Page 9 - Index

Figure 1.

once the “marginal safety boundary” is procedure. An initial observer might stop of every TSB investigation, an eight-step
crossed, an operator ends up in a space there, and say, “Well, that’s that. Proce- process that guides our safety investigators
that isn’t safe. The result won’t always be dure not followed.” And for many people, from A to Z. Or, in this case, from the initial
an accident, but it almost always means a yes, that’s enough of a conclusion. You see occurrence to the release of a final TSB re-
significantly reduced margin of safety. it in news headlines, and on Twitter, and port and the communication of vital safety
Safety investigators, of course, don’t frankly almost anywhere on the Internet. information (see Figure 2, page 10).
rely on just two models any more than But it’s not a good enough conclusion I want to stress just a few things about
they rely on any two tools. That’s partly for this group, for safety investigators. So the TSB’s ISIM: First, it’s not necessarily
because investigators come from a variety to make sure that we look deeper than a linear procedure in which one starts at
of backgrounds and bring a variety of compliance with rules or regulations—in the beginning and proceeds through each
expertise to the job, but it’s also because order to make sure we get to the why— step to completion. Rather, it’s meant to
accidents can happen in many different investigators ask questions like: Why did be flexible and iterative. Second, ISIM is
ways; no two are exactly alike. And so the actions and assessments of the crew demanding—I like to use the word “re-
safety investigators—no matter what they make sense at the time, given the condi- lentless”—in terms of the emphasis that
first encounter on site or in a lab—must tions and circumstances they faced? Were it places on asking that question of why.
always be asking “why.” the procedures workable in the situation? And the reason is because there’s a why
That’s the most fundamental question Were the procedures communicated? behind every action or condition. And
of all, and it might even be the most pow- Was the crew trained? Was this an ex- often another why behind that why.
erful tool in the investigator’s toolbox: ample of “drift” or adaptation? And if so, Understanding that why is part of the
the ability to step back and examine a what external conditions contributed to reason TSB investigations don’t assign
scene or a piece of wreckage with dispas- the drift or adaptation? blame or determine criminal or civil
sion and reason and say, “Why did this Now, in doing all this, it helps our safety liability. We can do our job better when
happen?” investigators to follow a rigorous meth- we receive a fuller picture of events.
For instance: Let’s say a safety in- odology. Moreover, people are more forthcoming
vestigator learns early on that a flight The TSB’s Integrated Safety Investiga- about those events if they know their
crew didn’t follow a standard operating tion Methodology (ISIM) is the backbone statements won’t be used against them
October-December 2021 ISASI Forum • 9