgson and Hon Duynhoven, and from the Secretary of Transport and his staff.


Hon Bill Jeffries
Chief Commissioner

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