Is Your Safety Investigation Local?

The information gathered from a local investigation to determine 'what went wrong and how do we prevent it from recurring' needs to be local.

There is a tendency to defer investigations to higher authority, most likely because the local safety managers just do not have the equipment to analyze the DFDR and other technical records.

Yet the more that the investigation is centered locally, the more likely it is that the investigation will address the local safety issues involved with the mishap. Most often mishaps are the result of human error on the part of crew or others involved in operations or some other local element of the operation.

Yet hull and engine complete reconstruction often takes place at great expense but at no level of contribution to the prevention of future mishaps. Again the local investigators become intimidated by the metal smiths, but to what avail? How does all of that expense and effort profit us when the mistake was made elsewhere? Are some investigators really trying to conduct a belated administrative investigation of the air line operation in lieu of focusing all efforts on human error, the most common reason for aviation mishaps?

As a local safety investigator, it is most likely that the greater burden of determining what went wrong will fall eventually squarely on your shoulders.

This is why I believe strongly that all safety investigations contain a strong local component with a great focus on human error.

AF 447 again?

If no one at the AF Dispatch office is tasked with flight following, that is looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched AF flight and then tasked with coordinating a new and safer path diverting around the hazard, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.

The subsequent spending of tens of millions of dollars investigating any such mishap, will in the end not change the disastrous outcome, and in that sense will be money not spent to promote safety, but only rather to satisfy subsequent law suits. Remember, that is a legal function, not a safety function.

Safety's goal is to PREVENT THE MISHAP FROM OCCURRING IN THE FIRST PLACE, FROM OCCURRING AT ALL.

The job of lawyers is to just pick up the broken pieces and dead bodies and sit around with a pile of money and dole it out to whom they determine is the victim. How does that bring back the dead? How does that make anyone whole? Where is the prevention of loss in all of that?

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Who Was at Fault & Who Pays versus How Did This Happen & How Can We Prevent a Recurrance

1. If you are investigating an aviation mishap and asking the question, "Who was at fault and who pays," then you are doing a legal investigation.

2. If you are investigating an aviation mishap and asking the questions, "How did this happen and how can we prevent a recurrence?" then you are doing a safety investigation.

3. In either case, what is written on the door of your office, the door of your truck or car, the name tag you wear or the title of your agency is not as relevant as which question begins your investigation.

4. If the title of your agency says mishap investigation, but the purpose of your investigation is fault finding, the safety purpose remains unfulfilled.