ICAO Annex 13 states the following with which everyone in aviation is conversant with,

“OBJECTIVE OF THE INVESTIGATION The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.“

Past accidents

If that is so, then why do investigators end up blaming the pilots? Lets take the example of the AirIndia Express Mangalore accident VT-AXV in 2010, and the extract of the final report.

“Direct cause of the accident. The court of inquiry determines the direct cause of this accident was the Captain’s failure to discontinue the ‘unstabilised approach’ and his persistence with continuing with the landing, despite three calls from the First Officer to ‘go around’ and a number of warnings from the EGPWS”.

The accident report has wholly & squarely blamed the Captain. From a psychological point of view its easier to blame others than to determine the causes for their behaviour. It can be a very complex process and time consuming, therefore humans take the easier path, that of blaming.

The accident report of the Ghatkopar King Air C90 accident too pinned the blame on the crew and saved the others who were a party to an alleged act of criminal negligence.

Blame

Assigning causes requires little more than pointing fingers and assessing blame. Gerard Bruggink, former Deputy Director of the NTSB’s Bureau of Air Safety, rebutted those who argued that investigators do not indulge in casting blame:

By emphasizing ‘Who Caused the Accident?’ rather than ‘What Might Have Prevented It?’, investigation authorities engage in weighing causes and, therefore, weighing blame. Causal summaries identify the individuals and organizations that seem to be most at fault, balancing between probable cause and contributing factors. 

(Gerard M. Bruggink, “To Kill a Myth.” Proceedings of the Eighteenth International Seminar of the International Society of Air Safety Investigators, Atlanta, Georgia, October 6-9, 1988. ISASI forum, V. 20, #4, February 1988, pp. 4-9.)

The investigators then go about diluting the blame by using terms like probable and contributory causes. These terms have no effect since the blame has already been apportioned. The investigators for e.g. do not want to understand why the pilot , in the case of Mangalore accident persisted with the unstable approach despite all the warnings. Therefore taking the easier path , the investigators have resorted to blame the pilot. I have written a paper on “Psychology of an unstable approach” in an attempt to understand the ‘why’.

They conclude that the event itself is evidence that some person or persons did something that caused, or failed to do what was necessary to avoid the occurrence. It is consistent with the bottom line of MORT analyses, that something or other was “Less Than Adequate.”

In legal terms which encompasses the mind-set: Res Ipsa Loquitur – “the thing speaks for itself.” Once the thing has spoken, as a result of a mishap, the simplest response is to lay the blame on the most convenient culprit.

Pilot error and insurance

If the aircraft was flying without valid documents and the accident investigation report lists the probable cause as ‘Pilot error”, the insurance is processed as per law obviating the document validity clause. The Pilot is usually the first person to reach the site of an accident. The easiest is the person to be made the scapegoat and to be pinned for the cause of the accident too. In most of the cases, the pilots are not alive to defend themselves. Since the primary investigation is not a judicial investigation, there is always a sense of suspicion about the probable cause.

In Pickett v. Woods, an aviation case in which the plane’s airworthiness certificate was not valid as required by the insurance contract. Because the accident was due to pilot error attempting to land in bad weather and no condition of the aircraft contributed to the crash, the insurance company was not able to deny coverage based on the invalid airworthiness certificate.

Griffin v. Old Republic Insurance Co. The insured bought an airplane and crashed it into the plaintiff’s backyard. The plaintiff tried to collect from the insurer but was denied because an exclusion in the policy denied coverage if the aircraft did not have proper airworthiness certificates.

In Griffin, the owner believed his mechanic had performed a required inspection, when, in fact, the mechanic did not as the result of an oversight. Less than a month after picking up the aircraft from the mechanic, the owner, thinking his inspection was current, flew the aircraft. The crash was caused by the pilot switching to an empty fuel tank (pilot error) or by a problem with the fuel system unrelated to the required inspection. Either way, the cause had nothing to do with the inspection nor would it have been prevented by the inspection.

Why do investigators blame?

Blame requires subjective evaluation of alleged acts committed or omitted by persons involved in a mishap. Mishap reports often contain obvious clues to investigator subjectivity:

•        Judgmental verbs; e.g., “failed to” or “did not”, without specifying precisely the alleged error(s) of omission, and the law, regulation or procedure with which the actor allegedly failed to comply, and how that contributed to the outcome.
•       Comparative adjectives; e.g., “improperly” or “incorrectly”, likewise absent support-ing data specifying how the act varied from expectation, and how that influenced the outcome.
• Temptation to indulge in such judgments occurs because:
•       The investigator “knows” from personal experience what the actor “should have” done, and assumes that it wasn’t done properly because the mishap occurred; or
•       The investigator doesn’t know what the actor should have done, and assumes that obviously something wasn’t done properly because the mishap occurred.

 (Ludwig Benner, Jr., “Words Mean Something.” ISASI forum, V. 28, #3, (September 1995). Sterling, VA., International Society of Air Safety Investigators. At: http://www.bjr05.net/papers/Words.htm)

Role of the Investigator

Accident prevention is the sole objective of the investigation and the role of the investigator must be to determine what happened and why it happened. The investigation will be a success if it is able to prevent any future similar occurrences.

The investigators therefore must be well verse with the latest techniques of investigations and an expert level as a specialisation in their field of study. To remain current, ICAO Annex 13 recommends that the investigators can be associated with other investigation bodies like the defense forces or other countries.

For every expert there is an equal and opposite expert, but for every fact there is not necessarily an equal and opposite fact. – Thomas Sowell

Prevention

Human factor is an element in all accidents. Investigators must identify the specific human behaviors which led to disrupting the original plan. Facts, conditions and circumstances are never vague. They are tangible, measurable descriptions of what happened. Once we know what happened, we can dissect the scenario into events and conditions which encourage application of formal logic’s tests and proofs. Legitimate cause & effect relationships which determine the progress of a mishap process can identify potential early intervention points which possess realistic probabilities for effecting prevention and process improvement.

mindFly analysis

The investigation of the Air India Express VT-AXH accident at Khozikode on 7th Aug 2020 is an opportunity for us to build a robust and resilient safety system. let us not give away this opportunity to apportioning blame and correct the system.

There will be an attempt to shield the airport operator for not complying with DGCA, India and Global norms. This is why most accident reports pin the blame on the pilots and save the others who are contributors to the accident. There is an urgent need to change the cultural mindset of the aviation community. A generative safety culture is not a blame culture and puts the onus of safety on every individual. Unless there is a concerted effort from the community to get together and build the defenses, the fragile net of safety will wear out.

Accident investigators play a very important role in enhancing safety and the quality of the reports must be enhanced. The cogs in a system which works in sync with each other as a well greased machinery will lay the foundation of a safer environment.