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Lack of references in official accident reports

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Lack of references in official accident reports

Old 24th Nov 2019, 18:12
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Lack of references in official accident reports

I'm not specifically singling any body out here, but professionally or for my own education I read a great many accident reports - from AAIB, NTSB, MAAIB, ATSB, AAUI and so-on. Whilst some aspects may be unsatisfactory, generally they are all professional work that lead, as they should, to a set of recommendations aimed at preventing future accidents.

It must be well understood by the reports authors that many other people will read and analyse their work. Expert witnesses, academics, people in the authorities, insurers, and so-on. It isn't of-course the full time investigators jobs to facilitate that, but at the same time they have no reason in most cases to be obstructive.

Which brings me to my gripe. When I read a research paper, or an engineering report nowadays, it is normal - indeed usually considered essential, that it includes citations to the key documents used in the course of that work. My most recent academic journal paper, for example, is 4,400 words with 26 references (on aviation, nothing to do with accidents), whilst my most recent consultancy report (a re-analysis of an accident) contains 10,000 words and change, and 51 references - neither of these are faintly exceptional, it's just how I'm expected to work. Yet virtually no air accident reports, from anywhere in the world, contain a detailed and cited reference list. They may quote from some aircraft manuals or authority advice on something - but even then almost always you don't get the specific reference, issue state and date. This makes any kind of re-analysis, for any reason whatsoever, of official accident investigation reports, far more difficult than - in my opinion - they really should be.

I don't know of any university who is teaching (now) aeronautical engineers anything other than to accurately cite every document they used in their technical work. So are accident investigators living in the dark ages?, or do they do this deliberately because they think that there is some sound reason to conceal this information?

Genghis the Engineer is offline  
Old 24th Nov 2019, 19:34
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Join Date: Jun 2019
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I couldn't agree with you more - I also find this very strange indeed! I don't think it would be cumbersome to read with numerical citations linked to a references section. It would give me a bit more confidence in the rigour being applied at the investigator end.

For example, while I find the AAIB output very good at determining technical aspects (i.e., which bolt was fractured pre-impact), I'm often left with the distinct impression that opinion is being presented as fact when it comes to suggesting aircrew behaviour - while accepting it's a difficult area to establish.
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Old 24th Nov 2019, 21:57
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To be fair to our own AAIB(UK) they usually quote references as footnotes rather than appending a formal References section.
Grummaniser is offline  
Old 24th Nov 2019, 21:59
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I agree. Whilst ICAO Annex 13 is helpful in ensuring that reports follow an internationally accepted protocol, most reports tend to focus on what happened and how it happened, rather than why it happened. Perhaps this is to some extent due to a reluctance to be seen to apportion blame but it does, in my view, restrict the learning opportunities for readers.

A notable exception is the report of the Columbian authorities into the accident to American Airlines 965 at Cali in December 1965: Cali Accident Report

This report with its numerous footnotes referencing research material and its focus on human factors stimulated much of the present thinking around CRM and provoked the production by American Airlines of their seminal video "Children of the Magenta".

If only present day reports were as informative.

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Old 25th Nov 2019, 11:26
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Originally Posted by Grummaniser View Post
To be fair to our own AAIB(UK) they usually quote references as footnotes rather than appending a formal References section.
That caused me to question my logic, so I went to the most recent AAIB full report, on a B737 reduced thrust take-off here: https://www.gov.uk/aaib-reports/airc...gh-21july-2017. It';s a 94 page report, there are about 20 referenced webpages and 6 books, but no aircraft documents at-all. I take your point it's a lot better than historical practice, but with still a lot of room for improvement.

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