Introduction and invitation to contribute
The Transport Accident Investigation Commission 2009-10 Statement of Intent (SOI) has “better targeting of its resources” as one of four strategic objectives for 2009-10. Developing revised criteria for assessing which aviation, marine or rail transport accidents or incidents to open inquiries for is a specific deliverable under this objective for the year.
As well as helping target resources, any tool supporting decision making must be robust to review, compliant with legislation, and consistent with international obligations. It should also help the transport sector regulators know what information the Commission will be looking for when notifying the Commission of an event.
The tool in development has been named a “logic guide” (rather than “criteria”) to emphasise its role in supporting decision making under legislation.
The Commission is seeking feedback on the draft logic guide before finalisation and incorporation into its work processes from 1 July 2010. Any organisation or person with an interest in the work of the Commission is welcome to contribute. Discussion and feedback is welcome orally by phone, or in person, or in writing by email or letter. You may wish to download a
.pdf version of the consultation paper (please note that it is set up to print as a 12 page booklet, and you may wish to just specify pages 1, 3-9 to print if printing on A4).
Contact for discussion and feedback
Tim Burfoot, Chief Investigator of Accidents,
cia@taic.org.nz, phone 04-473 3112
Transport Accident Investigation Commission, PO Box 10 323, Wellington 6143
Consultation closes on 21 May 2010 in order to allow for finalisation and introduction from 1 July 2010.
Deciding whether to open an investigation – logic guide
This draft logic guide is designed to assist TAIC Duty Investigators and the Chief Investigator of Accidents to consider, recommend, and decide (under delegation) whether or not the Commission is to:
- open an investigation following notification of an event, or to
- seek further information or developments before recommending or making a decision, or to
- decline to open an investigation.
This document is structured for the purposes of setting out ideas and broad process for consultation purposes. It is not presented as it would appear in internal process documentation, where it would also be integrated with operational steps and instructions associated with a decision to open or not (including in respect of an overseas event involving a New Zealand registered or manufactured aircraft or ship).
The logic guide is ordered to reflect the tests and order of consideration set out at section 13 of the Transport Accident Investigation Commission Act 1990 (the Act):
13. Accidents to be investigated
(a) [Repealed]
(b) The Commission believes that the circumstances of the accident or incident have, or are likely to have, significant implications for transport safety, or may allow the Commission to establish findings or make recommendations which may increase transport safety; or
(a) Maintain a ship while it is not at sea; or
(b) Load or unload a ship; or
(c) Both—
unless the Minister directs the Commission to investigate that accident or incident.
(a) Where the Commission has decided not to investigate the accident or incident under subsection
(5) of this section; or
direct the Commission to investigate the accident or incident, and in any such case, the Commission shall do so.
(7) Where the Commission intends to undertake an investigation under this section, the Commission shall notify the Civil Aviation Authority, the New Zealand Transport Agency, or Maritime New Zealand, as the case may require, of its intention as soon as practicable.
The guide has three parts, with consideration moving onto a later part only if a recommendation/decision to open an inquiry has not been made in the preceding part:
- Consideration of circumstances invites consideration of the types of circumstances connected with an event and the potential impact of these on a recommendation/decision whether to open. It helps consider the primary test in the TAIC Act. The list of circumstances must not be regarded as preventing consideration of circumstances not captured by the list, and nor should the suggested impact of circumstances of differing qualities be regarded as definitive; they are indicative only. It is suggested that users simply mark a cross on or circle the appropriate point on the continuum for each suggested circumstance, making margin notes of any particular aspects that will not be easily discerned during any later review from notification or other information available at the time of recommendation/decision. The recommendation/decision is to be based on the overall balance of circumstances on the headline scale (unlikely, unsure/need more info, likely).
- Review against international obligations presents the ICAO and IMO definitions of events which shall or should be investigated.
- Review against watchlist contains a list of event types for which a policy decision has already been made to investigate events of these types, due to trends, history or other developments.
By using this guide, and recording the contributing date and intermediate decisions, the Duty Investigator and Chief Investigator of Accidents are helped to make a demonstrable and defensible recommendation or decision.
Part 1 - Consideration of circumstances
Do you believe that the CIRCUMSTANCES...have SIGNIFICANT IMPLICATIONS FOR TRANSPORT SAFETY, or may allow... FINDINGS...RECOMMENDATIONS WHICH MAY INCREASE...SAFETY? If so, recommend/open. S.13(1) (Consider the overall circumstances when forming belief. Scales are indicative guides only, mark scale for each circumstance, note down key words supporting ratings on the scale if not obvious from other supporting documentation – eg notification content/media reports.)
|
Impact on decision
|
Unlikely Don't know/need more info Likely
|
|
Circumstance
|
|
|
Fatalities and serious injuries, actual and potential number
|
0-1 2-4 5+
|
|
Vehicle capacity for POB, freight, or motive related pollutants
|
Small for mode Medium for mode Large for mode
|
|
Dangerous goods involvement
|
None involved Onboard Onboard
Not Compromised Compromised
|
|
Vehicle damage
|
None/little Moderate Extensive
|
|
Collateral physical damage, actual and potential
|
None/little Moderate Extensive
|
|
Involvement of interface issues such as traffic control, regulatory/legal, policy, shared service provision
|
Unlikely Possible Probable
|
|
Environmental, economic or social impact beyond those immediately involved
|
None/little Moderate Extensive
|
|
Any safety implications or recommendations likely to repeat previous or state the well known
|
Likely Don’t know Unlikely
|
|
Extent to which regulatory, coronial, or OSH investigation should satisfy safety interests
|
In full Somewhat Not at all
|
|
Extent of sector, public, media, or political interest
|
None/little Short term/pro forma Considerable
|
|
Other circumstances? (name and describe decision impact)
|
|
If the overall balance is to the right, then you are likely to recommend/decide opening an inquiry. If not, you should move to the next part (while also seeking more information for circumstances marked in the middle column and being prepared to revisit in the light of new information).
Part 2 - Aviation and Marine only - Review against IMO/ICAO
TAIC will open an inquiry for events meeting the IMO/ICAO definitions of events that SHALL be investigated. S.13(4). If an inquiry has not been opened under the previous part for events that SHOULD be investigated under IMO/ICAO and the event type is not on the watchlist (next part) then the circumstances are to be discussed and reviewed by the Duty Investigator and Chief Investigator of Accidents to see if a decision to open is justified under Review of Circumstances S.13(1).
IMO casualty code
- “shall investigate…every very serious marine casualty" (SOLAS ship PLUS total loss, or a death, or severe environmental damage)
- “should investigate…if it is considered likely that…investigation will provide information that can be used to prevent marine casualties and marine incidents in the future.”
ICAO
- "shall investigate" accident
- when person aboard with intention/during/after flight
- fatality/serious injury in aircraft, direct contact with aircraft, jet blast
- damage/failure adversely affecting strength, performance, flight characteristics AND would normally require major repair or component replacement
- "should investigate" serious incident
- near collisions, near CFIT
- aborted takeoffs on closed/engaged runway
- takeoffs from closed/engaged runway close to obstacles
- attempted/landings on closed/engaged runway
- gross predicted performance failures takeoff/initial climb
- fires/smoke
- use of emergency oxygen by flight crew
- structural failures/engine disintegration not otherwise an accident
- crew incapacitation in flight
- fuel emergency
- runway under/overshoot, excursions
- system failures, weather, ops outside approved envelope which could have cause operating difficulties
- failures of more than one system in a redundancy system mandatory for flight guidance and navigation
Part 3 - Review against watchlist
TAIC has a WATCHLIST of event types where trends, history or other developments means future events of these type are deemed necessary for investigation. If there is a match (circle it on the sheet), then you are should recommend/open unless there is good reason not to (record reason). S.13(4)
(Note: The following watchlist is indicative only, although comment on what is (or is not) included is welcome. A watchlist is to be developed and formally adopted by the Commission separately.)
All modes
- continues a now apparent cluster of similar events not otherwise identified by watchlist
- cell phone or similar distraction
- substance impairment (driver or survivability issues)
Marine
- private recreation fatality/serious injury
- tourist operations
- volunteer coastguard and similar operations
Rail
- platform overruns
- derailments where wheel bearings, side frame collapse, or dynamic interaction suspected
- maintenance issue suspected
- track warrant overruns/monitoring in warrant territory
Aviation
- runway incursions
- mountain flying
- top dressing aircraft in-flight accident
If there is a match with the watchlist, then you should recommend/decide opening. If there is a match, but you believe there is good reason not to open then this recommendation must be discussed with the Chief Investigator and the decision and reasons recorded.
[End of document]