Is Your Safety Investigation Local?

The information gathered from a local investigation to determine ‘what went wrong and how do we prevent it from recurring’ needs to be local.

There is a tendency to defer investigations to higher authority, most likely because the local safety managers just do not have the equipment to analyze the DFDR and other technical records.

Yet the more that the investigation is centered locally, the more likely it is that the investigation will address the local safety issues involved with the mishap. Most often mishaps are the result of human error on the part of crew or others involved in operations or some other local element of the operation.

Yet hull and engine complete reconstruction often takes place at great expense but at no level of contribution to the prevention of future mishaps. Again the local investigators become intimidated by the metal smiths, but to what avail? How does all of that expense and effort profit us when the mistake was made elsewhere? Are some investigators really trying to conduct a belated administrative investigation of the air line operation in lieu of focusing all efforts on human error, the most common reason for aviation mishaps?

As a local safety investigator, it is most likely that the greater burden of determining what went wrong will fall eventually squarely on your shoulders.

This is why I believe strongly that all safety investigations contain a strong local component with a great focus on human error.