Introduction to Safety

Investigation
Presented by
RITA NURHARYANTI
 hello !
I’m Rita
• PLLU 38
• Approach Control Surveillance Batch 59
• D-IV ATC 15
• Airnav Indonesia Trainer
• KNKT Aviation Safety Expert ( ATS)

+6281774977999
rita9977@gmail.com
IG Rita.noer
 Course Objectives
The participants will learn fundamental
techniques and procedures to conduct safety
investigations
 Course Overview
• 16 days classroom (theory & practice)
• 2 exams (mid & final)
- Introduction to safety investigation
- Investigation rules & regulations
- Investigation fundamentals
- Safety on accident site
- Evidence preservation
- Investigating Human Factors
- Cognitive interview
- Data collection
- Analysis framework
- Report writing
 Timing is Important!
Because we have a full schedule, we need to be
mindful of the time.

“TIME WAITS FOR NO-ONE”

For the same reasons please direct responses

through the presenters.

side discussions can be distracting

What is Safety?
 Definition
SAFE (adj.)
• Free of danger or injury, secure, not risky,
reliable, sure (Oxford Dictionary).
• Free or freed from danger or evil; placed so
that harm cannot come (Funk & Wagnalls).
 Definition (cont’d)
SAFETY (n.)
• The condition of being protected from or
unlikely to cause danger, risk, or injury (Oxford
Dictionary)
• The state of being safe; freedom from the
occurrence or risk of injury, danger or loss.
(Friss, 2014)
 Definition (cont’d)
HAZARD (n.)
“A condition or an object with the potential to cause or
contribute to an aircraft incident or accident” - ICAO
Doc. 9859

HAZARD perception depends on:

− National culture
− Organizational culture
− Society’s norms
− Region of operation
− Level of alertness
 Definition (cont’d)
Safety Risk
“The predicted probability and severity of the
consequences or outcomes of a hazard”
- ICAO Doc 9859
 Definition (cont’d)
Make it simple
Hazard: Existing condition or an object
Safety Risk: Predicted probability and severity

• a wind of 15 knots blowing directly across the

runway (hazard)
• the potential for a runway lateral excursion as
result of strong wind (safety risk)
What is Safety in Aviation?

STATE OF MIND THAT MAKE PEOPLE THINKING,

ACTING, BEHAVE IN SUCH A WAY SO THEIR ACTIVITY
CAN BE DONE SAFELY.

WAY SO THE AVIATION CAN BE DONE SAFELY

“SAFETY IS AN ATTITUDE, A FRAME OF MINE”

 The Concept of Safety
Depending on the perspective:
• zero accidents or serious incidents;
• freedom from hazards, i.e. those factors which cause
or are likely to cause harm;
• attitudes of employees of aviation organizations
towards unsafe acts and conditions;
• error avoidance;
• regulatory compliance;
• . . . .?
The Concept of Safety (cont’d)
Things to consider
• Absolute elimination of operational error or accident is
impossible
• Failures and operational errors will occur in aviation, in spite
of the most accomplished efforts to prevent them.
• No human activity or human-made system can be guaranteed
to be absolutely free from hazards and operational errors.
• As long as safety risks and operational errors are kept under a
reasonable degree of control, a system as open and dynamic
as commercial civil aviation is considered to be safe.
The Concept of Safety (cont’d)
“The state in which the possibility of harm to
persons or of property damage is reduced to,
and maintained at or below, an acceptable
level through a continuing process of hazard
identification and safety risk management”
(ICAO Doc 9859)
Traditional Approach of Safety
Focused to PREVENT ACCIDENTS
• Focus on outcomes (causes);
• Unsafe acts by operation personnel;
• Assign blame/punish for failure to “perform safely”;
• Address identified safety concern exclusively.

WHAT? WHO? WHEN?

Identifies: But doesn’t always disclose

WHY? HOW?
 Evolution of Safety
TECHNICAL ERA
F
HUMAN FACTORS ERA U
T
ORGANIZATIONAL ERA
U
TOTAL SYSTEM ERA
R
E
1950s 1970s 1990s 2000s 2010s
ICAO Doc 9859
 Safety Management
• Management dilemma, the resource of
organizations are finite.
• Resources must be allocated on an either/or
basis to what are believed to be conflicting
goals: production goals (delivery of services)
or protection goals (safety) - “Dilemma of the
two Ps”
Dilemma of the Two Ps

Management levels
Resources Resources

Protection Production
 Safety Space

Bankruptcy

pa ce
s
Protection

ta nce
es is
m r
x i mu
Ma

Catastrophe

Production
Safety Philosophy (cont’d)

ONE MINUTE, write a safety rules;

ONE HOUR, hold a safety meeting;

ONE MONTH, put it in operation;

ONE YEAR, win a safety award.

T
EN
One Second, to destroy those of all with an CI
D
AC
Safety Management System
• Seeks to proactively mitigate safety risks
before they result in aviation accidents.
• Four component of SMS:
- Safety policy and objectives
- Safety risk management
- Safety assurance
- Safety promotion
• Safety can be managed actively and pro-
actively
 Safety
Investigation
Overview
 Safety Investigation
• ICAO Annex 13
• Law no 1 of 2009 (Aviation)
• Civil Aviation Safety Regulation (CASR) part 830
• KNKT Policy & Procedure Manual
 Safety Investigation
“A 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/or contributing factors and, when
appropriate, the making of safety
recommendations” – ICAO Annex 13
 Safety Investigation
The sole objective of the investigation of an
accident or incident shall be the prevention of
accidents and incidents. It is not the purpose of
this activity to apportion blame or liability.

Why?
 Safety Investigation
• Blame & liability investigation often prevent someone willing
to cooperate.
- Defensive, afraid to give a good factual information.
- Blaming individuals is convenient, society likes a
scapegoat.
- Usually does not prevent a similar error happening again
particularly if the working conditions were unsafe,
equipment was deficient, safeguards were inadequate and
the way the task was being done was the normal way of
operating.
 Safety Investigation
• The process

Presentation of
Collection of data Analysis of data
findings

ICAO Doc.9756 Part 3

 Accident Causation
Risk Controls
SAFETY MANAGEMENT LINE (Recovery)

Incident

Individual
Actions
Organizational Risk Controls Local Production
Influences (Preventive) Conditions Goals
Technical
Failure
Mechanisms

Risk Controls
(Recovery) Accident
INVESTIGATION LINE
Safety Investigation Annex 13 aircraft accident
and incident investigation
Convention on
International Civil Aviation
Annex 19 safety
management
Other ICAO annexes

Decision Process
Civil Aviation
ICAO Doc 9859 Independent Accident
Incident Authority Authority
Conduct

STATE
State aircraft State safety
investigation Other State
accident and management
IAW State legislation
investigation regulations
legislation and
legislation
Annex 13

SERVICE PROVIDER Safety Department

Conduct investigation
IAW SMS requirements Safety
and report the occurrence Management
and the outcomes of the
investigation to the State
System

YES

Report Safety benefit NO

occurrence IAW and resources
agreed approach available?
Occurrence during Maintain
YES
operations or information for
hazard identified YES future reference

Meet NO Meet trigger NO

requirements requirements
for Annex 13 for
reporting investigation?
IAW: in accordance with
 Principles Involved
• Based on common sense, good judgment and
teamwork
• Supplemented by investigator training,
knowledge and experience
• Efficiency does not mean “jump to
conclusions” or “wrap up in a haste”
“ What you look for is
what you find !

What you find is what

you fix !
 Investigation Reference
Aviation is highly regulated, the investigator may
use the regulatory detail as “reference points”

What was supposed to be done?

versus
What was actually done?
 Principles Involved
• A major accident is ALWAYS a major political
event
• NEVER surprise anyone – communication
matters
• Involves media and family affairs
 Basic Principles
• Honesty and truth
• Sharing data and information
• Transparency
• Personal ambitions VS the good of the
investigation team
• Personal abuse/criticism
Who do the safety
investigation?
Transport safety investigator
 Investigator Qualities
Investigation outcomes largely dependent upon
knowledge, skills and experience of the
assigned investigators, they should have an:

Understanding of the depth of investigation

necessary to conform with the legislation,
regulations and other requirements of the
State conducting the investigation.
 Investigator Qualities
ICAO Doc. 9756 Part I

• A knowledge of aircraft accident investigation

techniques.
• An understanding of aircraft operations and
the relevant technical areas of aviation.
• The ability to obtain and manage the relevant
technical assistance and resources required to
support the investigation.
• The ability to collect, document and preserve
the evidence.
 Investigator Qualities
ICAO Doc. 9756 Part I

• Identify of components, instruments and/or

structural sections which may require more
detailed (off-site) examination.
• Identify and analyze pertinent evidence in
order to determine the causes and, if
appropriate, make safety recommendations.
• Write the final report that meets the
requirements.
 A piece of evidence may tells
so many stories to the experts
 Safety Investigation Team
• Transport safety investigator and everyone
who have right to participate (domestic &
international).
• Accredited Representative, Adviser, Expert.
• Lead by Investigator in Charge (IIC).
• Once appointed, the IIC becomes the central
point for all subsequent information.
• Team composition/numbers made up based
on the occurrence.
 Safety Investigation Team
Participant from other State:
• the State that instituted the investigation;
• the State of Registry;
• the State of the Operator;
• the State of Design;
• the State of Manufacture;
• any State having suffered fatalities or serious injuries to its
citizens; and
• any State that provided relevant information, significant
facilities or technical experts.
 Safety Investigation Team
Aircraft Proximity GA227 (PK-GMK) & PK-DCD

IIC

Media
Affairs

Flight Flight Human

ATS
Operation Recorders Factors
 Safety Investigation Team
LNI610 (PK-LQP)

IIC

Family Affairs Media Affairs

ATS & Accredited

Flight Operation Engineering Flight Recorders Human Factors Observer
Meteorological Representative

USA NTSB KSA AIB

Singapore TSIB

Australia TSB
 The Organization
• Accident Investigation Authority (AIA)
- KNKT, NTSB, ATSB, etc.
• Regional Accident and Incident Investigation
Organization (RAIO)
- BAGAIA (Africa), GRIAA (Central American), etc.
• Aviation organization – aircraft operator,
airport operator, ATS provider
• Private organization
 Accident Investigation
Authority
• Komite Nasional Keselamatan Transportasi
(KNKT)
• The authority designated by Indonesia as
responsible for aircraft accident and serious
incident investigations within the context of
transport safety investigation (ICAO Annex
13).
• Independent organization, separated from
civil aviation authority (DGCA).
Komite National
Keselamatan
Transportasi
Perpres 2/2012
 Aviation Accident Investigation
Sub Committee

• 1 head of Aviation Accident Safety Committee.

• 7 aviation safety investigator (max 10).
• 2 flight recorders specialist.
• More than 10 ad-hoc experts.
• More than 20 investigation per year.
KNKT Flight Recorders
Laboratory
Since 17 August 2009
 Data Collection
On-site & off-site data collection
• Accident particulars;
• Meteorological;
• Technical;
• Human factors;
• Organizational;
• Etc.
 Data Analysis
• Parallel with data collection.
• Often initiates additional questions that
require further data collection, simulation and
consultation.
• Use of analysis tools: reason model, SHELL,
the six M model etc.
 Presentation of Findings
• Investigation report as media to present the findings.
• Investigation report consist of factual information,
analysis, conclusion, safety recommendation.
• May consist safety action taken by related parties.
• Preliminary Report, draft Final Report, Final Report &
Interim Statement.
• The conclusion: findings & causes/contributing
factors.
Investigation Report
 Investigation Report
Dissemination
• As an accident prevention
• Sent to Direct Involved Parties
• Publicly available on website
• Press conference
Website

KNKT.dephub.go.id/KNKT
Press Conference
 THANK
YOU
Any question?