Airlines, Incidents and Investigators

As the aviation industry has grown and evolved, so too has its infrastructure for learning from accidents and incidents. The foundation of this infrastructure is defined and formalised in international conventions. As the Second World War drew to a close, international arrangements were drawn up to govern international civil air travel, culminating in the establishment of the International Civil Aviation Organisation (ICAO), an agency of the United Nations. In 1951, ICAO published the first international standards and recommended practices on aircraft 

This chapter aims to provide a picture of the typical organisational arrangements and practical work of analysing safety incidents to 

On handover, with the aircraft fully established on approach in landing configuration the copilot inadvertently pressed the autopilot switch. 

Disconnected manually and the flight director recycled, approach continued manually to normal landing. Minimal deviation from glideslope. 

The first I hear of the event is arriving in the office of the airline s safety team on a Monday morning. The air safety investigators are in a huddle talking about it. The call came in over the weekend to the on-call 

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PEAT is a structured, cognitively based analytic tool designed to help airline safety officers investigate and analyse serious incidents involving flight-crew procedural deviations. 

The Concorde aircraft tragedy in July 1999 involved a fuel tank puncture caused by tire failure.During the investigation, it was disclosed that there had been at least five previous incidents of almost the same scenario. In one of the previous incidents, a tire failed and punctured the fuel tanks, yet there was no ignition. The incident investigation management systems used by the airlines failed to adequately follow-up and apply lessons learned from previous investigations. 

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