Independent report

The Impact of Covid-19 On The Air Accidents Investigation Branch

Published 24 June 2021

Introduction

Whilst flying is the safest form of transport on the planet (per mile travelled), as a high technology industry it has always been an enterprise susceptible to a lack of attention to detail. However, few could have anticipated the devastation that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) particle, as small as 60µm, would have on aviation globally.

One of the significant challenges for aviation has been how, after such a long hiatus, to safely get aircraft, pilots and passengers back flying. The statistics for the past year make interesting reading, and show that despite a disproportionate lack of flying, the amount of safety reporting has remained relatively high, at levels 86% of the year before. Despite huge efforts by regulators, operators and manufacturers to raise awareness of the potential hazards to enable a measured safe return to flying for all types of aviation there have inevitably been mishaps, serious incidents and, unfortunately, accidents. This article covers how the UK Air Accidents Investigation Branch (AAIB) has reacted to these events in the midst of a pandemic.

The global challenge

The global nature of Aviation is exposed in accidents. An aircraft accident in the UK could, for example, involve design organisations in the US, regulators from Canada and component manufacturers in Europe and could be of interest to operators of the type all over the world. Thus, Accident Investigation Authorities (AIAs) rely on relationships with other AIAs, manufacturers, operators and other government departments to conduct investigations. So, finding effective methods of sustaining these relationships in a pandemic has been key to sustaining operational viability of not just the AAIB, but every AIA. In response to these and many other types of challenge being encountered by investigators, AIAs had to establish codes of practice and recommendations of how to cope in a pandemic. These are comprehensive covering all phases of the accident investigation from notification of the accident, deployment, the post field phase through to the giving of evidence in an Inquest.

Maintaining operational readiness

Firstly, for the AAIB, it was critical to establish a safe and secure base from which to conduct operations. This required the AAIB Business Support team to overcome the challenge of rapidly implementing procedures and mitigations in accordance with UK Government and World Health Organisation guidelines to ensure that a covid-secure workplace was sustained. Communications and IT are a critical enabler and the AAIB has taken huge strides forward in enabling collaborative remote working whilst retaining its ability to manage sensitive and confidential information. Whilst the AAIB was well positioned in having the right type of Personal Protective Equipment (PPE), the same challenges were faced as with many other organisations of maintaining sufficient stocks in the face of overwhelming global demand for these products. Finally, we needed to protect the AAIB’s most valuable assets – its people. Firstly, those within the organisation most at risk were identified and shielded; all unnecessary travel was avoided, particularly by public transport and access to healthcare resources facilitated. For the staff that needed to travel, the AAIB ensured they were designated as critical safety workers, with freedom to move around and operate as required.

A small accident in rural Britain will have multi-national interest.

Notification and deployment

In taking the decision to activate an Investigative Team, AAIB Duty Coordinators (DCOs) assess an incident against a range of criteria and decide if it crosses a threshold which supports a deployment. Covid-19 has not changed those criteria, so in one regard the decision whether the AAIB should deploy has not changed. The more critical aspect has been if the team can deploy. Within the UK this was largely surmountable thanks to the skilled efforts of the AAIB Operations Centre team, who managed to resolve the logistics challenges such as availability of accommodation or flights during lockdown. However, overseas deployments presented more significant hurdles with the introduction of quarantine periods both on arrival and return. There was also the risk of contracting the virus whilst on deployment and having investigators stranded in far-off places. This potentially would impact on the wider AAIB capability if a major event occurred in the UK, as such events quickly consume the available resources of what is a capable but compact organisation.

The decisions on deployment are more straightforward when there are fatalities involved, but more nuanced with less severe incidents and near miss events. It is the latter scenarios where DCOs are having to carefully weigh the potential safety benefits with the risks involved in deploying. Despite these challenges the AAIB has continued to successfully deploy teams to a wide range of scenarios, attending fatal accidents and serious incidents in the UK and overseas whilst sustaining its capability to respond to a large scale incident.

At the accident scene

In many ways conducting the physical investigation of the wreckage at the accident site posed the least challenge. With the numerous hazards inherent in aircraft accidents, of which inhalation hazards are often present, investigators were already well prepared from a PPE perspective for the hazards posed by SARS-CoV-2 (or Covid-19 as it more commonly known). The problems resided in the human side of the investigative process. Conducting interviews in-person with witnesses were made more difficult by the wearing of face masks, adding a barrier to the communication in which the ability of the investigator to build a rapport and gain trust is vital.

On the accident site the calibration of risk from Covid-19 can be difficult to maintain, the team are focussed on the hazards presented by the site and much care is taken to protect themselves and anyone else from harm. It can be a difficult mental adjustment to consider that each member of the team and other stakeholders present at the accident site could potentially be presenting a hazard to each others health as well. When an investigative team has spent hours in full body suits and masks combing over an accident site, the last thing they wish to do after getting out of the PPE is to put on another mask! But that is the discipline required to protect each other and keep the team operational. One of the challenging aspects of field investigations is managing stakeholders from different organisations who may have different perspectives on risk. On a small accident site this is relatively easy to control but ensuring consistent level of PPE on a larger scale accident can be more challenging. Covid-19 poses a similar problem, whilst the guidance on facemasks and social distancing is clear, it is common to observe lots of variance in adherence to these rules.

An important dynamic from the investigative team is to be able to meet together in the evening to discuss the day’s activities. Whilst the Engineering Inspectors will have spent most of the time on site, the Operations Inspectors will have been mobile, interviewing witnesses at varying locations. Similarly, the Recorded Data Group and Human Factors Inspectors may well have all spent time focussed on different areas. The opportunity to brief the investigator in charge and start to knit together the various strands of evidence and information into an initial concept of events is critical in enabling the investigation to focus its efforts in the right area.

This time is also important after an investigative team has undertaken the critically important task with the emergency services and Disaster Victim Identification (DVI) teams to carefully extract fatalities from the accident scene. Following exposure to what can be harrowing experiences, it is vital to have the opportunity for the team to talk and support one another.

Depending on the location of the accident this type of evening meeting was not always possible. On one deployment to the Channel Islands exemptions were granted from the quarantine with understandable strict conditions (given the Island had a zero incidence of Covid-19). Inspectors were required to go directly from the aircraft to their hotel rooms and only to leave to visit the aircraft. Technology can be used to try and overcome these issues, but there are some conversations that are not suited to the dynamics of video calls.

Post field phase

Whilst the actions taken at an accident site are often challenging, this element (known as the field phase) of the investigation tends also to be relatively short in duration. The post field phase, however, can last months, if not years and managing the investigation during this phase has raised its own challenges. Damaged or undamaged flight recorders have had to be transported to suitable laboratories, sometimes in a foreign state, to recover and analyse data.

Similarly, novel techniques have had to be adopted to conduct detailed wreckage and component examinations. The AAIB was not able to travel to the United States with critical engine components from a Bell Helicopter, but were able to conduct the forensic examination with assistance from Rolls Royce (UK), with reach-back to the Type Certificate holder in the US who had the in-depth product knowledge.

The effect of Covid-19 protocols

So, as can be seen, the AAIB and other AIAs have introduced numerous protocols to sustain investigations through the pandemic, but what has been the cost of these? As is often the case in life, new challenges often re-present old problems in a different context. Some readers may be aware of the famous Prussian Military Officer Carl von Clausewitz and his writings on his experiences of war as France defeated Prussia at the twin battles of Jena and Auerstädt on October 14, 1806. It may seem odd to be drawing lessons from such a distant event. What relevance can the experience of a 19th century infantry officer hold for us today performing accident investigation? The central tenet of Clausewitz’s writings are about the attritional effect of reality on ideas and intentions in war, for which he introduced the term ‘friction’. In modern day air accident investigation, the investigative protocols are the embodiment of AIAs ideas and intentions to manage the risks associated sustaining this important activity in a pandemic. Each mitigation, if applied correctly, is effective, but each brings its own friction in terms of a penalty of adding time, cost and increasing the energy needed to achieve the same level of effectiveness in an investigation. The effect of reality on all these protocols is that they also introduce delay, inertia and complexity at just about every step of an investigation.

And it is not just the protocols that have introduced friction. As mentioned earlier, aviation is a global business, and the business of investigating accidents relies on long established relationships with safety staff at operators, manufacturers and regulators. These safety teams have not been immune from the effects of the pandemic on industry. The hollowing out of industrial resources has meant that some company’s ability to respond to incidents has been significantly diminished, and their own investigations have taken longer than normal, or not been possible at all because the company has ceased to operate.

As well as the impact on investigations there has been the impact of the pandemic on individual’s health and wellbeing. There are the obvious first order consequences of personnel who have been unfortunate enough to contract Covid-19, both in its short and longer term effects. But more insidious has been the indirect effects of the pandemic on people’s sense of wellbeing. The effects of social distancing and the impediments to the mobility of people has the potential to affect people’s mental and physical health and undermine the morale and cohesion of the workforce. It is interesting to note that Clausewitz recognised the morale and will of a soldier as the most important component in warfare. For AIAs, which tend to be small organisations comprised of highly motivated individuals, maintaining these components is equally important.

Unexpected side effects

But what AIAs are also recognising is that the pandemic has expedited new ways of working and innovation that may have taken decades to progress otherwise. Home working is not a new concept, in fact it was common prior to the Industrial Revolution (and even sustained through it). However, the huge experiment in home working conducted over the past several months, has despite the understandable initial concerns of some, delivered surprising results.

It has generated a resilience by significantly reducing the risk of losing a cohort of investigators to an outbreak of Covid-19. By exploiting the advantages technology can offer it has strengthened the ability of AIAs to conduct remote investigations, particularly overseas. Whilst undoubtedly certain aspects of business, particularly networking, are better conducted face to face, the innovative ways of working adopted through the pandemic have shown that many routine aspects can be conducted remotely. AIAs have had an advantage in that the provisions of Annex 13 to the convention of civil aviation on aircraft accident and incident investigationprovide the statutory enabling framework for AIAs to assist one another. The working practices adopted under the pandemic have merely further exploited the co‑operation this enables.

Glimmers of light in the darkness

The importance of management and leadership, at all levels, in guiding the AAIB through this pandemic cannot be overstated. This demand is twofold. Firstly, there is the challenging task of trying to understand the cumulative effect of the friction generated by the Covid-19 protocols on the output of an AIA and the health and wellbeing of the workforce. The CIAA and the management team have gone to great lengths to sustain communication with their teams. As importantly, the wider AAIB team have needed to work to support each other across the psychological divides and barriers that can be created by social distancing protocols and remote working.

Secondly, there is the responsibility to exploit the opportunities that have been presented by the pandemic to enhance the way the AIA works. If there is one certainty during these very unpredictable times it is that SARS Cov-2 will not be the last virus with which the world will wrestle. The AAIB management team are focussed on learning the lessons from this pandemic. Finding the right blend of traditional and distributed working models and building on the technological capabilities and investigation techniques developed during Covid-19 will be key to the AAIB’s ability to sustain operations in the next pandemic.

Conclusion

The AAIB has responded effectively to the pandemic; it has remained operational and continued to fulfil its important role of improving aviation safety. It has deployed personnel throughout the pandemic and sustained the currency of its experienced cadre. It has also effectively recruited and trained new inspectors. It has achieved all this by employing innovative ways of working, exploiting technology and working with its extensive network of fellow AIAs to develop safe protocols for investigations. If there is a truism in the field of accident investigation it is that every accident is different and presents unique challenges. It is in the DNA of the AAIB to overcome challenge and to solve problems and this attitude can be seen at every level and discipline in the AAIB. Ultimately, it has been the harnessing of this corporate attitude that has enabled the AAIB to successfully overcome the challenges and continue to operate during the SARS Cov-2 pandemic.