1. Cranfield Safety and Accident Investigation Centre Independent Investigation How it works in aviation Prof Graham Braithwaite

2. Aviation High-reliability organisations Mature process Trusted system Variation in quality (worldwide) Threat of criminalisation Cranfield Safety and Accident Investigation Centre

3. Why investigate? Because we have to Legal / regulatory obligations Moral obligations Because we can learn Accident prevention To allocate responsibility Blame Financial liability Legal liability Cranfield Safety and Accident Investigation Centre

4. Technical stakeholders Regulatory / Government Operators / Infrastructure providers Other accident investigation agencies Manufacturers Maintainers ICAO Training providers Other operators

5. Cranfield Safety and Accident Investigation Centre Non-technical stakeholders Insurers Those involved Families / relatives News media Emergency responders Traveling public Third parties

6. Cranfield Safety and Accident Investigation Centre THE CONVENTION ON INTERNATIONAL CIVIL AVIATION (THE CHICAGO CONVENTION) SIGNED BY 190 STATES THE CONVENTION ON INTERNATIONAL CIVIL AVIATION (THE CHICAGO CONVENTION) SIGNED BY 190 STATES ANNEX 13 AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION ANNEX 13 AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION EUROPEAN COUNCIL DIRECTIVE 94/56/EC EUROPEAN COUNCIL DIRECTIVE 94/56/EC NATIONAL ACCIDENTS & INCIDENTS INVESTIGATION LEGISLATION NATIONAL ACCIDENTS & INCIDENTS INVESTIGATION LEGISLATION Aviation legal framework

7. Cranfield Safety and Accident Investigation Centre Purpose of accident investigation “ The sole objective of the investigation of an accident or a serious incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.” Annex 13 to the Chicago Convention (ICAO) EU Directive 94/56/EC Civil Aviation (Investigation of Air Accidents and Incidents) Regulation 1996 (UK)

8. Cranfield Safety and Accident Investigation Centre (www.europa.eu.int/) EU Aviation Directive 94/56/EC Article 6 (1) - Investigating body or entity: “Each Member State shall ensure that technical investigations are conducted or supervised by a permanent civil body or entity. The body or entity concerned shall be functionally independent in particular of the national aviation authorities responsible for airworthiness, certification, flight operation and, in general, of any other party whose interests could conflict with the task entrusted to the investigation body or entity.”

9. Cranfield Safety and Accident Investigation Centre THE CONVENTION ON INTERNATIONAL CIVIL AVIATION (THE CHICAGO CONVENTION) SIGNED BY 190 STATES THE CONVENTION ON INTERNATIONAL CIVIL AVIATION (THE CHICAGO CONVENTION) SIGNED BY 190 STATES ANNEX 13 AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION ANNEX 13 AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION EUROPEAN COUNCIL REGULATION 2010 EUROPEAN COUNCIL REGULATION 2010 NATIONAL ACCIDENTS & INCIDENTS INVESTIGATION LEGISLATION NATIONAL ACCIDENTS & INCIDENTS INVESTIGATION LEGISLATION Aviation legal framework

10. New European regulation Independence of investigation Free from pressure of regulatory authorities Protection of key evidence sources Witnesses Data recorders Unless there is an overriding reason for disclosure… Information for victim’s families 10

11. No blame investigations Positives Trust Quality of information Negatives Absolution Just culture? Justice? Cranfield Safety and Accident Investigation Centre

12. Independence Functional independence from regulator Independence from industry For… Gathering, recording and analysis of all available information on that accident or incident Determination of the causes Issuance of safety recommendations Completion of the final report Not out of contact from industry, regulator etc. Cranfield Safety and Accident Investigation Centre

13. Appropriate criminal investigations Suspected malicious actions sabotage terrorism corporate manslaughter Cranfield Safety and Accident Investigation Centre

14. The Police and transport accident investigation Primacy for safety investigation agencies - except in cases of deliberate criminality Evidence gathered to highest / Police standards Certain evidence protected

15. MOU with Crown Prosecution Service Established October 2008 “The aim is to ensure effective investigation and decision making processes while maintaining the independence of all parties and reinforcing the role of the AIBs as the guardians of public safety when investigating transport accidents and incident.” Cranfield Safety and Accident Investigation Centre

16. Basic principles of co-operation All evidence and factual information, except where there are specific legislative bars, can be disclosed between the AIBs and the CPS. The AIBs will not share their own opinions or analysis. The public interest requires that safety considerations are of paramount importance, the consequence of which may mean that the interests of an AIB investigation have to take precedence over the criminal investigation. The ability of witnesses to be able to talk openly to an accident investigator is fundamental to the operation of the AIBs. AIBs will provide a pre-publication copy of the finalised AIB report to the CPS if it is made aware of a CPS interest. The CPS may make comments to the AIB about the report before publication. Cranfield Safety and Accident Investigation Centre

17. Safety recommendation systems

18. Some cautions “We are different” Experience versus training Cultural change Purpose of investigation Cranfield Safety and Accident Investigation Centre

19. Thank you Professor Graham Braithwaite Tel. +44 1234 754252 Email. G.R.Braithwaite@cranfield.ac.uk Web. www.csaic.net