SubscribeSafety is something that you would expect every manager to state to be the first priority around the airport. Yet the accident statistics clearly demonstrate that the majority of aircraft accidents occur around the airport environment. Add to this the alarming level of accidents on the airport ramp and it provides a clear reminder as to why the role of the accident investigator remains an important element of modern safety management.
Cranfield University in the UK has run Aircraft Accident Investigation courses since 1977 in close collaboration with the Air Accidents Investigation Branch (AAIB). It is one of a small number of such courses available around the world and regularly attracts delegates from as far a field as Australia, Japan, Thailand and China. Since 2003, the Centre has also been working closely with the established Marine Accident Investigation Branch and the fledgling Rail Accident Investigation Branch, to share some of the experiences between each transport mode in investigating accidents.
Of course, not all accidents are going to be on the scale of the 1985 Manchester or 1989 East Midlands disasters. So, although the courses provide skills for the sort of investigator who will tackle these large ICAO Annex-13 style investigations, it also recognises the need for modern safety managers to conduct safety investigations as part of their wide range of activities. Of the two courses that Cranfield currently offers (6 and 2 weeks), the shorter course is aimed squarely at those who will investigate incidents and minor accidents – whether from an operator, airline, union or supplier’s perspective.
Both courses have been comprehensively overhauled during the last 2 years and new partnerships started to allow investigators to access the experience and occasionally conflicting perspectives of those who may be involved in an accident. These range from the role of the emergency services, pathologist and victim support through to the role of the news media, operator, manufacturer, maintainer and management. AAIB and overseas investigators present a range of investigation case studies to share techniques and findings and course delegates develop their own skills through a range of simulations and exercises.
William Tench, former head of the UK Accident Investigation Board once described the job of the accident investigator as “…a fascinating challenge, occasionally exciting but always involving patient, even monotonous examination of every aspect of the accident – the tedium of which may erode those qualities of tenacity, imagination and perseverance which are fundamental to the effective investigator.” (Tench, 1985)
The heroic image propagated by books and films of the role of the investigator is sometimes at odds with the reality with dealing with a complex puzzle and often-traumatic injuries or fatalities. As one NTSB investigator at the Valujet crash in 1996 observed, “some people think my job is glamorous, but I have spent the past few days in a rubber suit, unbearable heat and up to my waist in swamp feeling through the wreckage, whilst a State Trooper stands in a nearby boat with a gun pointed towards me in case of alligators…”
Investigators are required to be multi-talented and deal with whatever may be thrown at them – accidents on land or in the water, wreckage strewn over wide areas or buried deep in the ground or sometimes missing altogether and with witnesses who may be traumatised. In addition to the AAIB type investigators, airlines, airports, regulators, air traffic management providers, insurers and manufacturers may all get involved in investigation. As safety management systems have grown in popularity, so the need to investigate the multiple contributory factors behind occurrences has grown.
The focus of investigation has shifted away from blame and liability and indeed often a focus on individuals towards an emphasis on how the system failed. Work by the likes of organisational psychologist Professor James Reason has helped investigators look beyond the failures that occur immediately before an accident and towards the factors which influence them – such as the physical environment, organisational climate and so on. It is these latent conditions, which may be in place months or even years before an accident, that often have the greatest potential to prevent future recurrence. Human error is so often the symptom of much more serious system failures. Disciplining an individual may be nothing more than a sticking plaster if the management system, training programme or working environment means that someone else will make the same mistake in the future.
The spectre of corporate manslaughter has focused the minds of many senior managers to the importance of active safety management, but it is often the work of accident investigators that reveals how a complex combination of failures may sit behind an accident.
Investigators who train at Cranfield benefit from the experience of many investigators and are able to practise their skills through a number of simulations including a week-long aircraft accident exercise at the University’s own airport. The addition of input from the rail and marine industries has also enabled new lessons to be learned. Far from watering down the existing aviation-only syllabus, the inclusion of other modes allows a variety of perspectives to be considered. For example, the experiences of the rail industry in dealing with recent high-profile accidents such as Paddington, Potters Bar and Hatfield, complement aviation’s experiences of major accidents such as Pan Am at Lockerbie and Concorde at Gonesse. Working with BBC News helps investigators understand the news media’s priorities and motivations and provides a counterbalance to some of the ‘horror stories’ that investigators have experienced with the media.
True to their new life, there are plenty of surprises for the investigators during the courses. The lectures, simulations and assessment tasks are designed to be practical, yet also deliver a lot of technical information. It needs to drive home some strong messages to ensure that investigators can perform as soon as they return to their jobs. On the 2003 course, one of the Royal Navy delegates went straight from Cranfield to the investigation of a Sea Harrier accident, which had occurred during the last few days of the course.
A recent development has been in making investigator training assessable. Customers are increasingly recognising the need for assessment and accreditation, not least because of the additional scrutiny that many of them are facing in Coronial or Criminal courts. It is no longer enough to say that you have attended a course – you need to be able to say that you passed. Cranfield University now offers an MSc programme in Safety and Accident Investigation which allows investigators to develop a range of professional skills ranging from forensics and crashworthiness to human factors and marine recovery.
Accident investigation is an important area, but only if done well. Poor investigative techniques can lead to a blame-culture or lack of reporting and needs to be guarded against. Enthusiastic amateurs basing their technique on their favourite TV detective can do a lot of damage. However, with good training and support, investigations can make a significant contribution to aviation safety. Cranfield alumni have been involved in many of the high profile accident investigations over the last 25 years and are now able to share their experience with new investigators. Added to the research capability of the Safety and Accident Investigation Centre within the University, it is easy to see why Cranfield University has earned its place as the home of accident investigation training.
