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Annual Report 2005 - 2006

Chief Executive's Report


The year in review commenced with a surge in notifications in all modes under the Commission’s mandate.  Overall notifications increased 36 % on last year. Marine notifications in particular increased 67 %.  It is pleasing to think that the safety messages are manifestly getting across to transport operators so that self reporting of incidents is on the increase.  However, the increase in marine notifications can be linked to the environmental pressure group “Guardians of the Sound” activities protesting about the speed of ferries moving through the Marlborough Sounds.  A surge in notifications occurred early in the reporting year, with a discernable downward trend thereafter.  Notifications had slowed 14% by June.  So, perhaps counter intuitively, there remains a question as to the extent of under reporting of accidents and incidents in our transport modes of interest, particularly marine.


The Commission launched fewer investigations in the year.  Although the Commission’s information systems at present do not readily support deep enquiry into categories of occurrences, the Commission is working to remedy the situation through its future work programme.  However, the information available to the Commission does suggest that the number of significant accidents and incidents in all three modes is decreasing.  The Commission has just in this last year adopted a more focused approach to monitoring accident and incident trends but it is too early for us to draw substantive conclusions on the data available to us. We have set a baseline for reporting so we now will be able to evaluate the data with greater confidence going forward.


With investigation numbers down the Commission made the most of the opportunity to clear a backlog of cases.  Reports produced by the Commission increased 26 % on last year, dropping the level of open cases from 50 at June 2005 to 26 at June 2006.


The Commission ended the financial year with a deficit.   The deficit was difficult to avoid, arising as it did from the Commission’s decision to recover the fishing vessel Kotuku from Foveaux Strait in April.  Recovery of wreckage from seas and mountains is resource intensive in terms of labour, equipment and time.  This begs the question “Why do it?”  The answer lies with the remarks made by Chief Commissioner Hon. Bill Jeffries in his overview.  New Zealand has already placed positive value on learning lessons from adverse events so as to reduce the likelihood of similar event occurring by establishing the Transport Accident Investigation Commission.  Our work and our commitment are to get to the truth of events.  Our work practices arise out of international best practice for accident investigations.  Our investigative methodologies are common to the international community of accident investigators.  Our investigative discipline requires evidential analysis.  The wreckage of a vehicle is primary evidence in any inquiry.


The primacy of wreckage to an inquiry cannot be overstated.  The Commission recognises the distress to loved ones that bringing forth wreckage evokes.  However, each event tells its own story.  The vehicle, after the event, is like a messenger retelling the unfolding of events, which may have lessons for others in similar situations, or reveal system weaknesses that if left unattended could result in catastrophic collapse at some later stage. 


The Commission has learnt its own lessons about the value of salvaging complete wreckage having this year released its report into its resumed investigation into a helicopter accident in 2001 where 3 people died.  In the Commission’s original report released in February 2002 a finding as to likely cause precipitating the accident implicated maintenance engineers involved in the upkeep of the helicopter.  The Commission did not have the full wreckage of the helicopter.  Two years after the occurrence the Commission had laid before it new and material evidence involving similar components from two other helicopters that had crashed.  The new evidence threw doubt on the conclusions arrived at in the first report, so the Commission re-opened its investigation to get at the truth.  This was the first time in the Commission’s 16 year history that an investigation was re-opened.  The findings reported on in June this year, 5 years after the occurrence, showed that the original finding implicating the engineers was not sustainable.  Recovering wreckage is painful for family, but not recovering wreckage can be as hurtful to others.


Conducting investigations and reporting on findings of transport accidents is not the only work of the Commission.  There is the “housekeeping” associated with being an independent crown entity.  The Commissioners and Commission staff participated in various forums and meetings related more to the Commission as a crown entity than to its role as a Commission of Inquiry.  This is background work in the life of the Commission but just as important for the health and vitality of a state sector agency.  The Commission is pleased to participate in the transport sector’s strategic planning and management forums.  In addition, our meeting with the Equal Employment Opportunities Commissioner gave real benefit to our consideration of succession planning.  The Commission has an older workforce reflective of the required experience and skills of credible accident investigators.  The Commission is developing a good employer strategy that will, we hope, support our workforce for longevity while at the same time enabling timely succession in the workplace.


Finally words of thanks to our Chief Commissioner Hon. Bill Jeffries who has agreed to stay on as our Chief Commissioner for a further2 years after already 9 years of superb leadership; to John Goddard who retired after 24 years as an Aviation Investigator; and to Captain John Mockett who has retired after 9 years, 4 of those years as our Chief Investigator of Accidents. 


Also, thank you to Maritime New Zealand for its support in recovering the Fishing Vessel Kotuku.  Often there is a tension between regulator and inquirer.  This is not unexpected given the respective roles, however by and large the roles complement each other, working as we do to improve transport safety in the wider transport system.



Lois Hutchinson

Chief Executive

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