Description

Performing occurence investigations is an essential part of safety. This article is based on the ISASI Cabin Safety Investigation Guidelines.

Information Gathering

The process generally consists of the following actions:

Documenting damage to the cabin interior and its equipment

• Collection of general information about the aircraft, the crew and the passengers
• Overall damage description
• Information on the safety equipment (seats, seat belts, evacuation slides, other emergency equipment)
• Condition of storage areas and carry-on luggage
• Information on the communication systems (e.g. P. A., interphone, safety briefings, etc.)
• Information on the condition and operation of the exits (e.g. emergency exits, slides, rafts, etc.)
• Additional information in case of water contact (e.g. condition and use of ELTs, life vests, rafts, etc.)

Interviews with cabin crew

• The interviews should not be used to apportion blame
• The main goal is to find out what happened in order to enhance cabin safety and survivability
• Each person should describe what happened to them in the form of a narrative
• After the narrative is complete, follow-up questions may be used to further clarify some aspects
• By the end of the interview the following information should have been gathered:
  • General information on the interviewed (personal details, working experience, previous incidents, medical conditions, sleep/wake cycle, etc.)
  • Pre-flight and in-flight activities described in as much detail as possible
  • Description of the occurrence and the actions taken during the event, including e.g. preparation for emergency landing
  • Description of the training received before the event (initial, recurrent, specialised (e.g. firefighting, ditching, first aid, etc.), CRM, etc.) as well as personal opinion on the training received (e.g. helpfulness, realism, etc.)
  • Specific information based on the occurrence type, e.g. evacuation, turbulence, fire, ditching, etc.
  • Additional comentnts, e.g. further information, experience-based advise, etc.

Interviews with passengers

The interviews with the passengers are intended to obtain additional information as well as an alternative point of view on the effectiveness of safety measures. By the end of the interview the following information should have been gathered:

• General information on the interviewed (personal details, aviation experience, skills used during the occurrence, medical conditions, injuries received, etc.)
• Pre-flight activities described in as much detail as possible (e.g. seating adjacent to emergency exit, pre-flight safety briefng, etc.)
• Description of the occurrence and the actions taken during the event (e.g. preparation for emergency, difficulties experienced, etc.)
• Specific information based on the occurrence type, e.g. evacuation, turbulence, fire, ditching, etc.
• Additional comentnts, e.g. further information, experience-based advise, understandability of the information received, etc.

Additional Actions

• Gathering information from other people (e.g. medical, human factors, operations, Rescue and Fire Fighting Services, etc.)
• Determination of causes of injuries, based on the information collected
• As a conclusion, development of recommendations or strategies to minimize injury in future accidents or incidents

Further Use of the Information

Information collected during cabin safety investigations can be used for:

• education and training of flight crews, cabin crews, air traffic controllers and other relevant personnel;
• research of new materials, equipment, etc. and development of new rules and procedures;
• safety promotion and general raising of people awareness;
• accident and injury prevention in the future.

Related Articles

• Safety Occurrence Investigation
• Information Sources for Investigation
• Investigation Methodology
• Investigation - Final Report
• Regulation 996/2010 on the investigation and prevention of accidents and incidents in civil aviation
• Just Culture

Further Reading

• Cabin Safety Investigation Guidelines, by the ISASI Cabin Safety Working Group