Aviation Accident Investigations

...Should be for enhancing safety

In recent years, some issues related to aviation safety have highlighted the media. Aircraft crashes, skids, the banning from European Union, neglected investigations and also airline certificate revocation, seem to be familiar in our daily lives.  Yet, attempts to improve the aviation safety and to manage those problems have been far from comprehensive.

If flight crews are blamed such as for Yogyakarta crash, should they face criminal courts for being guilty of manslaughter? What should be done, after publishing that crews made mistakes in the Adam Air crash? It seems that the underlying problems have been found but in fact not. In these cases, the authorities have not acted completely.  It should be noted that the main focus of aviation safety investigations is to enhance flight safety and not to allocate blame.

Rather, the main purposes are to identify and assess contributing factors and safety deficiencies as well as to communicate those contributing factors and deficiencies to the relevant parties.  The expected outputs include local safety action, safety recommendation, safety advisory notice and public reports.

We should bear in mind that the most obvious human error-related factors are not always the most significance in terms of precipitating human error. There is usually no one simple solution to human error problems and it should be known that humans do not always act as they are expected to, especially when they face critical situations.

Blaming, excusing or exonerating individuals will not solve the problems because the investigations tend to be stemmed and perhaps can hide possible factors that determine the accidents. In other words, this will not enhance the aviation safety in the future indeed. There are some organisational factors that may contribute to the latent errors in aviation accidents.

Then, what happened at the managerial level? Did the government make the right decision to revoke the operating certificate of Adam Air? Some organizational issues can be considered to answer this question.

It is important to recognize whether or not the company actively search for their weaknesses, regularly evaluate the risk controls before and after a change, utilise available resources/expertise and only reliance upon technological wonders. Also, it is utmost important to know whether or not the company has had effective formal risk management programs. If the decision was made based on those issues, then the government is on the appropriate track.

What about the other airlines? That's the next question to ensure whether the government has applied the same standard for all airlines or not. It's a good start and will be beneficial if it can be sustained without political considerations.

All possible aspects should be examined both from the human and organisational factors to achieve the best solution for enhancing the future safety. Main focuses should be given to the organisational factors that contribute to the latent problems in Indonesian civil aviation.

There is still a lot of homework for enhancing the aviation safety in the future. The related authorities should be aware and avoid using superficial corrective action that cannot touch the nature of the problems.

Updated: 25 April 2008