1. INCIDENT & ACCIDENT INVESTIGATION – OPERATORS’ PERSPECTIVE
PRESENTED BY f. A. OPOT

2. background Safety Concerns:
Initial technological inadequacy – resulted in poor designs, which demanded modifications and improvements;
Accidents / Incidents – when they resulted in loss of limb and life and involved cross-border operations it became a serious CONCERN.
A solution had to be found.
Loss of control as a result of the gusting wind

3. Evolution of safety management
The reactive method responds to the events that have already happened, such as incidents and accidents.
The proactive method looks actively for the identification of safety risks through the analysis of the organization’s activities based upon the belief that system failures can be minimized by:
Identifying safety risks within the system before it fails;
Taking the necessary actions to reduce such safety risks.

4. Evolution of safety management
The predictive method captures system performance as it happens in real-time normal operations based on the belief that safety management is best accomplished by aggressively seeking information from a variety of sources, which may predict emerging safety risks.
Maintenance reliability program;
Engine condition monitoring;
Flight Operations Quality Assurance (FOQA) or Flight Data Monitoring and Analysis.

5. INVESTIGATION AS A TOOL FOR SAFETY
Most appropriate for serious incidents and/or accidents:
events caused by errors and violations (CFIT, Runway Incursion, Incorrect Rigging, Use of bogus parts, Restricted airspace);
situations involving failures in technology (Engine failure, Landing gear failure, Pressurization failure); or
unusual events (Airframe icing, Sand storm, Contaminated runway surface).

6. Over-running the runway during take-off

7. INVESTIGATION (cont.)
In order to minimize the number of and severity of accidents, the process of investigation must ensure that:
The sole objective of the investigation is for the prevention of similar occurrences and not to apportion blame or liability.
The report must be precise, and whilst not always conclusive, must nevertheless bring out the salient factors.
Although the report is not expected to be an aid to litigation, it must however be factual, avoid conjecture, guess work, and be able to stand the test of probity.

8. IMPEDIMENTS TO INVESTIGATION
Bureaucracy:
Often the local Authority or the Investigation Branch would invoke regulations;
Access to wreckage and / or records may be restricted (especially in foreign jurisdictions);
The official investigation is at times shoddy (may not focus on relevant safety concerns);
The official investigation report may take long to come out.

9. Landing on a marginal airstrip

10. Impediments (cont.) Resources
Trained manpower (Team should comprise of at least one trained investigator);
Equipment (Camera, Measuring tape, Magnifying glass, Magnetic compass, Note pad);
Time (Possible repeat visit to site / wreckage, may involve liaison with OEM, other expert organizations e.g. laboratories, data retrieval etc.).
Accident investigation process may be quite an expensive exercise.

11. Impediments (cont.) Conflict of interest:
In case of errors or violations (report? Insurance liabilities?)
When interviewing witnesses i.e. crew can be sensitive, hostile or tricky;
If not handled with tact, investigation can be misunderstood and can be counter-productive to the spirit of safety management

12. How to proceed
Occurrence investigation is the responsibility of the Safety Department – Yes and No;
The investigation should be the duty of the concerned AOC holder or AMO – True;
The Safety Manager should be part of the investigation team – True.

13. How to proceed
The Safety Manager should decide whether incident /accident is:
likely to have been due to operational circumstances;
possibly due to maintenance related circumstances;
Either case will have a human factors element (critical) and this should determine the investigation team to be formed.

14. If involved in the resulting investigation…
document each stage however minor;
photographic evidence would be invaluable;
Incorporate appropriate experts e.g. flight data analysis (pilots), system or structural failure (engineers), flight following (dispatchers).

15. Investigation report
The standard report format as given in Annex 13 of ISARPs is recommended as it would ensure that all aspects have been considered during the investigation. So we do not lose sight of the purpose of investigation – to arrive at safety recommendations that would prevent similar recurrence in future.
Most accidents have their cause associated with human factors;

16. Investigation report
The Safety Manager who would be the custodian of the report, shall present its findings and safety recommendations to the Accountable Manager to be approved by the SRB for action.
The process of safety assurance shall confirm the effectivity of the mitigation taken.

17. conclusion
Incidents should be investigated and causes should be identified to prevent similar recurrence;
It is advisable to run a parallel accident investigation (along the official one) so as to finalize in good time in order to arrive at safety recommendations;
The resulting safety recommendations, which if arrived at objectively would be a valuable learning process.

18. END.
Q / A?