Aicraft Accident Investigation Flashcards by Marian Angelica Peña

means the publication issued by the Authority in accordance with ICAO Annex 15.

Aeronautical Information Publication (AIP)

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means a person designated by a Contracting State, on the basis of his or her qualifications, for the purpose of participating in an investigation conducted by another State.

accredited representative

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means a person appointed by a Contracting State, on the basis of his or her qualifications, for the purpose of assisting its accredited representative in an investigation conducted by another State;

adviser/advisor

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means actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident. The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability;

causes

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means the Chairman of Aircraft Accident Investigation and Inquiry Board appointed under RA 9497 section 42.

Chairman

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Actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduces the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident.

contributing factors

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means a report of an accident or incident in the format set out in ICAO Annex 13 and which may be adapted to the circumstances of the accident or incident under investigation;

final report

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means any type of recorder installed in the aircraft for the purpose of complementing accident or incident investigation;

flight recorder

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An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of suc
operation;

incident

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A process conducted for the purpose of accident prevention which includes the gathering and analysis of information , the drawing of conclusions, including the determination of causes and/or contributing factors and, when appropriate, the making of safety recommendations.

investigation

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means an Investigator of Accidents appointed under paragraph 13.100(b);

investigator

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means a person designated by the Chairman on the basis of his or her qualifications as such under paragraph 13.100(d) and charged with the responsibility for the organization conduct and control of an investigation;

Investigator-in-charge

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means a person organization or enterprise engaged in or offering to engage in aircraft operation

Operator

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in relation to an aircraft which is registered means the registered owner of the aircraft;

Owner

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means the communication used for the prompt dissemination of data obtained during the early stages of the investigation;

Preliminary Report

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means an aircraft that is registered in the Republic of the Philippines;

Republic of the Philippines aircraft

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means an operator whose principal place of business is located in or permanent residence is in Republic of the Philippines;

Republic of the Philippines operator

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A proposal of an accident investigation authority based on information derived from an investigation made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident.

safety recommendation

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An incident involving circumstances indicating that there was a high probability of an accident and is associated with the operation of an aircraft

serious incident

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means the State in whose territory an accident or incident occurs;

state of occurence

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An integrated set of regulations and activities aimed at improving safety. (per Memorandum Circular No. 18-15 series of 2015)

State Safety Program (SSP)

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Damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component.

Substantial Damage

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ACCID

Accident

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AFTN

Aeronautical Fixed Communication Network

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AIP

Aeronautical Information Publication

AOC

Air Operator Certificate

ICAO

International Civil Aviation Organization

IIC

Investigator-in-Charge

INCID

Incident

Implementing Standards

Kilogram

PIC

Pilot-in-Command

UTC

Universal Coordinated Time

12.015 Purpose of Investigation (Based on PCAR Part 13)

Purpose of Investigation

state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management

safety

is a dynamic characteristic of the aviation system, whereby safety risks must be continuously mitigated.

safety

evolution of safety thinking

technical factors, human factors, organizational factors

Aviation emerged as a form of mass transportation in which identified safety deficiencies were initially related to technical factors and technological failures.

technical era

technical era years

early 1900s until the late 1960s

In the early 1970s the frequency of aviation accidents was significantly reduced due to major technological advances and enhancements to safety regulations.

human factors

human factors era years

early 1970s until the mid-1990s

During this era safety began to be viewed from a systemic perspective which was to encompass organizational factors in addition to human and technical factors

organizational era

organizational era years

from the mid-1990s to the present day.

illustrates that accidents involve successive breaches of multiple system defenses.

Swiss-Cheese Model developed by Professor James Reason

The Reason Model proposes that

all accidents include a combination of both active and latent conditions

are actions or inactions, including errors and violations, which have an immediate adverse effect. They are generally viewed, with the benefit of hindsight, as unsafe acts. generally associated with front-line personnel (pilots, air traffic controllers, aircraft mechanical engineers, etc.) and may result in a harmful outcome.

active failures

are those that exist in the aviation system well before a damaging outcome is experienced. The consequences may remain dormant for a long time. Initially, these are not perceived as harmful, but will become evident once the system's defenses have been breached.

latent conditions

concept of accident causation

organization, workplace, people

Activities over which any organization has a reasonable degree of direct control

organization

Factors that directly influence the efficiency of people in aviation workplaces.

workplace

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect

people

environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety

human factors

They are the social and personal skills, such as communication and decision making which complement our technical skills. These are important for safe and efficient aviation.

human performance

Due to a large number of maintenance-related aviation accidents and incidents that occurred in the late 1980s and early 1990s, Transport Canada identified twelve human factors that degrade people's ability to perform effectively and safely, which could lead to maintenance errors.

dirty dozen

were eventually adopted by the aviation industry as a straight forward means to discuss human error in maintenance.

dirty dozen

DIRTY DOZEN

LACK OF COMMUNICATION; COMPLACENCY; LACK OF KNOWLEDGE; DISTRACTION; LACK OF TEAMWORK; FATIGUE; LACK OF RESOURCES; PRESSURE; LACK OF ASSERTIVENESS; STRESS; LACK OF AWARENESS; NORMS

key human factor that can result in suboptimal, incorrect, or faulty maintenance

lack of communication

Each exchange holds the potential for misunderstanding or omission. But communication between AMTs may be the most important of all.

lack of communication

is a human factor in aviation maintenance that typically develops over time.

complancency

repetitive task, especially an inspection item, may be overlooked or skipped because the technician has performed the task a number of times without ever finding a fault.

complacency

when performing aircraft maintenance can result in a faulty repair that can have catastrophic results.

lack of knowledge

when performing aircraft maintenance can result in a faulty repair that can have catastrophic results.

lack of knowledge

Technicians must be sure to use the latest applicable data and follow each step of the procedure as outlined. They must also be aware that differences exist in the design and maintenance procedures on different aircraft. It is important for technicians to obtain training on different types of aircraft

lack of knowledge

while performing maintenance on an aircraft may disrupt the procedure.

distraction

can be mental or physical in nature. They can occur when the work is located on the aircraft or in the hangar.

distraction

Sharing of knowledge between technicians, coordinating maintenance functions, turning work over from shift to shift, and working with flight personnel to troubleshoot and test aircraft are all are executed better in an atmosphere of teamwork.

lack of teamwork

is a major human factor that has contributed to many maintenance errors resulting in accidents.

fatigue

reduces alertness and often reduces a person's ability to focus and hold attention on the task being performed.

fatigue

can interfere with one's ability to complete a task because there is a lack of supply and support.

lack of resources

Aviation maintenance demands proper tools and parts to maintain a fleet of aircraft. Any lack of resources to safely carry out a maintenance task can cause both non-fatal and fatal accidents. For example, if an aircraft is dispatched without a functioning system that is typically not needed for flight but suddenly becomes needed, this could create a problem.

lack of resources

Aviation maintenance tasks require individuals to perform in an environment with constant pressure to do things better and faster without making mistakes and letting things fall through the cracks. Unfortunately, these types of job pressures can affect the capabilities of maintenance workers to get the job done right.

pressure

Assertiveness is the ability to express your feelings, opinions, beliefs, and needs in a positive, productive manner and should not be confused with being aggressive.

lack of assertiveness

Aviation maintenance is a stressful task due to many factors. Fast-paced technology that is always changing can add stress to technicians. This demands that AMTs stay trained on the latest equipment. Other stressors include working in dark, tight spaces, lack of resources to get the repair done correctly, and long hours. The ultimate stress of aviation maintenance knows that the work they do, if not done correctly, could result in tragedy.

stress

add to the personnel's workload and make it uncomfortable for him or her in their work environment.

physical stressors

high temperatures in the hanger increase perspiration and heart rate causing the body to overheat. Low temperatures can cause the body to feel cold, weak, and drowsy.

temperature

have high noise levels (due to aircraft taking off and landing close by) can make it difficult for maintenance personnel to focus and concentrate.

noise

poor lighting within a work space makes it difficult to read technical data and manuals. Likewise, working inside an aircraft with poor lighting increases the propensity to miss something or to repair something incorrectly

lighting

small work spaces make it very difficult to perform tasks as technicians are often contorted into unusual positions for a long period of time.

confined spaces

relate to emotional factors, such as a death or illness in the family, business worries, poor interpersonal relationships with family, co-workers, supervisors, and financial worries.

phychological stressors

over anxiousness can hinder performance and speed while conducting maintenance if there is any apprehension about how to do a repair or concerns about getting it done on time.

work-related stressors

impending bankruptcy, recession, loans, and mortgages are a few examples of financial problems that can create stressors.

financial problems

divorce and strained relationships can interfere with one's ability to perform their job correctly.

marital problems

problems with superiors and colleagues due to miscommunication or perceived competition and backstabbing can cause a hostile work environment

interpersonal problems

include fatigue, poor physical condition, hunger, and disease.

physiological stressors

trying to work when ill or not feeling well can force the body to use more energy fighting the illness and less energy to perform vital tasks.

poor physical condition

not eating enough, or foods lacking the proper nutrition, can result in low energy and induce symptoms like headaches and shaking.

proper meals

fatigued, the maintainer is unable to perform to standard for long periods of time and can become sloppy with repairs and miss important mistakes.

lack of sleep

the affect of changing sleep patterns on the body's circadian cycle can lead to a degradation of performance.

conflict shift schedule

is defined as a failure to recognize all the consequences of an action or lack of foresight.

lack of awareness

After completing the same task multiple times, it is easy for technicians to become less vigilant and develop a lack of awareness for what they are doing and what is around them. Each time a task is completed it must be treated as if it were the first time.

lack of awareness

is short for "normal," or the way things are normally done. Negative norms can detract from the established safety standard and cause an accident to occur. Norms are usually developed to solve problems that have ambiguous solutions. When faced with an ambiguous situation, an individual may use another's

norms