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Annual Report 2014 - 2015

The Chief Commissioner's overview is reproduced below, while the entire report is available to view in .pdf.

Chief Commissioner’s overview

Commission operations

The Commission’s optimal operating capacity is 30 open cases. At the beginning of 2014/15 the caseload was 32. Over the year the Commission opened as many inquiries as it closed (11), and therefore at the end of 2014/15, the caseload remained at 32.

In July 2014, the Commission issued an interim report into the failure of a passenger train to stop at a station. Included in the report were four urgent recommendations; a further two recommendations were issued in April 2015. The inquiry is continuing.

In December 2014 the Commission released its report into the grounding of the Rena. The inquiry was a significant one for the Commission. At the time of the Commission making its determination on the grounding of the Rena, it was reduced to one sitting member. The inquiry itself was resource-intensive. Significant public interest coupled with substantive legal issues meant that the inquiry was extended to allow for hearings, with comprehensive submissions made from the Rena’s owners and operator.

In addition to the inquiry caseload, the Commission has been working with independent experts on further inquiries into the September 2010 sky diving accident at Fox Glacier aerodrome involving eight parachutists. The Commission decided to consider further evidence in 2014 following issues raised in the Coroner’s inquest into the deaths of the parachutists and concerns raised by families through the media. As part of the evidential review, substantive flight tests have been undertaken. The results of the flight tests were being considered at the time of this report.

Strategic highlights

The findings from the inquiry into the grounding of the Rena had international implications for maritime safety, as did another of the Commission’s inquiries into a lifting sling failure on a freefall lifeboat on a general cargo ship. In both these inquiries, the Commission recommended that the Director of Maritime New Zealand raise the safety issues identified through the International Maritime Organization.

During the year, the Ministry of Transport developed a discussion paper on options to reduce the risks of alcohol- and drug-related impairment in aviation, maritime, and rail. The paper was developed in response to the Commission’s report on the 2012 Carterton hot-air balloon accident, and to the Coroner’s findings on the accident. The Commission had recommended regulatory changes to strengthen the management of alcohol and drugs in the aviation, rail, and maritime transport modes.

The New Zealand Transport Agency, the rail regulator, has appointed a new staff member who will be responsible for reviewing and following up on all Commission recommendations relating to rail.

Stakeholder highlights

In January 2015, the Commission released its first issue of the Watch List, a safety monitoring publication. The Watch List presents the Commission’s highest-priority safety issues in the transport modes covered by its mandate. The aim of the Watch List is to highlight where transport systems need to change so that safety is improved, to ensure the public is aware of these issues, and to communicate to the industry matters of particular interest to the Commission. In the Commission’s view, the issues on the Watch List need more attention and effort on the part of those who can make a difference to transport safety.

Over the year, the Commission undertook its third, independently conducted, formal survey of inquiry participants and key stakeholders. Most who took part were positive in their responses, and were of the view that Commission staff were knowledgeable, open and honest, and professional. Most were also of the opinion that the Commission has a positive influence on transport safety. Respondents suggested areas where they thought staff could do better. Suggestions included timeliness in finalising reports, which will be a major focus for 2015/16.

Capability and capacity highlights

Progress in improving investigative and corporate procedures and processes has continued. In 2014/15 the Commission began the development of a Quality Assurance Framework. The project will include a review of investigation processes and case management systems. One outcome will be managers’ improved ability to monitor work progress.

A senior manager has been assigned Major Accident and Business Continuity Preparedness as part of his portfolio. During 2014/15 he completed a review of major accident preparedness and made several recommendations. Workshops with other senior staff have further refined these recommendations, which will be developed into a programme for the new financial year.

Work continued over the year on the Commission’s records management systems. Records from the old system have been transferred to the newly-reconfigured electronic documents and records management system. Information management policy and guidelines have also been reviewed.

Managing organisational risk

Over the year, managers worked with the Ministry of Transport on a review of the Commission’s business model and funding. The review confirmed a need for an increase in baseline funding to maintain capacity and competency in the face of several challenges: 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. The funding review found this environment had resulted in timeliness issues with respect to publication of its reports. No quality issues were found.

Acknowledgement to Mr John Marshall, QC, CNZM

Commissioners and staff were deeply saddened at the death in June 2015 of Mr John Marshall, QC, CNZM. Mr Marshall was appointed to the Transport Accident Investigation Commission in March 2010, becoming Chief Commissioner in May 2010, and retiring in March 2015. He made an outstanding contribution to the work of the Commission, presiding over significant inquiries including the Easy Rider fishing boat and Carterton hot air balloon tragedies, and several other accidents and incidents in which alcohol or cannabis had a role. His firm advocacy for better regulation and zero tolerance of substance impairment in safety critical transport roles leaves a lasting legacy for transport safety in New Zealand. Mr Marshall was made a Companion of the New Zealand Order of Merit in the 2015 Queen’s Birthday Honours List.

Helen Cull, QC
Chief Commissioner