Introduction to TAIC

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Transport Accident Investigation Commission

Introduction to the Transport Accident Investigation Commission (TAIC)

Establishment

Purpose

Independence

Structure

Investigation process

Powers

Responses to requests for information

Reporting on transport regulatory authorities

Safety recommendations

Relation to transport regulatory authorities

Establishment

The Transport Accident Investigation Commission (TAIC) was established by Act of New Zealand's Parliament on 1 September 1990. TAIC's legislation, functions and powers were modelled on and share some similarities with the National Transportation Safety Board (USA) and the Transportation Safety Board (Canada). England, Australia, Holland, Sweden, and Finland also have similar boards or authorities for conducting independent inquiries into transport accidents and incidents.

TAIC is similar to a standing Commission of Inquiry. A standing Commission eliminates the time taken to set up individual judicial inquiries into significant accidents, and retains the skills and experience necessary to undertake what can be very complex and far-reaching investigations into almost every facet of a transport system. The ability of the Commission to carry out much of its investigation work in camera contributes to shorter and more effective inquiries because the parties assisting the Commission with its investigation can concentrate on the inquiry's purpose without the distractions, pressures, and posturing sometimes associated with public inquiries.

TAIC's multi-modal approach facilitates the sharing of investigative process expertise across the transport modes. Some investigations will also span the modes.

Unlike some overseas independent safety investigation agencies, TAIC has no mandate to investigate road or pipeline occurrences.

Purpose

TAIC investigates all aviation, rail or marine accidents and incidents within New Zealand the circumstances of which, in TAIC's opinion, have or are likely to have significant implications for transport safety. The investigation is known as a safety investigation (some other agencies refer to a safety investigation as a technical investigation). As the sole purpose of every TAIC investigation is to determine the causes and circumstances of the accident or incident with a view to avoiding similar occurrences in future, rather than to ascribe blame to any person, other agencies in New Zealand (for example the transport regulatory authorities: Maritime Safety Authority, Land Transport Safety Authority, and Civil Aviation Authority) and the Police may also investigate the same accidents for blame or law enforcement purposes. Enforcement investigations may also be called judicial investigations.

The words "accident" and "incident" are defined in the relevant civil aviation, marine, or land transport legislation. "Accident" often includes an event resulting in death or serious injury, or resulting in substantial structural failure. "Incident" normally means any occurrence, other than an accident, that affects or could affect the safety of a transport operation. For simplicity in these pages the word "accident" or "occurrence" encompasses both accidents and incidents, since it is often only a matter of chance whether the outcome of the occurrence was an accident or an incident.

Independence

TAIC is independent of all organisations and has an arm's-length relationship with the Police, transport operators, transport regulatory authorities, unions, insurers and any other organisations that may have some involvement in the investigation or in the occurrence under investigation. This independence is seen by the transport industry as making an important contribution to TAIC's effectiveness in determining causes and making effective recommendations to prevent similar accidents.

TAIC maintains its independence for four important reasons:

Independence from the regulator, operators, and the transport industry enables TAIC to investigate and comment impartially on any role the regulator or other groups might have been able to play in preventing the accident;
Independence from the Police and regulatory authorities allows people to talk to TAIC's investigators freely in the knowledge that the Commission can not use that information to punish someone or discipline and organisation;
Independence from the Police and regulatory authorities ensures that any prosecution brought by them does not compromise or delay TAIC's own investigation and report on the accident.
Independence from other agencies gives TAIC full control over approving and publishing its reports, subject to the right of any party to apply to a Court to obtain a stay of publication to facilitate judicial review of the contents of a report.

Structure

TAIC is based in Wellington, New Zealand. TAIC's structure is consistent with international practice for multimodal independent safety investigation agencies. TAIC comprises three Commissioners, 11 staff, and a small number of assessors and contractors providing specialist services.

The three Commissioners are:

Hon Bill Jeffries

Chief Commissioner

Mr Jeffries is a Barrister and was involved in general practice and major constitutional litigation from 1973 to 1988.

In 1981 he was elected to Parliament, and in 1987 was appointed Minister of Transport, Civil Aviation and Meteorological Services. Mr Jeffries was also appointed Minister of Justice in 1989. During his parliamentary term he also held the positions of Associate Minister of State Owned Enterprises and Minister of Works and Development.

Since leaving Parliament in 1990 Mr Jeffries has continued his barristerial practice in Wellington and has sat on various boards and hearings.

Mr Jeffries was appointed to the Commission in May 1997.

Pauline Winter

Deputy Chief Commissioner

Pauline Winter is a management consultant. She chairs the Auckland Energy Consumers Trust, and the Pacific Island Business Development Trust. Pauline is currently a board member of the Legal Services Agency and a Trustee of the Auckland Mayoralty Foundation. She was recently the Chief Executive Officer of Workbridge Inc. a dynamic organisation that specialises in providing jobs and training for people with disabilities throughout New Zealand.

Pauline cut her teeth in the building industry, and drew on her private sector experience to successfully introduce a commercial model to Workbridge. Under her guidance, the organisation sharpened its focus on quality services, gained recognition internationally and developed unique service products for the accident rehabilitation industry.

Ms Winter was appointed to the Commission in September 2001.

Bryan Wyness

Commissioner

Bryan Wyness' industry knowledge is primarily aviation related with particular knowledge in flight safety along with his skills as a Flying Instructor, Flight Superintendent, Fleet Captain and Flight Operations Manager (Technical). He also holds a Bachelor of Science degree and an Airline Transport Pilot's Licence and Flight Navigator Qualification.

Bryan is the former Vice President Flight Operations of Air New Zealand and has held appointments with the International Advisory Committee of Flight Safety Foundation and the Independent Aviation Advisory panel.

Mr Wyness was appointed to the Commission in November 2004.

TAIC is almost entirely Crown funded, currently at about $1.6 million p.a.

Investigation process

TAIC's investigation policies and procedures are based on well-developed international practices, particularly those recommended by the International Civil Aviation Organisation (ICAO). The concept of independent investigations for safety was pioneered in the aviation industry, which has led all other modes in the effective use of 'not for blame' safety investigations.

TAIC initiates investigations into about 50 accidents and incidents per year. Those which, after initial investigation, are considered to have significant implications for transport safety are investigated to the extent necessary and a summary of the investigation issued in the form of a public report.

TAIC prioritises its investigating and reporting according to the potential to prevent similar accidents. The severity of the occurrence investigated may have little bearing on its potential for preventing similar accidents. For example an incident where no injury occurred may yield far greater safety benefits than an accident involving loss of life, so the investigation of the incident may receive a much higher priority, than the accident which might not be investigated at all if it is considered not to hold significant implications for transport safety.

If, after an investigation has been closed, new evidence becomes available which has or is likely to have new and significant implications for transport safety, TAIC will re-open the investigation.

Neither economic considerations nor the extent of pollution of the environment influences the selection of accidents for investigation: TAIC's focus is safety of people.

Powers

TAIC's powers are similar to those conferred on a Commission of Inquiry by the Commissions of Inquiry Act 1908.

In recognising the importance of preventing similar accidents in future, TAIC's Act gives it primacy of access to and control over an accident site and evidence at the site.

In addition, TAIC's inspectors, under a standing warrant issued by the Chief Commissioner, have the power to:

enter and inspect any transport related thing;
inspect, copy, or retain any documents or records;
prevent tampering with evidence, prohibit access to an accident site or related things;
direct a transport related thing to be taken to a nominated place;
seize, detain, remove, preserve, protect or test any place or thing.

The powers of investigators can be extended by special warrant to include entry to a dwelling or marae.

Responses to requests for information

TAIC is pleased to answer queries about its work. While an investigation is under way TAIC cannot discuss the causes or circumstances of an accident or incident except with the parties and specialists assisting it with the investigation. This is because disclosing the information would inhibit the supply of similar information to TAIC in future.

Consistent with the Commission's responsibility to ensure that it has the best possible access to vital information, the TAIC Act requires the Commission and other parties to keep certain types of information confidential. These same obligations give informants certainty that information they provide to the TAIC for an investigation into an air, rail, or marine accident or incident will not be revealed, except in a de-identified form in the TAIC final report and if the information is pertinent to the analysis of the occurrence. The practice has international precedents in Australia and Canada and is advocated by the International Civil Aviation Organisation which has for a number of years recognised that people will not provide information if they are afraid about the possible uses to which that information may be put.

Paragraph 5.12 of Annex 13 to the Convention on International Civil Aviation states: Information … which includes information given voluntarily by persons interviewed during the investigation of an accident or incident could be utilised inappropriately for subsequent disciplinary, civil, administration and criminal proceedings. If such information is distributed, it may, in the future, no longer be openly disclosed to investigators. Lack of access to such information would impede the investigative process and seriously affect [transport] safety.

Records such as witness statements, submissions (for example, on preliminary reports), records of interviews, and notes or opinions taken down by the TAIC investigators in the course of an investigation cannot be released by the TAIC other than for accident investigation. These records cannot be obtained from the TAIC by execution of a search warrant, by order of the Court, nor through an inquiry by the Ombudsman or Privacy Commissioner.

The TAIC Act gives similar protection to cockpit voice and video recordings, transcripts of such recordings, and records (other than those included in the preceding paragraph) held by the Commission containing information about an identifiable natural person. However, the Court may order their disclosure for civil proceedings if the Court determines that the interest of justice outweighs the adverse impact disclosure may have on the investigation to which the record relates, or any future investigation.

The protection provided by the Act still allows people who have provided information to the TAIC to make the same (or different) statements to others. If a person does not wish to make the same statement to others, their reason may be precisely that which would have inhibited that person from making the statement to the TAIC had the TAIC not been able to protect their information.

The TAIC Act also allows other agencies and individuals to carry out their own investigations and to make their own inquiries. Alternatively, TAIC reports are freely available in libraries or from TAIC at a modest charge.

The Commission seeks to ensure that its investigation processes are well understood and is happy to explain these. It has a policy of responding to public and news media inquiries as promptly as practicable and as helpfully as possible.

TAIC recognises the important role the news media can play in the aftermath of an accident: conveying the facts, assisting public comprehension, and gathering witnesses. TAIC will assist the news media to the extent that it is able without frustrating the TAIC investigation or compromising TAIC's role. (see Essential background for the news media)

Reporting on accidents and incidents

After analysing the information collected during the investigation TAIC prepares a preliminary report which makes tentative or draft findings as to the causes and contributing factors and recommendations for preventing similar accidents in future.

TAIC's legislation requires that where a preliminary report indicates that the conduct of any person has contributed to the occurrence, TAIC must allow that person an opportunity to comment on the report. The consultation process usually adds at least two months to the process of completing an investigation, and sometimes a second or third round of consultation may be required. (link to "Commission's Consultative Procedures")

Having considered all submissions and made any amendments it thinks appropriate TAIC then publishes its findings and any safety recommendations in a final report. Final reports are public documents. The legal and practical framework within which TAIC operates means that a report normally takes between five and eight months to finalise. A particularly complex investigation may take more than 12 months to complete.

TAIC's reports make no attempt to assign fault or blame or to determine liability since neither the investigation nor the reporting process has been undertaken for that purpose. TAIC vigorously opposes any attempt to introduce its reports or opinions into any judicial or disciplinary hearing. An exception might be made for a serious case of unlawful interference with a vessel, train, or aircraft, such as sabotage, hi-jacking, or intentional use of bogus parts.

Safety recommendations - levers for change

"The ultimate goal of a truly effective investigation is to improve safety. To this end recommendations are made in general or specific terms in regard to matters arising from the investigation whether they be directly affected by causal factors or have been prompted by other factors in the investigation."

Safety recommendations (SRs) are made to the most appropriate party as soon as any safety opportunities are identified, and do not depend upon the publication of the final report, nor even completion of the investigation. Some 80% of TAIC's recommendations are acted upon.

Safety recommendations are arguably the Commission's most important product for avoiding similar occurrences in the future. Consultation on preliminary SRs will not always reveal the difficulties or cost of putting the final SR into practice, so it is not reasonable to expect all SRs to be implemented. It would also be inappropriate for TAIC to enforce all its SRs as this would erode the Commission's independence. If a recipient does not implement a SR, the option always exists for the state to assess importance, cost, and benefit, and if necessary intervene and enforce implementation.

TAIC's 1500 SRs made in the last 10 years may have gone unheeded. However, given the relevant information, TAIC can provide an opinion on whether a SR has been implemented, or whether a decision not to implement is reasonable.

Recognising the potential importance of TAIC's SRs, the Minister of Transport in October 2000 asked the safety authorities to participate in returning information to TAIC showing completed action to implement all new SRs. TAIC now forms a view as to whether the evidence proves beyond reasonable doubt that each new SR has been implemented. The process covers all SRs developed since October 2000.

If the recipient of a SR or the safety authority provides sufficient evidence of completed action, TAIC records the SR status as "closed - acceptable". Seven SRs were "closed - acceptable" since October 2000. While the number closed sounds low in relation to the 112 SRs finalised, this system is in its infancy. It may take some time to implement an SR to ensure lasting benefit through appropriate integration with existing systems.

If sufficient evidence is provided that the SR cannot be implemented, for example cost outweighs benefit, TAIC records the status as "closed - cancelled". No SRs have been assigned "closed - cancelled".
Until sufficient evidence is received to close the SR, the status remains "open".

The text of all SRs will be published on the TAIC website www.taic.org.nz, together with the status of the SR. The status of all SRs developed before the status system was launched will be listed as "unknown", unless information received (for example, a subsequent investigation) enables TAIC to assign another status.

Relation to transport regulatory authorities

TAIC's concern is for the safety of New Zealand transport, not for its cost, whereas the purpose of the transport regulatory authorities is safe, sustainable transport at reasonable cost. The two interests do not conflict because TAIC's recommendations are not binding. Safety studies, the promotion of transport safety, identifying trends, and anticipating what will affect safety are the ambit of the regulatory authorities, which keep statistics on accidents and incidents and research these as they think necessary. The Ministry of Transport and the regulatory authorities monitor statistics on safety outcomes and trends. TAIC may use the statistics for specific investigations. However, TAIC also contributes to the promotion of transport safety by publishing impartial and objective reports and recommendations, providing qualified representatives for investigations overseas, supporting other safety investigation agencies, contributing to the international network of safety investigation agencies, and providing input to New Zealand's accident investigation legislation.