The Purpose of Accident Investigations- your opinion

[Cosmo]

I thought that this might be an appropriate forum to post a question regarding accident investigations and their purpose. The reason I ask is that I'm digging into the subject (writing a paper on it) and would be interested in hearing your viewpoints.
As you probably are aware, an Annex to the Chicago Convention on International Civil Aviation, namely Annex 13, sets out the purpose of an investigation in the following words:
Chapter 3.1

Objective of the Investigation

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.


What are your reactions taking into account that the SQ006 crew at Taipei apparently were arrested at one point pending a criminal inquiry? (just to name one example)


Regards,

Cosmo

[might as well mention that I'm not a journo :) ]

[HugMonster]

I entirely concur with the ICAO definition, and it was not helpful that the SQ crew were arrested while the investigation was still under way.

HOWEVER, it should perhaps be noted that there is nothing in any Ops Manual, International Treaty or National Statute that gives flight crew invulnerability from prosecution in cases of gross or ciminal negligence.

And note the definitions (generally accepted). A mistake is one thing. Negligence is another.

It is beneficial if an accident investigation highlights how a crew were led to making a mistake - to highlight the Human Factors, the Environmental Capture etc.

But if an accident is, quite simply, the result of gross negligence on the part of the crew, then is there any reason why they shold not be subject to the response of the law?

[Cosmo]

Thanks for your reply.

<font face="Verdana, Arial, Helvetica" size="2">It is beneficial if an accident investigation highlights how a crew were led to making a mistake - to highlight the Human Factors, the Environmental Capture etc.</font>

I concur. The way I've understood the article that I quoted above, is that safety was realised as being of importance. This way someone is given the task of finding out what happened. However, since accident reports can be used in criminal trials, for example, doesn't the possibility of someone making an out of context interpretation of a probable cause exists?. Take pilot error as one.

<font face="Verdana, Arial, Helvetica" size="2">But if an accident is, quite simply, the result of gross negligence on the part of the crew, then is there any reason why they shold not be subject to the response of the law?</font>

In my opinion, no. On the other hand it seems that pilots tend to protest vigorously if someone is detained after an accident or incident on the suspicion of criminal negligence. Why?


Cosmo


edited a spelling error

[This message has been edited by Cosmo (edited 18 March 2001).]

[HugMonster]

I would make an accident report inadmissable as evidence without the verbal evidence of the chief investigator for that accident.

Why arrest members of a crew? Possibly because you fear they will quietly disappear if they know they have been negligent. Possibly to distract press attention from the fact that your own officials have been negligent. Possibly because you don't understand the principles of accident investigation. Possibly because you don't know, don't care, are throughly corrupt and want people to bribe you to have their crews released...

[fudpucker]

I would agree with Hugmonster. Unless and until accident investigations are conducted by independabt bodies , they are unlikely to use the model proposed by Prof: James Reason , namely that the causes of accidents start , or can start , at a point much removed from the the immediate apparent causes of the accident.
To illustrate this , consider the ANZ crash in Antarctica. It took a Royal Commission to get to the bottom of it . Initial investigations blamed the crew , but closer scrutiny laid blame both on the airline and the NZ regulatory bodies.
If the crew were negligent , then yes of course they should be legally answerable for their actions. However , this of course raises wider questions of corporate responsibility , or even that of the various regulatory bodies who might have failed in their monitoring duties.
Good luck with your paper , you probably see , if you had'nt realised before , that it potentially is a wide-ranging subject , and will keep you hard at it for many nights to come.

[matelot]

Cosmo - I have been investigating serious and fatal road traffic accidents for a number of years (ex - Police). Obviously I can't relate directly to any specific a/c incidents (Taipei), not knowing circumstances.

The generally accepted principles of accident investigation (in the UK) is to find out the sequence of events which led to the incident/accident, taking into account mechanical condition, road and weather conditions, physical state of the driver, speeds etc. i.e. 'what happened'. All this obviously has to be done within the area of expertise of the investigator. Any aspects he doesn't know about, he doesn't comment.

Unless asked by the court, he makes no recommendations, and does not apportion blame. That's for the court to decide. It's the production of as much fact and reasonably supported interpretation as possible.

In the quest for truth, he is quite prepared to find against the interests of his client (which often they don't like!)

Hope this helps a little with the ethos of the investigator.

Cheers.

------------------
Me, sweat? I'm that cool, it's condensation.

[Cosmo]

Thanks once again for your replies!
Yes, the subject is far more wide-ranging than I initially thought and causing me a bit of grief in presenting it. I'll get back to your comments in a few days. At the moment I'm trying to stay focused while putting all effort into beating the dead-line. :)

regards,
Cosmo

[HugMonster]

Cosmo, best advice I can give you is to read "The Naked Pilot" by David Beatie.

It is THE best work on Human Factors in aviation, and should be required reading for all.

[traffic cop]

Cosmo,

This is my very first post, so I'm sticking to a subject with which I am familiar!

<font face="Verdana, Arial, Helvetica" size="2">Objective of the Investigation

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.</font>

If you're looking for comparison between air and road as part of your research, then there is little difference (although in a road traffic sense the immediate aim is not prevention: this comes with recommendation to the appropriate bodies afterwards).

What is paramount is an objective search for the truth (as Matelot pointed out), and absolute impartiality; although not many believe that!

If you want some accident investigation sites - and some do cover air accidents - you could start initially with the Institute of Traffic Accident Investigators (ITAI) www.itai.org. (http://www.itai.org.) They have links all over.

Be pleased to help further if I can.