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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.
Annex 13
8.1 INTRODUCTION
8.1.1 Effective safety management systems depend on the investigation and analysis of safety issues.
The safety value of an accident, a hazard or an incident is largely proportional to the quality of the
investigative effort.
State investigations
Accidents
8.1.2 Accidents provide compelling and incontrovertible evidence of the severity of hazards. Too often
it takes the catastrophic and grossly expensive nature of accidents to provide the spur for allocating
resources to reduce or eliminate unsafe conditions to an extent otherwise unlikely.
8.1.3 By definition, accidents result in damage and/or injury. If we concentrate on investigating only the
results of accidents, not the hazards or risks that cause them, we are being reactive. Reactive investigations
are rather inefficient from a safety perspective in that latent unsafe conditions posing significant safety risks
may be overlooked.
8.1.4 The focus of an accident investigation should therefore be directed towards effective risk control.
With the investigation directed away from “the chase for the guilty party” and towards effective risk
mitigation, cooperation will be fostered among those involved in the accident, facilitating the discovery of the
underlying causes. The short-term expediency of finding someone to blame is detrimental to the long-term
goal of preventing future accidents.
Serious incidents
8.1.5 The term “serious incident” is used for those incidents which good fortune prevented from
becoming accidents, for example, a near collision with another aircraft or with the ground. Due to the
8-2 Safety Management Manual (SMM)
seriousness of such incidents, they should be thoroughly investigated. Some States treat these serious
incidents as if they had been accidents. Thus they use an accident investigation team to carry out the
investigation, including the publication of a final report and the forwarding to ICAO of an ADREP incident
data report. This type of full-scale incident investigation has the advantage of providing hazard information to
the same standard as that of an accident investigation.
In-house investigations
8.1.6 Most occurrences do not warrant investigations by either the State investigative or regulatory
authorities. Many incidents are not even required to be reported to the State. Nevertheless, such incidents
may be indicative of potentially serious hazards — perhaps systemic problems that will not be revealed
unless the occurrence is properly investigated.
8.1.7 For every accident or serious incident, there will likely be hundreds of minor occurrences, many
of which have the potential to become an accident. It is important that all reported hazards and incidents be
reviewed and a decision taken on which ones should be investigated and how thoroughly.
8.1.8 For in-house investigations, the investigating team may require the assistance of specialists,
depending on the nature of the occurrence being investigated, for example:
a) cabin safety specialists for in-flight turbulence encounters, smoke or fumes in the cabin, galley fire,
etc.;
b) experts in air traffic services for loss of separation, near collisions, frequency congestion, etc.;
c) maintenance engineers for incidents involving material or system failures, smoke or fire, etc.; and
d) experts able to provide airport management advice for incidents involving foreign object damage
(FOD), snow and ice control, airfield maintenance, vehicle operations, etc.
8.2 SCOPE OF SAFETY INVESTIGATIONS
8.2.1 How far should an investigation look into minor incidents and hazard reports? The extent of the
investigation should depend on the actual or potential consequences of the occurrence or hazard. Hazard or
incident reports that indicate high-risk potential should be investigated in greater depth than those with lowrisk
potential.
8.2.2 The depth of the investigation should be that which is required to clearly identify and validate the
underlying hazards. Understanding why something happened requires a broad appreciation of the context
for the occurrence. To develop this understanding of the unsafe conditions, the investigator should take a
systems approach, perhaps drawing on the SHEL model outlined in Chapter 4. Resources are normally
limited, thus the effort expended should be proportional to the perceived benefit in terms of potential for
identifying systemic hazards and risks to the organization.
8.2.3 Although the investigation should focus on the factors that are most likely to have influenced
　
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