The Transport Agency's handling of a Northland garage that issued a warrant of fitness to an unsafe car reflected wider systemic failures within the organisation, an independent report has found.
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William Ball, 65, died from injuries sustained when his seatbelt failed and he hit the windscreen in a crash near Dargaville in January 2018.
Less than a month earlier it had been issued a warrant by Dargaville Diesel Specialists.
Police officers found the front passenger seatbelt Mr Ball was using was frayed. The front A pillars were also corroded. It was "highly likely" these faults were present when the car was inspected.
An independent investigation, headed by Kristy McDonald, QC was set up and was released today. It found a raft of weaknesses and made 25 recommendations.
She found the agency had a "very low threshold" garages had to meet to continue to be allowed to issue warrants, and the agency did not regularly assess them.
The agency "does not prioritise rigourous regulatory action and does not support staff to take robust enforcement when it is patently needed", it said.
In the Dargaville case, compliance officers found faults in 11 out of 14 visits to the garage between 2010 and 2017.
These faults included:
- Failing to check vehicle steering thoroughly
- Failing to properly use a beam setter to check lights
- Failing to check brakes thoroughly
- Not picking up seatbelt faults
An inspector at the garage told the agency that "occasionally, when he was 'familiar' with a vehicle, he would issue a WOF without fully inspecting it".
The garage's remit to keep doing WOFs was rolled over year-on-year "with no regulatory action taken beyond issuing the infraction letters" - six infraction letters and one serious infraction letter over the years.
It finally had its remit totally revoked only last month.
Ms McDonald has found the agency had "no meaningful way" to make problems cases a priority.
The agency adopted a strategy in 2014 of seeing garages - or inspection organisations - primarily as "customers" that it served, which was "not consistent with public safety".
Some agency staff told Ms McDonald that garages in their region had not received any performance reviews since vehicle licencing reforms in 2014 "due to a lack of resource" - though in the Dargaville case there were plenty of reviews, just lack of sanctions.
Ten of the 25 recommendations had been partly or fully implemented, the agency's chair Michael Stiassny said in a statement.
"I am deeply saddened that Mr Ball tragically lost his life when the Transport Agency's regulatory function was not focused on public safety," he said.
The report did not specifically address accountability, but gave clear examples of systems, processes and actions that were significantly lacking, and noted that frontline staff acted in accordance with instructions from their superiors and management, he said.
Past reviews of the Transport Agency did not pick up these failings.
The April 2018 Performance Improvement Framework written by two highly-placed independent reviewers said the agency was "well-placed" in regulating safety rules.
Part of the agency overhaul has seen the number of top executives reporting directly to the new acting chief executive cut from 18 to 12.