Emphasising on Safety Recommendations.

//Emphasising on Safety Recommendations.

Emphasising on Safety Recommendations.

By | 2018-03-19T02:05:32+00:00 March 19th, 2018|Categories: |

Incidents and accidents happening in the aviation industry require investigations in order to find the root cause and, when necessary, issue safety recommendations as stated in International Civil Aviation Organisation (ICAO) Annex 13 [1]. There are accidents that make world headline news such as the Concorde crash in 2000 [2] or the uncontained engine failure happening on the Qantas A380 in 2010 [3] and others that the public does not ever hear about. An investigation must take place if an accident or incident results in death, serious injury, or indicates a defect in the aircraft.

Existing papers suggests that, compared to the efforts concentrated on root cause investigation, there is less emphasis on the creation, implementation and issuing of safety recommendations [4]. Research has found that recommendations may be at risk of causing unintended consequences [5] and are deemed to be only 70% effective by investigators themselves [6]. It is by issuing and accepting safety recommendation that the origins of incidents and accidents are addressed with the aim of preventing recurrence and developing the safety of the aviation industry. So how do investigators improve the likelihood of getting these recommendations accepted?

There is currently some guidance on what a safety recommendation should contain by ICAO in Annex 13 Chapter 6 [7] along with its Manual of Aircraft Accident and Incident Investigation [6, 8]. For member states of the European Aviation Safety Agency (EASA), 996/2010 Article 17 [9] also provides some guidance. The NSA (National Safety Agency), including the UK Air Accident Investigation Branch (AAIB), have their own manuals; however, these are not available to the general public.

Investigators aim to close safety recommendations, and the adequate, partially adequate, and not adequate grading is dictated by how well the response from the addressee aligns with the intent of the safety recommendation.

To assess if the content influenced whether the safety recommendations would be accepted, they are split into three categories

  • Regulation and legislation—covering the legal aspect.
  • Review in-service product— covering the technical aspect.
  • Notifications, training, policies, and procedures—covering the process aspect.

Common reasons given by the experts for not accepting a safety recommendation included badly formulated and poorly supported safety recommendations, different views between investigators and addressees, and results of a cost-benefit analysis. When an incident results in fatalities,
it is the latter of these that is affected most, unless the likelihood of the incident recurring is seen to be minimal. The results of analysing the recognition of AAIB safety recommendations and identifying key factors that contribute to a good safety recommendation could be used by NSAs to improve strategies, planning and processes for investigators.

It is a challenge indeed for investigators to write good-quality safety recommendations, and NSAs need to provide guidance as best they can. ICAO and agencies such as EASA and the FAA (Federal Aviation Administration) need to work together, in a fully co-ordinated way, to assist NSAs with this challenge and increase global harmonization. This is crucial to ensuring that the outcome of investigations are effective in improving the safety and reliability of this sector, therefore contributing to a worldwide safer aviation industry.



Based on the articled titled What Makes a Good Air Safety Recommendation?, published by Maria Gregson in the Journal of the International Society of Air Safety Investigators, December 2017.

  1. ICAO. (2010) Annex 13 to the Convention of International Civil Aviation, Aircraft Accident and In- cident Investigation, Tenth Edition, Chapter 1—De nitions.
  2. Bureau d’Enquêtes et d’Analyses. (2002) Accident to the Concorde registered F-BTSC operated by Air France occurrence on 07/25/00 at Gonesse. Available at: https://www. bea.aero/les-enquetes/les-even- ements-noti es/detail/event/ lors-du-decollage-de-la-piste-26- droite-de-laerodrome-de-paris- charles-de-gaulle-peu-avant-la- ro-1/ (accessed on Dec. 10, 2016).
  3. Australian Transport Safety Bureau. (2013) In- ight uncontained engine failure Airbus A380-842, VH-OQA, overhead Batam Island, Indonesia, 4 November 2010. Available at: https://www.atsb.gov.au/publica- tions/investigation_reports/2010/ aair/ao-2010-089/ (accessed on Dec. 10, 2016).
  4. Lundberg J, Rollenhagen C, Hollnagel E and Rankin A. (2012) Strategies for dealing with resistance to recommendations from accident investigations. Accident Analysis and Prevention, Vol 45, pg 455-467.
  5. Lefevre A. (2013) Are Safety Recom- mendations at Risk of Creating Un- intended Consequences? Cran eld University, MSc esis.
  6. ICAO. (2012) Manual of Aircraft Ac- cident and Incident Investigation— Part II Procedures and Checklists, First Edition, Doc 9756.
  7. ICAO. (2010) Annex 13 to the Convention of International Civil Aviation, Aircraft Accident and In- cident Investigation, Tenth Edition, Chapter 6—Final Report.
  8. ICAO. (2003) Manual of Aircraft Ac- cident and Incident Investigation— Part IV Reporting, First Edition, Doc 9756.
  9. EASA. (2010) Regulation (EU) No 996/2010 of e European Par- liament and of the Council of 20 October 2010 on the Investigation and Prevention of Accidents and Incidents in Civil Aviation and Repealing Directive 94/56/EC. Avail- able at: https://www.easa.europa. eu/document-library/regulations/ regulation-eu-no-9962010 (accessed on Dec. 3, 2016).