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Not Enough Accidents, Not Enough Data:

Incident Investigation with

The Focus on Aerodromes

By Adrian Young, Aviation Accident Investigator with To70, an Aviation
Consultancy Based in The Hague, Netherlands

(This article was adapted with permission The safety of airports and maintenance
from the author’s technical paper Not Enough safety tag along behind. This should not
Accidents, Not Enough Data: Incident be seen as a complaint or a criticism but
Investigation with the Focus on Aerodromes as a reflection of the development of the
presented during ISASI 2021, a virtual seminar
hosted from Vancouver, B.C., Canada, from Aug. aviation industry.
31–Sept. 2, 2021. The theme for the seminar was Before moving on, here is a brief
“Staying Safe, Moving Forward.” The full tech- thought about the status of airport
nical paper is available on the ISASI website, safety: The ICAO Annex 13 definition
www.isasi.org, in the Library section under the notes, “takes place between the time
Publications and Governance/Technical Papers any person boards the aircraft with the
tabs.—Editor)
intention of flight until such time as
hile airport accidents and all such persons have disembarked….”
incidents are often not fatal This means many safety events that
accidents and they may not may occur airside at an airport are not
Weven be accidents in the actually accidents. These events range
sense of the definition contained in the from health and safety accidents such
International Civil Aviation Organization as injures to catering or cleaning staff to
(ICAO) Annex 13 to the Chicago Con- airplanes being accidently towed across
vention, the area of airport accident and an active runway without a clearance.
incident investigation is an important The former may involve the loss of life
part of the overall safety of the aviation but is still officially not an aviation acci-
industry. dent. There is no great practical problem
Aviation safety at airports and safe- posed by this, as the definition, further
ty related to infrastructure is not a in the same paragraph of Annex 13, for
new topic, not in general and not in “incident” is not as limiting. Unfortu-
the annals of this organization and its nately, the ICAO document that provides
conferences. The fourth annual confer- further guidance shows that accident
ence in August 1973 included a paper and incident investigation is primarily
on discouraging birds arounds airports. limited to flight operations.
Further back, well before ISASI was Regardless of the scale of the problem
founded, the influential aviation author that the above may cause, it is principal-
Assen Jordanhoff noted in 1941 that 12% ly an issue for the state-appointed inves-
of scheduled domestic airline accidents tigation body. The issue only arises when
were caused by “airport and terrain.” It procedures are developed to decide what
is no surprise that as a pilot and flight events are reported to the investigation
instructor, Jordanhoff chose not to elab- body. Airport owners and operators are
orate further on this statistic and stuck not limited in what they choose to inves-
to matters relating to flight operations. tigate, and from the airport’s perspective
Jordanhoff ’s approach is, to some why would the airport only care about
degree, like the environment that has ex- incidents and accidents only once the
isted since then. The focus of attention is crew arrives? What would that say about
on flight operations first, followed by air- our approach to safety and safety cul-
worthiness and air traffic service issues. ture? Thus, it is the airport owner/opera-

4 • January-March 2022 ISASI Forum