Session 1: Past, present, future
1. A global view – basic patterns, some developments and trends
After every major accident in human history, people have always asked the question: why? Both in earlies times and even today, some people answer the question with a religious interpretation: it is the will of God. Such accidents could be either natural catastrophes such as earthquakes, floods, hurricanes, wild fires, landslides, heat or cold waves, tsunamis, sand and dust storms or severe disasters damaging houses and even towns, shipwrecks, pest, hunger, pandemics etc. In order to influence the god(s) will and prevent disasters, many people turned to different kind of sacrifices, such as offerings, prayer or penances. Later, due to the technological development, new risks for other types of major accidents become more threatening, as accidents connected to aviation, rail and road, to nuclear power plants, to offshore installations, to industrial productions etc. Examples of new, emerging risks are climate change (global warming with droughts, storms, floods), biotechnology, nano- technology, artificial intelligence.
Gradually, a competing or parallel type of explanation developed, based on a secular and sometimes scientific attitude: accidents and incidents are mostly man-made, they can be investigated by systematic, rational methods, causes can be identified, and preventive measures be proposed.
In many sectors, investigation of accidents was for many decades done within the affected firm or institution or branch. Sometimes the company used an ad hoc-solution for each accident. Within a few sectors, typically the railways, the monopolistic situation included the responsibility to investigate all kind of accidents involving passenger transport on tracks. So, the international picture is rather complex and complicated.
In a historic perspective, the roots of modern accident investigations by a permanent, public commission can be traced to 1915, when a military aviation commission was established under “The Royal Flying Corps”, Accident Investigation Branch (AIB), in Great Britain, later (1922) expanded to include also civilian accidents. This invention was later followed by the establishment of similar commissions in other countries, first in the aviation sector, followed by the maritime and railway sectors, while the use of permanent commissions was not common in the road sector until recently.
It is obvious that an AIB cannot investigate all type of accidents and incidents. Several criteria may be used for deciding whether or not they should be used in a certain case. Common limitations are the nature of the event, e.g.:
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• The seriousness of the accident or incident (e.g. only accidents with more than x fatalities and/or which include economic losses of a certain magnitude are investigated etc.),
• The probability that such event(s) will recur, • The potential of the consequences of an event, • The learning potential of an investigation, • The societal interest or priority,
• The resources and competence of the actual AIB.
In addition, security events, clearly such as a criminal act and terrorism, and sometimes also natural disasters, will often be omitted. By tradition, some sectors in society are also omitted from AIB-investigations, usually the defence sector, working environment and the health sector. However, a few AIB include arenas as defence and health services, as the Dutch Safety Board (established 2005, when the board replaced the former Dutch Transport Safety Board). In fact, DSB has a very broad scope. Its mandate includes aviation, shipping, rail transport, road transport, pipelines, defence, industry and trade, crisis management and aid
provision, healthcare, and nature and environment.5 The Dutch Transport Safety Board has
been an international role model in promoting the need for independent accident investigation6.
In some sectors, international organisations have issued common procedures for investigations of accidents, such as:
– ICAO: Annex 13 (Aircraft Accident & Incident Investigation) to International Civil Aviation Convention
– IMO - International Maritime Organisation – has issued several resolutions to adopt code of international standards and recommended practices, guidelines to assist investigators and to harmonise reports.
EU has through the latest decades (since 1980) issued several regulations and directives to promote harmonised performances within the EU on a sectorial basis. Many commissions have been established, and the setup of European networks contribute to enhance safety.
ESReDA has also published (June 2009) a common, international guideline for safety
investigation of accidents.7 In addition, ESReDA has published a book “Shaping public safety
investigations of accidents in Europe”, which has a broad description and discussion of many aspects of the historical and the recent development of AIB, including a chapter about
challenges of investigation.8
5 https://en.wikipedia.org/wiki/Aviation_accidents_and_incidents
6 Van Vollenhoven, P. (2003) “Independent accident investigation: every citizen’s right, society’s duty”.
Elaborated Version of Third European Safety Transport Safety Lecture. European Transport Safety Council,
Brussels, 23 January 2001.
7 https://esreda.org/wp-content/uploads/2016/07/ESReDA_GLSIA_Final_June_2009_For_Download.pdf 8 Roed-Larsen, S., Stoop, J. and Funnemark, E. (2005) “Shaping public safety investigations of accidents in Europe”, ESReDA Safety Series, Oslo: DNV Publishers.
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In addition to the sector-based cooperation within established organisations (ICAO, IMO), a new kind of cooperation between independent commissions in the transportation sector were founded 25 years ago:
ITSA – International Transportation Safety Association - is an international network of
heads of independent safety investigation authorities (SIA). ITSA covers all modes of transportation, including aviation, marine, railways, road transport, pipelines and underground infrastructure.
In 1993, the independent safety investigation authorities (SIA) of 4 countries met and agreed to form the International Transportation Safety Association. ITSA was founded on the notion that independent non-judicial investigations of transportation accidents and serious incidents contribute significantly to the safety of the traveling public. Furthermore, that an international network, which brings together the safety investigation agencies from many nations, would be a mutually beneficial forum to share safety information.
Today, ITSA is composed of independent safety investigation authorities from 16 countries, including Finland, Norway and Sweden.
The mission of ITSA is to improve transport safety in each member country by learning from
the experiences of others.9