Improving Aviation Accident Investigation: Challenges and Strategies

Introduction

Over the past few years, the aviation sector has experienced tremendous growth and development driven by rising air traffic. Despite this growth, safety concerns continue to increase even as new technologies are adopted to improve aviation safety. One of the major areas characterized by ongoing concern is aviation accident investigation. Aviation accident investigation plays a crucial role in aviation safety because it generates recommendations used to prevent future accidents, thereby improving safety overall.

Aviation accident investigations have been characterized by challenges that hinder the effectiveness of recommendations in preventing future reoccurrences under similar circumstances. Even though the current strategies employed in aviation accident investigations are relatively effective, the process faces obstacles that necessitate improvements. These challenges include the involvement of different stakeholders with differing interests, complexities in the investigation process, interference from external forces, and the generation of conflicting reports and opinions. As a result of these difficulties, the investigation process has been slow.

The most suitable and effective approach toward improving aviation accident investigation is combining independent investigations with structured investigative frameworks. This combination improves the efficiency and effectiveness of the investigation process by eliminating complexities and reducing uncertainties. Through this approach, investigators can more reliably determine the root cause of an accident and develop suitable recommendations to prevent future reoccurrences under similar circumstances.

The aviation industry has experienced tremendous growth given the expansion of air traffic. According to Milosovski (2008), by the start of the 21st century, airlines across the globe operate over 22 million flights every year, transporting more than one billion passengers worldwide. This demonstrates the significant role air traffic plays in modern transportation. Air traffic has emerged as a prevalent means of transporting passengers and cargo over long distances, to the extent that it has surpassed road and marine traffic in many respects.

Even though air traffic has significantly increased in recent decades, safety concerns have grown as well, given that aircraft navigate complex terrain. Aircraft fly across oceans, vast ice wastelands, deserts, and remote desolate regions, all of which introduce adverse conditions. Additionally, there have been increased cases of human errors, unprecedented events, and equipment malfunctions. Aviation safety research consistently shows that human factors account for a significant percentage of aviation mishaps. Drury (2000) estimates that nearly 20% of aviation accidents are attributable to human factors, particularly in aircraft maintenance. Xavier (2005) argues that while aircraft maintenance programs have been established and improved over time, they remain characterized by inconsistencies that limit their effectiveness in preventing accidents. These factors imply that aviation accidents still occur despite the measures undertaken to enhance safety. Although aviation accidents are increasingly rare, they are usually devastating when they happen. Milosovski (2008) reports that more than 1,600 aviation accidents resulted in 64,000 deaths over the past five decades worldwide, illustrating that air traffic remains imperfect.

Since aviation accidents still occur, the field of aviation accident investigation has continued to develop. Investigations are carried out to determine the causes of accidents and to promote the establishment of suitable measures to prevent similar incidents under similar circumstances. However, aviation accident investigations have been characterized by numerous challenges that have compromised their ability to achieve their primary goal of preventing future reoccurrences. Therefore, aviation accident investigation ought to be improved by addressing these challenges in order to establish strategies and measures that prevent future accidents.

The purpose of this study is to explore the current challenges in aviation accident investigation and recommend strategies for improving the process. This exploration is conducted on the basis that aviation accident investigation requires improvement in order to enhance aviation safety. By identifying these challenges, more effective measures for preventing future reoccurrences can be established and aviation safety enhanced.

Aviation accident investigation has been characterized by numerous challenges that compromise its effectiveness in enhancing aviation safety. This research will help deepen understanding of the major challenges that characterize aviation accident investigation. Through improving understanding of these challenges, the study will also contribute to enhanced aviation safety. The study seeks to provide recommendations on measures that can be used by relevant aviation professionals to improve aviation safety outcomes.

The main goal of aviation accident investigation is to prevent accidents and incidents in the future without apportioning liability or blame (Balcerzak, 2017). Aviation accident investigation is usually a complex process since it is both an art and a science (Federal Aviation Administration, n.d.). Some of the scientific processes involved include laboratory testing of materials, sample evaluation, and failure mode analysis. Over the past few years, numerous measures and strategies have been established to enhance aviation safety and accident investigations, focusing on both the scientific aspects of accident investigation and human factors that cause these accidents or incidents.

However, aviation accident investigation is still characterized by numerous challenges that hinder its effectiveness in promoting aviation safety. McCain (1997) states that accident investigations and the implementation of successive safety recommendations in the aviation industry have been criticized for being bureaucratic and slow. Therefore, there is a need to address these challenges and improve the speed and quality of aviation accident investigation.

To achieve the purpose of the study, two research questions were identified to guide the research:

1. What is the state of the current measures and strategies employed in aviation accident investigation?

2. How can the current challenges and complexities in aviation accident investigation be improved?

Literature Review

The issue of aviation accident investigation has been the subject of numerous studies, particularly in aviation safety and aircraft maintenance. This chapter reviews existing studies on this issue, providing background information and identifying any gaps in the literature.

Boyd and Stolzer (2015) conducted a study examining the causes and trends in aviation accidents related to aircraft maintenance. These researchers examined aviation accident data published by the National Transportation Safety Board for accidents between 1989 and 2013. The study established that the accident rate for general aviation remains very high, attributable to a combination of pilot-focused errors (human factors) and aircraft maintenance errors. This study highlights the persistent role that human errors play in aviation accidents in the modern aviation industry.

In an earlier study, Shappell and Wiegmann (1997) established that human errors continue to be a major factor in a large number of aviation accidents, accounting for nearly 80% of accidents in civil and military aviation. As a result, most post-accident analysis in the aviation industry focuses on examining the causal role of human errors.

According to Singer (2002), the fatal accident rate in commercial aviation has remained relatively static since the 1980s. While this rate was initially considered insignificant, it has assumed greater importance because of the growth of air transportation in the 21st century. A flat fatal accident rate alongside rapidly growing air travel volume is now considered a major issue of concern. As a result, many organizations and stakeholders have undertaken various measures to help reduce accident rates. Some of these programs established by the Federal Aviation Administration and the National Transportation Safety Board include the Aviation Safety Action Partnership (ASAP) and the Flight Operations Quality Assurance Program (FOQA).

Oster Jr., Strong, and Zorn (2013) offer a more optimistic perspective, contending that scheduled passenger airline service has become safer given the reduction in the number of aviation accidents in recent years. For example, 2011 is regarded as the safest year in global aviation history, with only one passenger fatality per 7.1 million air travelers. The International Air Transport Association reported that there was only one accident per 1.6 million flights globally that year, representing a 42% safety improvement since 2000. This improvement is attributable to technological advancements, enhancements in flight data recorders, and improved cockpit voice recorders.

Fultz and Ashley (2016) contend that weather-related factors account for a significant portion of modern aviation accidents in the United States. Regardless of numerous technological developments, weather remains a major concern, contributing to a large number of general and private aviation accidents. Based on recent statistics, 35% of fatal general aviation accidents are caused by weather-related factors, and 60% of these accidents occur amid instrument meteorological conditions. The complex relationship between weather and aviation means that modern technological advancements remain inadequate to fully address weather-related accident causes.

While the rate of aviation accidents has significantly reduced in recent years, aviation accident investigation is still an evolving process. McCain (1997) contends that aviation accident investigations have been criticized for being slow and bureaucratic, partly because the implementation of safety recommendations has been increasingly sluggish. One recommended measure is improved collaboration between the FAA and NTSB, industry specialists, and private aviation organizations. There is also a need for better management of available resources to aid and enhance aviation accident investigations.

Stoop and Kahan (2005) contend that independent investigation of aviation accidents is a valuable tool for enhancing the effectiveness of the process and overall aviation safety. Independent investigation would help improve the process by identifying the sequence of events that offer a satisfactory explanation of the accident, the results of which are used to develop recommendations that help prevent future reoccurrences. Independent investigations are considered valuable because they are free from external interference that could compromise findings and recommendations. Stoop and Kahan (2005) suggest that current ineffectiveness in aviation accident investigation is attributable to a lack of independence and interference from external forces.

Coury et al. (2008) concur by arguing that major aviation investigations carried out by the NTSB tend to be characterized by uncertainties surrounding the cause of accidents, complexities in channels of inquiry, and the absence of a clear solution path. The involvement of multiple stakeholders contributes to numerous complexities, and these stakeholders sometimes interfere with the investigation process, making it difficult to generate appropriate findings and suitable recommendations. Therefore, Coury et al. (2008) argue that structured approaches to aviation accident investigation — with clear responsibilities and tasks defined for each stakeholder — should be designed and used to enhance the effectiveness of the process.

The case for independent investigations is also supported by Macrae and Vincent (2014), who examined how safety investigation in healthcare can be improved through lessons from industries like aviation. They argue that safety-critical industries like aviation stand to benefit from independent investigations, noting that aviation accident investigation can be improved by establishing independent, permanently staffed organizations mandated to investigate major failures and serious safety risks. The independence of such organizations is critical because any interference or compromise in the investigation process yields poor findings and inadequate recommendations.

Balcerzak (2017) offers a different perspective, arguing that aviation accident investigations are characterized by conflicts of interest, as numerous stakeholders with different interests sometimes compromise the process by interfering with crucial data or information. The study recommends that aviation accident investigation can be improved through proper and safe handling of related data, without victimization of those who provide it. Balcerzak (2017) also suggests that regulatory changes should be made to promote collaboration between the different stakeholders involved in the investigation process.

Results

Thematic analysis was utilized to examine data obtained from the research participants and relevant cases or documents. This chapter presents the results of the thematic analysis in relation to the research questions and purpose of the study.

The search conducted on electronic databases yielded limited literature on the issue of aviation accident investigation. Based on the inclusion criteria, the researcher identified ten relevant documents or studies on this issue. These were classified into two major categories: challenges in aviation accident investigation and improving aviation accident investigation, with five studies in each category.

For the interviews, five research participants were identified. Two worked in the National Transportation Safety Board, two worked in aircraft maintenance organizations, and one worked in the safety department of an airline.

One emerging theme from the dataset is that aviation accident investigation is characterized by interference from external forces, including relevant government authorities and agencies. Sixty percent of the reviewed documents indicated that interference from external forces is a major impediment to effective and timely aviation accident investigation. Many individuals and institutions are motivated to influence the investigation process and its outcomes, since aviation accident reports have significant impacts on individuals, manufacturers, airlines, maintenance organizations, air navigation service providers, and government institutions. Four of the five interviewed research participants stated that interference in the investigation process is a major stumbling block to generating credible accident reports and recommendations for preventing future reoccurrences.

The second emerging theme is that the aviation accident investigation process conducted by the National Transportation Safety Board is usually very slow and takes a relatively long time before the release of a final report. All five interviewed participants stated that the NTSB's investigation process is complex and tends to drag on for a long period. Additionally, these participants noted that the investigation process is not well understood by the public, making it difficult for external parties to interpret reports and recommendations. The complexities generate significant burdens on the various stakeholders involved as they collaborate with the NTSB. These participants also argued that the NTSB faces growing challenges because of rapid advancements in aviation accident investigation tools and techniques, making it increasingly difficult to generate recommendations within a short timeframe.

The third theme is that agencies involved in aviation accident investigations sometimes produce conflicting reports. All five research participants reported that while expert opinions are critical to understanding the cause of aviation accidents, they sometimes contradict each other. Seventy-five percent of the reviewed studies stated that variance in expert opinions is driven by differing witness accounts or oral testimonies, which complicate the investigative report and raise questions regarding the findings and recommendations.

Analysis of the dataset also shows that independent investigations free from external interference are the most suitable approach for improving aviation accident investigations. All five interviewed research participants contended that independent investigations would help address the current challenges facing the process. While the NTSB is an independent body mandated to investigate accidents, the process still involves other stakeholders who may interfere with it. Eighty percent of the reviewed literature supports independent aviation accident investigations and considers the NTSB a suitable model, although its reliance on a network of experts from other governmental agencies and the private sector can introduce additional complexities.

Finally, both the existing literature and the research participants propose the establishment of structured approaches to accident investigation to complement independent investigations. All five research participants argued that structured approaches would help eliminate the complexities and uncertainties that sometimes characterize the investigative process. For instance, structured approaches within the NTSB framework would help eliminate complexities emerging from the involvement of experts from other governmental bodies. Such approaches would establish procedures and rules of operation to guide the process, limit complexities and uncertainties, and generate credible investigative findings as well as recommendations for preventing future reoccurrences under the same circumstances.