Guest editorial: No repeat accidents... ever!

Lookout! Issue 26, September 2012

An aspirational goal of the Transport Accident Investigation Commission.

‘Yeah right’ I hear you saying, but before you write it off as nonsense, let me explain. This is an aspirational goal of the Transport Accident Investigation Commission (the Commission), rather than one we realistically think we can achieve. It is philosophy we use when analysing what contributed to an occurrence and how we can help prevent it happening again.

‘No-repeat-accidents’ is not something the Commission can achieve on its own. Preventing accidents is a partnership between everyone involved in maritime activities, whether you are a lone recreational kayaker out on the water for a bit of R & R, a commercial operator, an industry organisation, a regulator, or even an international maritime organisation, we all have a part to play.

Never waste a good accident

After a lifetime of recreational boating – 17 years in the merchant navy and five years managing Cook Strait ferry operations – and then 12 years investigating accidents with the Commission, I have seen enough to know that accidents and incidents happen more often than statistics show.

I have seen the same type of accidents happen for the same reasons, but involving different people – particularly frustrating. I also know that accidents and incidents can happen to anyone, regardless of how experienced or how good we think we are.

And if you think mariners are different or special, for better or for worse, think again. The Commission investigates aviation and rail occurrences as well and we have seen the same mistakes repeated across all three modes.

The lessons learnt by one industry are not always passed on to another, maybe because we all think we are a bit special. One of the Commission’s strengths is the ability to apply the lessons across the different modes of transport.

Air-lifting from Rena
Investigators from the Commission and MNZ are air-lifted off Rena.
Maritime New Zealand ©2019

Did you ever wonder why it is a requirement to report all accidents and incidents? It is so that that they can be investigated, analysed and the maximum lessons be learnt and shared with the wider community and industry.

Many mariners at all levels (including myself), are involved in accidents, incidents and near misses of some kind. For the most part we survive with a feeling of relief that it only nearly happened, or a ‘thank god it wasn’t worse’. Others are not so lucky. You as an individual learn from your experiences and are less likely to repeat the same mistake. If it wasn’t too embarrassing, you might even share your experience with your colleagues. If your lesson could be passed on to many others, imagine how many accidents could be prevented.

The Commission is a standing commission of inquiry. Commissions normally preside over bigger events – catastrophes, major accidents and the like, but being a permanent commission gives us more flexibility to deal with emerging or actual safety issues without waiting for the major accident to happen.

We have permanent fully-trained investigators, support staff and three permanent part-time commissioners, who are the decision-makers when it comes to making findings and recommendations. However, the Commission only investigates a small proportion of the occurrences that happen out there. For it to detect an emerging or actual safety issue, the Commission relies on data, and this is where the partnership is important.

I have often had it put to me that the Commission should be resourced to investigate more accidents and incidents from a safety or ‘no blame’ perspective. While I have never been one to look a gift horse in the mouth, let us consider that for a moment. The Commission is part of a wider system. There are many players in the maritime industry that have a responsibility for investigating accidents and incidents. I mentioned some of them above.

You, the person involved in an occurrence, are the best investigator. More often than not you know what happened and you know why. You don’t need professional investigators to tell you that. Commercial operators are required by maritime law to investigate occurrences in their own operation. They should want to do that so that it doesn’t happen again, because accidents are expensive. They can cost lives and result in damage to marine craft and infrastructure, and to the environment.

If mariners were to feed all of those lessons in to MNZ, it would be able to regulate more effectively and be in a good position to share the lessons with the wider community. It will be able to detect emerging issues before they become a big problem. In an ideal world there would not be any need for the Commission to exist. But the world is not ideal and the Commission provides other functions as well. It helps meet New Zealand’s obligations under the International Maritime Organization conventions to provide independent accident investigations into serious casualties. The Commission also provides a ‘health check’ on the system for government and the general public.

Because the Commission is an independent Crown entity, it is able to provide an independent overview of the maritime system. When the Commission investigates an occurrence it looks at the wider systemic issues, because they are often found to have contributed to an accident. This could also mean the performance of the regulator.

MNZ controls ‘entry’ into the maritime system, which means that it might also on occasions ‘exit’ an individual or organisation from the system. Yes, like it or not there are rules and guidelines that should be adhered to. They are necessary for ensuring appropriate standards are maintained. They are there to keep the system safe – to keep us safe. The Commission will often test the appropriateness of these rules because bad, unworkable or out-dated rules have been known to contribute to accidents.

MNZ might decide to conduct its own ‘parallel’ investigation into an occurrence that the Commission is investigating. This is not a duplication of effort. The two investigations have a different purpose. MNZ might be carrying out its statutory function of testing for compliance issues, whereas the Commission’s purpose is to investigate independently, to see if there are any implications for transport safety, rather than to ascribe blame.

These parallel investigations are managed through a memorandum of understanding between our respective organisations to ensure that the needs of each investigation are not compromised. So do not be surprised if you see MNZ investigators working alongside our own at an accident site. However, there are strict provisions in the Transport Accident Investigation Commission Act preventing disclosure of certain information gathered by the Commission. Without going into too much detail, an example is witness statements provided to the Commission. These are protected from disclosure so that people can talk to us freely and frankly without fear of reprisal.

Moving on up the line, accident reports are submitted by New Zealand to the International Maritime Organization so that the lessons can be included in the international database. Lessons from other countries’ accident reports can be drawn from that same database to be used to better the New Zealand maritime industry.

So the ‘partnership’ is important. It helps to keep us all safe. No matter what part you play in the maritime industry, sharing the Commission’s goal of ‘no repeat accidents… ever!’ can only be a good thing. The more that we share this goal, the closer we can all come to achieving it.

Tim Burfoot, Chief Investigator of Accidents
Transport Accident Investigation Commission

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