Process Review by Sofema Aviation Services www.sassofia.com
What is the Investigation Process?
For a variety of reasons it is important that we ensure a methodical approach to the process of accident investigation – to ensure that we preclude as far as possible the chance of missing something. Moreover to make sure we have a document audit trail of the timeline which may become critically important later on in the process.
The entire investigation process is Data Driven with the entire process being best considered in the following terms.
Investigation of accidents consists of three distinct phases
1/ Data Collection (Including Physical, Documentation & Photographic)
2/ Analysis of Data
3/ Presentation of Findings
What Does ICAO Say?
Accident investigation is a systematic process whereby all of the possible causes of an adverse event are evaluated and eliminated until the remaining causes are identified as applicable to that investigation. Furthermore, during the investigation, if other deficiencies are identified that were not part of this accident, the investigation team should note them and provide this information to the applicable authority, even though it may not become part of the official investigation report.
Although many accidents appear to be similar to others, this may be misleading. Therefore, it is imperative that investigators keep an open mind so as not to focus on one aspect and thus overlook another.
Because accidents are infrequent, investigators must take every opportunity to obtain training with air carriers, military, aircraft manufacturers and other accident investigators so as to retain currency and acquire the best methods for investigation.
Many large air carriers and aircraft manufacturers have established accident investigation resources that should be consulted in support of periodic training.
Air carriers and aerodromes conduct periodic emergency exercises, and these also provide an opportunity for the accident investigators to utilize these scenarios for training.
In the event of an actual accident or serious incident, these relationships will be useful to the investigators in efficiently determining the causes.
Is Accident Investigation an Art or a Science?
So actually it may be considered as both
For example consider the need for laboratory testing of materials, failure modes, sample analysis, etc. without doubt these are all scientific processes that provide useable data.
However when we also consider the decision making process related to the selection of the items which we need to be tested which items do we actually choose to test?
Whilst we may want to test everything, the concept of bringing an entire aircraft into a lab will not necessarily reveal much more about WHAT happened to the aircraft and why it was in an accident.
Again we may consider that while a laboratory may discover that a part failed due to fatigue.
However we again come to the why?
So we also need to employ are skills related to the performance of detective work.
Detective work is necessary to determine if the part was correctly designed or not? Manufactured correctly or improperly, maintained improperly, or abused to either start the fatigue crack or allow it to go unnoticed, or worse, noticed but not corrected. (Possibly in this case a connection with competence related to the performance of maintenance)
Once we dip into the detail we will generate a whole raft of additional questions – For example
a) Was it designed or manufactured improperly because of poor staffing, organization, and Quality Control at the manufacturer?
b) Or was there a local maintenance problem with lighting, inadequate equipment, and time constraints?
c) Was there any cultural or behavioural issues in the manufacturing or maintenance organisation?
d) Was there an indifference to quality and standards?
None of the above questions will be answered in a laboratory. It is necessary for the investigator to find out the answers to the WHYs at the source. Interviews, photography, and an eye for detail are just the beginning.
Information regarding Aircraft Accident Investigation Process & Procedures course can be obtained by writing to office@sassofia.com or to review details here
