Chief Commissioner's Overview
This is the 16th Annual Report to the Minister of Transport of the Transport Accident Investigation Commission. It is perhaps timely to reflect on the larger developments driving the actual performance of the statutory duties of the Commission. These duties are to investigate judicially, inquisitorially, independently, and on a scientific/forensic basis, the facts of a transport accident or incident in order to discover the lesson or lessons which may serve the New Zealand public and others to prevent a similar occurrence in the future. The Commission’s mission is to extract positive value from negative or potentially negative events involving priceless human lives and lost wealth.
What generally has the Commission learned in the 16th years of meeting the heavy responsibilities of its statutory function? I shall sketch out our lessons learned. I begin with the precipitating event of an inquiry.
Standing at the smoking ruins of an aircraft crash or railway accident or observing that the “cruel” sea has captured another vessel with the drowning of those “who sailed upon her”, the Commission’s investigators begin an ordered process of inquiry in accordance with the statute and international practice standards.
The essence of the process of inquiry is to wind-back the accident chain of events, similar to reversing a movie film. The new development of thinking, which I record in this broad over-view, is the Commission’s growing realisation that the process of inquiry into the causes of and accident, or incident, must penetrate further and further back in time.
This is because such deeper retrospective analysis into the genesis leads to better understanding of significant causes. All transport involves the inter-action of often quite sophisticated transport technology, planes, ships and trains, the people who own, manage and operate these transport vehicles and the general environment within which they function, which includes communications infrastructures serving the operation.
Transport operations may for the purpose of analysis, be described as the “out-put” of an organisation. Therefore, the functioning of the transport organisation itself is an early and essential part of the chain of events which lead to the accident or incident under examination by the Commission.
The next question is, what criteria should the Commission adopt to assess whether the transport organisation is functioning in a way which may have contributed to the accident or incident under examination?
The international leaders in the theory of accident investigation have defined these very criteria by which the Commission’s investigators may assess whether or not the transport organization’s function, policies, practices, procedures or management may have in some vital respect, contributed to, or caused, the accident or investigation under examination.
The first influential international thinker in this respect, is Professor James Reason of the United Kingdom. The “Reason Model” of assessment of the transport organisation’s functioning may briefly be summarised as being based on the premise that, within any given transport organisation, “latent pathogens” – unseen, unsafe conditions – tend to build up before an accident or unsafe event occurs. The dangerous pathogens lie dormant in any transport organisation, and information flow is the means by which these unsafe conditions are spotted or acted upon. Understanding of these “pathogens” and their role in accidents or incidents yields very high value lessons.
Professor Reason’s famous metaphor involves the “Swiss-cheese” model whereby the accident “arrow” penetrates through the succession of “holes” in what ought to be defences, causing the final accident or incident.
The other leading thinker in this area is Professor Ron Westrum (US – Eastern Michigan University) who advises that an investigator can judge the organisation and its members for accident investigation purposes by the way it or they respond to information (about the latent, or indeed open, pathogens).
According to Professor Westrum, there are 3 broad categories of response: the worst is the “pathological” response which is stupid denial. The next, and the most common, is a “bureaucratic” response whereby they or it in the organisation respond to vital safety information by recording but not analysing for significance. For example, the post 9/11 syndrome used against the American Central Intelligence Agency and the Federal Bureau of Investigation, – the failure to “join the dots”, that is, connect the events into a meaningful conclusion, illustrate the pitfalls of the dull bureaucratic response to early warning signals or “pathogens”.
The best response is the “generative response” whereby latent pathogens are quickly spotted and corrected. A “generative” transport organisation is eternally vigilant, every working moment identifying and responding to early warning signals so that pre-emptive action to avoid an accident can be taken. These “learning organisations” are safer in their operation than those which do not operate according to such standards.
The overall justification for the Commission in adopting the Reason/Westrum accident investigation philosophy is because our statute demands that the Transport Accident Investigation Commission conduct its investigations in order to avoid recurrence of similar events.
These philosophies assist in that task. Another new development is the use of technology in providing evidence.
In March 2006, accompanied by the Deputy Chief Commissioner Pauline Winter and the newly appointed Chief Executive, Lois Hutchinson, I attended the annual meeting of the International Transport Safety Association in Canberra, Australia.
A high-light was meeting and hearing Dr David Warren, the Australian inventor of the “black-box”, the instrument which records the voices of the pilots in aircraft and which is built in such a way as to withstand the huge physical trauma of an aircraft accident. With this surviving voice information, and flight data investigators are provided with vital clues to assist them in the investigation of the aircraft accident.
Building on the pioneer work of Dr David Warren in the 1950’s, information in crash-proof form is now available which describes in vast detail the actual workings of all the vital systems of the aircraft. The “black-box”, which is actually painted orange, is now available for shipping and railway operators as well.
“Generative”, that is, astute transport operators, interrogate operational data from these various recording devices in a comprehensive way, to learn valuable safety lessons which can avoid accidents. Air New Zealand has such a programme.
A further development relates to human performance. An aviation concept is “crew resource management” or “CRM” whereby cockpit crews are trained to act jointly in critical situations in order to tap the knowledge of all the responsible participants. This “CRM” model is now being introduced into maritime operations and also to the railway sector. The art is to reconcile the necessary hierarchy of the prime responsibility of a Captain, with the recognition that better decisions in crisis often result from a collegial approach. Separately, current medical scientific insights into “micro sleep” and performance impairment caused through inadequate sleep, casts more and more light on the Commission’s understanding of the conduct of some personnel in transport operations.
In summary, the development of deeper investigation back into the accident or incident chain of events, using the Reason/Westrum models of assessing the part played by the transport organisation from which the transport operation emerges, together with increasing use of high technology data recording devices, means the Commission is better able to fulfil its mission of turning negative events into positive lessons in order to avoid a repeat occurrence. The Transport Accident Investigation Commission continually challenges itself, to meet the high responsibilities placed upon it, by its statute and to serve you, as Minister of Transport, in the aim of building a safe New Zealand.
The conscientious interest in the Commission by the Minister for Transport Safety, the Hon. Harry Dunyhoven, as well as your immediate attention and action in respect of substantive extensions of the Commission’s safety mandate, is appreciated by the Commission.
The Commission records its appreciation of John Goddard, Aviation Investigator of 24 years standing, and Captain John Mockett, Chief Investigator of Accidents, who have both retired from the Commission in this year. Both these men’s work for the Commission has helped make New Zealand transport safer.
Hon W P Jeffries
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