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Investigations by Aviation Service Providers

There are a number of safety occurrences that do not warrant official investigations by States. Nevertheless, those occurrences may be indicative of high risk hazards and could lead to the identification of systemic problems that will not be revealed unless thoroughly investigated. Sound safety management principles and practices require that aviation service providers investigate all occurrences which put or might put at risk the safety of their services. Occurrence investigation is a major component of the organisation’s safety management system.

Often, it is not possible or simply is not productive for an organisation to investigate every single reported occurrence. In such cases the occurrences collected by the safety reporting system shall be accurately assessed and prioritised for investigation based on their perceived risk potential.

The safety management value of the investigation is proportional to the quality of the investigative effort. The following example of poor and high quality incident investigation practices in ANSPs, portray a clear connection between Just Culture concept and the investigation process.

ANSP Occurrence investigation practices example Image source:Safety Culture Enhancement Toolbox for ATM.

Without a structured investigation methodology it is difficult to collect, integrate and analyse all pertinent information, assess risks and produce impartial output that would help improve safety. As investigations are often carried out by a single person, the organisation should ensure that investigators possess the necessary skills, experience and support to carry out their duties.

The investigation reports should be communicated organisation-wide and distributed to other parties that are likely to benefit from the findings. Appropriate de-identification measures may be applied. Safety recommendations and suggested corrective actions should be recorded in a database, and their implementation and effectiveness monitored.