The event investigation process is implemented to manage the risks being caused by the events that occur due to human errors, which may affect the flight safety, lead to personal injuries and cause ground handling equipment damage. There are two kinds of human actions namely errors and violations. An error is a human action which unintentionally deviates from the requires and expected action. Violation is an intentional action of a human to deviate from the company policies and procedures1
The purpose of conducting event investigation is to help the organization to identify and understand the different contributing factors for the occurrence of errors and violations. Some of the contributing factors are, hard to understand procedures, time pressures, task interruptions, communication mismatch and a variety of additional workplace conditions. The event investigation systems are often a part of the company's risk and safety management systems as they provide the organization an insight on the contributing factors of events which helps the organization to prevent the future occurrence of errors.
Importance of Event Investigation process
- The flight safety foundation FSA (2009)2 estimates that the ramp accidents cost the major airlines in the world at least US$10 billion a year. These accidents affect the airport operations and they also cause personal injuries, damage to aircraft and ground support equipments.
- An effective event investigation program helps in identifying the contributing factors for the errors and violations and based on the result the preventive plans can be developed.
- The human performance issues in an organization can be identified and communicated throughout the organization's workforce with the help of an event investigation process.
- Event investigation is of such importance because it is a key aspect of the safety management systems required by many national aviation authorities.
Developing an Event Investigation process3
The development of an event investigation process involves the following steps
- Identifying the ownership of the process by selecting a department to be responsible for the entire process and have authority for the process.
- The investigation process should b selected in such a way that it systematically determines the threats and contributing factors to events. The policies and guidelines for the event investigation process should be communicated throughout the organization.
The department should adopt the following steps to conduct an event investigation
- Preserve scene and gather data immediately. The investigation should be initiated as soon as possible because the first hand reports of event participants and witnesses tend to alter with time due to stress and inaccurate memory.
- The problem should be defined clearly with a statement.
- The personnel involved in the investigation process should be given adequate training to ensure consistent and accurate data collection.
- Analyzing the data - All of the data which has been accumulated is now analyzed to arrive at the conclusions to determine the contributing factors for events. A team must be set up to review the investigation findings, selecting the areas for improvement and create a suitable prevention plan for each area.
- The investigation findings reveal the root causes which are the most basic causes for the occurrence of an error and the contributing cause which adds severity to the event. The potential for the root cause should be identified and eliminated through suitable action plans.
- After the process of identifying the root causes and contributing causes for the incidents, the appropriate corrective action are to be formulated which will prevent the events occurring due to human error in the future. A number of corrective actions are recommended to be developed and put together to form a Corrective Action Plan (CAP).
- The results obtained through the event investigation process needs to be communicated to the entire workforce of the organization so that the future errors can be minimized.
- Finally, a database can be created for documenting the investigation findings. The event and its contributing situations and the results of the event investigation process can be classified according to a standardized system in order to analyze an summarize the data
How to know the event investigation process works
According to FAA (2007)1The following are the results of successful implementation of an event investigation program
- The event investigation process findings reveal the cause of threats and provide necessary improvement strategies to overcome these threats.
- The consequences and likelihood of future occurrence of an incident is reduced by the findings of the event investigation process.
- The deviations in the existing procedures are detected and corrected by an event investigation program.
- The number of errors caused due to impaired human performance shows a considerable decrease.
- The organization such as an airport saves a lot of time and money by reducing personal injuries, ground equipment damage and aircraft damage.
- The results of the event investigation process will be discussed throughout the airport organization among the workforce about the threats and error management actions.
- Finally, it can be seen that the workforce strictly adheres to the regulatory guidelines, policies and procedures of the organization which results in safe and efficient airport operations.
Want to know more?
- Aviation Safety Action Program (ASAP)
- This page offers more information about establishing an Aviation safety action program.