ISASI 44
(Adapted from remarks presented by Director Troadec in his keynote address to the delegates of the ISASI 44th annual international conference on air safety accident investigation in Vancouver, B.C.,Canada,on Aug. 22, 2013.
The organization of aviation safety investigations is regulated by a basic text, Annex 13 to the Chicago Convention. This text is an essential reference for the conduct of international investigations.
In general, it has made it possible for investigations to be undertaken systematically after accidents and the most serious incidents and for the safety lessons from them to be shared with the international aviation community. It is based in particular on an intangible principle of international law—the sovereignty of the state of occurrence, which is responsible for the investigation and solely authorized to communicate on its progress. Is this principle of international law still effective regarding the objective of safety investigations? For this, an investigation would have to be conducted systematically by a relevant and motivated authority whenever the importance of the event justified it and that the international aviation community be duly informed of the safety lessons resulting from it.
This is generally the case, but there are exceptions. Of course, all major accidents, or nearly all, are the subject of a safety investigation, but it is not always conducted effectively and diligently, despite the implication and support of the safety investigation authorities that are associated with it—the main ones being the state of manufacture of the aircraft and that of the state of operation or registry. The reasons for this are various.
The investigation authority’s lack of experience or lack of resources, the fear of raising questions awkward for national interests, lack of motivation, various types of pressure…. At the BEA, we occasionally see specific investigations stall despite all our efforts to have them move forward.
Of course, most investigations end up being completed, but sometimes so late that it is almost useless. It took the BEA five years of continuous effort with the investigation authority to finally obtain the report on the accident of the MD-80 that occurred in 2005, and four years for the report on the Yemenia accident that occurred in 2009 to be published.
What can we do when the investigation authority keeps quiet whereas, being associated with the investigation, we believe it necessary for air safety to take urgent safety measures and to inform the parties concerned? For incidents in particular, there is the problem of assessing the merits of an investigation in relation to the safety lessons that could be drawn from it. Yet the state of occurrence is not necessarily the best place to judge, especially if its experience is limited.
The other question bears on the investigation authorities’ limited resources, which may not encourage the authorities to use all the resources to conduct investigations into events that only concern them indirectly, compared with other priorities.
This situation may occur when the incident threatens the operator of a third country, without implicating the air traffic control or airport services of the country of occurrence.
There are, therefore, serious incidents The Principle Of National Sovereignty In Air Safety Investigation By Jean-Paul Troadec, Director, Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA), France Director Troadec in his keynote address speaks about safety investigation that may not be conducted effectively and diligently and offers a framework of new practices to compensate for the lack of resources, skills, or motivation of some authorities. E. Martinez October–December 2013 ISASI Forum • 7 that are not the subject of investigations because the state of occurrence decided so, either from incorrect assessment of its potential consequences or due to lack of resources. This was the case recently when an A330 suffered icing of all three of its angle of attack sensors, causing the airplane to pitch down, a situation from which the crew recovered as a result of an improvised input.
Yet in an era where, fortunately, the number of major accidents has fallen steeply, investigations into serious incidents are one of the tools enabling us to detect new risks because operators, acting in the framework of their SMS, do not necessarily have access to all the information enabling them to carry out an in-depth safety analysis. How then can we ensure that all investigations into major accidents are conducted in a diligent way and that information that is useful for aviation safety is communicated as soon as possible to the aviation community? How can we ensure that the potential seriousness of incidents is correctly assessed and that an investigation is conducted whenever safety lessons can be learned? An attempt to find a solution is given in Appendix 13 itself, which provides for an investigation to be delegated by the state of occurrence to another state without, however, any existing texts to regulate this practice.
A total delegation of investigation into a major accident bearing on all the aspects dealt with in Appendix 13 is difficult to imagine, as the accident calls into question considerations that go beyond the safety investigation and that directly concern the political and administrative authorities of the state of occurrence, such as managing the site of the accident, managing the bodies and autopsies, relations with the victims and their families, coordination with legal authorities, airport or ATC problems, and so on. Yet if the investigation is not delegated, the current regulations do not authorize the authorities taking part in the investigation, whatever their level of involvement, which may be quite high, to communicate on the progress of the investigation.
Nothing, however, prevents sharing the functions attributable to the investigation authorities under Appendix 13 between the state of occurrence authority and another authority with the skills and resources required to conduct the technical and safety dimension of the investigation, including communication on the safety lessons learned.
The BEA’s role in the investigation into the Afriqyah A330 accident anticipated this type of relations, which of course presupposes mutual trust. Such a sharing of roles should be recognized and formalized in the framework of a protocol between the authorities concerned, and we think it would be useful for International Civil Aviation Organization (ICAO) to publish recommendations on this subject. In contrast, full delegation of investigation into a minor accident or a serious incident is easier to implement and is more frequently undertaken when the state of occurrence is not directly involved in the event. Such a decision should be taken immediately after the incident after consultation with the authorities of the state of manufacture, registry, or operation in order to assess, in the event of doubt, the seriousness of the incident and to establish the authority that is best placed to conduct the investigation. This may be the case of the state of manufacture or the state whose safety authorities issued the airworthiness or operating certification. What, however, can we do when no investigation is conducted or delegated, or when it is, it is done negligently whereas aviation safety appears to be compromised by the inertia of the authorities in charge of the investigation? Legally, the participants in the investigation have no right to intervene.
But from a moral point of view, can they do nothing if they deem that the investigation, whatever its stage of progress, brings to light a serious danger for air operations? It seems unrealistic to imagine a procedure allowing the shortcomings of this authority to be declared and to replace it with another, as there is no supra-national authority able to do this. Nevertheless, it is our duty, as a participant in an investigation, to push any authority at fault to complete an investigation and, if this authority fails to fulfill its duties, to inform the aviation community of the safety lessons that should be drawn from it.
Faced with this type of situation, the BEA has always respected the privilege of public communication given to the authority in charge of the investigation, but has also ensured that the main bodies involved were notified of urgent safety measures that needed to be taken, if any. Again, we also believe that this practice should be structured so that it is not interpreted as interference with the sovereignty of the state of occurrence. In conclusion, I would like to stress that most investigations into accidents and serious incidents are conducted in a satisfactory manner, sometimes even by authorities with limited resources when they know they can rely on other authorities with the necessary capabilities.
It is, however, unacceptable that some events that are serious enough for safety lessons to be learned are not the subject of investigations. While remaining within the scope of Appendix 13, which must remain the international benchmark survey of aviation safety, I propose a framework of new practices to compensate for the lack of resources, skills, or motivation of some authorities: Partial delegation of the investigation into major accidents, limited to the technical and safety dimension of the investigation and total delegation of the investigation on serious incidents when the event does not directly concern the state of occurrence.
And finally, as a last resort when the state of occurrence does not conduct an investigation diligently and when urgent safety measures are required, the right for the authorities participating in the investigation, in the context of the provisions of Appendix 13, to communicate to aviation stakeholders on the safety measures required. ◆