AAP investigating

3.2 Internal Safety investigation

From the CASA CAAP SMS - 1(0)
From the CASA CAAP SMS – 1(0)

Critical to this element is all personnel understanding that an internal safety investigation is NOT about apportioning blame to individuals following an incident or accident.  Rather, it is about establishing a Root Cause for it, and therefore strategies and defenses to prevent it occurring again.  While every accident and incident must be reported, not every one needs to investigated.  Further, not every investigation needs to be total.  There may be instances where only certain aspects (such as the HF contribution) needs to be analysed and investigated. Resources may be limited (particularly time) so the outcomes need to identify systemic risks and hazards to an organisation. The SMS manual should contain the procedures and process to an investigation.  Specifically it should detail;

  • The scope of the investigation
  • All personnel involved in the investigation
  • Any SMEs required
  • Recording of the findings
  • Any trend analysis
  • Which personnel need to be interviewed
  • The timeframe for completion
  • How the outcomes will be communicated within the organisation

 Any investigation needs to determine the factors that contributed to the incident, not just focus on the incident itself. The active failures need to be corrected, but it is the root cause analysis and remedial action to prevent re-occurrence that provides the greatest long term benefit. Click to download Root cause analysis national unit of competencyBuilding SMS 3

Human Factors input

When conducting an investigation, there will always be some form of Human Factors involvement.  The use of the SHELL model or the Reason model is useful in determining where the HF breakdown occurred or which HF defense failed.

SCHELL model
Adaptation of Shell model
Reason Model adaptation
Adaptation of the Reason model