The Transport Accident Investigation Commission is calling for significant reform of alcohol and drug regulation across the aviation, rail and marine modes in its final report of the inquiry into the January 2012 hot-air balloon collision with power lines near Carterton that left dead all 11 people on board.
The Commission found the pilot was a cannabis user who had a level of cannabis in his system that was likely to have resulted from long term and recent use. The Commission found it was highly likely that he had smoked cannabis on the morning of the flight.
“Having considered all the evidence, the Commission found that the accident was caused by errors of judgement by the pilot, and the possibility that the pilot’s judgement was impaired by the use of cannabis cannot be excluded,” Chief Commissioner John Marshall QC told a media conference this morning (31 Oct 13).
The report said the pilot’s errors of judgement were in letting the balloon get below the level of power lines in a paddock in which he was unlikely to be landing, then in trying to out-climb the power lines, and in not taking the recommended action of making an emergency deflation when collision was inevitable.
The Commission is calling for legislation or rules across the aviation, rail and marine sectors – including recreational boating – that:
· set maximum limits for alcohol
· prohibit people operating aircraft, vessels or rail vehicles if they are substance impaired
· require operators to implement drug and alcohol detection and deterrence regimes, including random testing
· prescribe post-occurrence testing requirements for drugs and alcohol.
“It is totally unacceptable for anyone in a safety-critical transport role, such as a pilot, to be working while impaired by a substance, whether legal or not,” Chief Commissioner John Marshall QC told a media briefing this morning. “Cannabis has both short and long term impact on judgement, decision-marking, and reaction time depending upon the person, the quantity, and the frequency of use.”
The Commission acknowledged new regulation of the adventure aviation sector brought in since the accident, and Mr Marshall said new rules requiring those operations to establish a drug and alcohol programme for monitoring and managing the associated risks “should give increased confidence in the adventure aviation industry and help reduce the risk of a recurrence”.
“The Commission has investigated six occurrences in the last 10 years where persons operating aircraft, vessels or rail vehicles, or where persons performing functions directly relevant to the safe operation of these, have tested positive for performance-impairing substances. Thirty-four people have died in these accidents. While substance impairment may not have been a cause, its presence and potential to be so is a matter of real concern to the Commission. There are many more accidents, including fatalities, that do not reach our threshold for inquiry and are investigated by other agencies,” he said.
In a reply to the Commission’s recommendation, the Ministry of Transport said it had commissioned research on the question of developing a post-occurrence testing regime, and the Ministry saw the results of this study as necessary to inform whether limits should be set, and detection and deterrence regimes put in place.
“The Commission has not formally considered the Ministry’s response as it was received just a few days ago,” Mr Marshall said, “however I would observe that alcohol and drug testing – including random testing - is accepted practice in road transport, and in other modes in other jurisdictions. I would also observe that accidents such as this one – in addition to the personal tragedy, and the impact on the families and local community - can affect New Zealand’s reputation, and have economic impacts that extend well beyond those immediately involved.
“The Commission will be monitoring the rate and nature of progress in this area closely.
“The Commission has done its job of a conducting an exhaustive, independent inquiry to find out what caused the Carterton tragedy. Substance impairment has again been highlighted as an issue. We have made yet another recommendation. It is time for public debate and action,” Mr Marshall said.
Other recent relevant Commission cases and recommendations (available on www.taic.org.nz):
12-201: Fishing vessel Easy Rider, capsize and foundering, Foveaux Strait, 15 March 2012. Eight persons died and one survived this accident. Of the four bodies recovered: one passenger had a blood alcohol reading 1.5 times the driving limit which was enough to impair decision making and co-ordination, and to hasten hypothermia. Another passenger and one of the crew members had cannabis levels consistent with recent use, which may have affected their ability to escape the upturned boat. This inquiry report published in May 2013 cited the recommendation remaining open from 09-201, below.
11-103: Track workers nearly struck by passenger train near Paekakariki, North Island Main Trunk, 25 August 2011. A worker responsible for declaring the track was clear of workers to allow trains through did so without checking whether this was the case. He tested positive for cannabis and was found to be a regular user. KiwiRail has since introduced random testing. In April 2013 the Commission called for an industry standard to require all rail participants to have zero-tolerance policies for substance impairment, require post occurrence testing, include random testing, and require a system for discreet reporting of suspect behaviour. The New Zealand Transport Agency accepted the recommendation and said it would begin discussions with the industry. The recommendation remains open.
10-009: Walter Fletcher FU24, ZK-EUF, loss of control on take-off and impact with terrain, Fox Glacier aerodrome, South Westland, 4 September 2010. The pilot of a Walter Fletcher aeroplane with 8 parachutists on board lost control during take-off from Fox Glacier aerodrome. The aeroplane crashed in a paddock adjacent to the runway, killing all 9 occupants. Although not contributory to the accident, two of the tandem jump masters tested positive for cannabis. As a result, the Commission recommended to the Secretary for Transport in March 2012 that he promote the introduction of a drug and alcohol detection and deterrence regime for persons employed in safety critical transport roles. This recommendation was accepted, but remains open.
09-201: collision: private jet-boat/private watercraft, Kawarau River, Queenstown, 5 January 2009. Two of five persons involved in this accident died. Alcohol had been consumed but was not considered a cause. The inquiry report published in 2011 noted a 2008 research report that said “between 2000 and 2007 alcohol was identified as a factor in 18% of recreational boating fatalities in New Zealand, and was found to have been a contributing factor in 8 fatalities over a 35-month period”. The Commission said “until legislation is made setting limits for and testing of alcohol and other performance impairing substances for recreational and commercial boat drivers, the risk of alcohol-related accidents will be elevated”. It recommended that the Secretary for Transport promote appropriate legislation to set maximum allowable levels of alcohol and other performance impairing substances for persons in charge of recreational and commercial craft, and supporting legislation to allow testing for such levels in these cases.” The recommendation remains open.
05-003: Piper PA34-200T Seneca II, ZK-FMW, controlled flight into terrain, 8 km north-east of Taupo Aerodrome, 2 February 2005. The three occupants of this aircraft died. No obvious cause could be determined. Autopsy reports showed the pilot had consumed cannabis, probably between 12 and 24 hours before the accident. No recommendations were made in this inquiry because as a result the Ministry of Transport formed a Substance Impairment Group charged with scoping the problem and making recommendations to the Minister of Transport.
02-116: Train 533, derailment, Te Wera, 26 July 2002. The train driver was killed and a second crew member injured when the train derailed and plunged down a 12 metre bank. The driver, who drank alcohol before work, lost attention and situational awareness consistent with falling asleep. He was estimated to have had a blood alcohol level above the legal limit for driving road vehicles when he started his shift. The Commission recommended that all rail operators be required to have a policy for managing the risks associated with substance induced performance impairment.