The no-prize answer is ‘because we have to’. The correct one is because we cannot afford not to.
ICAO Annex 13 lays out the consolation that ‘the sole objective of the investigation of an […] incident shall be the prevention of […] incidents. It is not the purpose of this activity to apportion blame or liability’. The tangible outcome of an incident investigation is the Investigation Report housing sections on Factual Information, Analysis, and Conclusions. It only stands to reason that Factual Information has to be obtained and suitably analysed for conclusions be drawn as to WHAT actually happened, and WHY it happened. Now comes the sticky part, for the Investigator is also tasked with coming up with Safety Recommendations. I admit that, as an Incident Investigator, I have often slept uneasy over this last responsibility. I have gathered and examined written and verbal reports, I have listened to voice recordings and transcribed them, I have watched the video recordings of the occurrence or the radar screen as well as the relative keyboard inputs, I have interviewed all involved and obtained as much information as to what was happening. I have made myself familiar with all the circumstances at the time. Armed with all available data, I have absolutely no problem with reaching conclusions about causal and contributing factors. On these I am now an authority. But to make recommendations? I look back to the courses I attended, and the training seminars I endured (and lately made others endure), and note with disappointment that this ultimate ‘must do’ has, all-too-often, been very much glossed over. We make it sound as if coming up with recommendations is simply a natural follow-up to all the digging made, and these will simply fall into the lap of the deserving. The bad news is that this is far from it.
I can put suggestions on how to right obvious shortcomings; I can also extrapolate the actual happening to include ‘what if’ scenarios and decide if the available procedures or resources carry enough resiliency. But I have, at times, felt insufficiently equipped to confidently reassure myself that I have covered all possible recommendations. Is it enough to point out that inappropriate phraseology was a contributing factor to a runway incursion? Or, that better employment of speed control could have averted an unwholesome situation? Or, that letters of agreement between sectors do not cover all eventualities? I question myself, should I spell out a recommendation that personnel attend mandatory phraseology or speed control refresher training? Or oblige the powers that be to revisit procedures? What if I overlook a recommendation which could avert another incident in the future? Should I conscientiously take responsibility for my recommendations to not adversely impact my company financially? Should I even be questioning myself about such? Uneasy is the head that wears the headset marked Incident Investigator.
Making recommendations is an onerous responsibility. A medical doctor, having examined the patient and carried out the required tests, writes out the appropriate chemicals to be ingested to right the ailment. The Investigator prescribes appropriate remedial attention to avert a repetition of an unpleasant happening. The patient implicitly puts his trust in the good doctor and happily downs pink capsules before meals; the system trusts the recommendations to be the best cure to a malady. The recommendations being delivered, the ANSP decides if they should be implemented: whether in their entirety or in part, the method and the timing. The Investigator’s report is only testament to her findings coupled with her experience; it is the ANSP’s call to implement the corrections. The entity is answerable to its clients, its professionals, and the overseeing Authority.
Approaching summer of 2020, we are in a shell-shocked state. We do not know what the postdiluvian world will look like. Regarding Investigator training, we have, in recent years, witnessed the progressive reduction of the instruction and practice period. One can only assume these will be decreased even further. e-TOKAI* has wonderfully enabled the reporting and investigation process to be conveniently wrapped up in a seamless package with a deliverable document rolling out at the other end. The Tool has taken out the hassle and intricacies of building a report while ensuring that all possible data is collected. Investigation reports have become more standardised, coherent and thorough. e-TOKAI sees to that. Sadly, the free-text areas can be more disappointing. Investigator training, even more limited as it might evolve, will continue to train candidates in data gathering, interviewing techniques and gaining personnel trust, but more consideration should be given to the quality of report writing.
Writing reports is an art form. The writer has to keep the intended consumer in mind. The report culminates in the Recommendations area, and the Investigator has to ‘sell’ her recommendations in the most convincing manner. A badly structured report will not inspire a sale, and a badly written one will only alienate its audience, rendering the exercise futile.
At the end of a report come the recommendations. Mine is to revisit the Investigator training material, give e-TOKAI its room to do what it does best, and better employ time and resources to train our professionals to construct better reports and put forward meaningful recommendations.
We cannot afford otherwise.
* e-TOKAI is Eurocontrol´s toolkit for air traffic management occurrence investigation.
Renald Galea is an Air Traffic Controller with vast experience as an Incident Investigator and the use of e-TOKAI and RAT.