Does anyone out there know what are the Terms of Reference (TORs) for Accident Investigators - AAIB/NTSB, or even military BOIs?
For example, are they encouraged, from the start of the investigation, to consider the organisational influences upon the accident, as well as the local direct-efffect causes?
An example of Organisational factors would be company ethos or commercial cost impacting on crewing levels, rostering policy, lack of fatigue monitoring, poor training system etc. Whereas, the local factors could be crew mishandling, incorrect procedures, lapses, errors, violations etc?
It would be interesting to know as it has taken years for aviation to get commerce (eg airlines) and the govt to accept that such organisational influences are important in major accidents (eg Chernobyl, Piper Alfa, Zeebrugge, Dryden etc) but has Annex 13 been changed and have individual countries' aviation authorities ammended the TORs for their investigators?