Commission staff working document
The need for independent accident investigation and occurrence reporting
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- Organisation of accident investigation and the parties involved
- Role of occurrence reporting in civil aviation
The need for independent accident investigation and occurrence reportingIndependent investigations of accidents are essential in the drive to improve transport safety. Analysis of the circumstances of accidents leads to recommendations being made to prevent these dramatic events from re-occurring. Accidents rarely result from a single failure but rather from a combination of events - for example, an error in maintenance that causes a failure in flight that a member of the flight crew then responds to incorrectly. In other words, accidents result from a chain of events that make them difficult to analyze but also provide multiple opportunities to prevent them. If any link in the fatal chain is removed than the accident can be avoided.24 Thus, beyond accident investigation, the crucial element in prevention of accidents is open reporting and careful analysis of even the smallest incidents, failures and other occurrences in daily operations which may indicate the existence of serious safety hazards, and which if not corrected may lead to subsequent accidents.
Organisation of accident investigation and the parties involvedDue to international character of civil aviation, involvement of many States in accident investigation is a common situation, and the success of the process depends on the ability of all the States concerned to cooperate efficiently. Unless the conduct of the investigation was delegated, the State of Occurrence25 will institute the investigation and its NSIA will appoint the investigator-in-charge (IIC), responsible for the overall supervision of the investigation. The IIC will rely on the teams of experts in various areas of expertise. Each team will collect data related to its domain under the supervision of the IIC. The representatives from foreign countries (in particular the State of Design26, Registry27, Manufacture28 and Operator29) will also participate in the investigation by appointing their "accredited representatives" who may be accompanied by technical advisors, in particular from the airline, design organisation, manufacturer or a foreign aviation authority as appropriate (Figure III).30 Other States having an interest in the investigation may also participate on a case by case basis.31 Although organisation of accident investigation may vary in detail from State to State, the process is usually structured along the three main phases. In the first phase the investigation team conducts examinations at the crash site. After the on-scene examination of the wreckage is completed further studies and examinations may be undertaken, including the read-outs of the flight recorders ("black boxes"), reconstruction of a part of the wreckage, autopsies, simulations and the overview of the overall context of the event. Once all the data is gathered, different scenarios are built and analysed to determine the probable cause of the accident. If needed, further studies and examinations are undertaken to collect supplementary data or verify the probability of alternative scenarios. Figure III: Principal actors in the accident investigation process 
Briefings and updates will be given by the ICC as the investigation unfolds. Interim reports may also be published or immediate safety recommendations issued. The investigation is concluded with the publication of the final report, determining the probable cause of the accident and specifying safety recommendations to be acted upon to prevent re-occurrence of similar events in the future. Role of occurrence reporting in civil aviationWhile the role of accident investigation is improvement of safety through analysis of serious events, occurrence reporting aims to improve safety by timely detection of operational hazards and system deficiencies, which if not properly addressed could escalate into much more serious catastrophes in the future. In practical terms, occurrence reporting are sophisticated systems which call aviation professionals to report, in a protected environment, errors, abnormal events and other irregular circumstances, and which allow to analyse the data collected in order to draw and disseminate safety lessons and identify safety risks. Occurrence reporting is an essential tool in promotion of organisational safety culture (“Just Culture"), understood as a working environment where "front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated".32 "Just Culture" in general and occurrence reporting in particular take a system wide approach to accident prevention and recognise that moving beyond blame is essential in enhancing safety in a proactive way – notions which have been confirmed through decades of safety and human factors research.33 Directory: pub -> ECD ECD -> Commission staff working document ECD -> Table of contents I instruments Error: Reference source not found ECD -> Table of annexes annex I: Glossary 4 ECD -> En commission of the european communities brussels, 12. 12. 2008 com(2008) 853 final annex annex II to VIII ECD -> Report from the commission to the european parliament and the council european community safa programme aggregated information report ECD -> Report from the commission european community safa programme ECD -> Commission staff working document ECD -> Commission of the european communities brussels, 24 2008 ECD -> Communication from the commission to the european parliament, the council, the european economic and social committee and the committee of the regions ECD -> Annex I iccat species Download 0.51 Mb. Share with your friends:
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