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Investigation as Feedback

The problems with the B-737MAX were revealed after two fatal accidents. It was the process of investigation that provided the details of what went wrong. Accident investigation agencies occupy an interesting niche. They are mandated under an ICAO requirement, represent a feedback loop within the aviation system but lack the formal authority to effect change. They can simply advise, suggest, recommend and nudge. They lack the power to hold regulators to account. In this section, I look at the history of aviation accident investigation before looking at an investigation in detail.

In 1912, in the United Kingdom, the Royal Aero Club created the Public Safety and Accidents Investigation Committee. A member of this committee became the first Inspector of Accidents for the Royal Flying Corps in 1915. At the end of the Great War (1914-1918), the Accident Investigation Branch was created in the Air Ministry in 1919. With the formation of the CAA in 1972, the renamed Air Accident Investigation Branch (AAIB) was moved to the predecessor of the current Department of Transport, with the chief inspector of the AAIB answering directly to the Secretary of State for Transport. In the USA, the responsibility for investigation initially lay with the Department of Commerce, but after the crashes mentioned above, the wisdom of allowing an agency to, effectively, investigate itself was questioned. An independent investigation ‘Air Safety Board’ was established in 1938. In 1967, all transportation agencies were brought under the Department of Transportation, and the new NTSB moved with them. Recognising the importance of independence in investigation, the NTSB was established as an independent entity in 1974.

Regulation and investigation have developed in much the same way in different countries, and there are two key characteristics of all investigation agencies: they (usually) have independence from the regulator but they have no power to mandate action; they simply make recommendations, and it is for the authority to act. From a systems perspective, an accident, especially, and some very serious incidents represent a special case of failure given that extreme events are uncommon. During an investigation, the limitations of regulation and oversight are often exposed and, thus, the process provides important feedback.

The demands of an investigation can create tensions between different agencies. A simple example would be the fact that a fatal accident crash site is technically a crime scene until the legal authorities have been satisfied that no illegal act has been committed. The idea of preserving evidence is relevant to both criminal and air accident investigations. In a legal sense, evidence must also be quarantined so that, in the event of prosecution, it can be presented in such a way that no claim can be made that it has been tampered with or manipulated. Investigating an accident requires the evidence to be handled differently. In the event of a fatal accident, a Coroner’s Court is usually convened to establish who died and how they died. Again, in an aircraft accident, the coroner often defers to the investigating agency. Any contradictions between these different agencies are dealt with through agreements and memoranda of understanding (MoU). The key issue here is that accident investigation occupies a space between multiple agencies with, often, conflicting requirements. The tensions that arise from this will be explored later.

Reuss (2016) makes the point that accident investigation has historically focused on the technical issues but changes in our understanding of failure mean that the challenge now is to understand the relationship between humans, technology and organisations. He also points out that investigations are increasingly being influenced by the media, the views of family members of victims and, paradoxically, the challenge of cooperation between departments and agencies. Hutter and Lloyd-Bostock (2017) identify two key changes in safety regulation. First, risk regulation is becoming supranational - we have to comply with rules that are negotiated across multiple jurisdictions - and, also, is increasingly driven by non-state actors. They also observe that investigation has shifted away from ‘what happened and why’ to ‘how to anticipate what might happen next and stop it’. On this latter point, society has become increasingly intolerant of failure. As such, a catastrophic loss is seen as an affront, and victim groups demand reparations: someone has to pay. Interestingly, victim groups - an example of a non-state actor - can often be more effective at imposing demands upon regulators than accident investigators are able to. After a Bombardier Dash 8 Q-400 crash at Buffalo, New York, in 2009 (NTSB, 2010), families lobbied the US Congress for, among other things, tighter rules on pilot experience requirements for employment, a factor that had nothing to do with the original accident (Zremski, 2019). Level 5 in my hierarchical systems model - the Environment - includes those factors that influence behaviour in the system but are not, in turn, influenced by those subordinate elements. Aviation authorities are subject to political control and, while acting as an independent body, nonetheless have a political master. Authorities are also exposed to public scrutiny. Equally, investigation agencies are notionally independent, but environmental factors can shape the relationship between regulators and investigators and ultimately, the industry itself, as we will see in the next case study.

 
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