The Transport Accident Investigation Commission’s year ended 30 June 2012 has been dominated by inquiries into three high profile accidents which occurred during the year:
- The inquiry (11-204) into the foundering of the containership Rena on Astrolabe Reef in the Bay of Plenty on 5 October 2011 provided the first authoritative account of what occurred when the Commission published an interim report on 8 March 2012.
- The collision with power lines, fire, and deaths of 11 people in a hot air ballooning accident near Carterton on 7 January 2012 necessitated the issuing of an urgent safety recommendation to ensure that maintenance discrepancies found in the early stages of the continuing inquiry (12-001) were not spread more widely. An interim report published by the Commission on 10 May 2012 was able to give an account of factual information gathered to date.
- An urgent safety recommendation was also issued from the continuing inquiry (12-201) into the capsize and foundering of the fishing vessel Easy Rider in Foveaux Strait on 15 March 2012 with the deaths of eight people and survival of one, when it was discovered that the vessel design had stability limitations that operators needed to be aware of for safe operation.
The Commission also released, on 9 May 2012, the final report of its inquiry (10-009) into the loss of control on take-off and impact with terrain of a skydiving aircraft at Fox Glacier on 4 September 2010 with the loss of nine lives. Among other things this inquiry highlighted concerns about the use of performance impairing substances by persons involved in adventure tourism, and the lack of proper systems and rules to detect and prohibit such use.
The Commission had 42 (2011: 55) active inquiries in the year of which 15 (2011: 13) were new inquiries, 12 (2011: 14) continued from previous years through the year, and 15 (2011: 28) of them were inquiry closures. Significant new or recent cases accorded priority in aviation (12-001 Carterton, 10-009 Fox Glacier, 10-008 Feilding) and marine (12-201 Easy Rider, 11-204 Rena, 11-201 Volendam) delayed work on earlier inquiries. The ability to complete cases was also constrained in the aviation and marine modes which have been operating at half to two-thirds of full investigator strength of 3 per mode due to impacts of staff turnover during the year under review and the one prior. All investigator vacancies were filled by about mid financial year, however a new investigator’s estimated effectiveness in their first four years is 15%, 50%, 75%, and 100% reflecting training and supervision demands and normal development to fully competent in the role.
The efforts to clear backlog plus the careful application of the Commission’s criteria when considering cases for possible inquiry over the past two years (15 cases were opened in the year ended 30 June 2012 (2011: 13)) and a fortunate lack of more events requiring inquiry mean that the organisation is in a good position for the years ending 30 June 2013 and 14 to continue to improve timeliness. About half of estimated 25 completed inquiries expected for the year ending 30 June 2013 are expected to be within 330 days (compared with 20% in the year under review). The estimate is that there will be just 2 inquiries aged over a year remaining at 30 June 2013, comparing very favourably with 12 (2011: 14) at 30 June 2012, and this would complete a solid foundation for continuing improvements to timeliness.
Transport Accident Investigation Commission | Annual Report 2011-2012 | 5
Final acceptance of a new computer-based accident investigation information management system was delayed several months into this year while implementation difficulties were resolved within the fixed price contract. The deliberate carrying of a researcher/analyst staff vacancy for 11 months and the time taken by corporate staff to support the high profile inquiries saw completion of some corporate priorities delayed or deferred until the new financial year.
The Commission continues to manage cost pressures within its budget, including through realising benefits from whole of government efficiency projects where appropriate.
Strategic planning by Commissioners and senior management during the year has focused the organisation’s corporate development work programme on improving operating efficiency (including inquiry timeliness and major accident preparedness), developing and maintaining investigation best practice, growing stakeholder relationships, and communicating more about what we do and learn. These priorities are reflected in the Statement of Intent 2012-15 now active.
I would like to acknowledge the sometimes intense personal, social, cultural and economic costs that the accidents we investigate may represent to those people involved or affected by them and to thank them for their graciousness when working with staff and Commissioners on the Commission’s inquiries as we work to help prevent similar events occurring in the future.
I would also like to record the sadness of Commissioners and staff at the accidental death of Commissioner Bryan Wyness on 20 July 2012 and our gratitude for his outstanding contribution to the Commission since his appointment in 2004; part of a lifetime’s career largely dedicated to improving transport safety.
John Marshall QC