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Independent Investigation How it works in aviation

Independent Investigation How it works in aviation. Prof Graham Braithwaite. Cranfield Safety and Accident Investigation Centre. Aviation. High-reliability organisations Mature process Trusted system Variation in quality (worldwide) Threat of criminalisation.

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Independent Investigation How it works in aviation

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

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

  3. Cranfield Safety and Accident Investigation Centre 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

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

  7. 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) Cranfield Safety and Accident Investigation Centre

  8. 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.” (www.europa.eu.int/) Cranfield Safety and Accident Investigation Centre

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

  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

  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 Cranfield Safety and Accident Investigation Centre

  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 Cranfield Safety and Accident Investigation Centre

  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 Cranfield Safety and Accident Investigation Centre

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