It is great to be with a group of air safety investigators and leaders from around the world and I really appreciate the opportunity to speak this evening. I thought long and hard about what I would like to say. I settled on a topic near and dear to my heart: Investigative integrity.
Investigative integrity means doing what is right for the investigation, regardless of personal, political or other outside influences. I think it applies regardless of the hat you wear or which organization you represent.
Let me start by offering that one of the most critical elements in achieving investigative integrity is independence of accident investigations. The history of this independence for the Safety Board is important to me.
Some of you may know that I enjoy collecting airmail from the 1920’s and early 30’s, much of which never made it to its final destination because it was in a plane crash.
The “youngest” in my collection is from 1931. That year is significant because in 1931 a Fokker F-10A operated by Transcontinental and Western Air (TWA) crashed in Kansas, killing all onboard including famed Notre Dame football coach, Knute Rockne. The nation was stunned.
Even more stunning, however, was that the investigation was overshadowed by the public perception of incompetence, secrecy, and conspiracy.
In response, Congress amended the Air Commerce Act to require that reports on probable causes of fatal aircraft crashes be made public.
In 1935, a DC-2 crashed in Missouri, claiming five lives including a US Senator. Public debate and criticism over the cause of the crash demonstrated the need for, and led to the formation of, an independent accident investigative body.
And although we have undergone structural and organizational refinements in the intervening years, independence of accident investigations has remained central to the way we conduct business in the United States.
Congress further reinforced the criticality of the Board’s independence by passing the Independent Safety Board Act of 1974. The Act noted: “Proper conduct of the responsibilities assigned to this Board requires vigorous investigation of [transportation] accidents… No federal agency can perform such functions unless it is totally separate and independent from any other department, bureau, commission, or agency of the United States.”
Not only does the US Congress see wisdom associated with independence, but so does ICAO. According to ICAO Doc 9756, “The accident investigation authority must be strictly objective and totally impartial and must also be perceived to be so. It should be established in such a way that it can withstand political or other interference or pressure.”
Because Congress and ICAO recognize the importance of independence, I firmly believe that we must preserve, protect and defend our independence.
To be clear, independence does not mean not being accountable for our actions and decisions. We do need accountability, but we also need to appreciate that there is a direct relationship between independence and credibility. When independence is eroded, credibility is diminished.
We must conduct investigations that are free of political and other pressures.
Again, investigative integrity means doing what is right for the investigation, regardless of personal, political or other outside influences.
Keeping in mind the independence of the Safety Board, I’d like to share three key components of investigative integrity: 1) making tough decisions, even when they may be unpopular; 2) keeping uppermost in mind the goal of accident investigation; and, 3) knowing who you are serving.
Making tough decisions
First, making tough decisions, even when they may be unpopular. If I don’t make decisions that sometimes make people uncomfortable, then I’m probably not doing my job well enough. Not that making people uncomfortable is my goal, but if I never did this, it would suggest that I am not pushing the safety envelope in ways that I feel strongly about.
For example, recently the Safety Board voted not to hold a public hearing on a particular investigation. Our professional staff held the opinion that a public hearing would provide no additional information to help us successfully complete the investigation. Even more compelling was that staff felt that if we held a hearing, there was a significant downside that could adversely affect the investigation.
I certainly understand, appreciate and support the notion that our investigations are to be conducted in a transparent manner. I strongly believe it is critical that we allow the public to see inside our investigative process.
I was also keenly aware that some groups and individuals felt strongly that we should hold a hearing. I knew that if we didn’t hold a hearing, there would be backlash.
I pondered the decision for several months. At the end of the process, I weighed the pros and cons of each decision. Through that analysis, I, along with the Board’s majority, voted not to hold a hearing.
Yes, I knew we would receive political and media backlash. But, I understood that the credibility of the agency would be adversely affected if we made a decision based solely on real or perceived outside demands and pressures.
I believed that it was more important to allow the traveling public and families of victims the ability to put closure on why this accident occurred.
I knew that, despite the value of transparency, a public hearing is not the only means to achieve transparency. As everyone in this room knows, all Safety Board investigations, have transparency by several methods, including opening of the public docket, utilization of the party system, frequent public updates regarding the investigative process, and finally, through the Board’s sunshine meeting.
I highly value the Board’s independence, and I believe that my role is to help preserve it.
Investigative integrity means putting the needs of the investigation ahead of personal or political needs. The backbone of investigative integrity and the Board’s credibility is exercising the ability to make decisions based on what is best for the investigation - not on the basis of personal or political concerns.
This is one critical component of investigative integrity.
I am sure that you, as air safety investigators, face difficult decision like this each and every day.
Keeping in mind the goal of the investigation
The second component of investigative integrity is keeping uppermost in mind the purpose of accident investigation. We all know that Annex 13 says the sole purpose of an investigation shall be the prevention of accidents and incidents. This means that as air safety investigators, we’re not there to point fingers, to lay blame, to assign fault, to push a personal agenda, or to help the lawyers build their cases. As air safety investigators, our job is to determine what happened so we can prevent it from happening again.
And to remain true to that notion, we need to dig beneath the obvious human error. I am convinced that most accidents are not simply failures of individuals, but rather, are the result of system failures, as well.
It is one thing to say a person committed an error. It is quite another to try to understand all of the factors that may have influenced that error. What were the elements of the system that allowed, or perhaps even encouraged, errors to exist? Where was the rest of the system that should have prevented a simple error from being catastrophic?
I’m disappointed to still hear comments such as, “It’s just another pilot error accident,” or “The stupid workers should have known better.”
And why does this disappoint me? Because if we focus solely on the errors of front line operators, we may miss valuable prevention opportunities. Systemic flaws may remain undetected, and thus, uncorrected.
Framed outside of my office is the cover of this ISASI Forum. It says, “The discovery of the human error should be considered as the starting point of the investigation, not the ending point.”
It hangs on the wall to serve as an icon to remind us all or the importance of going beyond simply stating that someone committed an error. We need to answer why the error was made.
Investigative integrity means keeping in mind that our goal is to improve safety. We do that by looking at the entire system and not just focusing solely on the front line personnel.
Knowing who you are serving
Finally, I believe investigative integrity means knowing who you are serving. We are here to serve the traveling public by conducting proper investigations that enhance safety. We are not here to please the manufacturers; we are not here to please the regulatory authorities.
We are here to conduct honest, competent, thorough and timely investigations that identify systemic or individual weaknesses and then issue recommendations aimed at correcting those deficiencies. That is our job.
We demonstrate investigative integrity by remembering that we are servants of the traveling public. Keeping this focus has helped me make many difficult, and sometimes unpopular, decisions – decisions that I can look back on and feel confident in.
In conclusion, investigative integrity means three things: 1) making tough decisions, even when they may be unpopular. 2) keeping uppermost in mind the goal of accident investigation. 3) knowing who you are serving.
I don’t believe investigative integrity is something you either have or you don’t. I think it is something that must be constantly striven for.
Today I read the current issue of ISASI Forum. The cover article is about Ron Chippendale. I believe the professional life of Ron epitomizes those characteristics associated with investigative integrity. He will be missed, but his spirit lives on.
In closing, I applaud your investigative efforts, and I sincerely enjoy the camaraderie and teamwork that we exhibit in working with one another to maintain and improve the quality of investigations across boundaries. I agree with Frank Del Gandio, in that, “Safety has no boundaries.”
I challenge you to preserve, protect and defend the independence of your investigations. I challenge you to continue striving for investigative integrity. Through these efforts, we truly are making our transportation system safer.
Thank you very much for all that you do! Keep up the great work!