World Conference on Transport Research Society
Istanbul. Turkey. July 4-8, 2004,
Presuppositions for upgrading the reliability and the comparability of the accident reports in order to upgrade aviation’s safety level
Yiannis S. Lainos Ph.D. in Aviation economics-management human factors
ICAO’s exclusive objective for air accident investigation is the prevention of future accidents/incidents. For an effective and efficient contribution to the upgrading of the aviation’s safety level, the various accident reports have to be comparable. A reliable comparability of the various accident reports requires a unified perception of the examined environment by the investigators. A unified methodology and structure of the presentation of the findings, conclusions and recommendations is also required. Reading the various accident reports one realizes that in each one of them, the different fields of the same managerial function are allocated in different paragraphs of the given structure. In the institutional framework that the ICAO has established regarding the air accident investigation report, the following presuppositions are defined:
- for being an investigator (the general qualifications of the investigators)
- for making an accident investigation and
- for presenting the results in the accident report (the structure of the accident report and the titles of the contents)
The lack of detailed description in the aforementioned information leaves space for differentiation of the investigators’ perception-knowledge-qualifications. Consequently, this weakness does not contribute positively to the maximization of the effectiveness and efficiency of the accident reports and finally to the upgrading of aviation’s safety level. (C2 Safety Analysis and Policy)
Aviation-accident-incident-final report, aviation-accident-investigation, aviation-safety,
Air-carrier-management-functions, determinants of human perception.
Aim of the paper
Aim of the paper is to determine:
- the vagueness of some sectors of the general framework, that the ICAO has established in order to set the presuppositions for being an investigator, making an accident investigation and presenting the results in an accident report. and
- the consequences of this vagueness on the reliability and comparability of the accident reports
The author’s contribution is:
- The determination of the existing vagueness at some sectors of the general institutional framework, that the ICAO has established, for the presuppositions of an accident investigation, and its negative consequences on the reliability and comparability of accident reports
- The proposals for overcoming the aforementioned vagueness and its negative consequences on the reliability and comparability of the accident reports and
- The methodology applied, that is the dialectic analysis and synthesis, which discriminates the symptoms from the causes, focusing on the primary causes. The specific methodology can be implemented efficiently to any similar case.
For an effective and efficient contribution to the upgrading of the aviation’s safety level, the various accident reports have to be comparable. A reliable comparability of the various accident reports requires a unified perception and comprehension of the examined environment by the investigators and a unified methodology and structure of the presentation of the findings, the conclusions and the recommendations. .
Reading the various accident reports one realizes that in each one of them the same issues are included in different paragraphs of the given structure.
Of course the absolute unification of the objectivity-reliability level of the perception of each investigator is not possible due to:
- the existence of factors that cannot be determined,
- the infinity of the stimuli by the environment towards the human organism
- the fact that the biological and mental abilities of the human organism are limited.
Among the determinants of the investigators’ perception, the ICAO mentions their general job specialty (doctors, pilots etc) and the minimum level of their knowledge (titles of the issues of the investigators training syllabus)
However it does not determine:
- the specific job specialty of the doctor (pathologist, psychiatrist etc), or the specific job specialty of the pilot (jet, tourboprop etc) and the specific aircraft type they have to be certified at, the duration and the field of their experience. This weakness has a negative impact on the unification of the investigators’ level of knowledge
- the content of each title of the syllabus, consequently the uniformity of the investigators’ level of knowledge
- the qualifications of the investigators’ trainers (the science the sector and the level of their knowledge and experience)
- the investigators’ psychological and physical health
The a,b,c, weaknesses contribute negatively to the uniformity of the investigators’ level of knowledge although, knowledge is a basic determinant of the quality of the investigators’ perception. The d weakness determines the objectivity-reliability of the investigator’s perception.
The problem of the ability, of the process and the determinants of the perception and comprehension of the environment by the human being, is one of the first and main issues that ancient Greek philosophy (Andriopoulos 2003) had faced. (Xenopfanes, Heracletus, Parmenides, Anaxagoras, Democretus, Plato, Aristotle etc.)
Two main aspects were posed from the beginning:
- the ability or the inability of the human being to have access to the cognition of the physical environment and
- the predominance either of the human senses or the human spirit as to their contribution to the cognition of the physical environment (Andriopoulos 2003).
Since then, the aforementioned problems that compose knowledge theory, have Been an integral part of any philosophical theory or system. (Windelband & Heimsoeth 1976). Research during the last (20th) century has concluded that: (Goleman 1995, Hayes 1994, Louria 1978, Papadopoulos 2003, Scharfetter 1976, Steanberg 1996)
- Perception is one of the mental processes of the human being
- The human’s mental processes involve: consciousness, attention, perception, memory, thinking, emotion, intelligence, learning, orientation etc,
- The parameters of the human mental processes are in a continuous interaction
- The senses are the gates through which the stimuli from the environment are transferred to the relative brain centers through the nervous system.
Consequently the identification of the causes of a particular level of perception requires the analysis into its parameters and the examination of each of these parameters separately. It is obvious that, due to the interaction of the various parameters of mental processes, a disorder in one of them, may cause the disorder of all the others in a different level and intensity This is the reason for our decision to make a brief presentation about: a) mental processes, b) the presuppositions of their regular function, and c) the determinants and the consequences of their disorder.
The present paper is focused on the determinants of the investigators’ perception-comprehension, including their level and areas of knowledge as well as the structure of the accident report, using as case study the paragraph 1.17. Organizational and Management information
Brief theoretical approach
“Investigation. (ICAO 2001)Α process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety recommendations.
Investigator-in-charge. (ICAO 2001) Α person charged, on the basis of his or her qualifications,with the responsibility for the organization, conduct and control of an investigation
”Qualifications” are defined as the totality of capabilities, theoretical knowledge and practical experience upon a particular cognitive field. The qualifications of every employee are basic determinants of his-her quality and of the quantity of the employees’ product in a particular period of time.
- The necessary presuppositions for the comparability of all accident reports
The necessary presuppositions for the fulfillment of ICAO’s goal regarding the accident investigation- prevention of future accidents/incidents- is the comparability of all accident reports filled in by every investigator all over the world. This reliable comparability of accident reports, requires the unification of the level of reliability for every region of the world, regarding the:
- perception-comprehension of the environment by the accident investigators
- qualifications of the accident investigators (job specialty, knowledge, experience)
- structure of the accident report
- titles of the chapters of the accident report
5) content of the chapters of the accident report
6) methodology of filling in the accident report.
We must make clear that an absolute unification of the level of the aforementioned factors cannot be achieved, due to the differentiation and limitation of the capabilities of human nature. However we consider that the existing difficulties should not stop us from continuing the effort to achieve the higher level of uniformity which contributes to a higher level of aviation safety.
3) The mental processes as determinants of perception (Goleman 1995, Hayes 1994, Louria 1978, Papadopoulos 2003, Scharfetter 1976, Steanberg 1996)
Human perception is the resultant, the unified expression of a totality of components of mental processes, which are in continuous interaction. To specify the causes of a particular perception’s level, this perception should be analyzed into its components and each component should be examined separately.
The mental processes that form each component of perception are: consciousness, attention, memory, thought, emotion, intelligence, learning, orientation etc.
It is obvious that, because of this interaction, the disordered function of one of them causes disorder to the others, in different levels and intensity.
Perception, like any other mental process, doesn’t function independently. The quality of its function is in relation with the function quality of all other interacting mental processes. Perception is the mental process, which, along with other mental processes, gives an individual the ability to be aware of external or internal objects, by means of stimuli, which are received by the sensory organs, transmitted to the brain and processed by it. In psychiatry an “object” is defined as anything that can stimulate emotions in a human being. e.g. an idea, a fantasy, a person, a material object, a situation, one’s own self etc. The process of perceiving an object is composed by the phases of: observation-attention (stimulus), sensation, transmission of the stimulus to the corresponding brain centers through the nervous system, encoding of the stimuli (characteristics and qualities of the object) within the consciousness, processing, understanding and interpretation according past knowledge and experience, and finally transmission of the conclusions to those brain centers that will then give our nervous system the orders for the various reactions of the organism. Consequently, perception is not a static process of a given quantity and quality, but it evolves dynamically through development (learning etc).
Only one part of objective reality is possible to be perceived. Full perception of objective reality cannot be achieved by a human being, because our senses are not aroused by a series of visual, auditory stimuli, vibrations, movements of particles, atoms, electrons etc. On the other hand, human brain has the capacity of processing a limited quantity and quality of information. Consequently, the limited ability of our senses to be aroused by the totality of stimuli from the environment, correlates with the ability of our brain to process them, in the context of the defense mechanisms of our organism.
Factors influencing the functional level of perception (Scharfetter 1976)
The following factors influence the process of perception:
- the subjective factor (emotional state, previous experience, level of knowledge, level of intelligence etc) and
- b) the objective factor (intensity, simplicity or complexity of the object).
Disorders of perception
Perception disorders may be caused by conditions such as:
- Organic disorders
1) of the receptive capacity of the sensory organs,
2) of the various brain centers (e.g. the individual can see or hear, but cannot recognize)
- Psychological disorders
1) Hallucination (perception of a non-existing object),
2) Illusion (distorted perception of an existing object).
“Consciousness” in psychiatry is described as the level of alertness of the individual and it is analyzed in two parts:
- the sensory part, which involves the ability of the individual to process the stimuli provided by the external environment and
- the kinetic part, which involves the ability of the individual to process stimuli of the external environment, to select the answer and finally give it.
In the course of this process, defense mechanisms are also involved. They act as a filter and decide which stimuli from the external environment will be kept in consciousness and which will pass into the subconscious. It is obvious that consciousness disorders affect every other mental process.
Consciousness disorders may be the result of:
- psychological causes (stress, fear, psychiatric personality disorders etc)
- organic causes (injuries, brain tumors, toxic and infectious causes etc)
- biochemical causes (medications, alcohol, other toxic substances, drugs etc).
The consequences of consciousness disorders are a decline in other mental processes, such as perception of objective reality, attention, judgment and association processes.
By the term “attention” is specified the mental process through which the individual classifies by time and space in his memory an internal or external stimulus.
The causes of attention disorders are head trauma or injury, physical and psychological burnout, anxiety, normal phobias, stressful situations, intense emotions (anger, sadness etc), medications, alcohol, other toxic substances, drugs etc).
The consequences of attention disorders are: exhaustion, easy fatigue, fixation, short attention span, distractiveness, selective and non-selective inattentiveness. In the context of the above-mentioned disorders, the individual is incapable of performing the process of attention :
- a) concentrates on one or a few objects,
- b) is incapable of concentrating in general,
- c) is incapable of evaluating external or internal stimuli
- d) is not able to concentrate on one or more stress-inducing objects (defense mechanism of repression).
Memory is the mental process that gives an individual the ability to store past experience, to recall it and motivate it (recognition, recall, constructive memory) each time this is considered to be necessary. All these facts make memory a basic component of the quality of perception and normal behavior. Memory, along with thinking and learning, is a cognitive mental process.
Factors affecting the function of memory are: function level of consciousness-alertness, lapse of time between encoding and storing of the information, function level of perception, function level of attention, motivation and interest of the individual, emotional investment on the information to be stored, various rules of memory techniques for organising information.
As consequences of the memory disorders are reported:
- amnesias (incapability of storing information due to e.g. chronic alcoholism, brain injury and incapability of recalling the information because of recent emotional disorder, intense anxiety, fear etc, permanent or temporary brain damage)
- hypermnesia, panoramic revival of experience, hyperactivity of constructive
memory, exceptionally vivid memory
- paramnesias-delusional memory: recalling events or situations that never
- confabulation: the “making up” of memories in order to justify specific situations or just to show off, to the point that the individual comes to believe them as reality.
Emotion is a mental process that charges pleasantly or unpleasantly every human activity, determining our disposition regarding the activity’s intensity and duration, as well as communication with the environment. It is a strictly subjective situation, and for this reason it is rather experienced than described. Emotions can motivate the individual positively or negatively towards a situation or an object.
Factors affecting the function level of an emotion are: the normal function of the brain (central nervous system), which may be disrupted by injuries, tumors, functional disorders, the peripheral nervous system the endocrinal system.
Disorders in the above-mentioned systems cause emotional disorders, like:
- a) ambivalence (simultaneous appearance of positive and negative affect regarding a choice),
- b) euphoria (permanent and unjustified),
- c) depression and melancholy,
- shallowness of affect (incapability of expressing strong emotions),
- e) incapability of experiencing any feelings at all,
- f) emotional rigidity – inflexibility (incapability of differentiating a feeling according to different stimuli from the environment),
- g) instability (rapid change of emotions even as a result of unimportant stimuli),
- h) incapability of controlling feelings,
- i) inappropriate affect (the manifestation of emotions that do not correspond to the stimulus)
It is obvious that the emotional state of a person (fear, anger, happiness, anxiety, jealousy etc) invariably affects the function of perception.
It is a complicated process that affects the behavior of a person, and has to do (Skinner) with: “alteration of the probability of a response under the same conditions in which the conjunction between stimuli and response takes place.
Factors affecting the function level of learning are:
- A) Factors related to the person:
1) function level of the central nervous system,
2) motivation for learning
3) emotional interest towards the object of learning,
4) degree of a person’s maturity
5) previous experiences,
6) level of intelligence
The above-mentioned factors, in combination, form the conditions for faster and more complete learning. We underline the word combination, because for example, a high level of intelligence without emotional interest, or, even worse, with emotional aversion does not promote learning process.
- B) Factors related to the environment:
Personality and environment are in a constant interacting process. The quality (clarity, intensity etc), the quantity and coherence of the stimuli contribute positively or negatively to the learning process. As long as the environment is conducive to the emotional investment on the object of learning, or furthermore to the satisfaction of essential needs of the individual as the result of learning, the learning process is facilitated.
Functional disorders of learning are due to:
- disorders of the central nervous system
- psychological disorders that block emotional investment on the object of learning.
- the quality (clarity, intensity etc) and the quantity of external stimuli.
Thought – Reasoning
Thought-reasoning can be defined as the mental process which is related to the dynamic evolving process of problem-solving through which the classification of material and non material objects concerning the self and the environment is performed. (Scharfetter 1976) Through thinking, meaning and importance is attached to these objects, they are understood and their causal relations are explained, meanings are connected to each other, decisions are taken, judgments are made.
Thought-reasoning as a process is wider than perception, having as a basis the brain (central nervous phenomena).
It is activated when the man seeks the solution of a problem, the satisfaction of a need. It is the expression of a man’s personality, that’s why thought disorders initiate disorders of the personality. Action is the primary manifestation of thought and a crucial criterion for its rightfulness.
Factors affecting the function level of thought-reasoning are:
- A) Psychological and biological conditions, such as:
- consciousness state 2) state and level of memory, 3) level of intelligence, which is defined by biological and social parameters, 4) emotional state, 5) level of the organic function of the brain.
- B) Social and cultural factors
Thought-reasoning disorders are divided in: disorders of thought process and disorders of thought content.
- a) Disorders of process
1) the simple, temporary, frequent or constant blocking of thinking, 2) slowness of thinking, 3) flight of thought (distraction into many objects, incapability of concentrating on something specific), 4) verbiage, trifle talk, pedantic thinking (concentration on the examination of a single object in depth, focusing on details, on the insignificant aspects, which results in the incapability of perceiving the general essence), 5) incoherent, chaotic thinking (combination or differentiation of things, situations etc, without specific criteria) persistent repetition of particular words or sentences, with or without meaning, 6) incoherence -loose associations (articulated thoughts without any reasonable or emotional coherence)
- b) Disorders of the content of thinking
- compulsive thoughts against the will of the person
- paranoid or unreasonable thoughts
Consequently the necessary conditions of a minimum level of objective-reliable perception and comprehension of the environment by the investigator is his-her physiological function of:
- all the senses, b) the nervous system that transfers the external stimulus from the senses at the proper cerebral centers, c) the cerebral centers that process the stimulus,
all the mental processes since they affect perception and. e) the level of knowledge and experience upon the investigated environment (which is included in the determinant of mental processes)
- Κnowledge-experience as a basic determinant of perception (Lainos & Nikolaidis 2003, Marsh 2000, Paries Ashleigh 1998)
Κnowledge (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) is a basic determinant of perception’s-comprehension’s quality. Consequently it affects decisively the quality of decision-making and therefore effectiveness of action. But knowledge is useful only if it can facilitate the understanding of the environment (close and wider) by a human being who, based on that, may then proceed to decision-making and action towards the
fulfillment of a goal.
The optimum quantity of information relative to a particular environment is what the user can perceive, understand and process according to his-her biological, psychological and cognitive abilities. 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. Consequently it results to a lower quality of situation awareness instead of a higher one, to a further delay of decision making and acting, due to the user’s inability to process the available quantity and quality of information. 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. Perception includes the characteristics, properties, theoretical evolution principles-actual evolution during a particular period of time, relationships-interactions-consequences of the objects, events, situations.
For example when, during an aerobatic air-show an airplane dives with its nose vertical to the ground, the watcher considers this to be an aerobatic maneuver.
If however the same watcher 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 watcher has stored in his-her memory.
The reliability-objectivity of human understanding is based-apart from 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 and on unknown ignorance. It must be noticed that the absolute perception of the objective reality is impossible for every individual due to
- the infinity of external stimuli to the human organism
- the limited capabilities:
- of the human senses to recognize these stimuli,
- of the nervous system to transfer these stimuli to the proper brain centers
- of the brain centers to process these stimuli
- The role of the management functions on the accident occurrence
Even since the first quarter of the 20th century (Hawthorn etc.) up to recent times research has proved that the activity- behavior of every individual at his-her working place, during working time, is strongly, directly and indirectly affected by factors that compose the wider internal airline’s environment. (Andries-Kompier, -Smulders 1996, Beehr 1995, Bright-Mitchel.- Rickman 1996, Daniels-Harris 1998, MacDonald-Karasek-Punnett-Scharf 2001, Westfall 1998 )
“However the results of this research were not correlated with the managerial decisions and functions, through which the top management introduces the suggestions of the researchers in the internal corporate environment”. (Lainos 2003)
“[…]Only now are safety practitioners realizing the complex nature of accident/incident causation and the role organizations play in the genesis and management of human error. In fact it is the emphasis that organizational models place on the fallible decisions of managers, supervisors and others in the organization that sets them apart from the other perspectives previously discussed[…]” (Shapell-Wiegmann 2003 )
“[…] Organizational accidents may be truly accidental in the way in which the various contributing factors combine to cause the bad outcome, but there is nothing accidental about the existence of these precursors, nor in the conditions that created them.[…]” (Reason 1997)
Recent studies have proved that the activity-behaviour of the staff at working place, during working time, is strongly, directly and indirectly affected by factors from the wider internal corporate environment (Αnderson-Kjellberg-Lindberg-Skoldstrom 1996, Beehr 1995, Bright-Mitchel-Rickman 1996, Kelley 1996, Biner 2000,Fingret 2000, Hendy 2003, Caldwell-Caldwell 2003)
The introduction and preservation of these factors is ultimately determined by the top management decisions (C.E.O., B.O.D.). (Lainos 2003)
“[…] Responsibility for aviation safety begins at the very top of an airline company. History has demonstrated repeatedly that without the complete commitment of the highest management levels within a company, operational safety margins are seriously eroded. This does not suggest that a company will have an accident, but it does suggest that the risk of having an accident is high-the laws of probability will prevail. Management has great leverage in affecting operational safety within a company. Through its attitudes and actions management influences the attitudes and actions of all others within a company: Management defines the safety culture of an organization. This safety culture extends all the way to the maintenance shop floor, to the ramp to the cabin and to the cockpit. Further more the public and the government authorities are increasingly recognizing management’s role in air safety by holding management accountable for a serious incident or accident; this accountability is magnified many-fold if a company suffers several such incidents or accidents during a course of a few years […].” (Flight Safety Foundation 1994)
“[…]The ultimate responsibility for safety rests with the directors and management of the Company. The Company’s attitude to safety—the Company’s safety culture—is established from the outset by the extent to which senior management accepts responsibility for safe operations, particularly the proactive management of risk. Regardless of the size, complexity, or type of operation, senior management deter– mines the Company’s safety culture. However, without the wholehearted commitment of all personnel, any safety programme is unlikely to be effective[…].” (Airbus Industry 1999),
This consideration is based on the fact that the top management has the authority to program, organize, administrate, staff and control the corporate operation and to apply its decisions in the internal corporate environment, through the authorized members of the hierarchy (Lainos 2003). Even in the case that some of the factors of the internal corporate environment that affect negatively the staff’s activity are not the result of top management decisions, but the result of mismanagement by the members of the hierarchy at the various organizational levels, the ultimate responsibility still rests with the top management. The cause is that the top management has the ultimate responsibility of staffing. (Lainos 2003).
- The functions of the organizations’ management and their content
The knowledge of the functions of the corporate management, its consequences on the influenced areas of the internal corporate environment and the impact of these functions on the employees’ will is a basic determinant of the investigator’s opinion about the primary cause(s) and contributing factors of the accident incident (Lainos 2003)
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.
Performance Shaping Factors (PSF’s) from the internal organizational environment and the management functions which mainly affect them
|1. Wages level Programming-Administrating-Staffing|
|2. Hygiene and safety conditions (warm-cold,|
|light-dark, noise, radiation, chemicals etc.) Programming-Administrating|
|3. Stress and fatigue due to workload Programming-Administrating- Controlling|
|4. Job security Programming-Administrating (motivating)- Staffing|
|5. Skills and training Administrating (motivating)- Staffing|
|6. Meritocracy or favoritism Administrating (Culture)|
|7. The applied management style (human or product|
|oriented, motivation’s efficiency, virtual recognition|
|of the employees’ contribution to the development|
|of the airline, the superiors’ behavior etc) Administrating|
|8. Corporate culture applied by the top Management Administrating|
|9. Efficiency of the corporate labor|
|programming and organizing Programming-Organizing-controlling|
|10. Professional and social status|
|of a particular labor position Administrating- Staffing|
|11. Satisfaction from|
|achievement in work Administrating- Staffing –Controlling|
|12. Health and physical|
|situation of the employee Administrating- Staffing -Controlling|
|13. Social status of the airline Programming-Organizing-|
The case study of the ICAO’s manuals regarding accident and incident investigation
- The qualifications of the accident investigators
Assuming that all aforementioned presuppositions are fulfilled, job specialty, knowledge and experience play a decisive role in the process which shapes the objective perception.
The qualifications of the accident investigators are described in the ICAO’s Manual of Aircraft Accident and Incident Investigation 1-2-2 Paragraph 2.4.3.
7.1. “ Qualifications of the Aircraft Accident and Incident Investigator
“ It is essential that accident investigators have a practical background in aviation as a foundation on which to develop investigation skills. The experience can be acquired by working as a professional pilot, as an aeronautical engineer or as an aircraft maintenance engineer. Other specialized areas of aviation which could also provide useful experience include management, operations, airworthiness, air traffic services, meteorology and human factors. Since accident investigations will often involve all of these specialized areas, it is important that investigators understand the aviation infrastructure and are able to relate to each of these different areas. It is also beneficial for investigators to leave some piloting experience in addition to their other experience”
In the aforementioned paragraph, ICAO, describes as qualifications of the air accident investigators the required areas of their general job specialty (doctors, pilots, aeronautical engineers, aircraft maintenance engineers) and the required areas of their experience (management, operations, airworthiness, air traffic services, meteorology and human factors). As a basic job specialty and experience is considered to be piloting, a basic knowledge which is required by every investigator. However the investigator during the investigation is obliged to get involved in areas of knowledge different than his-her own job specialty. This is the reason why the ICAO considers necessary for every investigator to have a wider knowledge –regardless of his-her job specialty- in areas such as management, operations, airworthiness, air traffic services, meteorology and human factors. The titles of the chapters that the investigators have to be trained in are mentioned by the ICAO in the description of the information that has to be included in each paragraph of the accident report.
We consider that this system appears to have certain weaknesses, because it does not determine:
- the specific job specialty of the doctor (pathologist psychiatrist etc), or of the pilot (jet, tourboprop etc) and the aircraft type the pilots had to be certified at.
- the duration of the required experience of every investigator,
- the content of each title of the syllabus to which each investigator has to be trained.
- the qualifications of the investigators’ trainers: sector, science, level of knowledge, duration of experience)
- the physical and mental health of the investigator, although it is a necessary presupposition for an acceptable level of the investigator’s perception.
This vagueness causes ambiguities regarding which exact characteristics, properties, knowledge, experience etc., ICAO wants the air accident investigators to be armed with.
Consequently we consider that the system under these circumstances does not ensure the unified level of knowledge of the investigator although this unity is considered to be a necessary presupposition for the comparability of accident reports findings, conclusions and recommendations.
However, the investigators’ qualifications – like any other employees’- generally determine the quality of their perception. It is obvious that any differentiation in the qualifications differentiates-ceteris paribus- the quality of perception. This differentiation has a negative impact on the effort of ICAO: a) to focus on upgrading the unification of the perception’s level of the investigators per involved job specialty, during the accident investigation and b) to achieve a higher level comparability of the various accident reports.
- Criteria of the structure of an accident report
According to ICAO Annex 13 the structure of an accident report must be as shown in the table 3 below.
From the structure of accident reports it becomes obvious that ICAO uses both operational and managerial criteria indiscriminately and without prioritization (special weight). The operational criteria are related rather to the organizational functions while the managerial are related to the management functions
As a consequence, various fields of the same managerial function for example “staffing” are mentioned in more than two chapters, paragraphs etc. that is: 1.5. personnel information, 1.17. Organizational and Management information, 2.4. Flight Crew Performance, 2.5. Pilot Training 2.7. Emergency Response.
- FACTUAL INFORMATION
- History of Flight
- Injuries to persons
- Damage to Airplane
- Other damage
- Personnel information
- Airplane information
- Meteorological Information
- Aids to Navigation
- Airport Information
- Flight Recorders
- Wreckage and Impact Information
- Medical and Pathological Information
- Survival Aspects
- Tests and Research
- Organizational and Management information
- Additional Information
- Weather Factors on the approach
- Accident Sequence
- Flight Crew Performance
- Pilot Training
- Air Traffic Control Factors
- Emergency Response
- Controlled Flight Into Terrain
- Oversight Issues
- Flight Data Recorder Documentation
- Probable Cause
We consider that the mixing up of two completely different criteria and the mentioning of different fields of the same managerial function (e.g. staffing) in different paragraphs of the accident report, is more probable to confuse, and consequently to put barriers to the investigators’ perception (recognition-comprehension) rather than assist them to focus on the main, primary cause(s) and contributing factors.
- Content of the section “1.17. Organizational and Management information” of the accident report
Regarding the criteria of “ the content of the chapters of the accident report” this paper focuses on Section 1 paragraph 17 “Organizational and Management information”
The content of this section according to ICAO’s instructions (ICAO ANNEX 13) is described as follows:
[…]1.17.1. Provide pertinent information on the organizations involved in influencing the operation of the aircraft, if such influence had a bearing on the accident. The organizations to be reported upon in this section could include, but need not to be limited to the following: the operator; the maintenance organization; the air traffic services, aerodrome administration, weather service agencies, the aircraft manufacturer, the certification of listening authority, and the regulatory authority. The information could include, but need not be limited to the following: organizational structure and functions, safety culture; resources; financial viability status; management decisions, policies and practices, internal and external communications and relationships, certification, monitoring, and regulatory framework when these had a bearing on the accident or whose actions, or lack thereof, was related to, or influenced the accident”
1.17.2. Provide pertinent information concerning the operator, such as type and date of issuance of air operator certificate, types of operations authorized, types and number of aircraft authorized for use, and authorized areas of operation and routes. Also include relevant information concerning the operator’s company operations manual”[…]
A first indication from the comparison of accident reports of United States of America National Transportation Safety Board (NTSB 1996, 1997, 1998, 1999, 2000,
2002) and United Kingdom Air Accidents Investigation Branch (UK AAIB 1988,1990,2000a,b, 2001a,b) is that the “Management and organization” chapter of the NTSB reports is filled in more often and in a more detailed way than those of the UK ΑΑΙΒ.
From the aforementioned approach it becomes obvious that the NTSB investigators have wider and more accurate knowledge on issues such as:
- the meaning and content of the management functions,
- the impact from the introduction and preservation in the internal corporate environment of factors which affect decisively the employees’ will,
This knowledge is a basic presupposition for an objective classification and assessment of the findings during an accident investigation, because apart from others it contributes to the discrimination between the initial and the secondary cause(s)-contributing factors.
Error is the result of systemic and not of personal failure. The system of the commercial air transport industry is consisted of organizations such as manufacturers airlines, maintenance centers, airports, civil aviation authorities, airport authorities, weather forecasting service, air traffic controllers etc. That is the reason why ICAO changed its philosophy regarding the responsibility for an accident-incident, from causal factor to contributing factors. Consequently the investigator who wants to contribute positively to the upgrading of aviation safety is obliged to determine the initial cause(s), the actions or omissions of the managerial functions which affected the employee’s will and resulted in the accident-incident occurrence.
This consideration of the role of the investigator is for the benefit of:
- the shareholders and the top management of the air-carrier, because it determines the causes of probable future errors, and consequently it contributes positively to the upgrading of the quality of their functions (safer, cheaper, more competitive, wider market share, higher long term profits etc.)
- the passengers (safer and cheaper flights)
- the insurance companies (fewer accidents-less claims)
- the employees (safer work)
- a) if the investigators want to determine all the contributing factors of an accident/incident and make an objective assessment of these factors, they must be able to know the source of every error committed by any employee
- b) they must be aware of the functions of the top management, their content and the affected areas of the internal corporate environment.
Regarding the content of the chapter of the accident report “1.17.organization-management”.
Based on a number of recent accident reports, we noted that the implementation of the aforementioned process presents certain difficulties related to the presentation of the findings-facts. These difficulties refer to either the avoidance by the accident investigators to fill in the particular chapter “Organization and Management information” or to report findings that are the results of management functions under the proper chapter. These difficulties are considered to be the result of the classification weaknesses by the investigators. Perhaps due to ignorance of the meaning and role of the two different groups of criteria used in final reports: the operational which rather reflects the results of the organizational functions, and the managerial which concerns the results of the managerial functions.
- The ICAO’s Training guidelines for Aircraft Accident investigators
In the ICAO’s Training guidelines for Aircraft Accident investigators Chapter 2 “Background Experience For Investigators” Cir 298 AN 172 June 2003, it is mentioned:
“[…] 2.2. Potential accident investigators must have considerable practical experience in aviation as a foundation on which to build their investigation skills. The experience can be acquired from civil or military qualification as […] aviation related management might also be suitable for accident investigator training […]”
In the chapter 3 Training Guidelines in the paragraph 3.1.3. in the qualifications required for accident investigators’ trainers are included “[…] experienced investigators, aviation medicine physicians, psychologists, aeronautical engineers and manufacturers’ representatives[…]”
In the aforementioned description of the experience required for a potential accident investigator, the following remarks may be made
- As background experience for investigators, the verb “might” is used for aviation related management, while for the pilots, aeronautical engineers and aircraft maintenance engineers the verb “must” is used.
- Concerning the aviation related management qualification of the investigators, only the criterion of experience is mentioned and not for theoretical knowledge, while the job specialty of the pilots, aeronautical engineers and aircraft maintenance engineers includes the necessary theoretical knowledge as well.
- For the trainers, managerial knowledge and experience is not required. The omission of determining the trainers’ level of knowledge and specific field of experience in the air transport management, creates a wide vacuum in the investigators’ knowledge regarding the content and impact of the air transport management functions on the internal corporate environment factors which influence the employees’ will
- The accident investigators’ initial training syllabus (Chapter 3.2.) does not include any issue regarding the goal, content, areas of authority, impact etc. of the aviation management.
The aforementioned formulations might create the impression that the ICAO underestimates the knowledge and experience on the field of air transport management, although the investigators are appointed to investigate the negative impact resulting from the implementation of managerial functions on aviation safety.
In the Chapter 22.214.171.124. Organizational information of ICAO’s Training Guidelines For Aircraft Accident investigators, it is mentioned:
“[…] Conducting a review of the organizational structure and functions as well as the management policies and practices of the agencies, authorities and aircraft operator involved is a subject that should be covered. For example, an investigator should have the competence to review an aircraft operator’s management functions, policies and practice in their entirety. There are many aspects of the supervisory process which may have a direct bearing on the accident, such as acceptance of inadequate flight crew qualifications; deficient guidance material; maintenance shortcuts; improper crew rostering; failure to provide proper training in aircraft type; shortcomings in crew resource management; and unreasonable pressure to complete schedules on time. The methods of investigating management and organizational aspects of an organization to determine the presence of any risk factors or other shortcomings is a requirement of a well rounded accident investigation course. An examination of the means of supervision is very important and will include a review of orders regulations, manuals and independent audits as well as the performance of supervisors, instructors and company management
126.96.36.199. Human performance […]”
188.8.131.52. Determination of the flight crews suitability for the flight[…]”
Remarks on ICAO’s Training guidelines for Aircraft Accident investigators
Our consideration, regarding the content of the Chapter 184.108.40.206. “Organizational information”, ICAO’s Training Guidelines for Aircraft Accident investigators, is:
- There are certain ambiguities regarding the meaning under which the terms “ organizational function” and “managerial function” are used, since their content is entirely distinguished in the science of management nowadays.
- Issues that belong to different managerial functions are mentioned without any differentiation e.g. inadequate flight crew qualifications; failure to provide proper training in aircraft type (staffing), supervision (controlling), improper crew rostering (programming), administrating etc.
- The issues described in paragraphs 220.127.116.11. “Human performance” and 18.104.22.168. “Determination of the flight crews suitability for the flight”, mainly refer to the content of the managerial function of staffing. The isolated reference in these two different paragraphs of issues which are included in the previous 22.214.171.124. “Organizational information” paragraph, might create the wrong impression that these issues are independent from the managerial function of staffing which is included in the previous paragraph.
The aforementioned approach might generate areas of possible ambiguity , concerning the ICAO’s consideration of :
- the content and impact of the management functions in the life of the organization
- the need for implementation by the investigators of scientific criteria in order to assess the top management’s involvement in the accident/incident occurrence,
- the level of the hierarchy members that are burdened with the main responsibility in case of error commitment.
These facts might give the impression that aviation related management is not considered to be a basic necessary experience of accident investigators.
However, from the analysis of the aforementioned chapters the crucial role of knowledge-experience in situation awareness (recognition-comprehension) of the environment, the decision making and action became clear. How could the investigators recognize and understand the impact of the managerial functions on an accident occurrence, if they do not have adequate and proper theoretical knowledge combined with practical experience upon aviation management issues?
The investigators lack of knowledge regarding the content and the areas of internal corporate environment affected by the management functions, combined with the ICAO’s approach of operational and managerial criteria , might create obstacles in the objectivity and the unity of the investigators’ perception.
A higher unification of the investigator’s perception is necessary because leads to:
- a higher level of recognition and understanding of the various parts of the investigated environment
- it contributes positively to the unified categorization of the findings according to their sources, which leads to the identification and objective prioritizing of the contributing factors.
- it contributes positively to the unified assessment of the findings according to unified criteria and knowledge, based on unified methodology
- it helps the investigators to identify the source(s) of each contributing factor of the accident and consequently to suggest the appropriate safety recommendations
- it helps the readers to assess whether the conclusions and the safety recommendations reflect the source(s) of the identified contributing factors since they are presented under the appropriate chapter of the accident report
- it facilitates the unified understanding by the readers who belong to different cultures with different values, different considerations etc.
The obvious incompatibility between ICAO’s aim of upgrading the aviation’s safety level and the measures applied for achieving this aim, exists because it does not determine and ensure:
- a minimum level of the normal function of the investigators’ senses and mental processes which are decisive determinants of the investigators’ perception-comprehension
- a unified content of the syllabus of investigators’ training .
- the field and level of knowledge, as well as field, level and duration of the experience of the trainers
- the identification of the exact qualifications of the investigators; specific job specialty of the doctor -pathologist psychiatrist etc-, or the pilot –jet, tourboprop etc- the aircraft type they had to be certified at, and how long experience must each investigator have at his-her job specialty. These are necessary presuppositions for the unification of the investigators’ knowledge.
- the unification of criteria of the accident report structure (managerial and operational criteria are used indiscriminately)
- the obligatory filling in by the investigators of the accident report’s chapters with information compatible with the content of the particular chapter
1) The existing ICAO’s institutional framework which determines the presuppositions and the conditions of the accident investigation, has successfully contributed for decades years to the aviation safety .
For the achievement of the ICAO’s objective to upgrade the aviation’s safety level, the particular institutional framework needs restructuring in order to improve its efficiency and effectiveness in the near and distant future.
2) The purpose of this restructuring has to be the achievement of a reliable comparability between various accident reports. The achievement of this goal requires:
- unification of the perception and comprehension of the examined environment by the investigators
- unified methodology of the presentation of findings, conclusions and recommendations,
– restructuring of the accident report based on the differentiation of the use of the managerial and operational criteria. .
3) Regarding the reliability-objectivity of the investigators’ perception, any disorder of their mental processes may result to:
- selective attention or selective inattentiveness
- over generalization of a single negative fact, relation, condition etc
- evaluation of the –objective-environment with subjective criteria
- maximization or minimization of the negative impact of some contributing factors
- minimization of positive impact of some factors
- Comparing the ICAO’s consideration about its exclusive objective in an accident investigation and the tools that the ICAO uses for the accomplishment of this goal we consider that there is an incompatibility between the goal and the measures.
1) Introduction of tests to access the functional status of the senses and mental processes of each investigator
2) Determination the specific:
- job specialty of every accident investigator
- field and duration of the required experience
- content of the syllabus-field and level of knowledge (not only the titles) in which the investigators are trained, which must reflect the current global scientific knowledge on the particular cognitive field.
- field of knowledge, level of knowledge, field and duration of the investigators trainers experience.
3) Separation of the managerial from the operational criteria is imperative.
The managerial criteria must be used in the chapters-paragraphs concerning the investigation of the sources of the contributing factors, while the operational criteria must be used in the chapters-paragraphs concerning the investigation of the conditions of the accident/incident.
- To make a clear distinction between organizational and managerial functions and
their impact on the internal corporate environment
5) To introduce as obligatory in the investigator’s qualifications the theoretical
knowledge and practical experience on air transport organizational and
managerial functions and their impact on the internal corporate environment.
- Obviously the same qualifications must be required from the investigators’ trainers as well.
Airbus Industry, (1999) “Flight Safety Manager’s Handbook” Section 2 – Organisation & Administration
Αnderson, Kjellberg, Lindberg-Skoldstrom (1996) Fatigue effects of noise on aeroplane Work. And Stress V. 10 p. 62-71
Andries F., Kompier, Smulders P. (1996) Do you think your health or safety are at riskbecause of your work:? A large European study on psychological and physical work demands. Work and Stress V. 10 4/96 p.104-118
Andriopoulos D.Z. (2003) “Ancient Greek Cognitive Theory. Of the problem of perception and knowledge” Fifth Edition. Papademas. Athens Beehr T A (1995) Psychological stress in the work place Routledge.London
Biner R.B. (2000) Relationships between work environments, psychological environments, and psychological well-being Journal of the society of Occupational Medicine p. 299-303
Bright C.K. Dr -Mitchel K.- Rickman J.K.(1996) Study into potential sources of human error in the maintenance of large civil transport aircraft CAA paper 96004
Caldwell J. PhD Caldwell L.PhD (2003) The importance of Aircrew fatigue management and the effects of Fatigue countermeasures.12th International Symposium on Aviation Psychology Ohio
Daniels K., Harris C (1998) Work, psychological well being and performance Journal of the Society of Occupational Medicine V.50 (5) July. p.304 –309 Great Britain Transport Workers Federation London
Fingret, A. (2000) Occupational mental health Occupational Medicine V.50-5 July p. 289-293
Flight Safety Foundation (1994) Flight Safety Digest Dec 1994 Special Report: FSF Icarus Committee Report: “The Dollars and Sense of Risk Management and Airline Safety”
Goleman D. (1995) Emotional Intelligence Bantam books N.Y. U.S.A.
Hayes N.(1994) Foundations of Psychology – An introductory text Editions Routledge London
Hendy K.C. (2003) Systematic error and risk analysis A tool for accident and risk
ICAO (2001) Annex 13Manual of Aircraft Accident and Incident Investigation amendment 10, 9th Edition, p. 1-1, .
ICAO Training Guidelines for Aircraft Accident Investigators (Cir 298 AN/172, 2003/6 )Kelley R F. (1996) Worker psychology and safety attitudes: most companies give Production priority status. Yet a supervisor need not choose between production and safety to perform the job correctly Professional Safety July p.14-17
Lainos J.S.& Nikolaidis E.D. (2003) Presuppositions for the effective introduction of changes to the aviation safety culture, through Crew Resource Management training program. The case study of the Olympic Airways 12th Int’l Symposium on Aviation
Psychology Dayton Ohio USA
Lainos J.S. (2003) The impact of the airline top management functions on aviation safety in a globalize environment Annual Air Transport Research Society Conference France
Louria A.R. (1978) Cognitive development Its cultural and social foundation 3rd Edition Harvard University press Cambridge Massachusetts and London
MacDonald,L.A Karasek R.A Punnett, Scharf (2001) Covariation between workplace
Physical and psychological stressors: evidence and implication for occupational health, research and prevention, Ergonomics V 44. p.696-718
Marsh H. S. (2000) Beyond Situation Awareness. The battlespace of the future. Office of Naval research. U.S.A.
NTSB (1996) Aircraft Accident Report NTSB/AAR-96/02 DCA95MA001 in-flight icing encounter and loss of control Simmons Airlines , d.b.a. American Eagle Flight 4184 Avions de Transport Regional (ATR) Model 72-212, N401AM Roselawn, Indiana, October 31, 1994 Volume II: Response of Bureau Enquetes-Accidents to Safety Board’s Draft Report N401AM / 6486C
NTSB (1997) Aircraft Accident Report PB97-910406 NTSB/AAR-97/06 DCA96MA054 in-flight fire and impact with terrain VALUJET Airlines flight592 DC-9-32, N904VJ Everglades Near Miami Florida May 11,1996 6704B
NTSB (1998) Aircraft Accident Report NTSB/AAR-98/03 DCA96MA079 In -Flight Fire/Emergency Landing Federal Express Flight 1406 DOUGLAS DC-1 0-10, N68055 Newburg, September New York 5, 1996 6800B
NTSB (1999) Aircraft Accident Report PB99-910401. NTSB/AAR-99/01 CA94MA076 Uncontrolled Descent and collision with terrain USAIR flight 427 BOEING 737-300, N513AU Near Aliquippa, Pennsylvania September 8, 1994 6472A
NTSB (2000) Aircraft Accident Report Controlled Flight Into terrain Korean Air Flight 801 Boeing 747-300 HL7468 Nimitz Hill, Guam UAM August 6, 1997. NTSB/AAR-00/01 DCA97MA058 6952B PB00-910401 ‘I Washington, D.C. 20594
NTSB(2002)Aircraft Accident Brief NTSB/AAB-02/04, Accident Number: DCA00MA030 Operator/Flight Number: Southwest Airlines flight 1455, Aircraft and Registration: Boeing June 26, 2002
Paries J.-Ashleigh M. (1998) Error management Cognitive and Cultural Perspectives. Joint International Meeting FSF IFA IATA under the title “Aviation: Making safe system safer. Cape Town. South Africa
Papadopoulos N. (2003) Contemporary Experimental Psychology 8th Edition Athens-Greece
Reason J (1997) Managing the risks of organizational accidents Publishers Ashgate. USA
Scharfetter C. (1976) Allgemeine Psychopathologie. ThiemeVrlg.Stuttgard
Shapell S. – Wiegmann D. (2003) A human factors approach to accident analysis and Prevention. Proceedings on 12th International Symposium On Aviation Psychology. Write University. Dayton-Ohio-USA
Steanberg R.J. (1996) Successful Intelligence Editions Simon &Schuster U.S.A.
Speyer Ir. J-J, Mollard R. Dr, Bougrine S. Dr (1998/11) “Managing Operational Fatigue and Air Crew Alertness” Joint Int’l Meeting FSF, IFA, IATA, “Aviation: Making a safe system safer” Cape Town S. Africa.
UK AAIB (1988) Report No: 8/88 on the Incident to Boeing 737-236, G-BGJL at Manchester International Airport on 22 August 1985
UK AAIB (1990) Report No: 4/90 (EW/C1095) on the accident to Boeing 737-400 – G-OBME near Kegworth, Leicestershire on 8 January 1989
UK AAIB (2000a) Report No: 4/2000 (EW/C97/11/1) on the accident to Airbus A340-311, G-VSKY at London Heathrow Airport on 5 November 1997
UK AAIB (2000b) Report 5/2000 (EW/C98/1/3) on the accident to Boeing 767-322ER, N653UA at London Heathrow Airport on 9 January 1998
UK AAIB (2001a) Report 1/2001 (EW/C2000/4/6) on the accident to Boeing 747-436 at London Heathrow Airport on 28 April 2000
UK AAIB (2001b) Aircraft Accident Report No: EW/C98/03/73/2001 on the accident to HS748-Series 2B At London Stansted Airport on 30 March 1998
Westfall, P. (1998) Too tired to work? : fatigue presents a major obstacle to Safety” Safety And Health V. 154
Windelband W.-Heimsoeth H. (1976) Lehrbuch der Geschichte der Philosophie 16th Edition J.C.B.Mohr (Paul S