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Appendix 1 to this chapter provides further guidance for conducting effective interviews.
Caveat regarding witness interviews
8.4.5 Reconciling the often-conflicting nature of witness interviews requires caution. Intuitively, an
interviewer may weigh the value of an interview depending on the background and experience of the person
being interviewed. However, persons judged as “good witnesses” may allow their perceptions to be
influenced by their experience (i.e. they see and hear what they would “expect”). Consequently, their
description of events may be biased. On the other hand, people who have no knowledge of an occurrence
they have witnessed are often able to accurately describe the sequence of events. They may be more
objective in their observations.
Chapter 8. Safety Investigations 8-5
8.4.6 The skilled interviewer does not overly rely on a single witness — even the testimony of an
expert. Rather, information from as many sources as practical needs to be integrated to form an accurate
perception of the situation.
8.5 INVESTIGATION METHODOLOGY
8.5.1 The field phase of an investigation is used to identify and validate perceived safety hazards.
Competent safety analysis is required to assess the risks, and effective communications are required to
control the risks. In other words, effective safety management requires an integrated approach to safety
investigations.
8.5.2 Some occurrences and hazards originate from material failures or occur in unique environmental
conditions. However, the majority of unsafe conditions are generated through human errors. When
considering human error, an understanding of the conditions that may have affected human performance or
decision-making is required. These unsafe conditions may be indicative of systemic hazards that put the
entire aviation system at risk. Consistent with the systems approach to safety, an integrated approach to
safety investigations considers all aspects that may have contributed to unsafe behaviour or created unsafe
conditions.
8.5.3 The logic flow for an integrated process for safety investigations is depicted in Figure 8-1 —
Integrated Safety Investigation Methodology (ISIM). Using this type of model can guide the safety
investigator from the initial hazard or incident notification through to the communication of safety lessons
learned.
8.5.4 Effective investigations do not follow a simple step-by-step process that starts at the beginning
and proceeds directly through each phase to completion. Rather, they follow an iterative process that may
require going back and repeating steps as new data are acquired and/or as conclusions are reached.
8.6 INVESTIGATING HUMAN PERFORMANCE ISSUES
8.6.1 Investigators have been quite successful in analysing the measurable data pertaining to human
performance, e.g. strength requirements to move a control column, lighting requirements to read a display,
and ambient temperature and pressure requirements. Unfortunately, the majority of safety deficiencies
derive from issues that do not lend themselves to simple measurement and are thus not entirely predictable.
As a result, the information available does not always allow an investigator to draw indisputable conclusions.
8.6.2 Several factors typically reduce the effectiveness of a human performance analysis. These
include:
a) the lack of normative human performance data to use as a reference against which to judge
observed individual behaviour;
Note.— FDA, LOSA and NOSS data provide a baseline to better understand normal day-to-day
performance in aviation operations.
b) the lack of a practical methodology for generalizing from the experiences of an individual (crew or
team member) to an understanding of the probable effects on a large population performing similar
duties;
8-6 Safety Management Manual (SMM)
Figure 8-1. Integrated Safety Investigation Methodology (ISIM)
Hazard or occurrence notification and
assessment
Safety communication process
Risk control analysis
Defence analysis
Risk assessment process
Integrated investigation
Sequence of events
Data collection process
Assess notification and
decide to investigate or not
Identify events and underlying factors
Reconstruct logical progression
of occurrence events
Analyse facts and determine
findings regarding underlying
factors and hazards
Estimate risk and
determine acceptability
for each hazard
Identify defences that
are missing or inadequate
Identify and evaluate
risk control options
Communicate safety
message to stakeholders
Chapter 8. Safety Investigations 8-7
c) the lack of a common basis for interpreting human performance data among the many disciplines
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