A holistic approach to aircraft accident/incident investigation
Liberty University
AVIA 409 - Safety Management Systems
Professor: Andrew Walton
2022
Introduction
The goal of any non-blame aircraft accident or incident investigation is to identify the safety issues
early so that actions can take place to prevent recurrence. In a bid to maintain independence, some
State investigation authorities will exclude other stakeholders from the analysis discussions of the
factual evidence. With increasingly technically complex investigations, this can result in important safety
issues not being addressed in a timely manner.
This paper describes a holistic approach, used successfully by the AAIB in a number of significant
aircraft accident/incident investigations, where the stakeholders are encouraged to be involved in the
investigation, but in a way that does not conflict with the independence of the State investigating
authority. The approach has demonstrated to result in timely resolution of safety issues early in the
investigation. With a holistic approach, each stakeholder is very much part of the analysis, as well
as the gathering, of factual evidence. The investigating State’s investigators take the lead and determine
the direction of the investigation, thereby maintaining the independence. However, this is an iterative
approach, with analysis being conducted as the facts are gathered. This allows for early scoping and
focus of the investigation on the important safety issues and makes the most efficient use of resources
available.
Rather than a fixed set of groups, the initial groups develop as information about the accident
become
known, with some groups only having a short life. To maximise resource multiple groups may also be
chaired by the same investigator by the SIA, and indeed participants maybe included as part of multiple
groups too. Having gathered the facts they are then analysed by the “investigation team” which includes
the Accredited representatives, advisors and parties to the investigation, and not group by group – but
across groups. This holistic approach is to ensure that each group is aware of the factual evidence
gathered by the other groups.
During the analysis of the facts are three possible outputs:
1. The definition of the further scope and focus of the investigation, which includes the assignment of
more resource, the reallocation of the existing resource, the closing down of groups that no longer serve
a purpose and the release of resource for other investigations.
2. Identification of safety issues and the encouragement of safety action by the relevant participants.
Indeed, it is also at this stage the possibility of reporting on the identified safety issues may be relevant,
through interim reports or statements.
3. Comparison of the findings determined by the factual evidence. Concurrence indicates that the
finding has been agreed and can be concluded as a finding by the investigation in the report and maybe
reported in an interim report. Differences of opinion amongst the investigation team indicates either
there is not enough evidence and therefore further facts, research or testing is required to substantiate
or refute the position. There is also the possibility that there is some doubt about the findings from
the factual evidence that has been gathered. The SIA, who are conducting the investigation, will
determine the findings, to be reported to maintain the independent nature of accident investigation.
However, having identified this difference of opinion, this can now be taken forward and if not resolved,
may be objectively be presented in the final report.
The process is iterative, with facts being analysed as the investigation progresses. Having completed the
process and reached a stage at which the required factual evidence has been gathered. The draft final
report is produced by the SIA using the agreed findings, the report will also include the findings that
have been determined by the SIA but may not be full agreed on amongst the participants. However, as
the report will also include these valid differences of opinion on the analysis and the reasons for these,
then the report is balanced.
Benefits of the approach
The main benefit of the approach is that parties to an investigation who have the power to carry out
safety action are fully engaged with the investigation including not only the factual evidence as it is
gathered, but also the analysis of the facts, so they become aware of the safety issues at an early stage.
Indeed, the parties may also highlight safety deficiencies that require further research that may have
otherwise been missed by the investigation teams. This means that regulators for example are
able to issue mandatory action early and with the full agreement of the investigation team, rather than
waiting for the factual evidence to be presented in a report or safety recommendation. Indeed, at the
AAIB our philosophy is now moving toward encouraging proactive safety action taken when the facts are
known, rather than the reactive action following a Safety Recommendation, which could be several
years after the accident. This proactive approach means that rather than issuing Safety
Recommendations which have no indication of whether they will be adopted or not, reporting on Safety
Action that has taken place means the reader understands that safety has in fact been improved based
on the factual evidence.
With a focused holistic approach, only those areas which have a safety benefit are carried forward
into a full analysis for the identification of safety issues. This means the report is more focused and
doesn’t stray into reporting factual details on areas that had no bearing on the accident/incident.
Another advantage is that there is an efficient use of the resources available to the investigation team,
with the focus primarily on the main safety issues that caused or contributed to the accident.
As the parties to the investigation have been involved from the beginning, the investigating SIA
becomes aware of areas of potential conflict/controversy early on. This enables the SIA to understand
the reason why such a conflict/controversy exists and to acknowledge this. There will always be cases
where a participant will try to influence the content of the report with conclusions which are not based
on the factual evidence, this process identifies these early, such that they are dealt with at an early
stage and not when the report is about to be published.
The involvement of all parties during analysis discussions can mean that it remains balanced and is
not biased toward one point of view, and is verified by the inclusion of the regulator and other
specialists. Only those conclusions which are validated by the factual evidence should be reported, but
there maybe differences of opinion of the established facts. The SIA can then incorporate those valid
areas of differences of opinion in the main report to balance the views of other parties. The advantage is
it is then less likely that the other States to the investigation will criticise the report and request the
appending of substantiating comments to the report. The appending of comments only detracts from
the aim of the investigation which is the timely promulgation of safety information.
Indeed, the holistic approach allows for full and free discussion of the issues and open dialogue
following the formal consultation phase. Also, at this stage a rapport has built up amongst the
investigation team and the parties, which has shown to lead to more open dialogue than would
otherwise have taken place.
Maintaining independence
Although the holistic approach encourages full engagement with parties to the investigation, it is
still important that the investigating SIA maintains its independence from the other participants and also
to remain objective. Indeed, certain parties will have their own perspectives, cultural differences and
agendas for an investigation and will attempt to influence its direction. However, the holistic approach
should identify these early in the investigation as the parties are fully engaged from the start. Indeed, in
our experience this approach highlights areas of contention at an early stage and allows for the
investigation to deal with these during the investigation process, rather than at the end when the final
report is being drafted.
It is the function of the IIC to make sure that no one party has a strong influence on the direction of
the investigation and to make sure the viewpoints of all are taken into consideration. The IIC should also
be able to identify when a certain party may have over stepped the mark and take necessary action,
which could include expulsion from the investigation process.
The final word will always remain with the investigation SIA and they should reserve the right to
exclude parties to the investigation or indeed to manage the relationships to avoid would could be
destructive conflict. It is the skill of a good investigator to know when they are being misled or not being
given the answers they need to further the investigation. It always remains that the investigating SIA can
produce recommendations for safety action, even if this is not in agreement with the other parties,
should they feel it is necessary for continued aviation safety.
Confidentiality
For a holistic approach it is important that the participants maintain confidentiality of the information
and the analysis discussions. Care still needs to be taken with regard to the information flow, as certain
information may be protected from disclosure by local regulations and may not be shared outside of the
direct investigation team, and so at times advisors and observers may have to be excluded from certain
discussions.
However, they are likely to receive a summary of these areas, provided it is permissible within the
regulations. Should confidentiality be breached, either by leaks or by the unapproved release of
investigation information the trust between the parties also breaks down. This results in the
investigation participants becoming insular and the sharing of information effectively dries up or is
carefully scrutinised before its release to the other parties. This then leads to further delays as the
information flow disappears, and at worst the needed expertise could be removed.
The result of this is to slow down the investigation process and lead to delays in identifying the safety
issues and thereby reducing the timeliness of safety action. A situation that is detrimental not only the
investigation process, but the aims of the investigation not only for the investigation team but the other
participants.
