Aviation safety investigations, from mandate to approved report
In 50 words
A safety investigation establishes what happened, why it happened, and what must change so it does not happen again. In eAviora an investigation moves from its mandate through fact finding, analysis, findings and reporting, its recommendations become tracked actions, and its report is approved by someone other than the lead investigator.
At a glance
The module, on one sheet
- Suite
- Safety Management · Safety Operations
- ICAO Annex 19
- Component 2, safety risk management. FAA Part 5 uses the same component.
- Records
- INV investigations, linked to the occurrence they examine
- Stages
- Initiated, Fact finding, Analysis, Findings, Reporting, Review and approval, Closure
- Methods
- 5-Why, bow-tie, fishbone, HFACS, SHELL, MEDA, REDA, PEAR and the Dirty Dozen
- Works with
- Occurrences, Hazards, Action Plans, Governance
What it does
Four things, done on the record
A mandate first
The scope, what the investigation does not cover and its independence are set before fact finding.
Depth that fits the event
Light, standard or deep: the depth sets which checks apply, and a deep review rates every barrier.
Findings with their evidence
Factual and safety findings each cite the evidence that supports them.
Recommendations become actions
Each recommendation names the department it is addressed to, and raises an action or links one that exists.
In the product
An investigation, in analysis
- The root cause, the contributing factors and the just culture outcome.
- The barriers the event challenged, and the ones that failed.
- The occurrence it examines, and the actions its recommendations raised.
The rule it holds
The lead investigator does not approve their own report.
The lead signs the report off and someone else approves it, unless the lead is the accountable manager.
On the graph
What it links to
Questions buyers ask
Short answers
Which analysis methods are included?
Nine: 5-Why, bow-tie, fishbone, HFACS, SHELL, MEDA, REDA, PEAR and the Dirty Dozen. The investigation records which one it used.
Can the lead investigator approve the report?
No. The lead signs it off, then someone else approves it. The one exception is an accountable manager leading the investigation.
Do we record whether it is reportable?
Yes. Before the report is finished, the investigation records whether it is reportable to the authority.
See Investigations on your own records
A walkthrough with the people who build eAviora.