Safety and Accident Investigation MSc

• Professor Graham Braithwaite

To provide accident investigators with the fundamental knowledge and skills to conduct a general transport accident investigation.

Response

• The purpose of investigation
• Notification processes
• Getting started
• Group system of investigation
• Health and safety at the accident site
• Initial appraisal of land and sea based sites
• Disaster response
• Disaster management
• Competing interests, criminal investigations
• Recovery of wreckage
• Wreckage photography

Evidence

• Collecting evidence
• Site survey techniques
• Systems, engineering and operations investigations
• High profile investigations
• Organisational accidents
• Investigative interviewing
• Interview techniques
• Analysis of statements
• Physical evidence
• Crashworthiness
• Structures
• Material failures and composites
• Look and record
• Remote site survey
• Investigation site simulation

Human factors

• The human factor
• Physiology
• Psychology
• Ergonomics
• Passenger behaviour
• Investigation support
• Test capabilities
• The role of the media
• Witnesses
• Accident pathology
• Recovery and identification of bodies
• Court procedures for investigators
• The Coroner’s court

Analysis

• Recorders
• Data recorders (voice/flight data)
• Analysis of recorders
• Non-volatile memory
• Fundamentals of analysis
• Analytical approaches
• Applying analysis tools
• Traps in analysis

Recommendations

• A major event
• Management of large investigations
• Liaising with victims / families
• Relatives’ perspective
• Report writing
• Relations with the regulator
• Managing recommendations
• Multimodal investigations
• Follow-up actions

On successful completion of the module, you will be able to:

• Describe the accident investigation process for a transport accident including elements of preparation, emergency response, evidence collection, analysis and presentation of findings.
• Work safely under supervision at an accident site.
• Conduct witness interviews and collect material evidence from a variety of relevant sources.
• Conduct an analysis of evidence to develop a no-blame report of what occurred and recommendations for future prevention.
• Work successfully alongside relevant agencies including the police, coroner, media and regulator.

To facilitate the use of basic research methods and fundamentals of statistical analysis to solve research problems in the air transport industry.

Research Methods
• Introduction to research
• Case study research design
• Survey research/questionnaire design
• Qualitative methods e.g. In-depth interview

Statistics
• Descriptive statistics
• Probability distribution
• Estimation with confidence intervals
• Hypothesis testing
• Analysis of variance (ANOVA)
• Correlation and simple regression
• Multiple regression

• David Barry

To provide students with the fundamental skills required to manage operational safety within the aviation industry.

• The fundamentals of a Safety Management System, and introduction to associated guidance material provided by the International Civil Aviation Organisation (ICAO) and other State safety regulatory bodies;
• Safety data, safety information and analyses; including reporting systems, investigation and Flight Data Monitoring (FDM);
• Hazard identification and risk management, including an introduction to Enterprise Risk Management (ERM);
• Safety performance and safety health; including guidance on audits and safety promotion;
• Safety organisations, including guidance on effective management of safety teams.

• David Barry

To provide an understanding of Flight Data Monitoring within a commercial organisation and to detail the uses, processes and responsibilities of a successful FDM programme.

• The history of FDM and an overview of its objectives
• CAP739, EASA and ICAO regulatory frameworks
• Integration of FDM within a safety system
• FDM technology
• Setting analysis targets
• Data recovery and analysis tools
• Principles of data validation and assessment
• Trace interpretation, with both theoretical and practical sessions
• Database management
• The use of statistics in data analysis
• Animations and visualisation in data presentation
• FDM in accident and incident investigation
• The interface between the analyst and crews
• Legal aspects of FDM data collection, retention and use
• The use of FDM to justify operational and technical change
• The potential of FDM within maintenance programmes.

On successful completion of this module a student should be able to:

1. Describe the key elements of an FDM programme and appraise the security and anonymity safeguards of a given FDM programme.
2. Critically analyse an FDM event, including evaluating data integrity and present the analysis in an appropriate format.
3. Propose and defend an FDM regime for application in their own company.

The module aims to provide a broad overview of the nature and management of human error in the aviation maintenance domain. Key theories and frameworks for investigating maintenance human error, contributing factors and effects on operations are introduced. The challenges associated with practical application of currently available safety tools are examined together with the latest strategies to enhance understanding and management of maintenance error. This module does not require previous background in aviation maintenance and engineering.

• The nature of the maintenance environment:This includes both civil and military environments. 

• Maintenance management: Organisation, line and base maintenance, planning, maintenance control, error management systems, shift handover, blame cycle, communication in the workplace, workplace environment, work/job design. Regulatory framework: Legal requirements. EASA/Part 145 Maintenance Human factors.
• Designing for human factors: What can be done by the designer to reduce and mitigate human error. Design philosophies and human-centred design.
• Human error management in maintenance: The benefits and challenges associated with the use and application of reporting systems and safety tools.

On successful completion of this module a student should be able to:

1. describe the regulatory background and the environment within which aviation maintenance takes place Describe the regulatory background and the environment within which aviation maintenance takes place
2. evaluate current methods for maintenance error management (reactive, proactive and predictive)
3. appraise the links between aircraft maintenance and safety
4. analyse ways in which maintenance errors can be reduced at the design stage.

• Dr Simon Place

To familiarise Course Members with the various approaches to the problems of assessing the safety of increasingly complex aircraft systems.

Introduction and Background
Outline of relevant accidents and system design philosophy. Discussion of acceptable accident rates and recent advances in systems. Introduction to probability methods.

Regulatory background
The development of requirements for safety assessment, FAR / EASA CS25--1309.

Methods and Techniques
Introduction to the more common safety analysis techniques. Influence of human factors. Common mode failures, traps and pitfalls of using safety assessment and examples of mechanical systems and power plants.

Use of safety assessment techniques
Determination of correct architecture of safety critical systems. Fault Tree Analysis, Dependence Diagrams and Boolean algebra for quantification of system reliability. Zonal safety analysis (ZSA), Particular Risk Analysis (PRA) and Failure Mode and Effect Analysis (FMEA) of aircraft systems.

Practical examples of the application of safety assessment techniques
Minimum Equipment Lists (MEL), Safety and Certification of digital systems and safety critical software. Application of Aerospace Recommended Practice (ARP) 4761. Typical safety assessment for a stall warning and identification system.

Current and future issues
Integrated and modular systems and their certification. Certification maintenance requirements. Flight-deck ergonomics.

On successful completion of this module a student should be able to:

1. Demonstrate an understanding of the regulatory background behind the Safety Assessment of Aircraft Systems.
2. Evaluate and apply the technique(s) which is most appropriate for the system under consideration.
3. Explain the theory behind each technique, including the strengths and weaknesses of each one, and be aware of possible pitfalls.
4. Appreciate the role of safety assessment in the overall context of aircraft certification.
5. Illustrate the issues to be faced for the certification of new systems and aircraft.

• Peter McCarthy

The Investigating Human Performance Module encourages students to look critically at the contribution humans make in High reliability Organisations (HRO’s). Using psychological theory and analysis, the human contribution (positive and sometimes negative) is addressed. Theories and approaches of human performance explored on this module, help the investigator understand the human factors not only affecting those involved with accidents or incidents, but also the factors affecting the investigator.

• Introduction to Human Factors
o The role of human performance in accidents
o Objectives of the course
o Assignment briefing

• Individual Factors
o Human error
   Slips
   Lapses
   Mistakes
   Violations
   Skill-based errors
   Rule-based errors
   Knowledge-based errors
o Human cognition
   Human performance and limitations
   Perception
   Memory
   Attention and vigilance
   Information processing
   Decision making
   Situational awareness
o Medical factors
   Physiology and its effect on performance
   The role of the pathologist
   The role of the General Practitioner
   Ethics of accessing medical information
o Workload, fatigue and tiredness
   Tiredness versus fatigue
   Effects of fatigue
   Things that look like fatigue but aren’t
   Building up a valid history
   Using fatigue assessment tools

• Job / Workplace Factors
o Evaluating ergonomics
o Assessing task / workload
o Interpreting error prediction tools
o Environmental factors
o Team Factors
o teamwork
   communications
   leadership / followership
   cultural factors

• Organisational and Management Factors
o The role of culture in causation
o The role of management in causation
o Measuring safety culture
o Assessing responses to previous events
o Case study investigations

• Human Performance evidence collection tools
o Checklists
   Commonly used checklists and tools
   Benefits and limitations
   Case studies of use

• Analysis of human factors
o Biases and heuristics
o Ethical issues
o Interpretation of recorded data
o Interpretation of witness / interview data

• David Barry

Crisis management is a topic area relevant to airlines, airports and other organisations involved with delivering air transport. These organisations typically have dedicated personnel and departments to emergency response and crisis planning. The aim of this course is to provide students with an overview of how to plan for crises, what to expect when they happen, and how to deal with practicalities such as dealing with media, survivors and in the longer term, insurers.

• Crisis management planning
• Crisis communications
• Critical function and risk analysis
• Business continuity development and strategy
• Crisis management exercise

On successful completion of this module a student should be able to:

1. Describe the key elements of a crisis
2. Analyse the importance of effective crisis management
3. Critically evaluate past aviation crisis management
4. Facilitate business continuity planning.

• Professor Graham Braithwaite

The Interviewing for Accident Investigators module is designed to provide delegates with an enhanced level of theoretical and practical skills to effectively interview various types of witness to gather evidence in support of successful safety accident investigations.

The module adopts a balanced curriculum of theoretical learning and practical sessions involving interviews of live witnesses, with video debriefing, to deliver a practical learning experience supported by the latest academic thinking in investigative interviewing.

The module is intended to build on the interviewing skills developed during the Fundamentals of Accident Investigation, Applied Aircraft Accident Investigation, Applied Marine Accident Investigation and Applied Rail Accident Investigation modules. However, it can also be attended as a standalone module for delegates who wish to gain an enhanced qualification in investigative interviewing, and would be particularly suited to delegates with previous experience of conducting investigative interviews.

The module will have an emphasis on interviews forming part of safety (no blame/just culture) investigations of generic transport accidents. However, its content will be equally applicable to accident investigators from other safety critical domains and high reliability organisations, such as healthcare, process industries, and energy utilities.

Refresher of the fundamentals of investigative interviewing

• Basic principles of investigative interviewing
• Basic interviewing models:-
  -Conversation Management
  -Conducting a PEACE interview
• Use of different questioning techniques – Open v. Closed, Directed, Confirmatory, etc
• Fundamentals of cognitive interviewing
• Basic theory of memory and recall.

Enhanced theory of investigative interviewing

• Enhanced theory of memory and psychology applied during investigative interviewing.
• SE3R methodology for managing and recording interviews.
• Introduction to concept of enhanced cognitive interview techniques, including free recall.
• Biases and heuristics – investigator and witnesses.
• Introduction to non-cognitive interview techniques for interviewees who have not directly witnessed the accident.

Preparation for the interview

• Assessment of the emotional and psychological state of witnesses
• Awareness of the characteristics of potentially vulnerable witnesses and the challenges faced when interviewing them
• Consideration of cultural, religious, social factors that may have an effect on the witness interview
• Strategies for planning and structuring different types of interviews
• Identification of the most appropriate interview technique to apply.

Conducting the interview

• Management of the initial phases of the interview to build rapport and ensure that all legal and ethical aspects have been considered
• Implementation of the appropriate interviewing model in accordance with the interview strategy/plan
• Adopting a meaningful, effective and consistent strategy for summarising and recording witness evidence
• Introduction to strategies for dealing with challenging/difficult witnesses, including obstructive and inappropriate behaviour
• Identifying and employing appropriate challenge techniques for any inconsistencies/omissions during an interview.
• Dealing with other third party attendees at the interview, e.g. legal representatives, trade union representatives, friends/family.
• Effective interview closure strategies.

Post-interview phase

• Recording and summarising of the interview information
• Strategies for conducting an effective self-critique of the interview process to ensure continuous performance improvement.

• Demonstrate an understanding of the underlying interviewing theories, including memory theory and psychological factors affecting witness recall, and biases and heuristics of both witnesses and investigators
• Describe and critically assess the most appropriate interview technique(s) to be adopted during an accident safety investigation to ensure the effective gathering of witness evidence, including cognitive/non-cognitive interview techniques
• Develop an appropriate and effective interview strategy and plan to ensure the efficacy of the interview and optimise the gathering of the available information
• Conduct an effective witness interview with regard to the selection of the most appropriate interview methodology, the welfare of the witness, the quality of the evidence collected and the accuracy of note taking
• Develop an awareness of the characteristics of potentially vulnerable witnesses and the challenges faced when interviewing them
• Demonstrate the ability to conduct an effective self-critique of the interview process to ensure continuous performance improvement.

The aim of this module is to provide students with an understanding of the design of crashworthy aircraft structures and the considerations necessary when designing safe and crashworthy aircraft. The main purpose of crashworthy design is to eliminate injuries and fatalities in mild impacts and minimise them in severe but survivable impacts.

Overview of Aircraft Crashworthiness

• Objectives and Approach
• Regulations
• Human Tolerance
Crash Energy Management

• Structural Collapse
• Collapse of metallic and composite structural components
• Component collapse vs. structural collapse
Introduction to methods for crash analysis

• Hand calculations
• Hybrid analysis methods
• Detailed analysis methods
Role and capability of testing and simulation in the crashworthiness field

• Outline the main priorities and fundamentals of crashworthiness in aircraft in the context of protection in crash events
• Define the requirements for structural components used for impact energy absorption and structural collapse in aircraft
• Describe crashworthiness requirements on major equipment and systems
• Identify relevant regulations for aircraft crashworthy design
• Discuss human tolerance in the context of crashworthiness
• Identify the main experimental and analytical techniques used in design for crashworthiness
• Apply the systems approach in impact energy management to aircraft design
• Use simple approximate calculations on the performance of energy absorption components and structures to assess the crashworthiness of an aircraft structure.

• Yani Asmayawati

The module will allow the delegate to have an understanding of the relevant regulations, legislation and legal processes, to be able to conduct their evidence collection according to methods of best practice, and to be confident and proficient in giving evidence in court. At the end of the module the students will undertake a mock courtroom exercise and be able to receive feedback on their performance from their peers.

• Standards, Recommended Practices, Legislation and Regulation with respect to Transport Accident Investigation.
• Role and Legal Responsibilities of the Accident Investigator.
• Note Taking and Statement Writing.
• The Coroner’s Court.
• Fatal Accident Inquiries.
• Military Legal Processes.
• Public Inquiries.
• Civil Litigation Processes.
• Presentation of Evidence in Court by Investigator.
• Protection of Witnesses / Evidence.
• Civil Litigation in Europe, the UK and the USA.
• Criminal Litigation Processes.
• Civil and Criminal Litigation Processes.
• The Procedures, Order of Events and Roles of Participants.
• How to Give Clear, Honest and Objective Evidence.
• How to make Appropriate use of Supporting Evidence, Documents and Notes when Giving Evidence
• How to Prepare for Giving Evidence
• Techniques used by Lawyers in Cross-examination
• Role Play of Cross-examination

On successful completion of this module a student should be able to:
1. Evaluate the role of the accident investigator within the international and national legal frameworks and prepare strategies for managing their interaction with Coronial, Fatal Accident Inquiry, Public Inquiry and other relevant legal processes.
2. Define the role and responsibilities of the accident investigator as expert witness and demonstrate the ability to assess the best ways to execute this role.
3. Compose accident reports which can be used appropriately by parallel investigation processes.
4. Present oral evidence in court effectively and critically evaluate the experience.
5. Respond effectively to cross-examination and critically evaluate the experience.

• Yani Asmayawati

The module will allow the delegate to have an understanding of the relevant failure modes, be able to inspect wreckage to understand the most likely failure scenarios, and to be proficient in obtaining and evaluate the work supplied by material forensic specialists. At the end of the module the students will undertake simulated materials investigations and present their findings to their peers.

• Fundamentals: The student will gain an understanding of the fundamentals of material behaviour, mode specific design philosophies, and principles related to material failures.
• Failure modes of metallic materials: Fracture mechanisms and the resultant visual characteristics will be presented.
• Failure modes of non-metallic materials: Fracture mechanisms and the resultant visual characteristics will be presented.
• The process of structural investigations: Subject areas presented include the material investigation process; from the wreckage examination in the field to the laboratory investigation, sample removal and transportation, and the use of specialist laboratory equipment.

• Alan Parmenter

This module builds on the Fundamentals of Accident Investigation to develop specialist skills for the investigation of aircraft accidents.

Aviation specific investigation techniques (contact: 40/private study: 70)

Less complex fixed wing aircraft
• Impact and flight path assessment
• The operations investigator’s approach
• The engineering investigator’s approach
• Sources of evidence
• Conduct of the investigation

More complex fixed wing aircraft
• Impact and flight path assessment
• Aircraft structures (metal/composites)
• The operations investigator’s approach
• Aircraft performance
• Crew performance
• The engineering investigator’s approach
• Hydraulic systems
• Electrical systems
• Landing gear
• Flight Data Recorders
• Cockpit Voice Recorders
• Alternative recorded data
• Fuel
• Major case study – B777 BA38 at Heathrow, 2008

Rotary wing accidents
• Principles of helicopter flight
• Investigation approach
• Human factors in rotary wing accidents
• Recorder analysis
• Offshore helicopter accidents

Air Traffic Control
• Principles of ATC
• Use of radio telephony transcripts/recordings
• Major case study – Mid air collision at Überlingen

Technical site visits to:
• Air Accidents Investigation Branch
• Military Air Accidents Investigation Branch

Powerplants and propulsion
• Piston engine operations
• Turbine engine operations
• Role of manufacturer in investigation
• Engine teardown on site/at base
• Birdstrikes/FOD
• Case studies

Major Investigation simulation (contact: 35/private study: 90)
• Health and safety at the accident site
• Risk assessment of the accident site
• Physical examination of wreckage
• Accident site photography
• Accident site management
• Wreckage plotting
• Witness interviewing
• Analysis techniques
• Preparation of recommendations
• Formal report writing
• Debriefing

Investigation management (contact: 25/private study: 40)
• Dealing with other agencies
• Accredited representatives/technical advisors
• Participating in an overseas investigation
• Managing an investigation
• Managing the politics
• Managing the news media
• Cultural aspects
• Preparing to release an investigation report
• Ongoing litigation
• The role of the Investigator in Charge
• The role of the Chief Inspector

On successful completion of this module a student should be able to:

1. Work safely without supervision at an accident site.
2. Describe common failure types and their symptoms in terms of structures, powerplants and propulsion, aircraft systems and human factors.
3. Describe and contrast the differences between the investigation of civil and military; less complex and more complex aircraft, and between fixed wing and rotary wing aircraft accidents.
4. Describe the role of accredited representatives, technical advisors and other interested parties in the accident investigation process.
5. Successfully manage an accident investigation, both on-site and through to the publication and acceptance of recommendations.
6. Collect information / evidence from a variety of electronic, hard copy and witness sources to support investigations and research;
7. Appraise and critique the work of other practitioners and specialists;
8. Communicate effectively, in written form, research work and investigations produced;
9. Take responsibility for research and investigations produced, including, efficient time management, working to set deadlines and targets, demonstrating self-discipline, creative thinking and critical reflections of their own performance;
10. Collaborate and contribute effectively to group workshops, simulations and assignments, appreciating the contributions made by other team members, especially from different disciplines, national and cultural backgrounds.

• Yani Asmayawati

This module builds on the Fundamentals of Accident Investigation to develop specialist skills for the investigation of rail accidents.

The module builds on the Fundamentals of Accident Investigation module to develop specialist skills for the investigation of rail accidents.

Advanced investigative skills
• Rail accident site management and dealing with other agencies
• Rail accident site risk management
• Advanced interviewing skills
• Advanced investigative photography
• Advanced analysis methods
• Rail crashworthiness and passenger survivability
• Investigating Safety Management System


Investigating collisions, level crossing accidents, and Signals Passed at Danger
• Overview of factors contributing to Signals Passed at Danger, collision/level crossing accidents and case studies
• Basic principles of signalling
• Relevant safety systems in train control
• Relevant human factors aspects


Investigating derailment accidents
• Overview of factors contributing to derailment accidents and case studies
• Collecting, inspecting and interpreting evidence (on site)
• Dynamic modelling of wheel/rail interface response
• Relevant human factors aspects


Accident investigation simulation
A five-day practical exercise in a simulated accident investigation scenario where delegates can apply the skills and knowledge acquired in the Fundamentals of Accident Investigation course and other workshops in the Applied Rail Accident Investigation series. The simulation takes the delegate through the entire investigation process from notification, site investigation, interviews, analysis, report writing and formulating recommendations.
• Team and investigation management.
• Securing the accident site.
• Managing news media
• Health and safety at the accident site.
• Risk assessment of the accident site.
• Physical examination of wreckage/track.
• Documentation investigation (procedures, manuals, logs, etc).
• Accident site photography.
• Accident site management.
• Witness interviewing.
• Application of analysis techniques.
• Developing recommendations.
• Formal report writing.

On successful completion of this module a student should be able to:

1. Identify potential hazards at a rail accident site and assess the risks and mitigation methods in order to work safely whilst conducting an investigation.
2. Identify and evaluate common failure types and their symptoms in terms of structures, rolling stock, fire, railway systems and human factors.
3. Describe and contrast the differences between the investigation of the different types of rail operations and technology.
4. Describe the role of the different parties in the accident investigation process and manage the relationships between these parties.
5. Successfully manage an accident investigation, both on-site and through to the publication and acceptance of recommendations.
6. Compose an accident report and develop feasible safety recommendations.
7. Identify, collect and analyse information/evidence from a variety of electronic, hard copy and witness sources to support investigations and research.
8. Appraise and critique the work of other practitioners and specialists.
9. Communicate effectively, in written form, research work and investigations produced.
10. Take responsibility for research and investigations produced, including, efficient time management, working to set deadlines and targets, demonstrating self-discipline, creative thinking and critical reflections of their own performance.
11. Collaborate and contribute effectively to group workshops, simulations and assignments, appreciating the contributions made by other team members, especially from different disciplines, national and cultural backgrounds.