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Chief Commissioner's review

Chief Commissioner's overview

Inquiry highlights
The Commission's caseload was consistently high over the year. When the Commission has a full complement of trained investigators, its optimal operating capacity is 30 open cases. For the first eight months of 2013/14, the Commission's caseload was 35 or more, dropping to 32 by the end of the year. Investigator resources in the aviation and rail modes were particularly extended. Although the average age of open inquiries is under target, the high workload during the year is likely to affect the time to complete inquiries over 2014/15.

In October 2013, the Commission released its report into the Carterton hot-air balloon tragedy (12 001).  Recommendations arising from the inquiry included a call for reform of alcohol and drug regulation across the aviation, rail, and marine modes.  The Commission's recommended reforms included the introduction of preventative measures (such as alcohol and drug prohibition), and detection and deterrence regimes for people working in safety-sensitive roles. Alcohol and drug impairment of persons in safety critical positions in the transport industry is a matter of significant concern for the Commission, and it continues to feature in occurrences across modes.

The inquiry into the grounding of the Rena continued (11-204). The Rena's operator, Ciel Ship Management, made a substantial submission to the Commission, which extended the inquiry. The Commission expects to complete the inquiry and publish its report before the end of 2014.

Strategic highlights
The Commission contributes to safer transport in part by informing the transport sector about safety issues and influencing sector participants to act on those issues. Over an approximately 12-month period to the second half of 2013, the Commission had expressed its concerns to the rail regulator over the regulator’s effectiveness. The Commission was of the view that oversight of the rail industry would be improved if the regulator were more visible and assertive.  The regulator, the New Zealand Transport Agency (NZTA), subsequently restructured and reassigned responsibility for rail regulation higher within the organisation, and it has begun to raise its public profile as the regulator.  The Commission's release of a report into a near head-on collision Staircase-Craigieburn (11-102) is a case in point, where the NZTA made a media statement endorsing the inquiry's findings and asserting its role.  That inquiry had established significant concerns for KiwiRail's risk management and operation of train control.

Stakeholder highlights
In May 2014, the Commission was pleased to host and chair the annual Meeting of the Chairpersons of the International Transportation Safety Association. These meetings offer a valuable opportunity for the Commission and our peer organisations internationally to share experiences, exchange information on transport safety matters, and contribute to safer systems worldwide. This year's meeting was attended by 28 representatives of investigation agencies from 15 countries. One of the achievements of the meeting was to reach a resolution to support, and actively move towards adopting, International Civil Aviation Organization proposals to enhance the international standards relating to aircraft tracking and flight recorders. These moves arose in the wake of missing Malaysia Airlines Flight MH370. 

During the year, the Commission developed its inaugural Watch List. The Watch List is a monitoring tool. It is designed to communicate to the regulators, industry operators, and the public, the transport safety-related issues that the Commission is especially concerned about, and which it thinks require greater attention and action. The issues chosen for inclusion in the Watch List are drawn from previous recommendations of the Commission, or they may be international in origin but have domestic relevance. Watch List issues could also be emerging issues from investigation experience, domestic trend monitoring or other research.  The Watch List is expected to be published before the end of 2014.

Capability and capacity highlights
The Commission continued its commitment to adopting a better public service approach to its business operations. During 2013/14 it made further progress in improving its investigative and corporate procedures and processes. 

A review of the Commission's major accident manual and other investigative procedures, which began in 2012/13, continued. The focus has been on the Commission's evidence collection protocols and evidence analysis framework.  A review of the high-level quality manuals is near completion. Work for the coming year will focus on the next tier of documentation.

An information management and technology project to reconfigure the Commission's electronic documents and records management system was completed. The focus for the coming year is to transition records from the old to the new system, and to renew information management policy and guidelines.

Managing organisational risk
In March 2014, a television current affairs programme made allegations of poor wreckage scrutiny and handling, and unconsidered alternative theories and evidence in respect of the Fox Glacier parachuting aircraft accident (10-006).  The Commission instituted a formal review of evidence, analysis and findings, while Commission managers conducted a practice review.  Independent experts were involved in both processes. The review of the Commission's inquiry into the accident was near completion at the time this report was being prepared.

The Commission began working with the Ministry of Transport on a review of the Commission’s business model and funding to confirm whether, as the Commission believes, an increase in baseline funding (last increased six years ago) is needed. The Commission faces challenges in maintaining an appropriate capacity and competency in the face of an ageing workforce, changing expectations of inquiry breadth and depth, as well as technological and data analysis advances in the transport sector generally, and the challenges and opportunities these give accident investigation.  During the year, an independent reviewer completed exhaustive stakeholder research and business evaluation as the start of the process to determine whether an increase in Crown funding is justified.

In summary, the number of reports published during the year and the amount of progress made on corporate projects has been gratifying. The Commission's achievements have been realised despite the high tempo of work over 2013/14, as represented by the number of open inquiries; and an operating environment where resources are strained. It has been a challenging but successful year for the Commission.

John Marshall, QC
Chief Commissioner