Cabin Safety Aspects in Accident Investigations: A Crucial Link

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Though Cabin safety aspects, including survival factors, should be addressed as part of the aircraft accident or incident investigation process, they are often overlooked. States and industry might be missing out on the possibility of further safety enhancements.

A review of ICAO accident data from 2009-2013, which included commercial scheduled air transport, indicated that the majority of accidents (87.7%) resulted in no fatalities. The fact that most occupants survive accidents can be linked to improvements made in occupant protection. These improvements resulted from survival factor investigations which address cabin safety aspects during accident investigations.

Findings and recommendations from past accident investigations have led to significant improvements in the fields of cabin safety and aircraft manufacturing over the past 30 years: 16G seats, lavatory smoke detectors and fire extinguishers, floor proximity, emergency escape path markings, new requirements for cabin and insulation materials, and inclusion of human performance training for cabin crew members. These improvements have increased the survivability of occupants involved in later accidents and helped reduce fatalities among passengers and crew.

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The goal of a cabin safety investigation is to analyze all aspects of an accident or incident, in relation to the actions of cabin crew members and passengers, as well as the cabin environment, and relevant systems and equipment on board, in order to identify safety deficiencies and lessons learned. The investigation may result in the development of recommendations related to operator procedures, fatigue (such as scheduling practices), training, safety and emergency equipment, aircraft systems, etc.

ICAO recently published the Manual on the Investigation of Cabin Safety Aspects in Accidents and Incidents (Doc 10062) to encourage the uniform application of the Standards and Recommended Practices (SARPs) contained in Annex 13 – Aircraft Accident and Incident Investigation, particularly in relation to survival aspects. It provides information and guidance to States on the procedures, practices and techniques that can be used when investigating cabin safety aspects of an occurrence. It is the first ICAO manual dedicated solely to cabin safety in investigations.

The new manual was developed with the involvement of the ICAO Cabin Safety Group (ICSG), an international, joint industry-regulatory group comprised of cabin safety experts from civil aviation authorities, airlines, aircraft manufacturers and international organizations. The International Society of Air Safety Investigators (ISASI) and the US National Transportation Safety Board (NTSB) were among the members who provided support, advice and input. The content of the manual is consistent with guidance materials contained in the Manual of Aircraft Accident and Incident Investigation (Doc 9756).

The new ICAO manual provides recommended qualifications and competencies for cabin investigators (CI), enabling appropriate personnel to carry out necessary functions during an investigation. ICAO defines a CI as the person responsible for examining and documenting the factors that affect the survival of occupants involved in accidents or incidents. In addition to survival factors, the CI is responsible for determining factors that affect the safety of flight and contribute to an occurrence and its outcomes. ICAO developed a competency framework which encompasses performance criteria, skills, and knowledge that should be demonstrated prior to the issuance of a CI qualification. Guidance includes the content of the CI training programme to assist States and industry implementing such training. The content can be adapted to any role such as a CI employed by an accident investigation authority or by an air operator.

cabin-safety-secondary-photoIn order to assist States and industry to investigate cabin safety aspects in occurrences, ICAO details guidance on the types of events which often include a cabin safety dimension and are classified as accidents in the new manual. This information includes: evacuation, ditching or inadvertent water contact, fire, smoke, fumes, turbulence, decompression, aircraft damage, and fatal or serious injuries (e.g. where aircraft may not be damaged).

For each of these types of occurrences, the manual contains templates to assist investigators in addressing all areas of the survival factors/cabin safety portion of an investigation. These templates explain what specific information to collect and document and why (the objective of the analysis). Information is presented under six main categories:

  1. General information that should be gathered on the occurrence;
  2. Documentation that needs to be reviewed from several sources (operator, State of the Operator, aerodrome, etc.);
  3. Aircraft and cabin-specific information regarding the examination and recording of relevant aircraft systems (such as emergency exits and evacuation slides), safety and emergency equipment specific to the type of occurrence, and conditions of the cabin;
  4. Human performance, including actions by cabin crew members and passengers;
  5. Additional information which should be examined, specific to the occurrence, such as emergency response or search and rescue;
  6. Guidelines for conducting cabin crew and passenger interviews.

In addition, the manual includes guidance for the investigation of incidents which do not meet the ICAO definition of an accident and do not require a formal investigation by the State of Occurrence.

It highlights that incidents can provide evidence of hazards or deficiencies within the aviation system and should not be overlooked. Guidance is aimed at
the State of the Operator as well as the individual air operators, who may wish to conduct voluntary internal investigations. Templates contain detailed guidance for three types of incidents deemed of common concern to air operators: inadvertent slide deployments, medical events on board, and occurrences involving unruly passengers.

Safety improvements over the past 30 years are a result of cabin investigations. As demonstrated in past accidents, the role of cabin crew members expands far beyond that of service on board. Their primary duty is safety and they play a vital role in accident prevention and survivability of occupants in occurrences, such as aircraft evacuations. Further enhancements can be made by focusing a part of an investigation on cabin safety, a crucial link in development and maintenance of a safe aviation system. The ICAO Manual on the Investigation of Cabin Safety Aspects in Accidents and Incidents (Doc 10062) was developed to provide in-depth guidance to all stakeholders when conducting investigations in order to promote the examination of cabin safety aspects and further enhance safety in the future.

About the Author

Martin Maurino is the Safety, Efficiency and Operations Officer at ICAO who heads the ICAO Cabin Safety Programme. Before joining ICAO, he held safety analysis and safety management roles at Transport Canada and the International Air Transport Association (IATA). Martin began his career in aviation as a cabin crew member at Air Canada.