2nd International Cross-industry Safety Conference 02-03/11/17

Amsterdam University of Applied Sciences-AVIATION ACADEMY

 

 The impact of knowledge on perception’s credibility: the case study of accident investigators

 

 

Abstract

 ICAO Standards and Recommended Practices, for air accident investigation, aims to avoid re-occurrence, thus the prevention accidents/incidents in the future. Basic factors for a credible comparability between various accident reports are two parameters. First, the investigators’ perception-one of its basic determinants is their knowledge-and second a common structure and methodology of reporting the findings, conclusions and recommendations. Our research pursue to determine: whether ICAO guidelines for investigators training syllabus, includes the proper and adequate knowledge for investigators, to fulfill ICAO provisions, regarding the impact of managerial functions on a/c operation and on accident occurrence. A review of numerous of final accident reports, indicates a confusion-misunderstanding, as the managerial functions affected the accident, either may not mentioned, in the final accident report, and or are allocated in fields other than the appropriate and or are allocated in various irrelative fields. This fact obstructs shaping a unified readers’ perception, regarding the ICAO’s provision that is the impact of managerial functions on a/c operation and accident occurrence. It is obvious that the aforementioned confusion, has negative impact on the credibility and comparability of the accident reports and finally on aviation safety. Furthermore, factor for a credible comparability between various accident reports is the clarity of final accident report format. In our case it concerns the investigators’ obligation to report information regarding management functions, in different paragraphs. Third, is the adequacy of investigators’ job specialties/qualifications, description? Fourth factor is ICAO Final Accident Report Format, to ensure that in each paragraph are reported comparable facts. In our case it concerns the   coexistence in the same paragraph, of state authorities (whose role is to issue certificates-licenses) and to perform oversight on the private organisations and private corporations which acquire license from state authorities by whom are controlled.

 

Key words

Aviation-accident-investigation, aviation-safety, Aviation-corporate-management-functions, aviation-accident-investigators-training, ICAO-final-accident-report-format.

 

Methodology

  1. Study ICAO’s references, documents and circulars, concerning the:
  2. objectives of air accident investigation and the training guidelines-syllabus for Accident Investigators
  3. Comparison between ICAO guidelines for investigators training syllabus (ICAO Circ. 298) and what the investigators are required by ICAO to investigate and report, in regards to the impact of managerial functions e.tc., on a/c operation and accident occurrence (Annex 13 Appendix 1 & ICAO Doc. 9756 Appendix 1).
  4. Research of weather the accident investigator training syllabi of five accident investigator training organisations, include the corporate management functions.
  5. Research on the subjects that are reported at 50 intercontinental final accident reports, regarding “Organizational and managerial information” and comparison with the relative ICAO provisions.  (Annex 13, Appendix 1. Par.1.5. & 1.17)
  6. Research of whether ICAO description of investigators job specialties qualifications is adequate or allows “grey areas”.
  7. Research on whether the coexistence in the same paragraph, of state authorities and private corporations, (ICAO provisions of Annex 13 Appendix 1 Par 1.17.)  contribute positive on the clarity of conclusions.

 

Aim of the paper

Aim of the paper is to determine:

  1. Whether ICAO guidelines for investigators training syllabus, includes the proper and adequate knowledge for investigators, to fulfill ICAO provisions regarding the impact of managerial functions on a/c operation and on accident occurrence.
  2. Whether the final accident report format, obliges investigators to report managerial functions in different paragraphs.
  3. Whether the description of investigators’ job specialties/qualifications, contribute positively on aviation safety.
  4. Whether the coexistence in ICAO Final Accident Report Format, at the same paragraph, state authorities (controllers) and private corporations (controlled), contributes positively on the clarity of conclusions  (ICAO Annex 13 Appendix 1.17, Doc 9756 Part IV reporting Appendix 1 to Chapter 1, 1.17.1.).

 

Discussion

Some of the basic determinants necessary to fulfill ICAO’s provision for enhancing aviation safety -regarding accident investigation are:

  • Credibility and comparability of Final Accident Reports,
  • Final Accident Report format to ensure the readers’ unified presentation of each object,
  • Absence of “gray areas” in the description of the investigators’ job specialties’ and qualifications.
  • To avoid comparisons among facts-which although seem to be similar, however come from different causes.

ICAO’s provisions regarding the determination by investigators of the managerial functions’ impact on a/c operations and on accident occurrence. (Guidance Doc 9756 Part IV reporting Appendix 1 Chapter 1.17.1., 1.17.2., 1.17.3. & Annex 13 Appendix 1 Par. 1271.17.2. & 1.17.3.)

 

“Organizational and management information.

1.17.1. Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example: the operator; the air traffic services; airway, aerodrome and weather service agencies; and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices, and regulatory framework[…].

[…]1.17.2 When deficiencies in the organizational structure and functions had a bearing on the accident[…]

[…] 1.17.3 When relevant, provide pertinent information concerning the operator, such as type and date of issuance of the air operator certificate, types of operations authorized, types and number of aircraft authorized for use, and authorized areas of operation and routes. Also, include information concerning any deficiencies found in the operator’s company operations manual and other operator documentation, when the deficiencies had a bearing on the accident.[…]”

ICAO’s provision regarding the necessity-generally-of proper and adequate knowledge’s acquisition

“[…] 4. Qualified technical personnel

4.1 The State shall establish minimum qualification requirements for the technical personnel performing safety-related functions and provide for appropriate initial and recurrent training to maintain and enhance their competence at the desired level.[…]” (Annex 19 Appendix 1. Par 1.4.).

“[…]Since the outcome of an accident investigation is largely dependent upon the aviation

knowledge, skills and experience of the assigned aircraft accident investigators, they should have: […] the ability to identify and analyse pertinent evidence in order to determine the causes[…]” Doc 298 Chapter 2 BACKGROUND EXPERIENCE FOR INVESTIGATORS Par. 2.4.

Are the investigators trained to acquire the proper knowledge to fulfill ICAO provisions regarding the impact of the managerial functions on a/c operation and on accident?

ICAO ACCIDENT INVESTIGATION TRAINNING COURSE neither in BASIC nor in ADVANCED COURSE includes any lesson regarding aviation corporate management and its functions. This absence indicates that investigators are not trained relative to managerial functions, although ICAO requires from them, to determine the impact of managerial functions on a/c operation and on accident occurrence. (Guidance Doc 9756 Part IV reporting Chapter 1 Appendix 1. Par. 1.17.1, 1.17.2. 1.17.3.)

Which are the consequences due to the absence from investigators of the adequate and proper knowledge relative to managerial functions?

Results of our research from a sample of 50 final accident reports (see bibliography), regarding reporting of “Organizational and managerial information”. (ICAO Annex 13. Appendix 1, Par. 17.)

Remarks upon how “organizational and managerial” information is presented by investigators at ICAO final accident reports.

Australia (ATSB) do not follow ICAO final accident report format. Information regarding managerial functions are reported in various paragraphs, fact which break the unification consequently, arises confusion on readers perception.

From a sample of thirteen Canadian (TSB) accident reports, regarding major accidents airline jets, five of them (41.66 %) did not have information under the title “organizational and managerial” of ICAO final accident report format (as described in Annex 13 Appendix 1)

From 24 USA-NTSB, European and Asian final accident reports:

8.33% did not contain information at the “organizational and managerial” of ICAO final accident report format (as described in Annex 13 Appendix 1)

12.5% the “organizational and managerial” paragraph, were filled in 8-10 lines with a brief profile of the operator involved in the accident

The rest, at the “organizational and managerial” paragraph of ICAO final accident report   were reported information relative to:  a/c technical standards, flight procedures, cockpit and cabin crew duties, evacuation procedures, Crew Resource Management, personnel training,

medical certification process for flight crews, psychiatric evaluation during medical certification of flight crews, operator’s crew Schedule Information, corporate organizational structure, members of hierarchy, national and international legislation, authorities Oversight,

technical findings on the a/c, hazardous materials, operator’s previous accidents, aircraft deicing program (ground), Cockpit door security, ATC, flight plan data (control strips),

radar system of ACC, Situation in the control room at ACC, organisation of the night shift at ACC, management tasks during the night shift, the radar controller, Audit Information, Aviation Section Policies, procedures, and practices, description of the accident, conditions of the accident, Corporation’s economic state, structure of

operator’s network and frequencies, human factors theory, refueling procedures e.tc.

The majority of the aforementioned information has not any direct relation with the required by ICAO, impact of managerial functions on a/c operation and on accident.

The methodology, with which the aforementioned information is reported, interrupts the unification of the reader’s perception, because is reported among other irrelevant information.

The aforementioned way of reporting by the investigators-as result of their ignorance-of the content and the essence of the “organizational and managerial functions” do not contribute positively:

  • at the comparability and credibility of accident report,
  • at the fulfillment of ICAO requirement for determination of the impact of managerial functions on a/c operation and on accident.
  • at implementing of ICAO supreme target which is enhancing aviation safety

Our research on accident investigators training syllabus, of five major accident investigator training organisations

Having in mind the ICAO guidelines, we reviewed five well reputable organisations provide relevant accident investigators training. These were: ΙΑΤΑ, ISASI, The Cranfield University, Embry-Riddle Aeronautical University and University Southern California.

The aforementioned five well reputable accident investigator training organisations do not include in its publically available syllabi (Relative Aviation accident investigators training syllabi, published on internet, October 2017), the lesson of “corporate management and its functions” although ICAO requires from investigators to determine its impact on a/c operation and on accident.,

A dilemma that our research attempts to address regarding accident investigators knowledge relative to organizational and managerial functions, (Annex 13, Appendix 1. Paragraph 1.17.) Is whether investigators must record in accident reports their personal opinion which is not based on knowledge but on other subjective associations (considerations), or to deposit their personal opinion which is based on their knowledge. Which of the above two approaches contributes positively on aviation safety?

Plato, 2500 years ago, had replied the aforementioned dilemma, as follows: How will you investigate something you don’t know? And if, by chance, you meet it, how will you know that it is the thing you are searching? (a) Plato

The procedure through which is shaping the perception of a person regarding an object, a fact e.tc.

Human perception is mental process, which is in continuous interaction with other mental processes. Perception gives the ability to the human to be aware of the properties and the form of an object, fact, person e.tc. of our external and or internal environment. This is a result of comparison, between the entering stimuli, with the already stored in the sensory stores, from the past, of knowledge and experience. In psychology, object is defined everything that can stimulate senses-emotions. Perception is crucial and necessary presupposition for the cognitive process. (Sternberg 2007a)

The perceptions’ shaping, procedure, is composed by the following phases: Sternberg 2007 b)

  • observation-attention (stimuli from the environment),
  • creation of the cense,
  • transmission of stimuli through neurotransmitters to the proper encephalon’s fields,
  • classification of the stimuli (characteristics and properties of the object) in the conscious
  • comparison of the characteristics and properties of the object (stimuli) with the already registered in the proper sensory stores, knowledge-experiences from the past. This comparison results at the understanding and explanation of the object.
  • transmission of the conclusions at the proper fields of encephalon to give the proper orders at the neuron system of the body in order to stimulate the required reactions.

Factors influencing the functional level of perception (Hayes 1998, Lippa 1997,  Sternberg 2007 b).

The following factors (that among others) influence the process of perception are the subjective (emotional state, level of knowledge, previous experience, level of intelligence and consciousness, cultural environment, expectations, motives, values, attitude e.tc)  and the objective  (natural conditions, intensity, simplicity or complexity of the object).

Knowledge-experience as a basic determinant of perception (Hunt 1992, Lainos & Nikolaidis 2003, Sternberg 2007 b).

Knowledge includes (theoretical and practical-experience) that is: the characteristics, the properties, the theoretical principles of evolution – the actual evolution during a particular period of time, the relationships-interactions-consequences of the environment (objects, events, situations). Knowledge is a basic determinant of perception’s-comprehension’s quality. Consequently, it affects decisively the quality of decision-making and therefore the effectiveness of the action. Knowledge is useful only if it can facilitate the understanding of the environment (close and wider). A human being based on his knowledge, may then proceed to decision-making and action towards the fulfillment of a goal.

The optimum quantity of information relative to a particular environment depends on the user’s biological, psychological and cognitive abilities to perceive, understand and to process accordingly. The support provided by the available machinery and electronic means enlarges these abilities. Excessive, unnecessary information especially if it is irrelevant may cause additional ambiguities to the user, affecting the objectivity of his-her perception and also causing further delay to decision making. The user’s inability to process the available quantity and quality of information, results to a lower quality of situation awareness, instead of a higher one, to additional delay of decision making and acting. This can be described as “analysis-paralysis”.

Comprehension-understanding, is the result of a very complicated process. It concerns the correlation between information perceived and stored in the user’s memory. This information is relative to objects, events, situations perceived (developing a mental picture) from the environment through the senses.

For example when, during an aerobatic air-show an airplane dives vertical to the ground, the observer considers this to be an acrobatic maneuver. If however the same observer sees a commercial airplane at the same position, he-she rather considers that it is going to crash. These two different considerations are a result of the correlation between the position of each airplane and its characteristics, properties etc. that the observer has stored in his-her memory.

The reliability, credibility and objectivity of human understanding, is based-further to physical and mental functions-on the determination of the percentage of the understanding. This is based: on known information, on assumed information, on known ignorance (when we are aware of our ignorance) and on unknown ignorance (when we are not aware of our ignorance). (b) Plato “Alcibiades” It must be noticed that the absolute perception of the objective reality, is impossible for every individual, due to the infinity of the external stimuli towards the human organism and the limited capabilities of the human organism, especially of the:

  1. a) human senses to recognize these stimuli,
  2. b) nervous system to transfer these stimuli to the proper brain fields
  3. c) brain fields to process these stimuli

The relationship between opinion and knowledge

The decisive impact of knowledge on shaping of a credible or not opinion, has been pointed out by the ancient Greek philosophers. They considered that knowledge and opinion have different objects and different functions. (Plato c), different aims and different results depended on its different powers” (Plato d). There is not any chance to be the same thing, what we really know and something we imagine (Plato e). Knowledge is an infallible power- Opinion is a fallible power (Plato f). The opinion which is not based on knowledge is fallible and uncertain, so it guides its users at fallible and uncertain decisions. (Gorgias Helen). We consider that a human knows-understands the fact, if he possesses the scientific knowledge of its primary cause. (Aristotle a). We cannot recognize something, unless we have acquired previously, the knowledge about it. (Plotinus). It is obvious that if investigators’ opinion is not based on previously acquired knowledge but on other subjective associations-considerations, they will be guided at error commitment.

Associations Recollection, retrieve, is when we relive-even beyond our will (Aristotle b) (that is unconsciously)-what we saw or suffered in the past, based on succession of stimuli. (Plato g) Aristotle d), Plotinus.  What we recall at our memory is necessary to have already learned then in previous time (Plato h). How will you investigate something you don’t know? And if, by chance, you meet it, how will you know that it is the thing you are searching? (Plato a).

Which is the process of recollection? One must get hold of a starting-point. The cause is that they pass swiftly in thought from one point to another, e.g. from milk to white, from white to mist, and thence to moist, from which one remembers Autumn (the ‘season of mists’), if this be the season he is trying to recollect. (Aristotle c)

Pavlov (1849-1936)-Classical conditioning, Sigmund Freud (1856-1939)-free associations, Thorndike (1874-1949)-Operant conditioning, Watson (1878-1958)-Classical conditioning, Skinner (1904-1990)- Operant conditioning, Bandura (1925- )-social learning, brought in 19nth and 20th century and developed the ideas of Plato and Aristotle regarding “associations”. (Lainos 2008)

Association in contemporary psychology is defined as a mental process regarding connection between concepts, events, or mental states, which are usually stimulated by previous specific knowledge-experiences. (Klein, Stephen 2012).

  1. Our research concluded that ICAO Final Accident Investigation Report’s Format, obliges investigators to report information regarding managerial functions in different paragraphs:

– Annex 13 Appendix 1. Paragraph 1.5. and Paragraph 1.17, and in

– DOC 9756   Appendix 1 Par. 1.5 & 1.17

In “[…] Annex 13 Appendix 1. “1.5 Personnel information :

– Pertinent information concerning each of the flight crew members who involved in the accident.

– Brief statement of qualifications and experience of other crew members.

– Pertinent information regarding other personnel, such as air traffic services, maintenance, etc., when relevant.[…]

1.17 Organizational and management information. Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft.“ In “Doc 9756 Appendix 1

 

1.5 Personnel information

1.5.1 Provide a brief description of the qualifications, experience and history for each flight crew member (pilot, co-pilot and flight engineer) including age, type and validity of licenses and ratings; flying experience (total hours), types, flown and hours on the type; hours flown in the last 24 hours, 7 days and 90 days prior to the accident; results of recent training and mandatory and periodic checks; experience on route and aerodrome involved in the accident; relevant information on duty time and rest periods in the 48 hours prior to the accident; significant medical history and medical checks. Also, state the position occupied by each flight crew member and identifies who was flying the aircraft.

1.5.2 When relevant to the accident, give a brief statement of the duties and responsibilities of the cabin crew, as well as their qualifications, experience and training. For example, these details would be relevant if the accident involved an evacuation of the aircraft.

1.5.3 When relevant to the accident, include a brief statement of the validity of licenses and ratings, the qualifications and experience of air traffic services personnel, including age, position manned, total experience (in years), and details of experience specific to the position manned. Details of training and pertinent checks should be included, as well as duty times and rest periods in the 48 hours prior to the occurrence.

1.5.4 When relevant to the accident, information on maintenance personnel and other personnel involved should include qualifications, experience, time on duty, shift work rosters, workload and the time of the day.

1.5.5 When relevant to the occurrence, this section would also include information on any personal or medical factors that could have influenced human performance.

1.5.6 Use subheadings, as appropriate, to organize the information in this section. […]

1.17 Organizational and management information

1.17.1 When relevant to the accident, provide pertinent information on any organization and its management whose activities may have directly or indirectly influenced the operation of the aircraft.”

However, the term “management” mentioned by ICAO provisions (In Annex 13 Appendix 1 Par 1.17 and Doc 9756 Appendix 1 Par 1.17.), is consisted by its five functions the third of which is “Staffing” which is identical with ICAO term “Personnel”

3) In ICAO Cir 298 ICAO’s Annex 13 (in Manual of Aircraft Accident and Incident Investigation 1-2-2 Paragraph 2.4.3.) and in Doc 9756 are mentioned provisions relative to investigators’ job specialty’s qualifications.

Our research determined limited and somehow one could argue inadequate information regarding description of investigators’ job specialties qualifications. For example, are mentioned job specialties of pilots, a/c engineers, doctors, e.tc. without, however, determination of further detailed qualifications could be: for pilot’s a/c type, flight hours per type-for a/c engineers, a/c types, and years of experience per a/c type, for doctors’ specialty and experience e.tc.  Furthermore, is not mentioned weather the investigator must be specialized at the type of the investigated a/c.

 

4) In ICAO’s accident investigation final report format, coexist in the same paragraph state and private owned organisations.

In ICAO Annex 13, Appendix 1 Par. 1.17 and Doc 9756 Part IV reporting Chapter 1 Appendix 1 paragraph 1.17.1., our research, based on the criterion of ownership regime, determined two categories of organisations with essential different roles and targets:

-State authorities, whose role is to issue certificates-licenses and to perform oversight on the private organisations, whether they comply with existing legislation/regulations. Its main target is maintaining and enhancing, were necessary, aviation safety and

Private organisations, which are certified by the state authorities which perform the oversight.

Furthermore, private organisations target is maintaining and enhancing were necessary, of aviation safety, however the primary strategic target is its profits’ maximization.

“1.17 Organizational and management information

1.17.1 When relevant to the accident, provide pertinent information on any organization and its management whose activities may have directly or indirectly influenced the operation of the aircraft. The organizations to be addressed in this section could include:

  1. a) operator;
  2. b) maintenance organizations;
  3. c) air traffic services;
  4. d) aerodrome administration;
  5. e) meteorological services;
  6. f) aircraft manufacturer;
  7. g) certification and licensing authority; and
  8. h) regulatory authority.”

 

The five functions of scientific management (Fayol 1917, Urwick 1937, Koontz-  O’Donnell 1959, Montana & Charnov 1993)

The functions of the corporate management are: Planning, Organizing, Administrating,

Staffing, and Controlling. These functions pursue the achievement of corporate goals based on the economic principle, which is the maximization of the profits with simultaneously minimization of the cost. The knowledge of the functions of the corporate management, its consequences on the influenced areas of the internal corporate environment and its impact on the employees’ volition, is a basic determinant of the investigator’s opinion shaping, about the primary cause(s) and contributing factors of the accident incident (Lainos 2003).

Classification of the “managerial and organisational” factors,  (ICAO’s Annex 13 Appendix 1 para 1.5. & 1.17 Guidance Doc 9756 Part IV reporting Chapter 1) according to the structure of managerial functions.

As we may see in table 1 below, we show which functions as described by ICAO corelate to the theoretical managerial functions. More detail, we may see that safety culture is included in programming and administrating, resources and financial viability is associated with programming , administrating and controlling and so forth.

 

1.17.2.

  1. safety culture; Programming, Administrating
  2. resources and financial viability; Programming, Administrating-Controlling
  3. management policies and practices Programming, Administrating
  4. internal and external communications Programming, Administrating
  5. certification, safety oversight and regulatory framework. Programming

 

Organising-Controlling

Therefore our research concluded that ICAO Final Accident Investigation Format obliges investigators to report information regarding managerial functions, in different paragraphs: Annex 13 Appendix 1. Paragraph 1.5. and Paragraph 1.17., although “Staffing” which is the same with ICAO “Personnel” is the third of the five managerial functions.

ICAO’s Final Accident Investigation format ANNEX 13 Appendix 1. requires organizational and management information to be reported in Par. 1.17. while Personnel information, in  Par. 1.5.

 

Results

  1. The investigators are not trained to acquire the proper knowledge to fulfill ICAO provisions regarding the impact of the managerial functions on a/c operation and on accident.

We agree with the ICAO principle-mentioned in Annex 19, that the investigators must be appropriate trained at the desired level. It is obvious that the appropriate and desired level of training, concerns the compatibility of the acquired knowledge by investigators, with the ICAO provision, for investigators to determine “deficiencies in the organizational structure and functions had a bearing on the accident.” Consequently, the appropriate and desire level of investigator training must include the impact of the managerial functions (Lainos 2003) on a/c operation and on accident occurrence.

However, as our research proved, that the investigators, are not trained upon the aforementioned issue. As result of their ignorance regarding managerial functions, they may base their perception during investigation, on subjective associations-considerations. This will happen because the information, which they recall in their memory, is necessary to have been learned previously. (Plato Phaidon). What is the content of those subjective associations and what is its impact on shaping of a credible investigators’ perceptions’?  And which would be the credibility of the accident report based on subjective associations of each one of the investigators which is not based on their relevant and adequate knowledge? Investigator during investigation, receives mainly visual stimuli from a/c wreckage and other corporate documents. Investigators compare these stimuli with the knowledge-experience, which is already stored from the past in his-her brain stores. The result of this comparison is the creation of associations, which shape the investigator’s perception. From what factors will be shaped the investigators perception if there are not stored in their brain stores, of the proper knowledge to be compared with the incoming stimuli? Which associations will be created? There is not other reply than the subjective considerations of each investigator other than knowledge. What is the impact of-other than knowledge-subjective associations regarding the impact of the managerial functions on a/c operation and on accident? Does the absence of the relative knowledge from investigators, contribute positively on enhancing of the aviation safety? The ancient Greek philosophical psychology and the contemporary psychology as well, have concluded at the same thesis. When our subjective associations-considerations are not relied on knowledge we will commit error. (Lainos 2017). That is why it is obvious that ICAO accident investigators training syllabus guidance needs to include a lesson relative to corporate managerial functions.

  1. B) The ICAO Final Accident Investigation Report Format, obliges investigators to report information regarding managerial functions in different paragraphs: (As the text in Annex 13 Appendix-Paragraph 5. and Paragraph 17). does not contribute positively at:
  2. i) the unified presentation of the information relative to managerial functions of the involved organisations which directly or indirectly influenced the operation of the aircraft and the accident occurrence.
  3. ii) the unification of the readers’ perception relative to the accident’s main causes and contributing factors (confuses the readers).

Consequently, ICAO needs to amend the Accident Investigation report format regarding managerial functions, so to unify structure of scientific corporate management functions

  1. C) The description of investigators job specialties is inadequate (as described in Doc 9756 Chapter 2. Paragraph 2.4. “Personnel”)

The information regarding investigators’ job specialty’s qualifications, maybe characterized as limited-inadequate. This will result in absence of adequate and proper knowledge of the investigators. Moreover, this absence of knowledge does not have positive contribution on credibility along with the comparability of accident reports and finally on aviation safety. That is why ICAO needs to build a more detailed description of the investigators job specialties qualifications. For example for pilots: a/c type, flight hours per type-for a/c engineers a/c types, years of experience per type, for doctors’ specialty and experience e.tc.

  1. D) The investigators’ obligation to report in the same paragraph of Final accident Report Format, information come from state authorities and private corporations regarding: “activities may have directly or indirectly influenced the operation of the aircraft.” (Text in Doc 9756 Appendix 1. Par 17.1 Organizational and management information) may arise confusion to the readers.

However due to different ownership regime, of state owned and private corporations, their role and targets are different.

Consequently, the results of their activities even if they seem to be similar, their origin comes from different sources. This fact discriminates them, because similar results (for example Personnel malfunctions), come from different causes-sources (state authorities and private organisations) are not comparable. «[…] We must acquire the scientific knowledge of the primary causes (because only then we consider that a human knows, when he acquires the primary cause […]».(Aristotle f). «We cannot say that we know an object before we understand for what it has happened […]».(Aristotle g)

Consequently, these investigation results of managerial functions of organisations with different ownership regime are co-presented in the same paragraph-as it required in the aforementioned ICAO publications.  This may cause confusion of the reader’s perception. They may perceive that these results have the same cause (managerial functions).  Consequently, they may conclude that in order to correct them we must apply the same measures. This approach-conclusion is not necessarily correct. This fact has not a positive contribution on aviation safety. That is why ICAO needs to amend Accident Investigation Final Report Format so the results of managerial functions of state authorities and private corporations, to be reported separately (in different paragraphs).

 

 

Appendix 1

1.1  Final Accident Reports investigated

ASIA

1) KOMITE NASIONAL KESELAMATAN TRANSPORTASI PT. FINAL KNKT.14.12.29.04. PK-AXC Republic of Indonesia 28 December 2014

2) Bandaranayke International Aircraft, Katunayake, Sri Lanka  Accident 16th Oct. 2005

3) AirAsia QZ8501 A-320 Crash: Final Report Points to Faulty Component, Crew Action

4) TransAsia Airways Flight GE235 accident Final Report Released on Jul 1st, 2016.

AUSTRALIA-ATSB

1) Transport Safety Report Aviation Occurrence Investigation AO-2014-043 Final-13 November 2017.

2)  ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-039 Final – 5 September 2017

3) ATSB Final Investigation AO 2016-045 September 2017

4) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-051 Final – 30 August 2017

5) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-012 Final – 27 July 2017

6) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-079 Final – 17 November 2017

7) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-034 Final – 18 September 2017.

8) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2017-051 Final – 30 August 2017

9)  ATSB Transport Safety Final Report AO-2014-081 1 June 2017

10) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2016-167 Final – 24 May 2017.

11) ATSB Transport Safety Report Aviation Occurrence Investigation AO-2016-173 Final – 27 April 2017.

12) ATSB Transport Safety Report. Aviation Occurrence Investigation. AO-2016-169 Final – 24 March 2017.

13) ATSB Transport Safety Report External Aviation Final Investigation AE-2014-054-  . Published 3 October 2017. Operator Malaysia Airlines. Vanishing in March 8, 2014

 

1.2 CANADA-TSB

1) AVIATION INVESTIGATION REPORT A16Q0020. 03 February 2016

2) AVIATION INVESTIGATION REPORT A16O0016. 30 January 2016

3) AVIATION INVESTIGATION REPORT A16A0041. 20 April 2016

4) AVIATION INVESTIGATION REPORT A15Q0120. August 2015

5) AVIATION INVESTIGATION REPORT A15Q0075. 05 June 2015

6) AVIATION INVESTIGATION REPORT A15H0002. 29 March 2015

7) AVIATION INVESTIGATION REPORT A15F0165. 30 December 2015

8) AVIATION INVESTIGATION REPORT A14W0127. 04 AUGUST 2014

9) AVIATION INVESTIGATION REPORT A14Q0155. 07 October 2014

10) AVIATION INVESTIGATION REPORT A14O0165. 05 SEPTEMBER 2014

11) AVIATION INVESTIGATION REPORT A14H0002. 05 JUNE 2014

12) AVIATION INVESTIGATION REPORT A14F0065. 10 May 2014

13) Aviation Investigation Report A05H0002. 02 August 2005

 

EUROPE

1) HELLENIC REPUBLIC (AAIASB) AIRCRAFT ACCIDENT REPORT HELIOS AIRWAYS 14 AUGUST 2005 11 / 2006

2) Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile Final Report Accident on 24 March 2015, operated by Germanwings

3) German Federal Bureau of Aircraft Accidents Investigation: Accident Date: 1 July 2002 Type of aircraft: 1. Boeing B757-200 2. Tupolev TU154M

4) SWISS Federal Department of the Environment, Transport, Energy and Communications No. 1781 Final Report of the Aircraft Accident Investigation Bureau

5) Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. Final report AF 447, Published 27 July 2012

6) Civil Aviation Department Hong Kong. July 2013. AIRCRAFT ACCIDENT REPORT 2/2013

7) Foreign Investigation Authority: Dutch Safety Board (DSB). Final Report: Tuesday, 13 October, 2015. Accident involving Operator Malaysia Airlines, Flight MH17, Hrabove Ukraine, crash 17 July 2014. Donetsk

 

 

U.S.A. -NTSB

1) Accident Number: DCA11PA075

2) Aircraft Accident Report Asiana Airlines Flight 214 Boeing 777-200ER, HL7742 San Francisco, California July 6, 2013

3) Aircraft Accident Brief. Pilot/Race 177. The Galloping Ghost North American P-51D, N79111 September 16, 2011

4) Aircraft Accident Report. Pilatus PC-12/45, N128CM. March 22, 2009

5) Aircraft Accident Report GCI Communication Corp. de Havilland DHC-3T, N455A. August 9, 2010

6) Aircraft Accident Report, N606SP June 9, 2009

7) Aircraft Accident Report Empire Airlines Flight 8284 N902FX. January 27, 2009

8) Aircraft Accident Report. East Coast Jets Flight 81 Hawker Beechcraft Corporation July 31, 2008

9) Aircraft Accident Report Pinnacle Airlines Flight 4712. N8905F April 12, 2007

10) Aircraft Accident Report Southwest Airlines Flight 1248, N471WN

11) Aircraft Accident Report Corporate Airlines Flight 5966, N875JX October 19, 2004

12) Aircraft Accident Report NTSB/AAR-04/02 PB2004-910402 Notation 7501B July 26, 2002

 

 

Bibliography (alphabetically)

Aristotle (a) Small physics-On memory and recollection L.451b 10-33

Aristotle (b) Small physics-On memory and recollection L 451a 30-31

Aristotle (c) Small physics – On memory and recollection. L. 452a 13-16

Aristotle (d) Small physics-On memory and recollection L.451b 24-25

Aristotle (e) Metaphysics L. 983 a 27-29

Aristotle (f) Metaphysics L. 983a 27-29.

Aristotle (g) Metaphysics L 983a 30-35.

Bandura, A. (1963). The role of imitation in personality, The Journal of Nursery Education, 18(3).

Bandura, A. (1977) Social learning theory. Englewood Cliffs, NJ: Prentice Hall.

Gorgias Helen’s commendation.  L. 8-12

Fayol, Henry. (1917). General and Industrial Management. Dunod et E. Pinat.

Hayes N 1998, Foundations of Psychology-An introductory Text. Greek Edition Ellinika  grammata. Athens Greece

Hunt, J. W. (1992) Managing People at Work: a manager’s guide to behavior in organizations, 3rd edition. McGraw-Hill, London.

ICAO Basic Accident investigators training Course 4.2. Advanced Course.  Recommended topic ICAO Doc 9756

ICAO Manual of Aircraft Accident and Incident Investigation 1-2-2

“ICAO ACCIDENT INVESTIGATION TRAINNING COURSE GUIDELINES: BASIC and ADVANCED COURSE of ICAO ACCIDENT INVESTIGATION TRAINNING COURSE GUIDELINES (ICAO. Cir 298 AN/172 Training Guidelines for Aircraft Accident Investigators Chapter 4. 4.1 BASIC COURSE 4.2 ADVANCED COURSE).

Klein, Stephen (2012). Learning: Principles and Applications (6 ed.). SAGE Publications

Koontz, H.-O’Donnell C. (1959) Principles of Management: An Analysis of Managerial Functions. McGraw-Hill,

Lainos Y.S. (2003) The impact of the airline top management functions on aviation safety in a Globalize environment. Annual Air Transport Research Society Conference. Toulouse-France

Lainos Y.S.-Capt. Elias D. Nikolaidis (2003) Présuppositions for effective introduction of changes to aviation safety culture, through crew resource management training program :  The case study of Olympic Airways

Lainos Y. S (2008) The compatibility of the two learning procedures established by the European Aviation Safety Agency (E.A.S.A.)  for the candidate aircraft engineers,      with E.A.S.A.’s aim for high uniform level of civil aviation safety. Proceedings of EAAP Convention. Valencia. Spain

Lainos Y. S. (2017) The “error” at the ancient Greek thought. Editions KAKTOS. Athens. Greece. (Greek language).

Lippa (1997) Introduction to social Psychology Second Edition. Brooks/Hall Publishing Co.

Montana P. & Charnov B.H. (1993) Management.  Barron’s Educational Series Inc. Hauppaug N.Y. U.S.A. (Greek language).

Pavlov (1927), Conditional Reflexes. New York: Dover Publications

  1. a) Plato, Meno. L. 80d 5-8,
  2. b) Plato, Alcibiades.
  3. c) Plato, “State” or “Republic’ L. 477b.
  4. d) Plato, “State” or “Republic’ L. 478a.
  5. e) Plato, “State” or “Republic’ L. 478b
  6. f) Plato, “State” or “Republic’ L. 478e.
  7. g) Plato, Meno. L.81d,
  8. h) Plato, Phaidon. L.72

Plotinus, Enneads. L.1, 6, 8-9.

Skinner, B. F. (1938). The Behavior of organisms: An experimental analysis. New York: Appleton – Century.

Sternberg 2007 (a) Cognitive Psychology Edition Atrapos.  P. 146. Athens – Greece. Greek language)

Sternberg 2007 (b) Cognitive psychology. Edition Atrapos. P. 168-178. Athens – Greece (Greek language)

Thorndike E.L. (1898), Animal intelligence An Experimental Study of the Associate Processes in Animals. Columbia University,

Urwick, Lyndall, (1937) Organization as a Technical Problem: The Function of Administration, with Special Reference to the Work of Henri Fayol

Watson J. B.   (1913). “Psychology as the Behaviorist Views it”. Psychological Review. 20: 158–177. Columbia.

Watson, J. B. (1930). Behaviorism (Revised edition). Chicago: University of Chicago Press.