lec 1: intro + history Flashcards
types of investigations
list 5
criminal
civil liability
public inquiries
coroners inquest
safety investigations
criminal investigation
evidence gathered in meticulous manner
evidence not data
Goal: use evidence in prosectory process to convict individual: CONVICTION
standard: beyond reasonable doubt
Civil Liability Investigations
evidence is ad-hoc
discovery (share all evidence)
“Expert Witnesses”
Goal: apportion liability/Blame: tort case
award remedies
public inquiries
not judicial court process
commissioned by governing state
not punitive
Public inquiry: AIR Ontario 1989 Focker28
Moshanksy Report: Public Inquiry
Safety Investigations
purpose:prevention
collection of data is methodical (not ad-hoc) - guided by methodology (no need to establish chain of custody)
output/product=safety communications
not punitive
does not seek to apportion blame/ liability
Goal: communicate recommendations to organizations that can implement change
first fatal aviation accident
1785
uses hydrogen
goal: navigate across english channel - unsuccessful
“De Roziere Balloon”
powered fixed wing flight
1903
Wright Flyer
First powered flight of plane
first airplane accident
1903 (october)
samuel langley
developmental (no investigation)
not fatal
first fatal airplane accident
1908
kity hawk
propeller unit fractured and reminisce severed controlled lines and fabric
2 died
investigator : frank lahm
- factual report
- no recommendations
- father of accident investigations
1st formal accident investigations report
1912
safety report
british royal aeroclub crash
contained: facts, analysis, findings/conclusions/recommendations
Transatlantic flight
1919
1st ever
commercial aviation
scrutinized for safety - domestic regulations developed by nations
1st regulatory body
1920
british air navigation transport act
usa civil aviation regulations
1926
ad-hoc
department of commerce and labour
jet propulsion
1930
single stage power turbine
patented in 1930
built in 1938 and took flight successfully
commercial passenger flight
1935
DC3 (plane)
certified early 1930
still flying in Canada
ICAO established
1944
aviation is global activity
post WW2- allied states decided needed way to facilitate across statelines
Met in Chicago in 1944 and wrote Chicago Convention called International Civil Aviation Organization (ICAO)
originally S2 states (nations)
cabin pressurization
1947
DC6 (plane)
fly higher than 12000 ft, quieter
ICAO Annex 13
annex= appendix
governs how international cooperation is to be facilitated during accident investigation
whos responsible for investigation
FAA (ATC)
1958
nationwide coordination of air traffic control
Federal Aviation Admin
independent NTSB
1975
national transport safety board
tenerife
1977
deadliest air accident in history (by fatalities)
2 aircrafts collided on runway (runway incursion)
583 fatalities
CASB
1984
Canadas Aviation Safety Board
Aloha 243
2 ppl died
Boeing-737-200
accumulated 3500 flight hours
90000 flight cycles
most flights last 1/2 hour - pressurizing and depressurizing
many fatigue cycles in # flight hours not considered by Boeing
TSB Canada
1990
Transportation Safety Board
accident investigation authority for canada
1960 transport canada: regulating entity (TCA) - air safety branch
Dubin Report
Result of public inquiry in 1980 - published in 1981
Andrew Corswell
justice dublin
Resulted in CASB : Canada Aviation Safety Board
Andrew Corswell
canadas leading pioneer on aviation safety
justice dublin
judge on case resulting in dublin report
principal recommendation that canada needs its own independent national transport safety board (CASB)
CASB
Canada Aviation Safety Board
quasi independent
air arrow
1985
major - over 2000 serviceman of american military died
set stage
1st major accident
proceeded findings in draft final report and presented to 8 board members
FOCKER 28 Air Ontario
Dryden ontario
1989
crashed on takeoff with icing
all on board died
resulted in public inquiry 2 : Moshanksy Report
Resulted in TSB Creation 1990 - no more board members
TSB quadrants
marine, oil/pipeline, train, aero
TSB classifications
Class 1
Class2
Class 3
Class 4
Class 5
Class 6
TSB classifications Class 1
unique
multiple occurrences
systemic risk (unsafe)
2016 frequent runway incursions
TSB classifications Class 2
most severe
TSB classifications Class 3
most popular with class 4
aircraft skids off side of runway no fatalities
TSB classifications Class 4
most popular with class 3
porter airlines tail strike
damage reparable - 2 sore back passengers
TSB classifications Class 5
no reports- just data gathering
TSB classifications Class 6
foreign state support
canadian made product
3rd party
TSB-Canada Mission
To advance transportation safety in the air, marine, rail and pipeline modes
of transportation that are under federal jurisdiction by:
* conducting independent investigations
* identifying safety deficiencies
* identifying causes and contributing factors
* making recommendations
* publishing reports
TSB-Canada who we are
An independent agency that consists of up to five Board members,
including a chairperson, and approximately 220 employees.
* The TSB reports to Parliament through the President of the Kings’s Privy
Council for Canada and is independent from other governmental
agencies and departments.
* It is not the function of the TSB to assign fault or determine civil or
criminal liability.
The phases of a TSB
investigation
1 – Field phase
2 – Examination and analysis phase
3 – Report phase
TSB-C Investigations and reports
Approximately 3,800 transportation occurrences (accidents and incidents)
are reported to the TSB every year.
An occurrence is investigated when it is very likely that the investigation will
improve transportation safety in Canada by reducing the risks to which
people, property, and the environment are exposed.
Classification system for TSB
investigations
Class 1 occurrences – Safety issue investigation
Class 2 occurrences – Complex investigation
Class 3 occurrences – Detailed investigation
Class 4 occurrences – Limited scope investigation
Class 5 occurrences – Data gathering investigation
Class 6 occurrences – Foreign investigation
Noteworthy Investigation Authorities
National Transportation Safety Board (NTSB)
- huge budget
- 1st independent
- increase level of expertise = large products (aviation)
-multimodal
UK AAIB (Air accident investigation branch)
- small org
competent individuals
unimodal
ATSB: Australian Transport Safety Bureau
- multimodal
-similar to USA
Russian Aviation Interstate Committee (AIC)
competent technically
Aviation Safety Trends
need to normalize to get rates
revenue kms/yr
flight hours/yr
per passenger kms
___% fatal accidents are in final approach/landing
50
SCF-NP
system/component failure (non -power plant)
nothing to do with propulsion systm
RE
runway excursion - air craft lands but loses control insufficient braking
RI
runway incursion
C-FIT
control flight into terrain
COC-I
loss of control in flight
ICE
icing
TURB
turbulance
RAMP
ground handelling
ARC
abnormal runway contract - tall strike
MAC
mid air collision / risk of collision
