If you look around the aviation world you find a strange phenomenon: many of us pore over accident reports like ghouls. Indeed in places like Australia the authorities publish what is jokingly known as the "Crash Comic". I you look over here at Aviatrix you will find that she not infrequently talks about the results of crash investigations. I'm a sometimes compulsive reader of both aviation and marine accident investigation reports.
The reason for all this interest is to understand what happened and to ensure that it never happens to us! Accident investigation has also been useful in pointing the way for aviation safety. For instance the focus on human factors, CRM and the like was born out of a growing understanding that it was the human in the cockpit who was the weak link in many occurrences.
Most countries have an organisation that is mandated by legislation to carry out the investigation and reporting function. Increasingly in recent years these organisations have moved to having multi-modal responsibility, rather than just aviation.
New Zealand has the Transport Accident Investigation Commission to do this work. As TAIC's name suggests it had multi-modal responsibility. It's purpose (according to its Statement of Intent 2009-2012) is:
The Commission’s purpose, as set out in its Act, is to determine the circumstances and causes of aviation, rail and maritime accidents and incidents to avoid similar occurrences in the future.
What it doesn't mention in that purpose, and indeed anywhere else I can find is the most important word "timely". I don't know whether this is chicken or egg: either the Commission doesn't mention timely because it is not part of its brief (and it should be); or it doesn't mention timely because it would be embarrassing. And embarrassed the Commission should be.
New Zealand has a small population, estimated at just over 4 million last year by the CIA. The TAIC has currently 49 accident investigations for which it has not yet published a report. Some of those date back to 2005. As far as I can determine it published only one aviation accident report in 2008 and none so far this year.
It's no use reporting on accidents years after they happen. Mainly because the "same" accident could happen again, and maybe again whilst we are waiting for the report. Accident investigation and reporting is time consuming and often cannot be rushed. However it does not appear as if the TAIC has even subscribed to the increasingly common approach of publishing an "interim factual report" 1 month after the accident. Australia, the UK and the US all seem to be doing this now. At least it gives us something to go on.
Number 35 on the TAIC's list of accidents under investigation is the accident that killed my cousin. On 17 February 2008 he was killed when the aircraft he was flying collided in mid-air with a helicopter. Both occupants of the helicopter were also killed. My cousin was 17 years old.
The TAIC has slipped the date that it says it will deliver the accident report at least 3 times that I know of. His grandmother expected to have a report in March of this year. No report. Indeed this morning the Commission's website says:
Report unlikely to be completed before: Aug 2009Well they're at least right about something, given that it's now September 6.
Why can't the TAIC get off its backside and clear its backlog? Maybe it lacks the staff, maybe it lacks the will, maybe it lacks the management capability that it needs to lead a decent response. I have no idea. What I do know is that it's about time it got on with its job in a timely way for the sake of all of the people who might be affected, the families, the pilots and mariners and train drivers and not least the travelling public.
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