The Deputy Chief Commissioner's Overview is provided below, while the full report is available to view in .pdf.
Deputy Chief Commissioner's overview
Our role is to expose the critical elements of adverse events so they can be avoided in future
The Commission has an expansive overview of the safety performance of New Zealand’s transport system. Our attention is drawn to transport system safety performance in the aviation, rail and sea environments through notifications of adverse events, both accidents and incidents, that are occurring in these transport modes on a daily basis. Annually we receive, on average, about 1,000 notifications across our modes of interest.
Most of the events reported to us are of minor or moderate consequence. But they carry value in the information that comes to light when the lens of inquiry is placed over the circumstances surrounding the events, exposing the critical elements that drive similar systems towards failure. Understanding how these critical elements interrelate enables the Commission to determine the causes of the adverse events. We can then make the necessary recommendations to those best able to influence or remediate the circumstances surrounding the events, any systemic or behavioural changes required and/or any legislative changes required for improved transport safety.
Some events reported to us have eventuated in severe, sometimes catastrophic consequences, resulting in people being harmed or killed. Understanding what happened and how the critical elements became active drivers of the adverse events is necessary if loss of life is to be avoided in similar circumstances in the future. It is not the Commission’s task to inquire into the causes of deaths; that is the Coroners’ mandate. However, through our inquiries we can help the Coroners to understand better the circumstances leading to death.
We are continually striving to improve our investigation and inquiry processes
To improve our work in determining the circumstances and causes of accidents and incidents in the transport system we have adopted a two-pronged approach. First, concentrating on our internal organisational environment, we have strengthened our investigative capabilities, growing our investigation team by six investigators including a new forensic data role. We have also, for the first time in our 25 years of organisational life, four Commissioners rather than three. Having four Commissioners ensures continuity of the Commission’s work, particularly when vacancies arise.
In addition, we are supporting the work of our people through a programme of upgrading our quality assurance systems. The aim is to ensure that inquiry and investigation management processes are effective, efficient and easily implemented.
The second aspect of our organisational improvement programme concentrates on our operating environment. We are mindful of the values that guide us in ensuring that natural justice is maintained. We are progressively enhancing our information and communication systems to support accessibility to the Commission and the information it is able to share during the course of its inquiries. In this regard we are paying particular attention to our inquiry stakeholders, who include government, regulatory and industry organisations, commercial transport operators, international organisations and those most directly affected by the accidents and incidents we investigate — the people involved and their families.
We have been able to undertake the steps outlined above through the increased funding we received in 2015/16. The additional $1.4 million has enabled us to strengthen our resources in terms of our people and the tools available to support them in their work. With increased resources we look forward to: improving timeliness in the completion of the Commission’s inquiries; having a more accessible Commission in terms of making information available in a timely, responsive manner; and enhanced communications with inquiry stakeholders.
Our work depends on public trust and confidence
The Commission recognises that we cannot be effective in serving the public without their trust and confidence in the work we do. That public trust and confidence was called in to question in relation to our inquiry into a 2010 accident at Fox Glacier aerodrome. Aspects of the conduct of that inquiry were challenged through the media following the Coroner’s inquest into the deaths of nine people on board the aircraft.
The Commission was not formally requested to re-open its inquiry, nor did any party offer any new and significant evidence. However, we resumed the inquiry and released our addendum report together with an independent review of the investigation process. The review was thorough, the key safety issues were identified and the recommendations made during and following the inquiry did not change, although some additional findings were made. Nevertheless, the Commission acknowledges that we must work hard to maintain public trust and confidence in the robustness of our investigation processes. As a consequence, the Commission’s ongoing work programme is paying particular attention to being transparent in what we do and how we communicate effectively with all of our stakeholders, as well as ensuring that investigation processes are robust. The work centred on upgrading our quality assurance systems is a key activity in this area.
We are not always able to ascertain cause
Determining the circumstances and causes of accidents and incidents with a view to helping prevent recurrences is the prime purpose of the Commission. However, while circumstances may be ascertained, causes cannot always be determined. This is as frustrating for investigators as it is for those who want, and need, to know why things happened the way they did.
During the year the Commission dealt with three similar inquiries involving Robinson helicopters. The common theme in these inquiries was the circumstances of the accidents — in each case the helicopter broke up in flight, with loss of life, through a phenomenon known as ‘mast bumping’. In each case the Commission was unable to determine unequivocally the cause of the mast bumping. Being unable to determine the causes of these similar in-flight break-ups is of real concern. The Robinson helicopter is a popular aircraft in New Zealand. In addition, the number of accidents involving Robinson helicopters in New Zealand may have significant implications for the global Robinson helicopter fleet. As a first step, in an effort to capture the events immediately proximal to an accident, the Commission has made a recommendation to the Ministry of Transport to promote through the International Civil Aviation Organization (ICAO) the desirability of helicopter operators installing data and image recorders. This action will not prevent a reoccurrence, but it should help accident investigators to determine the circumstances surrounding accidents.
Because the Commission was unable to determine the definitive causes of the Robinson helicopter accidents, it resolved to add Robinson helicopter mast bumping to its Watchlist. The Watchlist is a safety monitoring publication and presents the Commission’s highest-priority safety issues across the aviation, maritime and rail transport modes. The aim is to highlight where transport systems need to change so that safety is improved.
The Commission’s work can have international impacts
The Commission’s work can have international impacts. In June 2016 Maritime New Zealand reported to the Commission on submissions it had made to the International Maritime Organization (IMO) in February 2015. The submissions were in response to one of the Commission’s recommendations in its report on the grounding of the container ship Rena. The recommendation and submission related to the sharing amongst IMO member states of information about their respective maritime education, training and certification systems.
Acknowledgement of the Hon Justice Helen Cull, QC
Helen Cull, QC resigned from the Commission in July 2016 following her appointment as a judge of the High Court. She had been appointed to the Commission as Deputy Chief Commissioner in May 2011 and later to the position of Chief Commissioner in March 2015. On behalf of my fellow Commissioners and the team at the Commission I would like to acknowledge the outstanding contribution Justice Cull made during her time on the Commission. Her drive for excellence in the inquiry process and reporting of findings was instrumental in shaping the Commission’s work.
Finally, thank you to the management and staff of the Commission, who have demonstrated their commitment to supporting the very important work of the Commission in helping to keep all those who travel across New Zealand’s territory safe. Our investigators deserve a special acknowledgement. They are our frontline team. They invariably attract intense scrutiny when undertaking their investigations on behalf of the Commission. The work is difficult, often unpleasant in nature and not without personal risk at times.
Peter McKenzie, QC
Deputy Chief Commissioner