Independent Investigation
How it works in aviation
Prof Graham Braithwaite
Cranfield Safety and Accident Investigation Centre
Aviation
• High-reliability organisations
• Mature process
• Trusted system
• Variation in quality (worldwide)
• Threat of criminalisation
Cranfield Safety and Accident Investigation Centre
Why investigate?
• Because we have to
• Legal / regulatory obligations
• Moral obligations
• Because we can learn
• Accident prevention
• To allocate responsibility
• Blame
• Financial liability
• Legal liability
Cranfield Safety and Accident Investigation Centre
Technical stakeholders
•
•
•
•
•
•
•
•
Regulatory / Government
Operators / Infrastructure providers
Other accident investigation agencies
Manufacturers
Maintainers
ICAO
Training providers
Other operators
Cranfield Safety and Accident Investigation Centre
Non-technical stakeholders
• Insurers
• Those involved
• Families / relatives
• News media
• Emergency responders
• Traveling public
• Third parties
Cranfield Safety and Accident Investigation Centre
Aviation legal framework
THE CONVENTION ON INTERNATIONAL CIVIL
AVIATION
(THE CHICAGO CONVENTION)
SIGNED BY 190 STATES
ANNEX 13
AIRCRAFT ACCIDENT
AND INCIDENT
INVESTIGATION
EUROPEAN COUNCIL DIRECTIVE
94/56/EC
NATIONAL
ACCIDENTS & INCIDENTS INVESTIGATION
LEGISLATION
Cranfield Safety and Accident Investigation Centre
Purpose of accident investigation
“ The sole objective of the investigation of an accident or a
serious incident shall be the prevention of accidents and
incidents. It is not the purpose of this activity to apportion
blame or liability.”
•
Annex 13 to the Chicago Convention (ICAO)
•
EU Directive 94/56/EC
•
Civil Aviation (Investigation of Air Accidents and Incidents) Regulation 1996 (UK)
Cranfield Safety and Accident Investigation Centre
EU Aviation Directive 94/56/EC
Article 6 (1) - Investigating body or entity:
“Each Member State shall ensure that technical
investigations are conducted or supervised by a
permanent civil body or entity. The body or entity
concerned shall be functionally independent in particular
of the national aviation authorities responsible for
airworthiness, certification, flight operation and, in
general, of any other party whose interests could conflict
with the task entrusted to the investigation body or entity.”
(www.europa.eu.int/)
Cranfield Safety and Accident Investigation Centre
Aviation legal framework
THE CONVENTION ON INTERNATIONAL CIVIL
AVIATION
(THE CHICAGO CONVENTION)
SIGNED BY 190 STATES
ANNEX 13
AIRCRAFT ACCIDENT
AND INCIDENT
INVESTIGATION
EUROPEAN COUNCIL REGULATION
2010
NATIONAL
ACCIDENTS & INCIDENTS INVESTIGATION
LEGISLATION
Cranfield Safety and Accident Investigation Centre
New European regulation
• Independence of investigation
• Free from pressure of regulatory authorities
• Protection of key evidence sources
• Witnesses
• Data recorders
• Unless there is an overriding reason for disclosure…
• Information for victim’s families
10
No blame investigations
• Positives
• Trust
• Quality of information
• Negatives
• Absolution
• Just culture?
• Justice?
Cranfield Safety and Accident Investigation Centre
Independence
• Functional independence from regulator
• Independence from industry
•
For…
•
•
•
•
Gathering, recording and analysis of all available information on
that accident or incident
Determination of the causes
Issuance of safety recommendations
Completion of the final report
• Not out of contact from industry, regulator etc.
Cranfield Safety and Accident Investigation Centre
Appropriate criminal investigations
• Suspected
•
•
•
•
malicious actions
sabotage
terrorism
corporate manslaughter
Cranfield Safety and Accident Investigation Centre
The Police and transport
accident investigation
• Primacy for safety investigation
agencies - except in cases of
deliberate criminality
• Evidence gathered to highest /
Police standards
• Certain evidence protected
Cranfield Safety and Accident Investigation Centre
MOU with Crown Prosecution Service
• Established October 2008
• “The aim is to ensure effective investigation and
decision making processes while maintaining the
independence of all parties and reinforcing the
role of the AIBs as the guardians of public safety
when investigating transport accidents and
incident.”
Cranfield Safety and Accident Investigation Centre
Basic principles of co-operation
• All evidence and factual information, except where there are specific
legislative bars, can be disclosed between the AIBs and the CPS. The
AIBs will not share their own opinions or analysis.
• The public interest requires that safety considerations are of
paramount importance, the consequence of which may mean that the
interests of an AIB investigation have to take precedence over the
criminal investigation.
• The ability of witnesses to be able to talk openly to an accident
investigator is fundamental to the operation of the AIBs.
• AIBs will provide a pre-publication copy of the finalised AIB report to
the CPS if it is made aware of a CPS interest. The CPS may make
comments to the AIB about the report before publication.
Cranfield Safety and Accident Investigation Centre
Safety recommendation systems
Cranfield Safety and Accident Investigation Centre
Some cautions
• “We are different”
• Experience versus training
• Cultural change
• Purpose of investigation
Cranfield Safety and Accident Investigation Centre
Thank you
Professor Graham Braithwaite
Tel. +44 1234 754252
Email. G.R.Braithwaite@cranfield.ac.uk
Web. www.csaic.net
Cranfield Safety and Accident Investigation Centre