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Accident Investigation in an Age of SMS

Safety is no accident,” the saying goes, and even if it’s a play on words, it’s a true statement. Safety is hard work. Part of the hard work of aviation safety is accident investigation. This forensic activity is all about history – the who, what, when, where, why and how something happened. It’s a noble undertaking, and has led to dramatic advances in aviation safety. And, like all facets of aviation, it is continually changing.


March 23, 2009
By Hooper Harris

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In Canada, the Transportation Safety Board is responsible for accident investigations. (Photo courtesy of the Transportation Safety Board)


 

Safety is no accident,” the saying goes, and even if it’s a play on words, it’s a true statement. Safety is hard work.

Part of the hard work of aviation safety is accident investigation. This forensic activity is all about history – the who, what, when, where, why and how something happened. It’s a noble undertaking, and has led to dramatic advances in aviation safety. And, like all facets of aviation, it is continually changing.

From the beginning, forensic accident investigation has led to many of our most effective safety initiatives. Some use the term “fix and fly” to describe this function. Basically, the phrase means we flew until a problem emerged, usually discovered in an accident or incident investigation, and fixed that problem. Then back to flying, looking for the next problem area by waiting for the next accident. It sounds fatalistic, but in the early days of aviation, that’s exactly how many changes were made.  

As we advanced, we codified the “fixes,” things like design requirements, flying techniques, and air traffic procedures in rules, regulations, orders and advisory materials. Actually, a lot of what you find in today’s aviation system is the product of accident and incident investigation and the “fix and fly” method.  It really served us well, but it has its limits.
If we are to really improve the safety of flight operations, to move beyond our current state, we have to move beyond reactive fixes. We need to identify safety shortfalls before accidents and incidents occur. That’s the basic idea behind a safety management system, or SMS. With the four pillars of Safety Risk Management, Safety Assurance, Safety Policy and Safety Promotion, SMS gives a foundation to leverage the forensic accident and incident investigation work with analysis and modeling to identify emerging hazards and assess their risks. 

Safety can be viewed from many perspectives. Safety makes air transportation attractive to customers, and it reduces costs. Safety makes sense from a business standpoint. The costs of an accident or serious incident are huge. Not only is there the direct cost of the loss of the aircraft and the first-tier liabilities to survivors and others affected, lost revenues from aircraft and crews no longer in service, loss of customer confidence, productivity and employee morale can easily exceed the direct monetary losses. And history has shown that access to landing facilities may be curtailed or even closed if the local attitude toward helicopter operations turns from support to fear. Accidents cost lives, destroy valuable equipment, and can mean the difference between success and failure of a commercial aviation venture. Investment in safety is an investment in the future. 

But there is a more important reason for safety – it’s the moral thing. Flying is one of the few activities in which people routinely put their lives in the hands of other people they do not know, in an environment they little understand. While they are under our care, we owe these passengers and their families our very best protection from the hazards of flight.

You may have heard of something called a safety culture. It’s a term that is used, but sometimes not well understood. One of the earliest uses if the phrase I have found comes from the International Nuclear Safety Advisory Group’s 1988 report on the Chernobyl accident. With apologies to the Group for inserting “aviation” for “nuclear power plant,” they described a safety culture as, “That assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, aviation safety issues receive the attention warranted by their significance.” 

One of the foundational aspects of a safety culture is the vigorous investigation of accidents and incidents.  From that investigation, previously unknown hazards can be revealed, risks can be understood, and mitigations devised. Investigation is at the very heart of safety.

Not all states manage accident investigation the same way, by any means. Some states have limited investigation resources, and may very well be willing to delegate major accidents to another state with more capability. Other states may place aircraft accident investigation under the authority of the judicial system, or the military. These differences can offer challenges to investigators as they ply their trade around the world, as well as operators who suffer accidents in those jurisdictions. Annex 13 (see sidebar) is clear: unless delegated, the state of occurrence leads the investigation.

The purpose of an accident investigation is to learn how to avoid similar events in the future. The outcome of an investigation typically is a set of recommendations. In the U.S. these typically are issued by the National Transportation Safety Board, the Annex 13 safety investigative body for the U.S., to the regulating agency, the Federal Aviation Administration (FAA). These recommendations, as well as internal FAA recommendations based on the nine factors, are often the foundation for safety improvements we see in standards, procedures, techniques, and regulations.  Accident investigation is an integral part of maintaining and improving safety in the aviation industry, especially when leveraged by an effective SMS.
  
Ultimately, accident investigation is about studying the past. And as George Santayana wrote, “Those who cannot remember the past are condemned to repeat it.”  It is the air safety investigator who ensures we do not forget, because, in the case of an accident, all of us do not want to repeat.


Hooper Harris is acting Director of the U.S. Federal Aviation Administration’s Office of Accident Investigation.


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