independent investigation how it works in aviation

Cranfield Safety and Accident Investigation Centre

Independent Investigation

How it works in aviation

Prof Graham Braithwaite

Aviation

• High-reliability organisations

• Mature process

• Trusted system

• Variation in quality (worldwide)

• Threat of criminalisation


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



Technical stakeholders

• Regulatory / Government• Operators / Infrastructure providers• Other accident investigation agencies• Manufacturers• Maintainers• ICAO• Training providers• Other operators


Non-technical stakeholders

• Insurers

• Those involved

• Families / relatives

• News media

• Emergency responders

• Traveling public

• Third parties


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 13AIRCRAFT ACCIDENT

AND INCIDENTINVESTIGATION



EUROPEAN COUNCIL DIRECTIVE94/56/EC

EUROPEAN COUNCIL DIRECTIVE94/56/EC

NATIONAL ACCIDENTS & INCIDENTS INVESTIGATION

LEGISLATION


LEGISLATION

Aviation legal framework


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)


(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.”


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





EUROPEAN COUNCIL REGULATION2010

EUROPEAN COUNCIL REGULATION2010


LEGISLATION


LEGISLATION

Aviation legal framework

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 families10

No blame investigations

• Positives • Trust• Quality of information

• Negatives• Absolution

• Just culture?• Justice?


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.


Appropriate criminal investigations

• Suspected• malicious actions• sabotage• terrorism• corporate manslaughter



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

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.”


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.



Safety recommendation systems

Some cautions

• “We are different”

• Experience versus training

• Cultural change

• Purpose of investigation



Thank you

Professor Graham Braithwaite

Tel. +44 1234 754252

Email. [email protected]

Web. www.csaic.net

independent investigation how it works in aviation

Documents

investigation body

aircraft accident

accident preventionto

ukcranfield safety

permanent civil body

incidents regulation

prevention of accidents

inteu aviation directive