The Commission met as a Commission of Inquiry 11 times in 2008/09 which included 3 special hearings to receive oral submissions, approving 18 preliminary (draft) reports to go to the parties involved for consultation, and finalising 21 inquiries. In addition, the Commission met as a governance board 11 times.
There were 1237 notifications of occurrences made to the Commission from the Regulators, leading to 28 new inquiries opened. That is one inquiry opened for every forty-four notifications. The number of notifications represents a 4% (48) increase on the number of notifications made to the Commission last year. This is a lower rate of increase compared with previous years. Notifications to the Commission have been increasing year on year since 2005 (average increase of 174 notifications a year) with a significant increase in 2007 (of 342 notifications).
The most common notified events to the Commission were airspace incursions from the aviation mode, derailments from the rail mode, and personal injury from the marine mode. This was the same pattern as the previous year.
The most frequent types of occurrences inquired into by the Commission were collisions with terrain in aviation, and collisions in the marine. Rail cases were varied with no one type of occurrence dominating.
Service performance followed a similar pattern to last year with fewer investigations opened than planned (28/40 compared with last year’s 27/39). This was mainly due to a more focused approach to opening inquiries in cases with the greatest opportunities for safety learnings. This is because the Commission’s investigation staff and Commissioners are operating at full capacity. The unit service capacity of an investigator is 4 cases in and out each year, with queues and delays forming if more inquiries have to be opened than planned, inquiry openings are bunched, or an existing inquiry is more complex than average. The caseload for the Commission is expected to be 40 open cases on average at any given time. The year ended with the Commission’s open cases at 47.
Similar factors apply to the work of Commissioners. They are at capacity when cases before them (preliminary or final) exceed 6 per month. The Commissioners require time for study, deliberation, and consultation when required. Interested persons have a right to be heard by the Commission on preliminary reports. Usual practice is for interested persons to make written submissions, but there are times when the issues are complex or suited to personal explanation or discussion. It is not unusual for the Commissioners to seek further clarification on points of issue or additional information to assist them in their deliberations. All this pushes out the time for inquiry completion.
Inquiry reports published were 18 compared with 24 last year. The reason for the fewer reports published is the service gap created when a senior rail investigator departed halfway through the financial year and was replaced by a trainee, while the marine team has had a trainee for the past two years so reducing its capacity. Meanwhile, aviation inquiries opened in the previous and year of report were below expectation leading to fewer reports.
The Commission has been focusing attention on clearing the rail backlog. Cases are not readily transferred to other investigators because case completion requires detailed and specific knowledge of the circumstances of the accident or incident which is obtained through a site investigation. However many of the cases are incident based, suitable for more shortened reporting formats, or for grouping under one report where the incidents are common to one type of event category such as derailments or platform overruns.
Work continues on refining our launch criteria to ensure we are opening inquiries into occurrences that will have valuable lessons for transport safety.
2008/09 was the first year of our 3 year Business Sustainability and Effectiveness Initiative. The purpose of the initiative is to build the Commission’s corporate capability. The main emphasis of the initiative is to strengthen the administrative infrastructure in support of the Commission’s inquiry functions. There are five key projects to the initiative:
- Corporate infrastructure & capability
- Quality Assurance
- Information systems upgrade
- Competency based staff training
The Facilities project is now completed. The Commission moved to new premises so it could accommodate staff recruited to the new positions. The Commission also upgraded its wreckage storage facility so that it could secure evidence and maintain compliance with occupational health and safety legislation.
The Quality Assurance project is programmed over 2 years. Year 1 involved undertaking a review of the Commission’s policies and procedures. This is now completed. A number of recommendations were made covering areas such as internal control processes, documentation management, evidence handling and human resource management systems. Year 2 of the programme begins with implementation of recommendations made to remedy deficiencies in the Commission’s Human Resources system.
The Information systems upgrade was deferred until after the Quality Assurance Review was completed because there are linkages to the outcome of the review with respect to investigation processes and documentation. Investigation processes and documentation management are key features of the proposed Accident Investigation Management System to be developed in 2009/10.
Similarly aspects of the corporate infrastructure & capability project were deferred while awaiting the outcome of the Quality Assurance Review. Most notably recruitment to the new roles relating to human resources, IT management and quality services was held over. As a result of the Quality Assurance Review and the recommendations made for process improvement, these roles are being reappraised in terms of scope of services and fit to the organisation.
Finally the competency based training programme for investigation staff is established and aligned with international standards for accident investigation practice.
The year end result is a deficit of $149k compared to a budgeted surplus of $1k. The deficit arose from providing for the loss incurred by the Commission when subletting it’s former premises. The Commission has minimized the losses incurred by securing a tenant for the remaining life of the lease under difficult market conditions. The provision covers the net present value of this loss over the 5 year term of the sublease less the expected rental income (refer to Note 15 of the Financial Statements). The Commission’s decision to defer aspects of the Business Sustainability and Effectiveness Initiative impacted on the capital expenditure program for 2008-2011 for the development of the Accident Investigation Management System (AIMS). The deferment of the AIMS project resulted in property, plant and equipment budget being under-spent by $111k. The overall expenditure over three years for this project is $800k.
The Commission’s on-going focus is to continue to improve upon its performance as New Zealand’s independent accident investigation organisation. Key activities ahead are completion of the Sustainability and Effectiveness Initiative with IT systems upgraded and quality assurance recommendations in the areas of records management, finance, evidence management and occupational health and safety implemented.