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Your Role on a Safety Investigation Board

Your Role on a Safety Investigation Board. Maj Kent Koran. Purpose of SIB. Determine what happened Step-by-step account Determine why it happened Provide recommendations on how to prevent it from happening again. SIB Members. Core Primary Members Board President Investigating Officer

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Your Role on a Safety Investigation Board

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  1. Your Role on a Safety Investigation Board Maj Kent Koran

  2. Purpose of SIB • Determine what happened • Step-by-step account • Determine why it happened • Provide recommendations on how to prevent it from happening again

  3. SIB Members • Core Primary Members • Board President • Investigating Officer • Pilot Member • Maintenance Member • Medical Officer • Conditional Primary Members • ATC Officer or SNCO--if ATC might have been a factor • WX, technical experts, etc. • As a Primary Member, equal standing with other primary members

  4. What SIB Members Do • Interview witnesses • May be conducted by group or by individual board member • Privileged information • Review documentation: logs, tapes, transcripts, interview transcripts • Research • Publications: AF, FAA, LOPs • Reconstruct wreckage • Model sequence of events

  5. Hashing it Out • SIB members jointly determine: • Findings • Based on evidence, knowledge, judgement • Essential step in mishap sequence • Listed in chronological order • Causal factors • Things that should have happened and didn’t or shouldn’t have happened and did • Had it been done properly, the mishap may not have occurred • Reasonable person concept

  6. Hashing it Out • Recommendations • Feasible solutions related to the causes • Other findings of significance • Didn’t contribute to this mishap but could contribute to future mishaps or warrant action • Tough decisions • Board president has final say

  7. The Report • Huge undertaking • Report in two parts • First part contains • Factual information, findings, causes, recommendations • Released as report • Second part contains • Privileged information • Goes to AFSC • Primary members may submit minority report

  8. Lessons Learned • Board members very professional • Highly qualified • Open minded • Looked for truth, not scapegoat • It’s hard work • Expect to take 30 days • Long hours • Tough decisions • AMIC would have been beneficial

  9. Lessons for AOFs • Have good mishap checklists • Gather and secure evidence: tapes, logs, strips, training records • Start making recordings/transcripts • Make sure personnel understand what is happening • Brief on SIB process • Provide maximum support to SIB But most importantly...

  10. Lessons for AOFs ...Do everything right in the first place so they won’t blame it on you!

  11. Questions?

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