Report

Writing
Fundamental

DEDICATED TO THE VICTIMS OF TRANPORTATION ACCIDENTS AND THEIR FAMILIES.

FROM TRAGEDY WE DRAW KNOWLEDGE TO IMPROVE THE SAFETY OF US ALL
 Today’s Topics
• Overview of investigation report
• Investigation report format
• Report writing conventions
 Objective
• Provide understanding how to make investigation
report as foundation to present findings in order to
initiate safety actions which are necessary to prevent
further accidents from similar causes.
 Investigation Process

Presentation of
Collection of data Analysis of data
findings
Overview of Investigation Report
 Investigation Report
• Investigators tend to be technically oriented and
generally view report writing as a necessary evil.
• The report is the only product of the investigation.
• It advertises the investigation facts, analysis,
findings, recommendations and safety actions.
• Foundation for initiating safety actions, necessary to
prevent further accidents from similar causes.
Doing business without advertising is like winking at a girl in the dark.
You know what you are doing, but nobody else does."
Stewart Henderson Britt
"Advertising isn't a science.
It's persuasion. And persuasion is an
art.” (Bill Bernbach)

Safety Investigation

Mostly
science
but

Partly art
 Investigation Report Fundamentals
• Investigation reports must conform to
objective standards in order to meet the ICAO
requirements – (safety investigation context);
• The use of simple, clear English (or other)
including the careful choice of words and
punctuation to aid understanding;
• Ideas must be placed in logical sequence, for
easy reference.
 Investigation Report Fundamentals
• Keep it short and simple (KISS).
• The report must be designed to aid access to
the information they contain.
• Do not write it on your own, use team input.
• Before release, the report must be checked to
ensure they are clear, concise, complete and
correct.
 Investigation Report Fundamentals
• Those who potentially have interest in the
investigation report constitute a diverse readership.
• The reports shall be:
‐ Technically accurate;
‐ Lucid;
‐ Well-reasoned;
‐ Motivating (for those with safety responsibilities).
 Writing an Accident Report
• All reports are written to influence an outcome.
“Accident investigation no better than the report of
it” (Sweginnis and Wood)

• A good investigation will be let down by a poorly

written report.
“A superbly written report cannot do much to
overcome a bad investigation, but a poor report
can definitely ruin a good investigation”
(Swegginnis and Wood)
 Investigation Reports
• Preliminary Report;
• Draft Final Report;
• Final Report;
• Interim statement.
 Preliminary Report
• Shall be published in 30 days after the
occurrence*, contain information of factual
data collected within 30 days. No analysis and
no conclusion.
• If necessary contains safety recommendation
to address identified safety hazard.
 Draft Final Report
• Published prior issuance of the Final Report.
• Consultation for 60 days from the date of the
transmittal letter.
• Inviting significant and substantiated
comments from direct involved parties.
• Not for public, restricted information.
 Final Report
• As accident prevention, shall be published as
soon as possible, if possible within 12 months.
• If cannot, shall make interim statement
publicly available on each anniversary of the
occurrence, detailing the progress of the
investigation and any safety issues raised.
• Shall be sent to direct involves parties.
Investigation Report Format
 Content of the Report
• Reports will be formatted and presented in a
consistent and uniform manner.
• Report should cover in detail, all of the
relevant aspects of the investigation.
• Must establish in detail: what, how, and why
it happened.
 Format of the Final Report
Refer to ICAO Annex 13
• Title
• Synopsys
• Body
1. Factual information
2. Analysis
3. Conclusions
4. Safety recommendations
• Appendices
 A Word on Factual Information
• FACT is FACT….
‐ After landing the pilot set the thrust reversers and brake,
however, due to the slippery runway, the aircraft stopped out
of runway. (conclusive)
‐ After landing, the pilot set the thrust reversers and brake,
unfortunately these efforts were insufficient to keep the
aircraft on the runway. (poetic)
‐ After landing, the pilot applied maximum brake to decelerate
the aircraft but was unsuccessful. (unclear statement)
‐ After landing, the pilot set the thrust reversers and brake.
The aircraft stopped 50 meters out of runway.
• Conclusion of an test or research can be considered as fact.
 Factual Information
• Do use plain English
‐ Poetic, academic, overly technical
• Do not use emotive words
‐ The pilot failed to lower the landing gear.
‐ The landing gear was not lowered.
• Pictures tells thousand words.
• Do use weighted words as appropriate.
• Theory that has publicly known may acceptable as
factual information.
Use of Weighted Words
How strong How
is the confidence
Evidence? are you?
Certain
Probable
Most Likely
Likely
Indicated
Suggested
Possible
Uncertain
 Use of Weighted Words
• Intended to indicate relative likelihood, not to
be measured with precision
• Avoid ‘possible’ where possible
• A low likelihood is not the same as a lack of
evidence
‐ If you cannot estimate with confidence then
say so
 Analysis
Process where available data is evaluated and
converted into a series of arguments, which
produce a series of relevant findings.
When do you start?
 A Word on Analysis
• State clearly what the Analysis will cover:
‐ This analysis will cover.....
• State clearly what is not covered:
‐ The following factors were not considered to
contribute to the development of this
accident.....
 A Word on Analysis
• Discuss the results of the investigation rather
than the process.
• Don’t repeat the factual BUT analysis must be
based on factual evidence.
• No “new” facts in Analysis.
 Conclusions
• Contributing factors is used to diminish any
potential blame or liability that might be
implied from its findings.
“Actions, omissions, events, conditions, or combination thereof, which, if
eliminated or avoided, would have reduced the probability of the accident
or incident occurring or mitigated the severity of the consequences of the
accident or incident”

• Based on a thorough, impartial and objective

analysis of all the available evidence.
 Contributing Factors
• When certain, a definite statement should be used
such as “probable” or “likely”.
• Usually a reiteration of statements made at or near
the end of the analysis and in the findings.
• If the analysis and the findings state that a cause
related event or circumstance was “probable”, then
the contributing factor statement should contain the
same qualifier (probable).
 Contributing Factors
• When there is insufficient evidence to establish why
an accident or an incident occurred, there should be
no hesitation in stating that the contributing factors
remain undetermined.
• In many instances, the most likely scenario could be
stated provided that a qualifier, such as “likely” or
“probable” is included. However, a list of possible
causes should not be given.
 Safety Actions
• The actions that organizations and individuals
do in response to the identification of safety
issues in order to reduce the risk of future
accident and incident prevention.
• Prefers to acknowledge such action rather
than make a safety recommendation because
it encourages proactive safety enhancement.
 Safety Recommendations
A proposal of an accident investigation authority
based on information derived from an
investigation, made with the intention of
preventing accidents or incidents and which in
no case has the purpose of creating a
presumption of blame or liability for an
accident or incident.
 Safety Recommendations
• When and where issued safety
recommendations?
• If safety issue is identified, at any time during
the investigation process.
• No need to wait until the final report is
finished.
 Making Safety Recommendations
• A recommendation should clearly state the
corrective action that may improve safety.
‐ Specific, practical and achievable
‐ Not prescriptive – what safety issue to
address but not how to do it
• Corrective action that has been performed
before release the final report will be
included as Safety Action and will not be
recommended.
 Making Safety Recommendations
a. Background section;
b. Supporting information section;
c. Deficiency analysis section;
d. Safety recommendation section;
e. Attachments.
 Making Safety Recommendations
The information of debris on runway has been
informed to the Medan Ground controller by JT197
pilot and to Medan Tower controller by another
departure aircraft pilot. Afterwards, there was one
aircraft landed on runway 23 and then the runway was
closed for debris removal. The debris on the runway is
a hazard for takeoff and landing aircraft.
• KNKT recommends air traffic controller to ensure all
hazard on the runway is properly mitigated without
delay prior to issue takeoff or landing clearance.
Report Writing Conventions
 Report Writing Conventions
• Convey an attitude of impartiality and write
objectively
‐ Not favor any party involved with the accident.
‐ The straightforward descriptive narrative which
avoids flowery descriptions and human interest
items should be used.
‐ If explain details of complicated area, explained in
a way that is easy to understand, the complex
explanation may be explained in appendix.
 Report Writing Conventions
• Clarity
‐ The use of an outline (e.g. Annex 13 format)
‐ Clarity can be enhanced by reporting sequentially (e.g.
history of the flight)
‐ Pronouns, especially “this”, “that” and “it” should be
placed close to their antecedents to ensure clarity
‐ Sentences should begin with the real subject of the
sentence, rather than with subjects such as “It is ...” or
“There are ...”
‐ Vague terminology should be avoided.
“Damage to the aircraft appeared to be the result of
impact loading”
 Report Writing Conventions
• Conciseness (KISS)
‐ Long sentences might make it difficult for the
reader to comprehend the point the writer is
trying to make.
‐ Avoid unnecessary repetition and extraneous and
irrelevant data
 Report Writing Conventions
• Consistency
‐ Verify that the terminology used is consistent
throughout the report.
‐ Should use the same terms for the same things and
should spell, hyphenate and abbreviate words
consistently.
‐ When using abbreviations, the writer should spell
out the words in full followed by the short form in
parentheses the first time they are used.
‐ Abbreviations used should be included in a glossary
 Report Writing Conventions
• Gender
‐ Avoid gender stereotyping, such as referring to the
investigator-in-charge or an engineer by using the
pronoun “he”.
 Tone of Expression
• Remember the objective of investigation!
• Blame or liability might sometimes be inferred
from the findings.
• Avoid words or phrases that have connotations
of blame.
“The operator did not notify ...” rather than
“The operator failed to notify ...”
 Tone of Expression
• Deviations from the accepted norms of compliance
with regulations and procedures should be clearly
identified, if relevant.
• The analysis should explain the reasons why the
deviation created a hazard, including the reason why
deviated.
• Should be clear that complying with the regulation or
procedure could have prevented the accident or
lessened the consequences of the accident.
 Read and Revise
• Revising is part of writing!
• Write – read, re-write – re-read.
• Review to have further clarification,
shortening, rearrangement or other changes.
• Peer review process is important.
• The writer wasn’t there.
 Investigation Report Dissemination
• As an accident prevention.
• Sent to Direct Involved Parties.
• Publicly available on website.
• Media release.
KNKT Website
KNKT Media Release