AAIB Investigators' Terms of Reference
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From: UK Sometimes
AAIB Investigators' Terms of Reference
Does anyone out there know what are the Terms of Reference (TORs) for AAIB Accident Investigators?
For example, once they have investigated the local direct-efffect causes of the accident, are the investigators mandated to consider the organisational influences that may have predisposed those involved towards having the accident. How deep are the investigators allowed/required to go?
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, poor supervision or documentation etc. Whereas, the 'local factors' could be crew mishandling, incorrect procedures, lapses, errors, violations, inappropriate cockpit gradient, distractions etc?
It would be interesting to know the current procedures, 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 Alpha, Zeebrugge, Dryden etc). As a result of this, however, has ICAO Annex 13 actually been changed and have individual countries' aviation authorities ammended the TORs for their investigators?
flipster
For example, once they have investigated the local direct-efffect causes of the accident, are the investigators mandated to consider the organisational influences that may have predisposed those involved towards having the accident. How deep are the investigators allowed/required to go?
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, poor supervision or documentation etc. Whereas, the 'local factors' could be crew mishandling, incorrect procedures, lapses, errors, violations, inappropriate cockpit gradient, distractions etc?
It would be interesting to know the current procedures, 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 Alpha, Zeebrugge, Dryden etc). As a result of this, however, has ICAO Annex 13 actually been changed and have individual countries' aviation authorities ammended the TORs for their investigators?
flipster
Last edited by flipster; 3rd March 2009 at 14:06.
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From: Kettering
The publication 'Aircraft Accidents - Guidance for Police, Emergency Services and Airfield Operators' (2008) describes the role of the AAIB but not really to the depth you are looking for.
If you read reports produced by the AAIB it is clear that, sometimes, they try to get close to some of the aspects you refer to. However, from the outside looking in it seems to me that a) they might not have the resources b) they maybe don't have the analytical tools needed to do the sort of investigation you are talking about and c) when they do get interested in organizational factors it is maybe dealt with outside of the report i.e they sit down with the operator, the CAA and some sharp pointy sticks. Which is why sometimes the reports seem to written in code.
If you read reports produced by the AAIB it is clear that, sometimes, they try to get close to some of the aspects you refer to. However, from the outside looking in it seems to me that a) they might not have the resources b) they maybe don't have the analytical tools needed to do the sort of investigation you are talking about and c) when they do get interested in organizational factors it is maybe dealt with outside of the report i.e they sit down with the operator, the CAA and some sharp pointy sticks. Which is why sometimes the reports seem to written in code.
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From: England
General guidelines are in ICAO Annex 13 ‘Aircraft Accident and Incident Investigation’, which originates from Article 37 of the ICAO convention; the UK is a signatory.
The ‘Manual of Aircraft Accident Investigation’ (ICAO Doc 6920-AN/855/4) provides:-
“… guidance to assist the investigation of accidents involving large modern aircraft and to ensure a logical and balanced presentation.”
Re ‘tc’ comments above – I agree, and add that with an improving understanding of the theories behind human/organizational factors, investigations could engage in greater speculative debate on these issues without deviating from the requirement for factual reporting. In instances where there were indications of HF/organizational issues (nearly all accidents), a discussion could aid safety by highlighting possible issues for others to learn from even if the specifics could not be proven to be associated with the particular accident being reported on.
The Australians, for example, appear to be moving in this direction.
The ‘Manual of Aircraft Accident Investigation’ (ICAO Doc 6920-AN/855/4) provides:-
“… guidance to assist the investigation of accidents involving large modern aircraft and to ensure a logical and balanced presentation.”
Re ‘tc’ comments above – I agree, and add that with an improving understanding of the theories behind human/organizational factors, investigations could engage in greater speculative debate on these issues without deviating from the requirement for factual reporting. In instances where there were indications of HF/organizational issues (nearly all accidents), a discussion could aid safety by highlighting possible issues for others to learn from even if the specifics could not be proven to be associated with the particular accident being reported on.
The Australians, for example, appear to be moving in this direction.
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From: LIVT
Originally Posted by PEI_3721
The ‘Manual of Aircraft Accident Investigation’ (ICAO Doc 6920-AN/855/4) provides:-
“… guidance to assist the investigation of accidents involving large modern aircraft and to ensure a logical and balanced presentation.”
“… guidance to assist the investigation of accidents involving large modern aircraft and to ensure a logical and balanced presentation.”
Part of this material is already available in ICAO Circular 240-AN/144 "Human Factors Digest No.7 - Investigation of Human Factors in Accidents and Incidents" published in 1993.
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From: Behind a dusty desk, and in some really hot, dusty, wet and cold places subject to who is paying the bill. But mostly Gods own land.
ICAO Annex 13 is clear on this matter, an Accident Investigator is not to attribute blame but investigate the Accident/ Incident with the aim of preventing such an occurance from happeneing again. They may take any and all factors into account.
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From: UK Sometimes
Thanks everyone for the links and references - I will read and digest - it may take me a while!
Miles you are quite specific - TVM! However, after they have addressed the local causes, it would be good to hear just how deep investigators find themselves going before they find themselves constrained by time/money and possible reluctance/interference/brick walls?
Anyone out there care to comment or have recent relevant experience?
Any links to the Oz procedures and..
Anyone got a copy of Annex 13 itself?
Miles you are quite specific - TVM! However, after they have addressed the local causes, it would be good to hear just how deep investigators find themselves going before they find themselves constrained by time/money and possible reluctance/interference/brick walls?
Anyone out there care to comment or have recent relevant experience?
Any links to the Oz procedures and..
Anyone got a copy of Annex 13 itself?
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From: England
aerolearner Re the ‘new’ "Manual of Aircraft Accident and Incident Investigation". Is this available, or will it be available on-line?
It’s about time that ICAO realised that if their valuable guidance material is to be read and used by the regulators and operators, then it should be made more widely available.
Do you know if ‘ICAO Circular 240-AN/144 "Human Factors Digest No.7’ was one of those included in the ICAO Human Factors Training Manual? Although Chap 4 of the training manual is titled ‘Human Factors training for Safety Investigators’, much of the information appears to relate to the conduct of investigations which might be relevant to the terms of reference for a new investigation.
ICAO Annex 13.
Other refs:
"Designing and evaluating a human factors investigation tool (HFIT) for accident analysis". R. Gordon, R. Flin, K. Mearns. Probably not on the web.
A tool for Human Factors Accident Investigation, Classification and Risk Management.
Human Factors in the Investigation of Accidents and Incidents
Human factors in incident investigation and analysis.
Reconstructing human contributions to accidents
Transport Safety Investigation Reports
http://www.atsb.gov.au/publications/2006/B20060094.aspx
http://www.atsb.gov.au/publications/2008/AR2007053.aspx
It’s about time that ICAO realised that if their valuable guidance material is to be read and used by the regulators and operators, then it should be made more widely available.
Do you know if ‘ICAO Circular 240-AN/144 "Human Factors Digest No.7’ was one of those included in the ICAO Human Factors Training Manual? Although Chap 4 of the training manual is titled ‘Human Factors training for Safety Investigators’, much of the information appears to relate to the conduct of investigations which might be relevant to the terms of reference for a new investigation.
ICAO Annex 13.
Other refs:
"Designing and evaluating a human factors investigation tool (HFIT) for accident analysis". R. Gordon, R. Flin, K. Mearns. Probably not on the web.
A tool for Human Factors Accident Investigation, Classification and Risk Management.
Human Factors in the Investigation of Accidents and Incidents
Human factors in incident investigation and analysis.
Reconstructing human contributions to accidents
Transport Safety Investigation Reports
http://www.atsb.gov.au/publications/2006/B20060094.aspx
http://www.atsb.gov.au/publications/2008/AR2007053.aspx
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From: LIVT
PEI_3721,
as far as I know, the Manual is currently available only on the ICAO-NET intranet (I do not have access to it). This is the status according to the minutes of the ICAO AIG Meeting in October 2008:
Yes, you are right. The Circular has been included verbatim in "ICAO Human Factors Training Manual Doc 9683-AN/950" as chapter 4.
as far as I know, the Manual is currently available only on the ICAO-NET intranet (I do not have access to it). This is the status according to the minutes of the ICAO AIG Meeting in October 2008:
Originally Posted by http://www.icao.int/AIGdiv08/docs/AIGdiv08_WP15_en.pdf
2.3 Manual of Aircraft Accident and Incident Investigation (Doc 9756)
[...]
2.3.2 The current status of the four parts is as follows:
a) Part I was published in 2000;
b) Parts II and III were published on the ICAO-NET in the English language this year and should be made available in “hard copy” in the near future; and
c) Part IV was published in 2003.
[...]
2.3.2 The current status of the four parts is as follows:
a) Part I was published in 2000;
b) Parts II and III were published on the ICAO-NET in the English language this year and should be made available in “hard copy” in the near future; and
c) Part IV was published in 2003.
Thread Starter
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From: UK Sometimes
Thanks for the links! Good stuff.
Sadly, the third link appears broken
http://www.rdc.uscg.gov/Portals/0/Pubs/hfw2002.pdf
Sadly, the third link appears broken
http://www.rdc.uscg.gov/Portals/0/Pubs/hfw2002.pdf
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From: UK Sometimes
BTW Anyone know what the military do with the AAIB after an accident and who has primacy? I suspect the mil Board of Inquiry has 'the con' but I am not sure. It used to in be AP3207 the 'manual of flight safety' but this all got changed to a JSP - 551 I think? Anyone help?
flipster
flipster
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From: Behind a dusty desk, and in some really hot, dusty, wet and cold places subject to who is paying the bill. But mostly Gods own land.
If an aircraft accident involves a fatality then the coroner has jurisdiction, if the accident doesn't then "technically" the police do.
The Police, normally, hand it over to the respective investigative authority ASAP; if Civil then the AAIB, military, then either the RAF/NAVY/ARMY investigation team.
All accident reports in the UK, civilian and military are given to the Secretary of State in there first publishing.
The military will undoubtedly form a board of inquiry, which unlike an accident investigation team, civil or otherwise can attribute blame.
The Police, normally, hand it over to the respective investigative authority ASAP; if Civil then the AAIB, military, then either the RAF/NAVY/ARMY investigation team.
All accident reports in the UK, civilian and military are given to the Secretary of State in there first publishing.
The military will undoubtedly form a board of inquiry, which unlike an accident investigation team, civil or otherwise can attribute blame.
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From: UK Sometimes
The UK mil don't/can't attribute blame anymore - not since late 1990s. At least, that is progress. That is one of the problems with older BOIs that did find people guilty of negligence eg Chinook in 1994.
Even now, however, it is possible that the mil or legal authorities may start legal/admin procedures against someone who has been wilfully negligent eg unauthorised airshow/aeros or flying under bridge etc.
Even now, however, it is possible that the mil or legal authorities may start legal/admin procedures against someone who has been wilfully negligent eg unauthorised airshow/aeros or flying under bridge etc.
