Introduction

 &  Course  Overview:

Safety  Investigation

By
HENRY  POERBORIANTO
 Who’s  this  guy?
Henry  Poerborianto
• JATC  46
• SATC  54
• Approach  Control  Surveillance  Batch  90
• D-­‐IV  ATC  15
• Magister  degree  of  Transportation
• Master  degree  of  Environment  &  Infrastructure  Planning
• KNKT  Safety  Investigator  (Aviation)  
+628112516622
henryknkt@gmail.com
henry_poerborianto@dephub.go.id
 Course  Overview
• 16  days  classroom  (theory  &  practice)  
• 2  exams  (mid  &  final)
⁃ Introduction  to  safety  investigation
⁃ Investigation  rules  &  regulations
⁃ Investigation  fundamentals
⁃ Safety  on  Accident  Site
⁃ Data  collection
⁃ Investigating  Human  Factors
⁃ Analysis  framework
⁃ Report  writing  
 Today’s  Topics
• What  is  safety?
• Safety  investigation  overview
• ATS  safety  investigation
 Objective
• To  get  a  better  understanding  of  safety  
investigation  in  aviation  
What  is  Safety?
 Definition
SAFE  (adj.)
• Free  of  danger  or  injury,  secure,  not  risky,  
reliable,  sure  (Oxford  Dictionary).
• Free  or  freed  from  danger  or  evil;  placed  so  
that  harm  cannot  come  (Funk  &  Wagnalls).
 Definition  (cont’d)
SAFETY  (n.)
• The  condition  of  being  protected  from  or  
unlikely  to  cause  danger,  risk,  or  injury  (Oxford  
Dictionary)
• The  state  of  being  safe;  freedom  from  the  
occurrence  or  risk  of  injury,  danger  or  loss.  
(Friss,  2014)
 Definition  (cont’d)
HAZARD  (n.)
“A condition or an object with the potential to cause
injuries to personnel, damage to equipment or
structures, loss of material, or reduction of ability to
perform a prescribed function” -­‐ ICAO Doc. 9859
• HAZARD  perception  depends  on:  
− National  culture
− Organizational  culture
− Society’s  norms
− Region  of  operation
− Level  of  alertness
 Definition  (cont’d)
Safety  Risk
“The predicted probability and severity of the
consequences or outcomes of a hazard”
-­‐ ICAO Doc 9859
 Definition  (cont’d)
Make  it  simple
Hazard:  Existing  condition  or  an  object  
Safety  Risk:  Predicted  probability  and  severity

• a wind of 15 knots blowing directly across the

runway (hazard)
• the potential for a runway lateral excursion as
result of strong wind (safety risk)
 What  is  Safety  in  Aviation?
STATE  OF  MIND  THAT  MAKE  PEOPLE  THINKING,  
ACTING,  BEHAVE IN  SUCH  A  WAY  SO  THEIR  ACTIVITY  
CAN  BE  DONE  SAFELY.

WAY  SO  THE  AVIATION  CAN  BE  DONE  SAFELY

“SAFETY  IS  AN  ATTITUDE,  A  FRAME  OF  MINE”

 The  Concept  of  Safety
Depending  on  the  perspective:
• zero  accidents  or  serious  incidents;
• freedom  from  hazards,  i.e.  those  factors  which  cause  
or  are  likely  to  cause  harm;
• attitudes  of  employees  of  aviation  organizations  
towards  unsafe  acts  and  conditions;
• error  avoidance;
• regulatory  compliance;
• .  .  .  .?
 The  Concept  of  Safety  (cont’d)
Things  to  consider
• Absolute  elimination  of  operational  error  or  accident  is  
impossible
• Failures  and  operational  errors  will  occur  in  aviation,  in  spite  
of  the  most  accomplished  efforts  to  prevent  them.
• No  human  activity  or  human-­‐made   system  can  be  guaranteed  
to  be  absolutely  free  from  hazards   and  operational   errors.
• As  long  as  safety  risks  and  operational  errors  are  kept  under  a  
reasonable  degree  of  control,  a  system  as  open  and  dynamic  
as  commercial  civil  aviation  is  considered  to  be  safe.
 The  Concept  of  Safety  (cont’d)
“The state in which the possibility of harm to
persons or of property damage is reduced to,
and maintained at or below, an acceptable
level through a continuing process of hazard
identification and safety risk management”
(ICAO Doc 9859)
 Traditional  Approach  of  Safety
Focused  to  PREVENT  ACCIDENTS
• Focus  on  outcomes  (causes);
• Unsafe  acts  by  operation  personnel;
• Assign  blame/punish  for  failure  to  “perform  safely”;
• Address  identified  safety  concern  exclusively.

WHAT? WHO? WHEN?

Identifies: But  doesn’t  always  disclose

WHY? HOW?
 Evolution  of  Safety

TECHNICAL FACTORS

HUMAN FACTORS

NOW
ORGANIZATIONAL
FACTORS

1950s 1970s 1990s 2000s

ICAO  Doc  9859
 Accident  Causation
Risk  Controls
(Recovery)

Incident

Individual  
Actions
Organizational   Risk  Controls   Local   Production  
Influences (Preventive) Conditions Goals
Technical  
Failure  
Mechanisms

Risk  Controls
(Recovery) Accident
 Safety  Management
• Management  dilemma,  the  resource  of  
organizations  are  finite.
• Resources  must  be  allocated  on  an  either/or  
basis  to  what  are  believed  to  be  conflicting  
goals:  production  goals  (delivery  of  services)  
or  protection  goals  (safety)  -­‐ “Dilemma  of  the  
two  Ps”
Dilemma  of  the  Two  Ps
Management levels
Resources Resources

Protection Production
 Safety  Space

Bankruptcy
Protection

Catastrophe

Production
 Safety  Philosophy
ACCIDENT
C
U
S  
T
O
M
E
R

TIME
EFFECT OF ACCIDENT CUSTOMER MARKET

HAS GOOD SAFETY IMAGE PROCESS

Safety  Philosophy  (cont’d)
ONE MINUTE, write a safety rules;;

ONE HOUR, hold a safety meeting;;

ONE MONTH, put it in operation;;

ONE YEAR, win a safety award.

One  Second,  to  destroy  those  of  all  with  an

Safety  Investigation  Overview
 Safety  Investigation
• ICAO  Annex  13
• Law  no  1  of  2009  (Aviation)
• Civil  Aviation  Safety  Regulation  (CASR)  part  830
• KNKT  Policy  &  Procedure  Manual
 Safety  Investigation
“A process conducted for the purpose of accident
prevention which includes the gathering and
analysis of information, the drawing of
conclusions, including the determination of
causes and/or contributing factors and, when
appropriate, the making of safety
recommendations”. – ICAO Annex 13
 Safety  Investigation
The sole objective of the investigation of an
accident or incident shall be the prevention of
accidents and incidents. It is not the purpose of
this activity to apportion blame or liability.

Why?
 Safety  Investigation
• Blame  &  liability  investigation often  prevent  someone  willing  
to  cooperate.
-­‐ Defensive,  afraid  to  give  a  good  factual  information.
-­‐ Blaming  individuals  is  convenient,  society  likes  a  
scapegoat.
-­‐ Usually  does  not  prevent  a  similar  error  happening  again  
particularly  if  the  working  conditions  were  unsafe,  
equipment  was  deficient,  safeguards  were  inadequate  and  
the  way  the  task  was  being  done  was  the  normal  way  of  
operating.
 Accident  Causation
Risk  Controls
SAFETY  MANAGEMENT  LINE (Recovery)

Incident

Individual  
Actions
Organizational   Risk  Controls   Local   Production  
Influences (Preventive) Conditions Goals
Technical  
Failure  
Mechanisms

Risk  Controls
(Recovery) Accident
INVESTIGATION  LINE
 Safety  Investigation
• The  process

Presentation  of  
Collection  of  data Analysis  of  data
findings

ICAO  Doc.9756  Part  3

 Safety  Investigation  Process
• All  aircraft  accidents  are  different however,  
basic  accident  investigation  process  not  very  
different.
• Fundamental  investigative  processes  same  for  
Cessna  172  as  for  Boeing747.  
• Scale  and  Management  of  the  investigation  is  
very  different.
 Safety  Investigation  Process
Regulatory  detail  provides  reference  points
Aviation’s  highly  regulated  environment  means  
investigators  have  good  ‘reference  points’  to  
work  from,  for  all  categories  and  types  of  
investigation:
What  was  supposed  to  be  done?  
versus  
What  was  actually  done?
Safety  Investigation  Process
Mostly  
science

but

Partly art
 Safety  Investigation  Fundamentals
Fact: All  aircraft  accidents  are  different.
• Investigation  process  similar  for  all.
• Initially  majority  of  effort  directed  to  collecting  data.

Myth:  Analysis  does  not  start  until  all  data  collected.

• Conclusions  not  developed  until  analysis  complete?
• Report  not  started  until  conclusions  have  been  
reached?
Example:
• Engine  (or  propeller)  is  examined (data  
acquisition)  
• evidence  shows  significant  power  at  impact
(analysis)  
• therefore  engine  was  not  a  factor  in  
development  of  this accident    (conclusion).
Who  do  the  safety  investigation?

Transport  safety  investigator

 Investigator  Qualities
Since  investigation  outcomes  largely  dependent  
upon  knowledge,  skills  and  experience  of  the  
assigned  investigators,  they  should  have  an:
Understanding  of  the  depth  of  investigation  
necessary  to  conform  with  the  legislation,  
regulations   and  other  requirements  of  the  
State  conducting   the  investigation.
 Investigator  Qualities
ICAO  Doc.  9756  Part  I
• A knowledge of aircraft accident investigation
techniques.
• An understanding of aircraft operations and
the relevant technical areas of aviation.
• The ability to obtain and manage the relevant
technical assistance and resources required to
support the investigation.
• The ability to collect, document and preserve
the evidence.
A  piece  of  evidence  may  tells  so  many  stories  to  the  experts
 Investigator  Qualities
ICAO  Doc.  9756  Part  I
• Identify of components, instruments and/or
structural sections which may require more
detailed (off-­‐site) examination.
• Identify and analyze pertinent evidence in
order to determine the causes and, if
appropriate, make safety recommendations.
• Write the final report that meets the
requirements.
“The  investigator  is  essentially   a  gatherer  of  facts  
and  the  resulting  analysis  and  conclusions   can  be  
no  better  than  the  facts gathered”
Robert  W.  Sweginnis
Richard  H.  Wood
 Safety  Investigation  Team
• Transport  safety  investigator  and  everyone  
who  have  right  to  participate  (domestic  &  
international).
• Accredited  Representative,  Adviser,  Expert.
• Lead  by  Investigator  in  Charge (IIC).
• Once  appointed,  the  IIC  becomes  the  central  
point  for  all  subsequent  information.
• Team  composition/numbers  made  up  based  
on  the  occurrence.
 Safety  Investigation  Team
Participant  from  other  State:
• the  State  that  instituted  the  investigation;
• the  State  of  Registry;
• the  State  of  the  Operator;
• the  State  of  Design;
• the  State  of  Manufacture;
• any  State  having  suffered  fatalities  or  serious  injuries  to  its  
citizens;  and
• any  State  that  provided  relevant  information,  significant  
facilities  or  technical  experts.
 Safety  
Investigation  
Team
 KNKT  Safety  Investigation  Team
QZ8501  (PK-­‐AXC)
IIC

Family  Affairs Media  A ffairs

Flight   ATS  &   Flight   Accredited  

Engineering Human  Factors Expert
Operation Meteorological Recorders Representative

BEA  France  &  

UK  AAIB
Airbus

USA  NTSB Malaysia  AAIB

Singapore  A AIB Korea  A RAIB

Australia  TSB
 KNKT  Safety  Investigation  Team
Aircraft  Proximity  GA227  (PK-­‐GMK)  &  PK-­‐DCD

IIC

Media  
Affairs

Flight   Flight   Human  

ATS
Operation Recorders Factors
 Data  Collection
• Accident  particulars;  
• Meteorological;
• Technical;  
• Human  factors;
• Etc.
 Data  Analysis
• Parallel  with  data  collection,  remember  the  
myth;
• Often  initiates  additional  questions  that  
require  further  data  collection,  simulation  and  
consultation.
• Use  of  analysis  tools:  reason  model,  SHEL,  the  
six  M  model  etc.
 Presentation  of  Findings
• Investigation  report  as  media  to  present  the  findings.
• Investigation  report  consist  of  factual  information,  
analysis,  conclusion,  safety  recommendation.
• May  consist  safety  action  taken  by  related  parties.
• Preliminary  Report,  draft  Final  Report,  Final  Report  &  
Interim  Statement.
• The  conclusion:  findings  &  causes/contributing  
factors.
 Presentation  of  Findings
• Findings
Statements  of  all  significant  conditions,  events  or  
circumstances  in  the  accident  sequence.  The  findings  
are  significant  steps  in  the  accident  sequence,  but  
they  are  not  always  causal,  or  indicate  deficiencies.  
Some  findings  point  out  the  conditions  that  pre-­‐
existed  the  accident  sequence,  but  they  are  usually  
essential  to  the  understanding  of  the  occurrence,  
usually  in  chronological  order.
 Presentation  of  Findings
• Cause:
Action,  omissions,  events,  conditions,  or  combination  
thereof,  which  led  to  the  accident  or  incident.
• Contributing  factors:
Actions,  omissions,  events,  conditions,  or  
combination  thereof,  which,  if  eliminated  or  avoided,  
would  have  reduced  the  probability  of  the  accident  or  
incident  occurring  or  mitigated   the  severity  of  the  
consequences  of  the  accident  or  incident.
Investigation  Report
 Investigation  Report  Dissemination
• As  an  accident  prevention.
• Sent  to  Direct  Involved  Parties.
• Publicly  available  on  website.
• Media  release.
KNKT  Website
KNKT.dephub.go.id/KNKT
KNKT  Media  Release
 THANK  YOU
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