Learning Lessons Through Investigations, Reviews & Analysis

Incident investigations have long been a key part of Safety Management System activities that a good airport operator is expected to undertake. And for many of us good airport professionals and for some airport incidents, this is an exciting thing to do. The paradox is any incident response is that we don’t really want things to go wrong but when they do, it gives a chance to really get involved in our operations. But it’s not always a simple process because airport incidents don’t always involve our team members (employees and contractors) or they aren’t triggered by our actions or systems or behaviours.

Take for example, a hard landing leading to a disabled aircraft on the runway. The natural focus of “the” investigation will be the causes of the hard landing. The investigators will look at the flight crew, the procedures, the team work on the flight deck, communications with air traffic control, the weather, etc. Hopefully, they will also look into resourcing, training and safety culture to build a bigger picture of how this landing came to happen.

There is little for the airport operator to do here. So do we need to investigate this incident?

Yes, Yes, A Thousand Times Yes

Accidents are often visualised as a chain of events. This metaphor is typically references to teach that any link can be broken and the accident would not have occurred. The metaphor holds for incidents as well and when it comes to investigations, I like to imagine that I am looking at every link in the chain and trying to work out how I can break that link in the future.

The term “investigation” carries a lot of baggage. The aviation industry has worked hard to overcome the “find-the-perpetrator” approach that comes from criminal investigations. But I think there still exists a general approach to investigation that focusses on an event and works backwards looking for causes.

What if the investigation also considered what happened after the triggering event?

In the case of the hard landing above, an airport operator might be very interested in how the initial emergency response and eventual disabled aircraft recovery went. In some ways, this might be considered a debrief or a review but in the end, I see them as the same process as an investigation.

In this post, I thought I would discuss an incident in which I was involved and led the review. I was pretty happy with my performance on the day of the incident but I am even more proud of the work I did in the aftermath in bringing people together to critically analyse what happened and what we could have done better in the future.

A Cold Winter’s Day

In July 2016, I was enjoying a varied Sunday with my family. My son and I had tried to get some snowboarding in on the nearby ski-field but the wind had closed the lifts and then the snow had closed the roads leaving us stranded on the mountain. We eventually made it home and looked to fill the rest of the day with something fun. A colleague had offered my children some old mountain bikes, so we picked them up, made a few quick repairs and went for a short ride to test them out. I remember checking my pockets just before we left the house and noticing that I didn’t have my phone. I thought to myself, “it’s okay, what can happen on a Sunday afternoon?”

Luckily, it was a short ride because 15 minutes later, I found out what can happen on a Sunday afternoon.

My airport had received a security threat and the airport police had decided to activate the Emergency Operations Centre (EOC). I made my way to the airport and assumed my role as Airport Operations Liaison and EOC Coordinator to our police sergeant who was the Incident Commander. The incident unfolded and we evacuated the terminal (a couple of hundred people thrown out into the cold), conducted a search and then resumed operations with quite a back-log.

The police and security services commenced their investigations into the threat but we identified that we also needed to investigate our own performance. You can call it a debrief or review or another name but the process would be the same - we wanted to establish what happened after the threat was received and how we could do better next time.

I’m not sure where this photo originated from but I downloaded it from youtravel.com.au

Establishing a Timeline

in the days that followed the event, many different little bites of information came to light. Things people said, who knew what when and what some people did that wasn’t shared on the day. To capture this information, we called together all our stakeholders for a debrief session with the goal of establishing a timeline.

We had over 30 people in the room and the process became hectic at times with people going off on tangents, being defensive or accusatory, or trying to find solutions before we had a complete picture. It required a strong chairperson to keep the process on track.

While we were developing the timeline, we asked the group to consider what went well and what could have been better. This step was essential to focus our analysis in the following steps. The reason behind capturing the positives from the timeline was two-fold. Firstly, I wanted to acknowledge the good work of the team on the day and secondly, I wanted to ensure that these wins were captured in our procedures.

This process took nearly as long as the event itself but a timeline was established and distributed within 10 days.

Analysing Failure & Success

To assist each stakeholder with identifying issues and corrective actions, we conducted a short review of the timeline to look for themes. This wasn’t overly scientific but rather than examine every single failure, we wanted to focus on systemic issues as they provide the best opportunity for future improvement.

Further analysis was given to each agency to carry out in accordance with their own procedures. Coordination issues were looked at by the airport operator as the overall controller of the Aerodrome Emergency Plan (AEP).

Fixing Problems

We took an immediate action and corrective action approach as we looked for quick fixes to some problems and more sustainable solutions to others. These actions and the actions proposed by our stakeholders were captured for tracking under our aerodrome emergency committee and collaborative operations group.

Opportunities are Everywhere

This approach, or something like it, can be applied to many situations. Obviously, anything involving emergency response is ripe for review but also other operational matters such as VIP transfers or significant flight delays. It can and should be used for near-misses.

Previous versions of safety management system guidance had investigations as a safety assurance activity and later ones have it under hazard identification. As Forrest Gump once said, “I think maybe it’s both”. Investigations, reviews, debriefs, etc., they all tell you about your performance; they could tell you about the status of identified risks or about new risks; and they all help you understand your operational context at any given time.

For mine, having a strong investigation capability with an airport operator is an absolute must. These are skills that can be learned and applied by technical and managerial staff…

Shameless Plug

And later this year, I will be working with airsight to deliver a 4-day course on in incident investigation in Berlin. I hope this will be the first of many courses I will deliver on the subject and with airsight but making the first one a success is of key importance.

If you or your team need help with developing your investigation capability and you can make it to Berlin in October, please contact airsight to book a place.

If you can’t make it this time, keep an eye of the airsight webpage for future dates or consider booking an in-house course at your convenience.