Sample Aviation Essay Paper on Air Safety Systems and Investigation

Air Safety Systems and Investigation

Air transport is one of the safest modes of transport through which people and cargo are transported to other destinations. However, this mode of transport is not immune to instances of accidents and incidents. In the recent past, the sector has been on the limelight after various accidents involving large commercial airlines such as the Germanwings Flight 9525, Air Asia Flight 8501 and the air crash involving a Russian Chattered aircraft, Kogalymavia Flight 9268 in the Northern Sinai. These accidents continue to cause uncertainties and worries on whether air transport remains safe, with aviation experts pointing the finger mostly on human factors and technical elements given the type of information gathered by aviation experts from the scenes of the crash.

However to unearth the cause of such incidences and accidents, a major aviation body, the International Civil Aviation Organization (ICAO) plays a role in developing procedures and standards which are used in the investigation of aircraft accidents. The organization coordinates with other bodies and is charged with developing an international framework with standards and procedures used in conducting investigations regarding aircraft accidents or incidents, with an accident being an action that compromise flight safety by causing death, while an incident being an action that affects flight operations (Tackett, 2000).

The organization promotes these standards and procedures and structures them into various components to help in the investigation. These categories comprise of the notification and planning element, accident site investigation, accident investigation, organization, reporting and publication. These elements are promoted by the International Civil Aviation Organization (ICAO) and are distributed to various state agencies and companies, as a standard procedure for investigating incidents and accidents across the globe (Beveridge, 2012). While ICAO develops the procedures, some states have independent investigation bodies with similar mandates of investigating air crashes that occur in their airspace. However, both coordinate with each other in instances where the crash is of bigger magnitude. ICAO not only promotes the standards and procedures for investigating accidents but also promotes others such as Personnel Licensing, Airworthiness of Aircrafts, Radio Navigation of Aids and Aerodrome design and construction among others. In order to understand the whole concept, it is important to understand how state and national laws across different boundaries govern their operations. This is because each country has different organs which help in investigation processes, each entirely following the laws of their states. ICAO maintains its mandate by promoting the following components that help in the investigation of air accidents and incidents.

Notification and planning

The notification element is the first phase of an air accident or incident. It basically involves relaying information to various authorities concerning an occurrence of an accident or incident. The notification attributes aim to direct the communication process of informing several agencies through the most appropriate means under the least time possible. The notification process involves the state of operator, registry, design and manufacture with the involvement of International Civil Aviation Organization on aircrafts with a mass of over 2000Kg. This process starts by informing the state of operator, in which the official operating business is located, where the aircraft involved in the accident belongs. This may be a residential office in a foreign location, or a business primary location in case the aircraft is of foreign origin.

Besides this, the notification is also sent to the state of registry, the state with the aircraft registration, state of design and manufacture, countries involved in the manufacture of the design and assembly of the aircraft involved in the air accident. The persons involved in notifying the company regarding the accident or incident may vary depending on information at hand. This is because certain circumstances are usually unknown, but the process could be initiated by an eyewitness may call the country’s aviation bodies. Alternatively, an air controller especially when an aircraft is off the radar may report the aircraft disappearance to the traffic controller in command. The aircrew or the pilot in command can also notify the control tower personnel regarding a possible accident mainly before it eventually occurs.

On the other hand, where there is an incidence, the cockpit or cabin crew can also notify the traffic controllers especially in instances where communication is cut off from the cockpit, where afterwards an independent investigator could come on board to help unearth the cause of the incident. In addition to this, there are procedures that advocate for the planning element, mainly involving crash site planning, an element that handles site access issues, but depends on the topographical nature of the area of the crash.

Accident site investigation

Accident site investigation is different from accident investigation. Accident site investigation is the site investigation conducted on the area of the crash while the latter is the actual investigation in which the elements of the crash are investigated. There are various elements promoted by the International Civil Aviation Organization that constitute the crash site investigation. According to ICAO, it stipulates that the voice recorder must be analyzed to guide the initial investigation procedure. This is a device that is capable of recording flight crew communication and instances of conversation during a flight (Tooley & Wyatt, 2009). The device is analyzed and processed by an Investigator-In-Charge (IIC) or a forensic audio expert present during the initial crash site investigation.

            This is to remove the assumptions which may be made through analyzing the sound elements and noises during the last moments of a flight. The process follows an organizational component of the investigation process which involves combining and assembling the right team with human and professional qualities to conduct the investigation. This is to ensure that professionals with good technical skills, sound judgment and integrity on aviation related accidents and incidents are brought on board to manage the accident investigation process.

            In the view of the organization (ICAO), the organizational element needs to be structured into various groups, under the watch of an Investigator-In-charge (IIC), the deputy and other group members to oversee the aircraft, systems, operations and human factor elements. The layout for the group structure is as follows.

            In the layout, ICAO stipulates that the IIC is the lead investigator, and also oversees each group’s objectives and coordinates the reporting elements. The structured groups on the other hand oversee the various elements of the crash, including drawing of an analysis and also reporting the findings to the lead IIC. Apart from overseeing the investigation process, the Investigator-In-Charge is responsible for managing access control, a way of safeguarding and preserving wreckage information located at the crash site. He/She is a person with years of experience in aviation safety related issues, charged with managing all phases of aircraft accident investigation. The IIC also has the responsibility of initiating an inquiry concerning the accident, while ensuring that the findings are not compromised and on the other hand follows the stipulated legal demands as stipulated in aviation laws (Rainford et al, 2006).  

Besides these, the IIC is charged with supervising the group teams, carrying out access control measures and providing overall leadership. In group supervision, he/she supervises the groups handling various investigative areas, assessing the validity and credibility of the team’s competency in terms of being able to deliver by presenting credible information regarding the aircraft accident. He/She also ensures that proper access procedures to the crash site are implemented, in terms of accessibility, including other logistical issues that may help in ferrying the teams to the crash site.      

Accident investigation

This is the actual analysis of wreckage components and parts in reference to the various structured groups. It is done after possible clues have been gathered from the cockpit voice recorder have been analyzed, and thereafter a scrutiny on the wreckage, flight data recorder as well as human factors and maintenance details. However, there are procedures and checklists as promoted by ICAO prior to the actual investigation process that should be considered prior to the actual investigation process.

Observation of procedures and checklists

Procedures and checklists are important elements as they enhance coordination during the investigation. They basically stipulate the mechanisms to be used, and requirements needed during the investigation. The checklists provide a way of standardizing items and procedures by outlining the various components that need to be adhered to during the investigation process. These include:

  1. The required equipment to help in the investigation process i.e. communication devices, labels and pins, identification credentials and notebooks.
  2. Preliminary forms and documents such as the ICAO annex 13 for references.
  3. Survivor kits, first aid supplies, medicines and clothes
  4. General information on accident location, casualty and set up of a command centre
  5. Procedures for briefing media and investigation personnel
  6. Assessing the scope of work, safety requirements and assignments.

The checklist and procedures vary depending on the nature and magnitude of the accident. It also depends on whether the accident is in a foreign country or a domestic aircraft within its airspace.   

Wreckage investigation

Wreckage is the recoverable part of an air crash. It is generally the structure of the fuselage, cockpit, wings and turbines which have been destroyed by the impact. The investigation process is conducted by an investigator-in-charge, an individual with qualifications, and is charged with controlling and conducting the aircraft accident investigation on behalf of an organization. The investigator would probably work in conjunction with other teams or groups that would examine other factors for a possible clue regarding the cause of the crash. These would include forensic and aerospace pathologists who would help in assessing and examining different aspects in place. The team would conduct an investigation on flight data recorders, cockpit voice recorders, maintenance details, human factors and aircraft power systems (Davis, 2008).   

Flight data recorder analysis

This device is housed in a special crash resistant container meant to preserve flight data for investigation purposes (United States General Accounting Office, 1997). It is different from the cockpit voice recorder and is used in the recording of some pertinent data concerning a given flight to help in the investigation process in the event of a crash. The device should be located after a crash to help in analyzing the probable events that led to the crash, with its content being analyzed by a flight data analyst or a flight safety manager. 

Maintenance details

Maintenance details are the aircraft maintenance records in terms of airworthiness, conformance to general air laws and regulations. It also takes into consideration the structural elements which are critical in sustaining the safety of a flight. Some of the maintenance details under this scope include a summary of the repair history, maintenance program and technical procedures used during aircraft maintenance in the past. The maintenance attribute could be analyzed by a chief safety officer, di-icing personnel where the cause of the accident could be weather-related elements, and maintenance engineers, who would help in examining the structural and mechanical attributes of the aircraft, in order to determine whether the maintenance factor caused the accident.   

Human factors

A number of studies indicate that human factors directly contribute to the occurrence of major accidents (Ferguson & Nelson, 2014), with research indicating that close to 70% of aviation related accidents are as a result of human error. The ICAO curriculum advocates that human factors should be integrated within the investigation process to help ascertain whether human-related factors may contribute to an accident.

            It clearly states that the objective of this element is to determine how the breakdown of human-related performance issues causes accidents, in relation to safety requirements and the need to understand their operations in order to reduce accidents. As such, ICAO advocates for this in a wider scope, through different frameworks. This consists of the SHEL (software, hardware, environment and liveware) framework, latent unsafe condition (LUC) framework and the behavior error framework that uses skills, knowledge and rule based performance attributes. This is because air accidents are caused by complex systems which are dependent to each other, and occur in a sequential manner (Janic, 2007), that presents an unavoidable event which can cause a catastrophic event. Therefore, in order to understand the inter-relationships, ICAO promotes the use of frameworks to help in an in-depth investigative process of aircraft accidents.   

SHEL framework

ICAO advocates for the use of this framework since it contains a critical element, liveware as accidents do not occur by themselves but upon an act initiated by a human. This central element therefore is used by investigators to help them understand possible scenarios that could have led to the accident. In addition, it also helps investigators to analyze various aerodrome factors which are important during an investigation.

Latent Unsafe Framework

ICAO uses the framework to help in the investigation process by analyzing various organizational and human factors. This framework is used in the investigation process to unearth the factors that promoted unsafe operations and maintenance. In this, investigators assess personal and organizational attributes such as an individual’s well-being, probably on the cockpit crew and the organizational factors, probably management practices which have been implemented by the company operating the aircraft. The organizational LUC factor helps in unearthing how personnel attributes and unaccepted operating practices can lead to an accident. The investigation process looks at the elements to help assess the intended verses unintended actions and how each can contribute to an incident.     

Behavior error framework

An investigation framework promoted by ICAO that links human error to the behavior, skills and knowledge of the crew. It is a critical element that investigators use during an air crash investigation, since it assesses the skills-based, rules and knowledge attributes during a flight in relation to the possible cause of an accident. These elements are analyzed by the lead investigator, or an independent contracted entity. ICAO advocates for the use of these frameworks in an investigation so as to help in carrying out an in-depth analysis regarding the cause of the accident or incident.

Aircraft power systems

The aircraft power system is the unit that propels and maintains a flight at a given altitude. In other aviation terms, it is referred to as the power plant, and consists of the engines, oil, fuel system and control systems. ICAO promotes an investigative approach on the power system to help assess the possible cause of an accident. Aircraft systems can malfunction during flight, which therefore necessitates for a structured approach of examining critical areas to enable investigators to unearth causes of accidents. ICAO promotes the approach to help airlines and other aviation safety bodies to ascertain the possible causes of accidents. In this element, a lab analysis can be performed to help in analyzing the last recordable flight patterns and characteristics which can help in a flight reconstruction process during the investigation.


An investigation process looks at the main propulsion units, the turbo propelled engines for any clue which may be used by investigators. They are examined for any malfunction and stress which might have occurred in the past, with the aim of establishing the cause of an accident. ICAO promotes the examination of this unit to help identify whether a possible engine failure can cause an accident.

Oil and fuel system

ICAO stipulates that oil and fuel compartments need to be examined to assess whether the oiling system can result to an accident. In the investigation process, the compartment is examined for possible fuel or oil leak. This is because oil compartments can heat above the normal temperatures, with this having the ability to trigger an on-board fire that is capable of affecting a normal flight leading to an accident.

Control system

ICAO stipulates that control systems should be investigated by examining the key strokes and inputs as recorded by the flight data recorder. In a normal investigation, an analysis should be done on the final flight pattern to assess the probable cause of such a movement. The components considered here include the computer system, hydraulic system, steering units and the communication units that are vital in aircraft navigation.      

Meteorological attributes

Meteorology is a branch of science that deals with the study of weather and climate. It also involves the study of how weather variables influence a given pattern as depicted in aeronautical satellite images. Thus in relation to aviation technology, the concept has prompted ICAO to promote mechanisms to guide aviation bodies on how to interpret weather related information that can be analyzed during an aircraft accident investigation processes. This acts as a guide since it develops certain standardized procedures, which are used by investigation firms to examine weather elements recorded during a particular flight and how they are involved in aircraft accidents. In this, a brief information regarding the meteorological condition and circumstances of the flight is shown to help in examining how the behavior of weather patterns can lead to an accident.

ICAO stipulates that the various meteorological elements such as aerodrome communication and navigation aide should be considered to help evaluate possible scenarios of an air accident.   

Technical reviews

ICAO also promotes the use of a technical review as the last stage of the investigation process. The technical review is basically meant to give the groups and parties involved a chance to review their submissions to the IIC. In this phase, parties in the investigation process submit their reviews regarding factual data obtained during the investigation, through scrutinizing and performing accuracy audits on the information presented. ICAO advocates the idea that managers, coordinators and safety board members should also submit their analysis based on the findings.    

While technical reviews play an important role in fine tuning the final piece of information related to an aircraft accident. ICAO also promotes or advocates for the use of investigative reports to report on the cause of an aircraft accident or incident. The ICAO standard and procedure of accident related reports is structured into several categories. These include consists of the groups reports, consultation of the final report and the final report besides which part of the investigative report is included in the ICAO digest and address.

Group reports

ICAO has established that there is a need to provide specific reports, which are independent on the groups structured during an aircraft accident investigation process. The purpose of group reports is to analyze the findings of each group, where each submits its findings to the IIC. Apart from this, a report based on consultation is also produced indicating the areas under which various groups, safety analysts and the IIC have consulted on, and their views are indicated, with a much finer review.   

Final report

ICAO advocates for the production of a final report that can be presented to various groups with interest in a particular air crash investigation. This could be the main body, ICAO, aircraft manufacture, company involved as well as contracting entities involved in the construction of large aircrafts, such as engine production companies.

Reporting and publication

This is ICAO standard procedure of releasing information regarding a crash to the various parties. This could be done through a written report or a pressing briefing at the company’s headquarters. This would then follow by the inclusion of the report into ICAO’s digest and address as a way of improving safety among the airline companies, by elaborating on recommendations that would be applicable in normal circumstances.

Apart from this, national legal systems also play a part in the investigation process. This because they play a key role in the formation and constitution of safety bodies charged with conducting investigations during aircraft accidents. For instance, the American legal system plays a role in this by constituting given laws and giving certain bodies such as the Federal Aviation Authority (FAA) and National Transport and Safety Board (NTSB) the mandate to determine a possible cause of an accident (Schnitker & Kaar, 2010). They help in gathering information in crash sites, analyze them, train professionals who then help in investigating the probable cause of major aircraft accidents. In addition to this, national legal systems also give congress the mandate to establish transport bodies such as the Department of Transport (DOT) with the mandate of helping in investigating air accidents whenever they occur (Federal Aviation Administration, 2009).

However, while national legal systems contribute towards a safe investigation process, there are differences which hinder or promote an investigation aimed at promoting safety. This for instance has watered part of the ICAO’s mandate in promoting safety in the aviation sector, in reference to the Chicago convention that led to the establishment of the International Civil Aviation Organization. This is because only aviation related accidents that involve member states can adhere to the ICAO’s structure and procedures of managing and investigating air accidents. In this instance, air accidents in non-ICAO member states such as the Cayman Islands become a stumbling block in regard to safety driven accident investigations.

In a typical scenario, national legal systems such as that of France established a national arm of aviation, the BEA that is involved in managing aircraft accidents in civil aviation. The French arm conducted a series of searches during the Germanwings crash, since it had occurred in France. The investigation was for safety purposes, as various groups were formed to help examine the possible cause of the accident.

The International Civil Aviation Organization plays a key role in streamlining aviation accidents involving aircrafts. The organization implements this through a set of standard procedures that it promotes across the globe to be used in investigating and managing aircraft accidents. The procedure looks at the human factors, maintenance details, power plant systems and the organizational element in aircraft accidents. However, despite the organization’s efforts, there are circumstances where national legal systems can contribute towards a safe investigation process during accidents. While this happens, ICAO continues to be a champion in a safer airspace as investigations help prevent possible future aviation catastrophes.    


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