It has been suggested that the Group System of aviation accident investigation is inflexible, costly and outdated. Critics claim that the system should be abandoned and instead, introduce a more streamlined approach that consists of a small group of multiskilled investigators who would investigate every accident.
While this argument may at first appear economically sensible in that it would reduce the number of personnel required to investigate each accident, it does represent a shift away from accepted international practice. A shift that may hinder the successful investigation of aviation accidents – and therefore prevent the identification of hazards and risks that may give rise to even more aviation accidents occurring.
This paper will first provide a brief outline as to what the Group System of accident investigation is. Both the advantages and disadvantages of the system will be discussed and examples from various aviation accidents will be used to assist in contextualising the benefit, or lack there-of, with this form of investigation technique.
Definition
The Group System of aviation accident investigation essentially uses a variety of specialised investigators working in separate groups – with each investigator being assigned to a group that is focused on one aspect of an accident. The group is focused on the part of the investigation that matches the individual’s knowledge, skills and experience. Each group has a “team leader” who reports the group’s progress and findings to the Investigator-In-Charge at regularly scheduled meetings. This leads to a sharing of information and facts which may assist another group in their own work (ICAO, 1970).
The Australian Transport and Safety Board (ATSB) uses this model but also recognises the potential shortage of key internal specialists within their organisation. As a result, they extend the group membership of an investigation to include possible external specialists (e.g. employees of Qantas, Boeing, members of key industrial organisations etc) as potential members of the individual groups. In the ATSB context, each group is led by a separate ATSB investigator and this ATSB resource reports the group’s efforts, research and specific information to the accident’s Investigator-In-Charge (Cavanagh, 2001).
ICAO Document 6920 – Manual of Aircraft Accident Investigation recommends eleven possible groups that can be utilized when conducting an investigation using the Group System (ICAO, 1970). These groups all vary in nature and specialization and the inclusion of a specific group is dependent on the factors involved or type of an accident. As an example, if weather is considered to be an important factor in an accident then it is advisable to have a separate group of specialists compiling pertinent weather and meteorological data.
Other groups that may exist relate to Operations (responsible for researching the history of the flight, flight planning, loading calculations – e.g. cargo, fuel, air traffic control, radio communications, briefing notes and also general knowledge relating to the crew); Air Traffic Services (responsible for the review of Air Traffic records, communications, radar records and navigational aids); Witness Statements (for contacting and interviewing various witnesses); Flight Recorder Group (obtaining and securing the flight and voice recorders and arranging for readout and transcription); Structures (responsible for investigations relating to the airframe and flight controls); Powerplants (for investigating the engines, powerplants, controls and includes fuel and oil systems); Systems (providing detailed examination of all system and components – hydraulics, electrical, navigation, A/C, pressurization etc); Maintenance Records (reviewing all maintenance records); Human Factors (related to the general physical and psychological conditions of the crew and includes and medical and injury aspects of the investigation); and, Evacuation, Search and Rescue and Fire Fighting (ascertaining the evacuation, search and rescue and fire-fighting performance) (ICAO, 1970).
Advantages & Disadvantages
Being able to draw upon the knowledge and experience of specialists and allowing them to focus on aspects that match their individual skills is a valuable contribution to any investigation. The combination of specialised views coming together may also provide alternative viewpoint(s) that can be further explored as opposed to having a single or small group of multi-skilled investigators attempting to ascertain all possible aspects of an accident.
Putting this advantage into context, Malaysia, being the state of registry and operation for Malaysian Airlines MH-370 had investigative responsibility for this accident. The Investigator-In-Charge was Malaysian and as were the Chairmen (and investigators) of the groups organized for this investigation – namely, Operations, Airworthiness and Human Factors (Air Accident Investigation Bureau, 2018). The ATSB, in accordance of ICAO Annex 13, assisted with the investigation and initiated and coordinated a search program for the missing aircraft. This search program proved to be more complex than originally thought and the ATSB subsequently enlisted the assistance of advisors from Thales, Boeing, the UK Air Accidents Investigation Branch (AAIB), US based National Transportation Safety Board (NTSB), the Defence Science and Technology Group1 (DST Group) and the Department of Civil Aviation Malaysia. The Commonwealth Scientific and Industrial Research Organisation (CSIRO) and Geoscience Australia also assisted (ATSB, 2017). This search process (group) was coordinated by a temporary division within the ATSB (ATSB, 2017) who in turn reported to the Investigator-In-Charge.
In this instance, the ATSB was classified as an Accredited Representative and the parties that assisted the ATSB (and worked within the Search group) were classified as Advisors (Air Accident Investigation Bureau, 2018). These advisors had very specialised skills that went beyond the skill set of a typical aviation accident investigator – that is, being able to triangulate radar pings via satellite and calculating drift via ocean currents (ATSB, 2017).
While this example may be considered extreme, it does highlight that the expertise and skill level of the specialist advisors who worked within the Search group greatly assisted in the search process. Even though MH370 was not found, the processes used and experience gained and shared has led to some important learnings related to locating missing aircraft on flights over deep ocean areas (ATSB, 2017).
One concern with the Group System of Investigation is related to the willingness of the various group members to fully participate in an investigation – especially when the results or outcome may conflict with their own professional (or corporate) interests (ICAO, 1970). The recent investigations relating to the grounding of the Boeing 737 Max aircraft highlight this negative aspect.
The participation of Boeing in the investigations of the Lion Air 610 (October 2018) and the Ethiopian Airlines Flight 302 (March 2019) accidents was due to Boeing being the aircraft manufacturer for both planes involved. Speculation mounted in the media about the cause of both accidents however in both instances, Boeing defended the manufacturing, compliance and training process used in the 737Max.
Responding to claims relating to the MCAS Flight system (as used in the 737Max), Boeing Chief Executive Dennis Muilenburg stated the relevant function was “adequately explained” in the Flight Crew Operations Manual (The Air Current, 2018). He put partial blame on the pilots in both accidents for not following the correct procedures (Economy, 2019). This is despite claims that Boeing knew about the problems with the 737 Max at least one year before the Lion Air Crash (DiCarlo, Grinberg, & Levitt, 2019) (Associated Press, 2019).
The participation of Boeing as a Group member in both these investigations, while at the same time, defending their internal processes and also laying partial blame on the pilots in both aircraft does not meet paragraph 3.1 of Annex 13 (ICAO, 2001). Guidelines do specify that Boeing, as aircraft manufacturer, does have a right to assist in these investigations (ICAO, 2001), however the nature of the claims against the corporation concerning knowledge of these problems does imply that a corporate conflict of interest may exist – and therefore may influence (or attempt to influence) the investigation. This potential influence in an investigation highlights one potential negative aspect of the Group System of accident investigation.
Concluding Thoughts
The Group System of accident investigation is widely adopted and used. It allows for the input of specialists in an investigation which in turn, provides benefits for the learning and sharing of ideas – that otherwise, a single investigator (or small group of accident investigators) may not have the knowledge, facilities or opportunities to explore.
A significant downside though is that some members of the various Groups within an investigation may not be fully committed in the investigation due to possible conflicts of interest – be it for professional or commercial/corporate reasons. This downside could influence the investigation and therefore prevent factual knowledge and information gains from the investigation.
The primary objective of any investigation is to seek information for the purpose of preventing further accidents and incidents (ICAO, 2001). By using as many resources as possible (with no perceived conflict of interest), who provide a wide range of knowledge and skills, can only assist in ascertaining the cause of an accident – and therefore, using that information to prevent further occurrences from happening.
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