From Incident to Insight: Understanding Aviation Investigation Process
INTRODUCTION
Although we have taken many measures to prevent incidents, incidents may occur. We can not reduce the risk to zero while we are keeping the action or operation.?
Last week, we discussed the risk assessment for aviation security. For instance, an incident has happened despite all risk assessment and preventive actions. We are going to delve into what is going to happen after an incident.?
The aviation industry is one of the most regulated industries in the world. So, almost every step of the operation was regulated by international and national authorities. On this subject, ICAO Annex 13 is considered essential for investigation of incidents and accidents. The other sources and regulations are as follows:?
In light of this information, we have to conduct an investigation in the aviation industry. So, are we going to conduct an investigation just for necessity??
The answer is NO. There are several reasons to conduct an investigation. Investigations are the improvement machines of the aviation organisations and this improvement stems from the Safety Culture. If we did not try establishing a Safety Culture in our organisation, we can not conduct an investigation properly. we will see the relationship of these terms at the end of the article. If you? would like to see the details of the Safety Culture, you may check this website: https://skybrary.aero/articles/safety-culture?
This week, we will focus on one scenario in the aviation industry. We are trying to find an answer for WHY? question.?
I hope you will enjoy your reading. I would appreciate it if you make comments regarding the article.?
INVESTIGATION PROCESS
“One day one aircraft was being prepared for the next flight. One of the ground handling agents was using the Hi-loader for the loading process to the aircraft cargo compartment. The other ground handling agent used the Hi-loader to gain access to the cargo compartment, particularly the raising platforms for ULDs instead of the step ladders. The ground handling agent on the Hi-Loader fell and broke his/her arm.”
The scenario mentioned above can be considered as an incident. We are going to investigate this incident in terms of the aircraft operator/airline and as a safety officer.?
STEP 1-? Reporting the Incident
What if the incident was not reported, can we investigate the incident?? If we do not know, we can not do anything.?
The reporting of incidents, any occurrence, and anything that feels not right is essential. This is one of the elements of the Safety Culture: Reporting Culture. For the investigation, we need reports. (The Thinking point: How can we encourage people to report?)
The quality of the report is another significant part of the reporting process. We need all the details of the report. We need to answer these questions: What-Where-When-Which. It should be borne in mind that footage can make a valuable contribution to the investigation
STEP 2- Understanding the Incident and Internal Communication
We've received the report and now need to categorise it based on the information contained within. During our review and dissemination of the report to relevant departments, we'll uphold confidentiality. Once the related departments are informed, we'll proceed to address any missing information and take corrective measures. This incident pertains to the Ground Operations Department, and we've gathered additional details from the Ground Operations Teams. We've been furnished with the GHA manual and Training Program, equipping us to thoroughly investigate the incident.
STEP 3- Introduction of the Investigation
We need to tell a story in this section according to the safety report. We need to answer these questions:?
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This section should be written for a person who has no idea of the incident. After this section, we will need to review the procedures.?
STEP-4: What is the procedure?
We should review both the airline and GHA manuals. Upon examination, we found no deficiencies in the instructions regarding the use of the Hi-loader. Our attention will now turn to scrutinising the training programme and associated records. It has come to our attention that the ground-handling agent in question was hired just three days before the incident. Furthermore, neither safety training nor on-the-job training had been imparted before the occurrence. Do you believe we have identified the root cause of the incident? Let's delve deeper.
STEP-5: Determining the Root Cause
When we have found a clue about the incident, we need to ask “Why”? questions as long as reaching the root cause.?
Why was the new employee assigned when the necessary training was not provided to the new staff?
Why does the GHA have no adequately trained personnel for operational duties?
The root cause has been determined as the lack of a proper employment plan for GHA. The contributing factor is the lack of monitoring for training.?
STEP-6: The Observations
This section can be considered as the summary of the investigation. We should summarize each section in one or two sentences while sharing our observations as a list. These observations are not opinions, they are facts.
STEP-7: Recommendations
This section is directly related to the Learning Culture of the organisation, which is one of the elements of the Safety Culture. We should give recommendations to prevent incidents like we have investigated. For example, we can give this kind of recommendation to internal departments of the organisation:
ONE-QUESTION
What do you think the investigation process can be applied in which industries except the aviation industry??