Report on fatal accident shows Transport Agency failed to prioritize safety

Tuesday, 12 February 2019

Transport Agency culture did not support staff to take robust enforcement when it was patently needed, according to an independent report into a fatal accident where a seat belt failed,

The Transport Agency's approach to safety was heavily criticised in an independent report into its oversight of a Northland garage issuing substandard warrants of fitness.

Dargaville Diesel Services (DDS) had warranted a vehicle on that crashed into a ditch less than a month later leaving front seat passenger William Ball with fatal injuries suffered when his seat belt failed.

QC Kristy McDonald was commissioned to investigate the incident and her report describes the agency's regulatory approach as 'flawed.'

She said the agency visited DDS 14 times over seven years and found it was not complying with standards on 11 of those visits, including a failure to properly check steering, brakes, lights and seat belts.

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In December 2017, just weeks before the fatal accident, a DDS employee admitted to an agency officer that when he was 'familiar' with a vehicle, he would issue a warrant without fully inspecting it.

The agency had also received seven complaints about DDS' inadequate inspection practices.

Despite this, no action was taken other than scheduling a follow up visit for March 2018, the garage and its inspectors were rated as 'compliant' in June, and only suspended from issuing warrants eight months after the crash.

A police investigation found the vehicle concerned had frayed seatbelts and corrosion to a pillar, problems which were highly likely to have been present when it received a warrant from DDS.

Sub standard WOFs have included a failure to properly check seat belts.(File photo)

In its dealings with the garage the agency had not prioritised public safety, McDonald said and the case was an example of wider systemic failures within the organisation that had existed for some time.

Organisations and inspectors licensed to do vehicle safety checks were treated as 'customers' and education was prioritised ahead of strong regulatory oversight.

She noted that front line agency staff acted in accordance with instructions from their superiors and management, and the agency's culture did not support them to take robust enforcement action when it was patently needed.

Performance reviews required staff to visit a certifier up to four times before compliance action could be taken, even when urgent safety concerns were identified.

'I was told that for a period of time, staff were actively discouraged from bring files forward for decisions.'

Appointments of inspecting organisations and vehicle inspectors were routinely rolled over every three years with no requirement for them to formally seek reappointment and satisfy the agency they met the required standards.

'Poor performers must be regulated to protect the public,' said McDonald who recommended the transport agency 'return to first principles' and focus on public safety.

In releasing the report board chairman Michael Stiassny said that the findings confirmed grave concerns regarding the efficacy of agency's regulatory approach.

'I am deeply saddened that Mr Ball tragically lost his life when the Transport Agency's regulatory function was not focused on public safety.'

Regrettably, the findings came as no surprise, but they clearly illustrated issues with all parts of the regulatory system and 10 of the 25 recommendations made by McDonald had been fully or partially implemented, Stiassny said.

Law firm Meredith Connell was appointed last September to review 850 outstanding agency compliance files and oversee a complete revamp of its regulatory work.

Almost 2000 vehicle owners who had obtained warrants through the Dargaville garage were urged to get them rechecked and a national clamp down on vehicle testing followed with suspensions of more than a dozen vehicle inspectors.

That led to nearly 25,000 vehicles being recalled because of concerns they may not have received proper checks of basics such as brakes, seat belts and tyres.

As of early February just under 7500 motorists had taken up the agency's offer of a free warrant inspection and about 60 per cent failed their first retest.

More than 300 Christchurch buses recently needed their brakes checked after it was revealed that VTNZ had not completed all the required tests on them.