Aviation Investigation & Analysis
“Data based decision making is one of the most important facets of any management system” ICAO SMM (Doc9859) 3rd Ed, Chapter 2
An organization that has a successful Safety Management System (SMS) will have a proactive reporting culture, encouraging any type of incident to be reported and not just the ones that contribute to regulatory control.
The review process then determines if the report is valid and if any further steps are required, for example take no further action, obtain further information or progress to investigation.
An investigation will review whether, through risk assessment, changes are required to reduce the level of risk in the future. The investigation will also identify whether there is a process change required, a review of documents needed or possibly further training requirements. A thorough investigation will help organizations react to facts rather than assumptions so that informed decisions can be made without fear of the event reoccurring or, worse, ending in a more severe outcome.
Capturing a variety of report types will create the basis for an effective analysis tool. Each report type will have different levels of severity and also different areas of responsibility.
Getting information into a reporting system is all well and good; however the key is what you do with it. Analysis of the data captured through reporting is beneficial in driving change management throughout an organization.
Ownership and delegation of a report type is key to ensure that the relevant department and person are identified to own the investigation from start to conclusion. Every report will also have a different workflow with different completion stages.
A simple workflow could be:
However, more complex workflows will follow whatever is appropriate to determine a root cause and risk assessment of the on-going investigation with the aim of reducing the existing risk to an acceptable level.
The workflow should manage all actions, findings, non-conformances and recommendations through to conclusion. The aim is to learn from experience with the intent of either eliminating the risk altogether, or ensuring that you have a complete understanding of why it happened and that you can manage controls to minimize the impact if it re-occurs.
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