1. If you are investigating an aviation mishap and asking the question, “Who was at fault and who pays,” then you are doing a legal investigation.
2. If you are investigating an aviation mishap and asking the questions, “How did this happen and how can we prevent a recurrence?” then you are doing a safety investigation.
3. In either case, what is written on the door of your office, the door of your truck or car, the name tag you wear or the title of your agency is not as relevant as which set of these questions begins your investigation.
4. If the title of your agency says mishap investigation, but the purpose of your investigation is to find fault, then you are conducting a legal investigation and it is very likely that the safety purpose will go unfulfilled. The Safety Purpose is to ask, “How did this happen and how can we prevent a recurrence?”
5. A legal investigation is designed to determine, “Who was at fault and who pays?” In many, perhaps most ways, the legal investigation looks backwards.
6.The safety investigation however only works if it looks forward, because the investigators have to determine how to prevent a recurrence. How often do you think mishap safety investigators get this right?
7.Safety investigations are only complete when the cause is found and recommended procedure and training changes are determined that, had they been in place, would have prevented this mishap from occurring. Therefore, Probable Cause determination is not good enough, because you will not know what to fix to prevent a recurrence. You have to know the cause or causes, so that if they are indeed valid, you can then develop a recommendation for corrective action, that if all were to follow in the future, and had been in place before the mishap, would ensure that this mishap never happened and would never happens again.
If for example, no one at the Air France Dispatch Office is tasked with flight following, and looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched flight, and then tasked with coordinating a new and safer path diverting around the hazardous weather, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.