Purpose of safety investigations
The AAIA is responsible for investigating accidents, incidents and other safety matters involving civil aviation operations in the Bahamas jurisdiction, as well as participating in overseas investigations involving Bahamas registered aircraft. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The AAIA performs its functions in accordance with ICAO Annex 13, the Aircraft Accident Investigation Authority Act and Regulations 2019, and other relevant international agreements.
The objective of a safety investigation is to identify and reduce safety-related risk. AAIA investigations determine and communicate the safety factors related to the aviation safety matter being investigated. The terms the AAIA uses to refer to key safety and risk concepts are set out in the section: Terminology Used in this Report.
It is not a function of the AAIA to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times, the AAIA endeavors to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the AAIA's investigation of aviation safety matters is the early identification of safety issues in the aviation environment. The AAIA prefers to encourage the relevant organization(s) to initiate proactive safety action that addresses safety issues. Nevertheless, the AAIA may use its powers to make formal safety recommendation(s) either during, or at the end of an investigation, depending on the level of risk associated with a safety issue(s) and the extent of corrective action undertaken by the relevant organization.
When safety recommendation(s) are issued, they focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on a preferred method of corrective action. As with equivalent overseas organizations, the AAIA has no power to enforce the implementation of its recommendations. It is a matter for the body to which an AAIA recommendation(s) is directed to assess the costs and benefits of any particular means of addressing a safety issue.
When the AAIA issues a safety recommendation to a person, organization or agency, they must provide a written response without delay. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.
The AAIA can also issue safety advisory notices suggesting that an organization or an industry sector consider a safety issue and take action where it believes it appropriate. There is no requirement for a formal response to an advisory notice, although the AAIA will publish any response it receives.
How AAIA safety investigation reports are organized
AAIA investigation reports are organized with regard to international standards or instruments, as applicable, and with AAIA procedures and guidelines. Reports normally contain the following main parts:
Provides an upfront, one-page summary of ‘What happened’, ‘What the AAIA found’, ‘What has been done as a result’, and any broader 'Safety message'.
The occurrence provides a description of the occurrence sequence of events and, if relevant, the consequences of the occurrence in terms of injuries and damage. It is an expanded version of the ‘What happened’ section of the Safety summary.
The context provides additional information necessary to help the reader understand the Safety analysis, and to some extent the occurrence. The information is intended to be relevant to the occurrence, rather than included just because it was collected.
The safety analysis provides a detailed discussion of the safety factors identified during the investigation. It provides the evidence and argument required to support the contributing factors and other factors that increase risk, and it is an expanded version of the ‘What the AAIA found’ section of the safety summary. It should also outline the basis for the ‘safety message’ section of the safety summary.
Based on the analysis of the safety factors identified during the investigation, the findings present three categories of findings: contributing factors, other factors that increase risk, and other findings.
Safety issues and actions
This section summarizes all the ‘safety issues’, or system problems that were identified during the investigation and details what safety action has been taken, or is planned to be taken by relevant parties to address those issues.
Contains additional information that supports the report, for example, specialist reports on materials failure or flight data analysis.
Note: Not all parts described above will be applicable in all circumstances. Reports of less complex investigations, for example, may not include safety action or appendixes.
Terminology Used In AAIA Safety Investigation Reports
Occurrence: accident, serious incident or incident.
Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure), individual actions (e.g. errors and violations), local conditions, current risk controls, and organizational influences.
Contributing factor: a safety factor that, had it not occurred or existed at the time of an occurrence, then either:
a) the occurrence would probably not have occurred; or
b) the adverse consequences associated with the occurrence would probably not have occurred or have been as serious, or
c) another contributing safety factor would probably not have occurred or existed.
Other factors that increase risk: a safety factor identified during an occurrence investigation which did not meet the definition of contributing safety factor but was still considered to be important to communicate in an investigation report in the interests of improved transport safety.
Other findings: any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which 'saved the day' or played an important role in reducing the risk associated with an occurrence.
Safety issue: a safety factor that:
a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
b) is a characteristic of an organization or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.
Safety action: the steps taken or proposed to be taken by a person, organization or agency in response to a safety issue.
The AAIA receives numerous notifications of aviation occurrences each year, many of which are accidents, serious incidents and/or incidents. It is from the information provided in these notifications that the AAIA makes a decision on whether or not to investigate. While some further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgment is needed to be exercised.
There are times when more detailed information about the circumstances of the occurrence allows the AAIA to make a more informed decision both about whether to investigate at all and, if so, what necessary resources are required (investigation level). In addition, further publicly available information on accidents and serious incidents increases safety awareness in the industry and enables improved research activities and analysis of safety trends, leading to more targeted safety education.
The AAIA Safety Officer gathers additional factual information on aviation accidents and serious incidents (except 'high-risk operations), where the initial decision has been not to commence a 'full' (level 1 to 4) investigation.
The primary objective of the Safety Officer’s mandate is to undertake limited-scope, fact-gathering investigations, which result in a short summary report. The summary report is a compilation of the information the AAIA has gathered, sourced from individuals or organizations involved in the occurrences, on the circumstances surrounding the occurrence and what safety action may have been taken or identified as a result of the occurrence.
These Short Investigation reports are released publicly. The reports are released periodically in a Bulletin format.
Conducting these Short investigations has a number of benefits:
Publication of the circumstances surrounding a larger number of occurrences enables greater industry awareness of potential safety issues and possible safety action.
The additional information gathered results in a richer source of information for research and statistical analysis purposes that can be used both by AAIA research staff as well as other stakeholders, including the transport agencies and research institutions.
Reviewing the additional information serves as a screening process to allow decisions to be made about whether a full investigation is warranted. This addresses the issue of 'not knowing what we don't know' and ensures that the AAIA does not miss opportunities to identify safety issues and facilitate safety action.
In cases where the initial decision was to conduct a full investigation, but which, after the preliminary evidence collection and review phase, later suggested that further resources are not warranted, the investigation may be finalized with a short factual report.
It assists the Bahamas to more fully comply with its obligations under ICAO Annex 13 to investigate all aviation accidents and serious incidents.
Publicizes safety messages aimed at improving awareness of issues and good safety practices to both the transport industries and the traveling public.