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actions, the dividing line between relevance and irrelevance is often blurred. Data that initially may seem to
be unrelated to the investigation could later prove to be relevant once relationships between different
elements of the occurrence are better understood.
Chapter 8. Safety Investigations 8-3
8.3 INFORMATION SOURCES
Information relevant to a safety investigation can be acquired from a variety of sources, including:
a) Physical examination of the equipment used during the safety event. This may include examining
the front-line equipment used, its components, and the workstations and equipment used by
supporting personnel (e.g. ATCOs, maintenance and servicing personnel).
b) Documentation spanning a broad spectrum of the operation, for example:
1) maintenance records and logs;
2) personal records/logbooks;
3) certificates and licences;
4) in-house personnel and training records and work schedules;
5) operator’s manuals and SOPs;
6) training manuals and syllabi;
7) manufacturers’ data and manuals;
8) regulatory authority records;
9) weather forecasts, records and briefing material; and
10) flight planning documents.
c) Recordings (flight recorders, ATC radar and voice tapes, etc.). These may provide useful
information for determining the sequence of events. In addition to traditional flight data recordings,
maintenance recorders in new generation aircraft are a potential additional source of information.
d) Interviews conducted with individuals directly or indirectly involved in the safety event. These can
provide a principal source of information for any investigation. In the absence of measurable data,
interviews may be the only source of information.
e) Direct observation of actions performed by operating or maintenance personnel in their work
environment. This can reveal information about potential unsafe conditions. However, the persons
being observed must be aware of the purpose of the observations.
f) Simulations. These permit reconstruction of an occurrence and can facilitate a better
understanding of the sequence of events that led up to the occurrence, and the manner in which
personnel responded to the event. Computer simulations can be used to reconstruct events using
data from on-board recorders, ATC tapes, radar recordings and other physical evidence.
g) Specialist advice. Investigators cannot be experts in every field related to the operational
environment. It is important that they realize their limitations. When necessary, they must be willing
to consult with other professionals during an investigation.
8-4 Safety Management Manual (SMM)
h) Safety databases. Useful supporting information may come from accident/incident databases,
in-house hazard and incident reporting systems, confidential reporting programmes, systems for
monitoring line operations (e.g. flight data analysis, LOSA and NOSS programmes), manufacturers’
databases, etc.
8.4 INTERVIEWS
8.4.1 Information acquired through interviews can help clarify the context for unsafe acts and
conditions. It can be used to confirm, clarify or supplement information learned from other sources.
Interviews can help to determine “what” happened. More importantly, interviews are often the only way to
answer the important “why” questions which, in turn, can facilitate appropriate and effective safety
recommendations.
8.4.2 In preparation for an interview, the interviewer must expect that individuals will perceive and
recall things differently. The details of a system defect reported by operational personnel may differ from
those observed by maintenance personnel during a service check. Supervisors and management may
perceive issues differently than line personnel. The interviewer must accept all views as worthy of further
exploration. However, even qualified, experienced and well-intentioned witnesses could be mistaken in their
recollection of events. In fact, it may be grounds to suspect the validity of the information being received if
during interviews of a number of people concerning the same event, the interviewees are not presenting
different perspectives.
Conducting interviews
8.4.3 The effective interviewer adapts to these differing views, remaining objective and avoiding
making an early evaluation of the content of the interview. An interview is a dynamic situation, and the
skilled interviewer knows when to continue a line of questioning and when to back off.
8.4.4 To achieve the best results, interviewers will likely employ a process as follows:
a) carefully preparing and planning for the interview;
b) conducting the interview in accordance with a logical, well-planned structure; and
c) assessing the information gathered in the context of all other known information.
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Safety Management Manual (SMM) 安全管理手册(58)
