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An important part of any investigation is the Safety Recommendations. In 2017, we made 29 Safety Recommendations. Within the regulations and the international protocols, the definition of a Safety Recommendation is:
Safety recommendation. A proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating presumption of blame or liability for an accident or incident.
In developing Safety Recommendations, there are many steps, but in the first instance they must be evidence-based. However, there should be no implication of ‘blame and liability’ toward those to whom Safety Recommendations are addressed.
Development of Safety Recommendations
When developing a Safety Recommendation, we consult those involved early in the investigation about the potential safety issues that have been identified and that need to be addressed. The preference is that those able to act and address the safety issue take this on board and carry out Safety Action proactively, thereby removing the need for a Safety Recommendation. This achieves the same goal of action being taken to prevent recurrence.
Should the safety issue remain, then a Safety Recommendation will be drafted. For consistency, at an early stage the Investigator-In-Charge will convene the Safety Recommendation committee to discuss the rationale for each recommendation, whether the evidence supports the identified safety issue and whether the addressee is best placed to act on the safety issue. The committee then discusses the text of each Safety Recommendation before it goes to the addressee for consultation.
A Safety Recommendation may be issued at any time and will appear in a Special Bulletin, a Bulletin report or a Formal Report.
Action by addressees
A Safety Recommendation is just that, a recommendation, and there is no obligation on the addressee to act on it. However, there is a legal requirement that addressees respond within 90 days of receipt of Safety Recommendations, giving their proposed actions and when they will be carried out, or if no action is to take place the reasons why.
When a response is received from an addressee, we have 60 days to assess the adequacy of the response. There are three types of assessment:
• A ‘Not adequate’ assessment means that the AAIB considers the response does not address the intent of the Safety Recommendation, nor does it address the safety issue concerned.
• A ‘Partially adequate’ assessment means the AAIB considers the response goes some way to meeting the intent of the Safety Recommendation and the action will address the safety issue to a certain extent, but further action would be required to fully address the issue identified.
• An ‘Adequate’ assessment means the AAIB considers the response fully meets the intent of the Safety Recommendation and the action is expected to address the safety issue.
Importantly, it is only the response that is being assessed and an Adequate response does not mean that all the actions have been completed and the safety issue has been addressed. When the response is assessed as Not Adequate or Partially Adequate, we write to the addressee with the reasons for the assessment and may request that the response and proposed actions be reviewed.
Closing Safety Recommendations
We keep open Safety Recommendations where we expect to receive further responses from the addressee. When no further response is expected, the recommendation is generally closed.
A closed status does not necessarily mean the actions for a Safety Recommendation are complete, nor that the Safety Issue has been addressed. In some cases, it is clear from their response that the addressee does not intend to carry out the recommended actions.
Ongoing monitoring of actions to Safety Recommendations
The responsibility to monitor the actions being taken for a Safety Recommendation lies with the addressee, the Civil Aviation Authority and the European Aviation Safety Agency as part of their relevant Safety programmes.
Publication of Safety Recommendations and responses
Any Safety Recommendation raised by a European Member State has to be recorded on a central database – the Safety Recommendation Information System (SRIS). Included on this system are not only the Recommendations but also the responses that have been received by the addressees and the Safety Investigation Authority (for instance, the AAIB) assessments.
The Safety Recommendations on SRIS are publicly viewable on Public SRIS.
AAIB’s Safety Recommendations are published on our website under each individual investigation, this includes the responses and our assessment. A summary is also produced in the AAIB Annual Safety Review and this includes any Safety Action that has been carried out during the investigations, which often means no Safety Recommendation was necessary.