Accident investigations and outcomes
 

We've had some detailed exchanges recently which center more on the techniques of accident investigation and how information/evidence is gathered and disseminated, than the specific accident itself. There are some interesting nuances and legalities in this exercise, and this would be a great place to discuss them.....

Good call DAR.

A thought, there are four reasons for an investigation and/or report, which are not mutually exclusive, but are generally produced by different people for different reasons.


(1) The technical investigation, simply so that everybody can learn as much as possible.

(2) The investigation aimed at providing recommendations which will prevent future accidents.

(3) The investigation, generally associated with civil legal proceedings, determining legal / financial liability. In simplistic terms, this is associated with deciding whose insurance will pay out, to whom, and how much.

(4) The criminal investigation - where there is a suspicion of wrongdoing that might attract punishment. It is there to decide if there was a crime, and if so by whom, and what punishment that should attract.


As technically interested aviators, (1) generally interests us most, but in reality there are very few investigations which are totally focussed that way.

AAIB do (2), but a lot of (1) to enable that.

(3) Is to some extent essential, given that most accident involve damage or injury somewhere. Equally however, because it involves money, many people find it morally problematic.

(4) Is the most controversial, and many (including me) would argue usually actively detrimental to aviation safety as people trying to avoid punishment tend not to be very constructive in supporting the learning of safety lessons for everybody else.


We are all bad in PPrune threads at getting the four mixed up!

Prior to flying in Norway last summer, I was introduced to this excellent publication:

http://luftfartstilsynet.no/incoming...202015-Web.pdf

I note that it contains a lot of (1) & (2), and presents the concept of self reporting with insulation from some punishment, so touches in the realm of (4) a bit too.

As I'm sure many do, I find reading accident reports fascinating. I'm not well versed in the civil and criminal aspects of the aftermath (and hoping to prevent getting to know them by first hand experience!)

Genghis

Many civil disputes are, as you say, ultimately disputes between insurance companies but many are not.
Just a couple of examples:
The activity complained about was not covered by insurance.
An insurance company has declined liability because the insured has allegedly breached the terms of the policy. (That may be the subject of a separate dispute between insured and insured, if the insured can afford to commence proceedings to challenge the insurer's decision. ) The exclusions in GA insurance policies are extremely wide but, unlike corporations, private owners have no real choice in practical terms but to accept the standard aviation policy.

Not only, and not necessarily, "people trying to avoid punishment".
It includes people who have done nothing wrong but fear that they may be prosecuted. If they are, it will mean many months at least of worry, perhaps more than a year. Even if they have done nothing wrong, people understandably worry that they might be convicted. No-one can guarantee that they will not be.

They also worry about the costs it would involve - legal advice/representation and engaging an expert to assist.

From time to time over the years I've read posts saying that people who have done nothing wrong have no reason to be worried. That is utter nonsense - very easy to say if it's not you being, or at risk of being, prosecuted.

I agree that many people are.
Not all.

All valid points, although those not mixing the four up occasionally are in a tiny minority (of which I'm certainly not a member).

It has occurred to me that there's a particular aspect to criminal proceedings related to air accidents that whilst probably not unique, is probably relatively unusual in an aviation context. That is the decision about whether a crime has been committed? For example, if somebody has been stabbed down a dark alley and died - it is probably a safe working assumption, in most cases, that a crime was committed. The question for the police and courts is primarily what crime, and by whom?

Where an aeroplane has crashed - whilst in a few obvious cases (Lockerby for example) it's clearcut that there was a crime - in the majority it is the opposite to the dark alley example. The issue is not whodunnit (it was the crew and operator), nor how (that's usually relatively obvious) - but whether what occurred was a crime or not? The legal process seems to handle those questions, but it seems to me to be conceptually a bit different to most criminal cases?


Most importantly however - as you identify, both the fact and the threat of criminal or disciplinary proceedings: or litigation where the recovery goes beyond what's insured, highly problematic from the viewpoint of trying to share lessons towards preventing future accidents. The current EASA framework of "just culture" has if anything moved us more in that problematic direction as well - as it seems partially to have removed the assumption of good intent, which I always found extremely helpful when trying to find ways to prevent future accidents as it meant that people involved in something were (usually) quite open about things, and that attitude seems to be receding somewhat.

A well known example was G-STYX, probably not AAIB's finest hour. The very direct finger pointing by AAIB at certain people and organisations, and the early involvement of CAA's enforcement function, probably put back the implementation of useful safety lessons by 3+ years. This seemed to me then, and now, that a desire in certain quarters to create retribution, was at the root of that and deeply unhelpful to the cause of safety.

Genghis,

G-STYX rang a bell with me, but I couldn't remember the details. However, a quick Google showed me it was the Eastchurch flexwing accident.

I had read the AAIB report but I didn't recall any controversy. Today I found this site:

https://sites.google.com/site/gstyxstory/Home

which is fascinating, but heart-breaking reading.

That is the accident. I was unaware of that website, nor who the author is. Reading a few bits, I don't think that it can be taken as a complete, tested and unbiased account - but equally it shows very well the massive problems caused by the approach taken in various quarters to it.

Genghis
Not as different as you might assume.
The following selection comes immediately to mind but there are many other examples: Dangerous driving, gross negligence manslaughter, rape where the defence is consent, fraud, assaults where the defence is self-defence.
In each, the issue is almost always whether a crime was committed – not 'Whodunnit'.

I fear that what is already a problem may become greater in future.

I agree.
Link to the G-STYX thread: http://www.pprune.org/private-flying...withdrawn.html
Note: It was a police investigation, not CAA enforcement, but that doesn't detract from the points you make.

(Edit) Upon reflection, you may be correct that CAA enforcement was also involved in the investigation. I don't recall them being, but I'm not certain.
The pair whose conduct remains clearly in my mind are the AAIB Inspector and the police officer in charge of the criminal investigation.

The G-STYX thread contains a link to another prosecution: http://www.pprune.org/rotorheads/187...ter-crash.html

The difference in attitude and approach between the AAIB Inspectors in those two cases could not have been more stark. I had great respect for the skill, objectivity and complete impartiality of the (now retired) Inspector who investigated the helicopter case. The G-STYX inspector was unique in my experience.

This stirs a few emotions with me. While I was at Shipdham, I noticed some slight movement on the stabilator of one of our Twincoms. Closer investigation revealed a problem with the two frames that supported the bearings for the stabilator cross tube. A chat with the Piper agents resulted in a complete breakdown of the rear fuselarge and replacement of the two frames. This was completed and signed off. A few weeks later the a/c crashed on circuit in misty conditions, five of the six occupants died. The pilot was a friend. You can imagine the feelings I had. I received a call from the CAA area surveyor, a regular visitor, who told me not to worry as 'my' tail was intact. The threat of prosecution was always a little niggle at the back of ones mind, mainly because the legal mob have their own interests.

In fairness, pilots on a pilot forum could be forgiven for not being entirely conversant in detailed legal matters, as perhaps lawyers on a law forum might slip up a bit if the topic shifts to aviation. Hopefully we (or I guess nearly all of us) can absorb more legal understanding as we go along....

I was not referring to either "detailed legal matters" or lawyers when I made that comment.


The legislative framework for air accident investigations is set out in posts 894 & 904 of the Hunter thread in this forum: http://www.pprune.org/accidents-clos...oreham-23.html

I explained a relatively recent very important Court of Appeal decision regarding the use of AAIB Reports in civil proceedings and the potentially adverse implications for future air accident investigations, and consequently flight safety, in various posts between 1481 and 1513 of the Hunter thread in the Mil Forum: http://www.pprune.org/military-aviat...irshow-75.html

I also summarised in that thread the concerns expressed by the AAIB Chief Inspector.
His concerns are relevant to the topic of this thread and well worth reading: See post 1490


No useful purpose would be served by repeating the background law in this thread.

FL

Though not aviation related, the report of this event

Hillsborough Stadium disaster: Jury finds 96 soccer fans were 'unlawfully killed' - World - CBC News

could be seen to have a parallel to aviation events where harm comes to the public through inadequate planning or execution of safety considerations.

My mistake, I did not understand the reference. I personally found GtE's description helpful and useful, and wanted to show support.

My too broad wording.

I should have written: "FWIW, I could forgive pilots on a pilot forum for not being entirely conversant in detailed legal matters".

I defer to those more qualified than I in legal matters and interpretations in those discussions. And, this is a good place for them!

Not to mention that the confusion between the desire for retribution, the desire in some quarters not to attract blame and retribution, and the need to learn lessons and prevent a recurrence have all tended to be in many ways mutually exclusive.

You probably won't be surprised Step to know that the particular story has filled the British media this week. It's an awful tragedy that has been compounded by poor practices, and been with us for a long time.

"It's an awful tragedy that has been compounded by poor practices"

.....and monumental unlawful deceit.

The irony is that the same brigade are now going about in an attempt to make a criminal matter.

You just couldn't make it up.

Step Turn
If you read the sequence of exchanges you will see that Genghis and I concluded in almost complete agreement.

When I said "Not all" I wasn't referring to lawyers but to the many pilots who understand that there can be, and often is, a conflict between productive air accident investigation and legal proceedings (whether potential or actual). As has been amply demonstrated in the Hunter thread in this forum, there are also many who don't.
In my experience, those pilots who have thought through the issues are more likely to understand the competing interests than most lawyers because most lawyers know little or nothing about air accident investigations and their purpose.

Understanding the problem does not require detailed (or any) knowledge of legal matters, merely common sense.
Human nature is such that people are less likely to be full and frank with the AAIB if they fear that there will or may be repercussions for them. That applies whether or not they have actually done anything wrong.

Genghis Precisely.

Answer: No.
The issue is flight safety.

The answer might be different if asked in a legal forum because different considerations apply but, as has correctly been pointed out, this is an aviation website.
I have answered as a pilot, who also happens to be a lawyer with experience relevant to the topic under discussion.

CHIRP and AAIB:
There is a big difference between taking the initiative to report an incident to CHIRP and assisting an AAIB investigation when approached directly and asked to do so.

There are two main features of a modern investigation. The "what" and the "why". The actual outcome is often self evident but even there you are constantly faced with surprises. Therefore you start any investigation by grabbing as much as you can. Pictures, measurements, manuals, records, data, witness statements, video etc. Time will start destroying your evidence the second after it occurred. Once you have your initial evidence, you can start putting it together and eventually you will create a picture of what (probably) happened. At the same time, you will have unintentionally netted a far bit of "side catch". Dealing with this can sometimes be more interesting than the initial investigation.

The next bit is the tough one. The "why". Only with a good understanding of the "what" can you move forward on this aspect. And once you have the "why" then what you have to do prevent reoccurrence normally becomes self evident.

This procedure depends on a full disclosure by all parties. Therefore, it is very important to provide protection to all of those involved, especially the ones at the sharp end. If you don't have that protection there is not much point in starting an investigation because information will go missing, details will be "forgotten" or data and records will be amended or destroyed. This is clearly demonstrated in the Hillsborough and the debacle over the Southern Health NHS Trust. The main players these events knew the heavy hand of the judicial system would be involved. Knowing the outcome would be be punishment, evidence was altered, buried and destroyed. There was no improvement in safety and the public have picked up the bill. Assuming a reasonably safe starting point, do we want safety or punishment? It is difficult have both in our modern society.