CERES :: Browsing by Author "Braithwaite, Graham R."

Browsing by Author "Braithwaite, Graham R."

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Open Access
Air traffic control radiotelephony safety: Investigating the English second language users’ perspective
(Cranfield University, 2007-10) Mohd, Noorlinah G.; Braithwaite, Graham R.; Brooker, Peter
Radiotelephony between air traffic controllers and pilots utilises standard phraseology as the medium of communications. Standard phraseology employs specific structure, terminology and pronunciation to ensure effectiveness and accuracy. On occasions when standard phraseology is found insufficient, plain language is used to efficiently relay vital information. By default, English is the designated language of communication between controllers and pilots of international flights. Deviations from the usage of standard phraseology and lack of language proficiency had been identified as one of the causal factors in safety occurrences. Language deficiencies, specifically of the non-native speakers of the English language, had raised much concern but there is limited information in the area. This research attempted to fill a small segment of this knowledge gap. It was focussed on the usage of standard phraseology and English language in an air traffic control environment involving English Second Language users. Audio data was sourced from routine radiotelephony recordings of ‘live’ air traffic control facilities in Malaysia to capture realistic communications between controllers and pilots in the Terminal Approach Radar, Area Radar and Aerodrome Control environments. A detailed cross sectional investigation of the radiotelephony characteristics, deficiencies and errors of transmitted messages revealed the radiotelephony performances of controllers and pilots in the environments. The recurrence of deviations from standards and occurrence of errors implied the likelihood of such deficiencies taking place. Demographic groups’ descriptions complemented the radiotelephony analyses as background information on language related training. The results were comparative to other similar studies and offered new information on English Second Language speakers in the Air Traffic Control environment.
Open Access
The benefits of integrated eye tracking with airborne image recorders in the flight deck: a rejected landing case study
(Elsevier, 2020-06-10) Li, Wen-Chin; Braithwaite, Graham R.; Wang, Thomas; Yung, Morris; Kearney, Peter
Aircraft accident investigation has played a pivotal role in improving the safety of aviation. Advances in recorder technology, specifically Cockpit Voice Recorders (CVRs) and Flight Data Recorders (FDR) have made a huge contribution to the understanding of occurrences for accident investigators. However, even these recorders have limitations such as the evidence they provide about pilots' situation awareness or behaviours. Supplementing audio and data recordings with video has been discussed for many years and whilst there continues to be debate among regulators, operators, manufacturers and pilot unions, the International Civil Aviation Organization (ICAO) has mandated Airborne Image Recorders (AIR) from 2023. The purpose of installing such systems is to provide evidence of crew operational behaviours in terms of both human-human and human-computer interactions (HCI) on the flight deck. Video alone is unlikely to provide sufficient evidence for investigators. This study examines the additional value that eye-tracking technology may provide through the case study of an accident involving an Airbus A330-300 aircraft which experienced a rejected landing. Currently, the investigation of such events, where crew interaction with automation is critical to their situation awareness, relies heavily on interview data. Such data may be unavailable (in the case of serious injury) or unreliable (based on hindsight bias). By integrating eye tracking technology into an AIR, accident investigators will potentially gain a better understanding of pilots’ visual scan patterns across flight deck instrumentation. This has implications for flight deck and procedural design as well as training and simulation.
Open Access
Developing capability for air accident investigation
(Cranfield University, 2019) Abushalla, Abdulwahd Mohamed; Braithwaite, Graham R.
The Member States of the International Civil Aviation Organisation (ICAO) are facing an increased challenge to improve their aircraft accident investigation capability. This area is the least compliant, according to the ICAO Universal Safety Oversight Audit Programme (USOAP). While existing literature covers many topics of relevance to transport accident investigation, there is a paucity of research that tackles the challenge of how to improve capability in States that have limited resources or absence of a functional Accident Investigation Authority (AIA). Understanding the many aspects of what may be described as ‘capability’ represents an important step towards identifying a roadmap for the lessdeveloped States. This study explores the concept of capability in the context of a ‘not-for-blame’ State-level aircraft accident investigation function. It achieves this through a systematic literature review, followed by interviews and a survey with experienced investigators. The output is a proposed eight-dimension framework to guide lessdeveloped States to establish their AIA and develop its capability. The results of the study demonstrate that investigation is a cooperative activity depending on multi-scale collaboration by all involved States. In turn, this requires international assistance to obtain appropriate expertise and achieve the required level of quality. Emphasising the independence of the AIA in local legislation and regulations and ensuring effective separation of the investigation process from any administration and/or judicial proceedings were the most notable factors apart from the organisation model. The study provides insights by generating guidance to develop the capability of the AIA. The achievement includes a maturity model to show the evolution of the AIA over three different stages, defined as initial, established and optimised, to help prioritise actions.
Open Access
The economics of safety: A case study of the UK offshore helicopter industry
(Cranfield University, 2006-11) Mitchell, S.; Braithwaite, Graham R.
The International Civil Aviation Organisation maintains that future viability of air transportation may well be predicated on perception of safety rather than any more tangible measures. In order to keep safety risks at an acceptable level it advocates a change of fundamental approach to the system of safety management, one that is more proactive. This study examines the causes of such a requirement for change, and the scope for improving the efficiency of what Calabresi refers to as the second principal goal of accident law, namely accident cost reduction. First, testing the validity of the traditional approach to safety analysis and management, as stated in regulatory guidelines. Secondly, examining the possibility that the efficiency of safety cost-benefit analysis can be practicably improved. A subsequent aim is to find an empirically based proxy measure for the acceptability of risk by examining the outcomes to potential safety related risk scenarios. Such a measure, if validated, may convert many existing intangible assessments concerning safety management into more transparent and reliable judgements. The offshore helicopter industry has many unique characteristics, some of which derive from the fact that the customers, the oil & gas companies, are more powerful than the operators. Others relate to the absence of any intermodal competition, and passengers who are specially trained to be properly aware of their safety. As choice is severely limited, this population is also likely to reflect a much broader range of risk preference. A carefully structured questionnaire was presented to a sample of these passengers, and the responses analysed in depth. The conclusions of this study are that choice is driven by the perceptions of safety, and that market stability is only maintained with the pre-condition that safety is deemed acceptable. Further, the failure of this pre-condition will follow a predictable pattern, based on a normal distribution for the population. The recommendation of this study is that such reactions to perceptions of safety risk are given due consideration alongside traditional costbenefit analysis, and in so doing it is likely that more secondary and tertiary accident cost factors will be more fully addressed. This will improve the overall efficiency of accident costs reduction, and make a significant contribution to the aim of proactive safety management.
Open Access
Evaluation of the concept of criminalisation of human error in aviation in the Middle East.
(Cranfield University, 2020-10) Bazaid, Ahmed Saleh M.; Braithwaite, Graham R.; Nixon, Jim
Aviation is one of the safest modes of transportation, due to the high standards and regulations that govern this industry. One of the methods that enhance aviation safety is accident and incident investigation, where root causes and contributing factors are analysed to generate safety recommendations that assist in the prevention of future, similar accidents. However, there has been an increasing trend of criminalising aviation professionals in the wake of aviation accidents where aviation accident investigators were also invited to testify as experts to help judges deliver justice for affected parties. The research was conducted over 9 phases starting with a literature review, exploring the issues surrounding the concept of the criminalisation of pilot error in the aviation industry. From there knowledge gaps were identified and research questions generated from them. To fill these gaps a questionnaire was developed and field studies and online surveys were conducted to gather data, which was used to generate an initial framework which was subsequently evaluated using subject matter experts (SMEs) and hypothetical case studies to validate them. The results of the evaluation and validation were then used to generate the final Criminalisation of Pilot Error (CoPE) framework for use in the aviation industry that helps to guide independent safety investigators to address and prevent the escalation of pilot error cases from reaching the court. The research also created well-defined elements that cover all aspects of the criminalisation of pilot error, as well as, a detailed study addressing cultural aspects in different parts of the world, with a focus on the Middle East, and how these affect the concept of the criminalisation of pilot error.
Open Access
Family support plan for Middle Eastern countries following aircraft accidents
(Cranfield University, 2010-08) Alahdal, Alhosain Abdullah; Braithwaite, Graham R.
Recent years have seen increasing acknowledgment that aircraft accidents affect not only those who are killed or injured, but also the families and friends of victims. Survivors, victims and their families require sensitive treatment in order to help them cope with what has occurred. Following high profile accidents including USAir 427 and TWA 800, the United State of America started a new program which they call it Family Assistance after Air Disaster. After that a several documents providing guidance for dealing with victims and their families were published in Australia, the UK and the EU. However, in the Middle East, there is no region-specific family assistance guidance for dealing with aircraft accidents. As such, operators tend to use plans which have been designed from a western perspective. This means that the impact of culture, ethical sensitivities and religion have not been addressed fully. This thesis explores the differences in dealing with the families of victims after an accident in the Middle East focusing on the Muslim population. Interviews were conducted with experts from airlines, family assistance providers, religious leaders and victim support groups. These were supplemented by a survey of passengers and family members in USA, Malaysia and Saudi Arabia to compare and contrast the expectations and needs of those who may be affected by an aircraft accident. Over 300 responses were received and the data were validated through further expert interviews. The results supported the findings of the literature review and matched with the bad experiences documented within case study accidents such as the mid-air collision involving Saudi Arabian Airlines flight 763. The study found that the three factors are inextricably linked, with religion being a strong factor in determining individual’s response to their loss; how they relate to others and the type of support they should be given. Suggestions are made regarding the design of a Family Assistance Centre, staff training, words that should / should not be used; and to explain how people may react.
Open Access
Flight deck engineering: impact of flight deck crew alerting and information systems on English as a second language flight crewmembers performance in airline flight operations
(Cranfield University, 2017-01) Sevillian, Dujuan Brandez; Jarvis, Steve; Braithwaite, Graham R.; Chen Li, Wen
There are many pieces of flight deck research on general use of written English language technical information and problem solving using technical documentation. Contributory causes of aircraft accidents have been due to misunderstandings of crew alerts and procedural divergence by English as-a-second language flight crewmembers (ESL). Research was conducted to understand impact of written English language technical information on ESL flight crewmembers’ performance. Two types of systems were evaluated, technical documentation and crew alerting systems that contain technical information, with respect to their impact on ESL flight crewmember performance. Preliminary analysis results indicated written English language technical information can be confusing, difficult to read and interpret, and leads to misunderstandings by ESL flight crewmembers during aircraft nonnormal conditions. English as-a-second language flight crewmembers indicated they often experience problems executing written English language technical procedures after outset of crew alerts. Conversely, experimental trials revealed ESL flight crewmembers did not experience many cognitive performance issues with use of crew alerting systems and technical information designed with an English language emphasis. English as-a second language flight crewmembers’ English language proficiency, background knowledge, and use of use of metacognitive strategies to read and comprehend written English language on crew alerting and information systems, indicated they utilized written English technical information with ease. Particularly, ESL flight crewmembers’ workload was low, they had fast response times to system faults, and they experienced minimal procedural deviations. On the contrary, when ESL flight crewmembers utilized written English language technical procedures translated into their native language during non-normal conditions, they experienced several cognitive performance challenges. English as-a second language flight crewmembers’ background knowledge of written English language technical information translated into their native language, use of metacognitive strategies to read and comprehend written English language translated into their native language, indicated they experienced difficulties with reading and comprehending translated technical information on information systems. Particularly, ESL flight crewmembers were challenged cognitively when they responded to crew alerts through execution of decision-making processes. They indicated translation of written English language technical information into their native language was a pre-cursor to procedural deviation, long response times to system issues, as well as high workload during experimental trials. It is recommended that further research focus on design and use of written English language technical documentation by ESL flight crewmembers during non-normal conditions. It is also recommended that if deemed practical by the aviation industry, further research should focus on design, integration, and utilization of technical documentation in a language(s) other than English, and measurement of ESL flight crewmembers performance on the flight deck.
Open Access
Hazards awareness for aircraft accident investigators
(Cranfield University, 2010) Boston, Nathalie; Braithwaite, Graham R.
Hazards on accident sites are such that investigators must balance personal safety against the risks involved in collecting evidence intended to prevent future loss of life. Better knowledge of hazards and their mitigation could reconcile these conflicting objectives to a point at which risk might be no greater than in other workplaces. Nevertheless, the magnitude and nature of the hazards at any accident site cannot be determined in advance. The perceptions of novice accident investigators of potential hazards are not greatly different from the realities encountered by experienced investigators, although the former tend to focus on general health and safety issues, while experienced investigators are more aware of hazards arising from aircraft systems and materials. Experienced investigators reported most of the hazards they encountered over six years as arising within a narrow range of hazard categories - yet they must be prepared to carry out thorough investigations while protecting themselves against all hazards, including those encountered very infrequently. Both generic and dynamic risk assessments are important in protecting investigators and the integrity of evidence. The ongoing management of an investigation in the field involves a continuous and iterative cycle: identification of hazards, determination of exposure, assessment of risk, introduction of controls, review and assessment of remaining risk, and identification and management of residual hazard. Lives and evidence depend upon the quality of this process. At present, great reliance is placed on personal protection equipment as a control on hazards. Observation of participants in training programmes has identified instances of poor selection and ineffective use of such equipment to the extent that it has provided no protection. The thesis points to required further directions in the training of investigators - an investment which will yield its dividend in the prevention of future accidents and loss of life.
Open Access
Human Factors Effects in Helicopter Maintenance: Proactive Monitoring and Controlling Techniques
(Cranfield University, 2010) Rashid, Hamadalneel Suliman Jumaa; Braithwaite, Graham R.; Place, Simon
Aviation maintenance errors account for between 13% and 23% of the global aviation incidents and accidents initiators, which require a wider global use of aviation maintenance safety improvement activities. The current research applies the Human Error Risk Management in Engineering Systems (HERMES) methodology that conceptualizes two main streams of study. These are the retrospective investigation of human errors within aviation maintenance contexts, and a prospective innovation of new tools that work to prevent errors occurring. In this research the impact of human reliability on aviation maintenance safety is investigated. Rotorcraft is taken as a focal case study. A new model to represent the accumulation of crucial maintenance human errors causal factors, within aviation maintenance companies, is introduced. A total of 804 recent maintenance-induced helicopter accidents were reviewed, from which 58 fatal accidents and serious incidents were thoroughly analysed using Human Factors Accident Classification System - Maintenance Extension (HFACS-ME). A 4th order of analysis is newly introduced into the HFACS-ME taxonomy under the notion of ‘Specific Failures’ for better analysis resolution and comprehensiveness. Hypothesizing that human factors errors within aviation maintenance industry can be more effectively managed by applying proactive monitoring and early error detecting techniques - at both organizational and individual levels, a proactive Aviation Maintenance Monitoring Process (AMMP) is formulated. AMMP is a holistic hybrid retrospective / prospective integrated process that is to be simultaneously and collectively implemented by main industry stake-holders - regulators, manufacturers and maintenance organisations. The aim is to proactively monitor the existence of human error causal factors that are initiated during design practices, manufacturing processes, or at later stages due to workplace conditions. As a result, such causal factors can be gradually eliminated to reduce the overall risk of maintenance errors. This generic AMMP model is based on a Root Cause Existence Scale (RCES) and a comprehensive sociotechnical user program, coded as ‘ErroDetect’, built applying the fuzzy Analytic Network Process (fuzzy ANP) theory. A total of 870 different assessment criteria were designed and then in-built within the software thus mapping the outcomes of the retrospective error causal factors investigative studies. Full simulation of the process is conducted, and then it was further validated practically in real world within industry for both design for maintainability within major rotorcraft manufacturer facilities, and for MRO’s performance safety enhancement. Validation results were thoroughly discussed. The AMMP is found to have significantly enhanced aircraft maintenance proactive safety for both designers and maintainers. The tool can also be adopted for regulation purposes.
Open Access
Human factors in air accident investigation: a training needs analysis
(Cranfield University, 2016-07) Burban, Camille; Braithwaite, Graham R.
Human Factors (HF) has long been identified as one of the main causes of incidents and accidents in the transportation industry, and more recently has become increasingly important in air accident investigation and safety improvement. As a result, many National Investigation Agencies (NIAs) are now explicitly acknowledging HF in their final investigation reports. Whereas engineering-and operations-led investigation can highlight what happened and how it occurred, it is increasingly recognised that the integration of HF into an investigation can help understand why a sequence of events led to an incident or accident. However, there are considerable challenges to more thorough integration of HF into air accident investigations. Most notably, there remains a reluctance amongst some NIAs to fully embrace HF and address potentially important HF issues in detail in their investigations. Consequently, there is a risk that some investigations are consistently overlooking potentially critical HF issues, and as a result fail to fully address why an incident or accident occurred. There is a need for research that examines these challenges, including the possible gap that exists between research and industry regarding the development and applicability of accident analysis tools, and that provides practical solutions to enable a better integration of HF in air accident investigations ... [cont.].
Open Access
Identifying resilience principles in the UK air transportation industry and developing an integrated conceptual resilience framework.
(Cranfield University, 2022-08) Steinmann, Fabian; Braithwaite, Graham R.; Pilbeam, Colin
Organisations across the aviation sector strive to become more resilient, and there is a great desire to integrate resilience into the operation. However, there is no clear definition of resilience, and people in academia and industry have interpreted the concept differently. The research aims to integrate different conceptualisations of resilience and develop a framework that holistically explains how resilience can be developed in the UK air transportation industry context. The development of the framework is achieved through an integration of the literature and empirical refinement of the subsequent preliminary framework. A systematic, multi-sector and cross-disciplinary literature review was conducted to determine four main themes of resilience: System Design, System Preparedness, System Response, and System Changes. A total of 26 high-level resilience principles were identified in the literature and grouped into different (sub-)themes, building the foundation for a Preliminary Resilience Framework (PRF). The empirical work of the thesis investigated five cases in the UK air transportation system. The qualitative research aimed to identify empirical evidence through thematic analysis of how the UK air transportation industry operationalised the identified high-level principles. The analysis of the cases found evidence for 19 of the 26 principles. Furthermore, the case study findings determined ten new connections between the various identified (sub-)themes and refined the PRF. The five case study findings were synthesised to develop an Integrated Conceptual Resilience Framework (ICRF). The ICRF combines findings from all five case studies and provides a holistic resilience framework, outlining the principles and features of a resilient UK air transportation system.
Open Access
Investigating accidents involving aircraft manufactured from polymer composite materials
(Cranfield University, 2013-03) Dunn, Leigh; Braithwaite, Graham R.; Greaves, Matthew
This thesis looks into the examination of polymer composite wreckage from the perspective of the aircraft accident investigator. It develops an understanding of the process of wreckage examination as well as identifying the potential for visual and macroscopic interpretation of polymer composite aircraft wreckage. The in-field examination of aircraft wreckage, and subsequent interpretations of material failures, can be a significant part of an aircraft accident investigation. As the use of composite materials in aircraft construction increases, the understanding of how macroscopic failure characteristics of composite materials may aid the field investigator is becoming of increasing importance. The first phase of this research project was to explore how investigation practitioners conduct wreckage examinations. Four accident investigation case studies were examined. The analysis of the case studies provided a framework of the wreckage examination process. Subsequently, a literature survey was conducted to establish the current level of knowledge on the visual and macroscopic interpretation of polymer composite failures. Relevant literature was identified and a compendium of visual and macroscopic characteristics was created. Two full-scale polymer composite wing structures were loaded statically, in an upward bending direction, until each wing structure fractured and separated. The wing structures were subsequently examined for the existence of failure characteristics. The examination revealed that whilst characteristics were present, the fragmentation of the structure destroyed valuable evidence. A hypothetical accident scenario utilising the fractured wing structures was developed, which UK government accident investigators subsequently investigated. This provided refinement to the investigative framework and suggested further guidance on the interpretation of polymer composite failures by accident investigators.
Open Access
Measuring the independence of aircraft accident investigation authorities in ICAO Member States
(Cranfield University, 2013-08) Alsrisari, Sami Mohammed; Braithwaite, Graham R.
This project examines the safety management of civil aircraft accident investigation authorities in International Civil Aviation Organization (ICAO) Member States, with particular emphasis on the independence of the investigations. The research aims to establish the current level of resources and methodology adopted by Member States’ accident investigation authorities. The output of this work not only identifies the current situation but informs initiatives for some of the States in the process of establishing their investigation capability. ICAO Annex 13 was analysed and found to be based on the principle of independent accident investigations. Also, a four dimensional measuring index (4DMI) has been developed to measure the independence of accident investigations in ICAO Member States. Data were collected from 45 States and are presented in the thesis. As a result of applying the 4DMI to the collected data, the States were ranked according to their scores, and divided into four categories of independence. Analysis of the four categories and the scores from the four dimensions revealed that States approach the concept of investigation independence in different ways; however, there are several practices that are common within the highest independence category and several other practices that are common within the lowest independence category. The research recommends that States should work towards improving their overall investigation independence by implementing the seven identified practices in the High-Independence category and distance themselves from the five practices identified as common in the Low-Independence category.
Open Access
Modelling of wreckage trajectories following in-flight breakup
(Cranfield University, 2013-04) Greaves, Matthew J.; Braithwaite, Graham R.
The study of ballistic trajectories is well-established, with work dating back to the 1940s. More recently, ballistic trajectory analysis has been used by air accident investigators in an attempt to understand events leading up to an accident, with notable examples including the investigation into the Lockerbie bombing. Building on the history of a previous model, this thesis offers an enhanced model for the calculation of ballistic trajectories incorporating altitude dependence for wind, density and gravity. Attempts to solve the model analytically were unsuccessful, and therefore, the model was solved numerically using an implicit scheme, to deal with the inherent stiffness of the equations, and an extrapolation technique. Cubic splines were used to accurately represent the wind proUile in an analytical way. The numerical solution was veriUied against a simpliUied analytical case and results are presented for two simulated breakup cases. Four key parameters were then varied to provide information about the sensitivity of Uinal wreckage location to variation in system parameters. The results indicate that for simulated large aircraft breakups, low ballistic coefUicient items are most heavily affected by breakup altitude, wind magnitude and wind angle whereas large ballistic coefUicient items are most heavily affected by breakup velocity, although to a much lesser extent (around 15% of the distance of low ballistic coefUicient). For small aircraft breakups, wind angle and breakup altitude have the largest effect on low ballistic coefUicient items, with velocity and altitude affecting high ballistic coefUicient items to a larger extent (around 50% of low ballistic coefUicient items). The results will allow investigators to understand better the factors which affect items of differing ballistic coefUicient in different situations. The project as a whole provides a new solution engine for the trajectory problem which can form the basis of a new software package for investigators.
Open Access
Regulation or criminalisation: What determines legal standards of safety culture in commercial aviation
(Elsevier, 2017-11-06) Lawrenson, Anthony J.; Braithwaite, Graham R.
This paper highlights that further development of safety culture as a quantifiable standard presents a considerable dilemma to policy makers. The imposition of legal standards in any area of human endeavour is generally predicated on the assumption that the affected parties are aware of their causal role and therefore legal responsibilities. An intuitive response to this expectation would be to provide a well-defined, measurable and manageable structure of safety culture. However, we will consider whether that by presenting an effective safety culture as an achievable final goal, safety performance could be compromised in the long-term. Identified in numerous case studies (presented in two tables), the contrary approach of leaving safety culture as a loosely defined and adaptable concept, allows the criminal justice systems the opportunity to criminalise those safety cultures perceived as being inadequate, in the aftermath of a fatal accident. This approach encourages hindsight bias and potentially inhibits the development of reporting cultures within organisations. Should fear of exposure to retrospective analysis by the criminal justice system inhibit the free flow of information, organisational learning would be inhibited. Restrictions to the rate and quality of safety reporting remains one of the greatest challenges to the effectiveness of SMS across commercial aviation at operator, national and international level.
Open Access
Safety culture: a legal standard for commercial aviation.
(2017-10) Lawrenson, Anthony James; Braithwaite, Graham R.
Although a link between organisational safety culture and human behaviour is well established within academic literature, ambiguity about the actual nature of the causal relationship has inhibited its practical application. This thesis aims to establish a legal standard of safety culture by producing a model which describes the relationship between organisational safety culture and potential corporate liability. The model, called d3SC, attempts to promote a defence of due diligence to potential prosecution by improving an organisation’s safety culture. The thesis consists of three sequential studies. The first study comprises of twenty-six accident case studies from which data is developed into a prototype model through a process of grounded theory. The subsequent studies then take the emergent model from a construct to a risk management tool that was applied and tested against a real-world data from commercial aviation and law. In attempting to develop a model, d3SC, the thesis has adopted a predominantly functionalist approach. However, it is recognised that the complexities of culture and causation are not sufficiently represented without adopting some methods of real world analysis. This recognition of the need to dig deeper into organisational dynamics is manifest in the use of qualitative methods in the thesis to triangulate the output of the d3SC process. It is also represented in the units of measurement or case studies from which safety culture is frequently described. The quality of safety culture is often described in terms of organisational performance yet a consistent theme in both the literature and the data collated in these studies, shows that aggregating organisational safety culture as a singular measurement can be misleading. Contrasting the data from different departments and hierarchical levels within an organisation gives a much deeper and contextual understanding of internal dynamics and influences. This is of particular relevance to corporate liability in the aftermath of an accident. Prosecuting agencies will not focus their investigation on the adequacy of overall metrics of organisational assessments, but on the perceived causal links between an accident and the weaker areas of organisational safety culture. By improving the visibility and understanding of the causal links between corporate liability and corporate culture it is hoped that this research can contribute to enhancing safety standards in commercial aviation.
Open Access
Safety Management Systems (SMS) for aircraft manufacturers and maintainers?
(Cranfield University, 2014) Gibbons, Blake; Braithwaite, Graham R.
There is much dialogue in the global aviation industry about Safety Management Systems (SMS) and how it should be integrated across all domains of the industry including aircraft design, production, flight operations, overhaul and maintenance, suppliers, service providers, airports, and so forth (Johnson, 2012). Regulators have made significant progress in recent years to implement ICAO’s SMS into airlines, albeit as a required or recommended practice. More recently the regulators are seeking to implement SMS into the aircraft manufacturing and aircraft maintenance domains. This research reviewed regulatory publications from multiple countries to assess the technical makeup of SMS, and understand what regulators are requiring, or recommending, and when. It was found that global regulators accept the ICAO published definition of SMS, but different regulators have varying approaches regarding implementation. However, they are consistent in initially targeting airlines for SMS implementation. SMS comments range from “The best thing since sliced bread” to “Worst thing since the creation of the FAA; I don’t need anyone telling me what’s safe when I already know it; waste of time and money”. This investigation experimented with field tests to connect the engineering, production and airline domains into one ICAO SMS model. Results indicate that because the different domains are risk-specific, the application of one safety risk management model to all domains is not viable. The SMS model applies to airlines because airlines’ primary risk is about operational safety. Aircraft production and maintenance is about production risk – therefore the risk model must be centric to process risk. Field test 3 tailored the ICAO SMS risk architecture to assess and mitigate process risk as applicable to the aircraft manufacturing and maintenance. Although the SMS architecture was usable, the content and focus was significantly adjusted to be production process-risk centric, to the point where the term “SMS’ was deemed out of place. The resulting model was therefore named Production Risk Management System (PRMS). Following the emergence of PRMS from field tests, this investigation reviewed industry, research and regulatory arguments for and against SMS in the airline industry, and correlated those arguments with the benefits and non-benefits of PRMS for the manufacturing and aircraft maintenance domains. The researcher advocates PRMS as a viable model that meets ICAO SMS-like architecture for aircraft production and maintenance. Methods were identified for developing and implementing PRMS, and for evaluating its ROI. If and when “SMS” is truly mandated in these domains, the researcher proposes PRMS as a viable model that should be considered. Furthermore, the researcher proposes that PRMS can be an effective production risk management system that can enhance the organization’s existing QMS, regardless of “SMS” regulations.
Open Access
The technology-culture interface and its impact on aviation safety: a North African perspective.
(2018-03) Belaid, Zakria Abdulhamid Gamudi; Braithwaite, Graham R.; Rashid, Hamad
The aviation industry in the North Africa Region (NAR) is still suffering from a high rate of fatal accidents in comparison to other regions. In 2016, about 128 passengers were killed in the Middle East and NAR, whereas in Europe just two passengers killed despite both regions using a similar aircrafts. Aviation companies within the NAR thus require safety performance improvement. The current research indicates that pilot decision-making performance in the cockpit is responsible for about 60% of aviation fatal accident in the global aviation industry. In addition, the current literature shows that pilots’ risk perception is directly influenced by the culture interface, which plays crucial role in shaping their decision-making performance. Accordingly, this study investigated the national culture impact on pilot decision-making performance in the cockpit within the NAR. A number of professional pilots from the NAR were surveyed and interviewed to explore this phenomenon. A mixed method research approach was implemented in this study, where 143 professional pilots from different levels were surveyed and 12 semi-structured interviews were conducted, to discover the extent to which these pilots are effect by the technology–culture interface within the NAR. The research investigated this phenomenon mainly based on four themes: cultural attributes, attitude to human and organisational factors, automation and risk perception; these are shown by the literature to be the most significant factors affecting the pilot risk perception in the cockpit. Ten factors were investigated, in addition to assessing the collective pilot’s risk perception within the NAR. The result indicated that NAR pilots are negatively affected by power distance, teamwork and automation as direct implications of the technology–culture interface. In addition, these pilots are suffering from high tolerance and acceptance of risk as an indirect impact of the regional national culture. Therefore, as the aim of this research is to enhance the pilot’s decision-making performance in the cockpit, a guideline for cultural calibration of the Crew Resource Management (CRM) training programme was proposed. This cultural calibration relies on development of the CRM curriculum by enhancing the pilot non-technical skills to overcome the effects of the technology–culture interface in the region. It also aims to improve their risk perception through introducing training in domain-specific risky events in the cockpit, which should enhance their ability to identify the cues that exist in risky situations. Furthermore, the limited research of aviation authorities and aviation safety departments’ roles regarding monitoring and enforcing the safety regulations and implementing proactive safety programmes in the aviation companies within the NAR negatively affect the progress of improving the safety performance.
Open Access
Understanding accident investigators : a study of the required skills and behaviours for effective UK inspectors of accidents
(Cranfield University, 2008) Flaherty, Sarah; Braithwaite, Graham R.
In the UK, accidents associated with maritime, aviation and rail transport are conducted by the Inspectors of Accidents at the Marine, Air and Rail Accident Investigation Branches. A review of current academic literature provides little insight into the qualities and attributes essential for the role of accident investigator. A wealth of material exists about accidents themselves but as yet, a study into the profile of the accident investigator has not been conducted. This research sought to determine the requisite skills and behaviours of an effective accident investigator based upon a three-phased, primarily qualitative, methodology. Content analysis was used to determine task and non-task specific themes from semistructured interviews conducted with accident investigators from the UK and the US, the findings of which are characterized by individualism and variability: the former having implications for effective teamwork and the latter indicating the paucity of structured analysis processes in use, which would lead to reproducible and transparent results. Repertory Grid interviews elicited five competency themes and one hundred attendant behavioural indicators which were employed during the final phase of the research to determine their relative importance in terms of recruitment, training and the superior investigator. The findings showed that it was believed essential to consider interpersonal and communication skills, cognitive abilities and personal attributes during recruitment and that technical skills were deemed to be most amenable to change through training interventions with personal abilities least likely. Further thematic analysis of highly rated behavioural indicators showed an emphasis on report writing and dealing with people. These findings have implications for recruitment with a need for non-technical competencies such as report writing and the ability to deal with people to be more prevalent in selection testing and decision-making. No specific skills or behaviours were found to distinguish superior performance in investigation, instead requiring a balance of competencies. With no defining threshold, the researcher proposed that superior performance should be measured "relative to mission" and is more usefully thought of an added value continuum rather than a set of discrete skills and behaviours. Evidence was provided to demonstrate how the organizational structure and philosophy influenced the working styles of the Inspectorate and therefore the expected skills and behaviours. The researcher advocates the combination of the competency framework and behavioural indicators derived with an extant Branch competence measure to strengthen the tools whilst responding to a call in the literature for a more blended approach to determining competences and competencies.
Open Access
What do aircraft accident investigators do and what makes them good at it? Developing a competency framework for investigators using grounded theory
(Elsevier, 2017-11-29) Nixon, Jim; Braithwaite, Graham R.
We present a new analysis of the tasks carried out by air accident investigators and propose a new competency framework which captures the competencies demanded of an effective investigator. Using a subject-matter expert panel, a hierarchical task analysis (HTA) was developed to frame and organise the diverse activities that are required of the air accident investigator. Supported by the HTA, a competency framework was developed using structured interviews based on repertory-grid interview technique. Grounded theory was used to abstract competencies derived from the interviews. The resultant competency framework could be applied to selection and training future investigators in other safety critical domains. More immediately, the framework can deliver insight into what differentiates the good investigator from the excellent investigator.