Major air disasters: accident investigation as a tool for defining eras in commercial aviation safety culture
Abstract
The air transport evolution has been littered with major air disasters, the occurrence of which has not only had the negative effects inherent to any disaster. Air accident investigation has provided a wealth of knowledge that has advanced the aviation industry and its safety. International Civil Aviation Organization has exercised international regulatory leadership since 1947, developing tools with international cooperation, such as the air accident investigation methodology. ICAO has forged a change in perspective on safety attributions or factors in different historical eras, using this methodology to deepen the understanding of the causes and thereby achieve aviation safety improvement. Authors aimed to analyze, through a detailed study of the world’s worst aviation accidents, their contribution to understanding the details of aviation safety culture. Beyond the technical issues and fatality rates, the necessary analysis is what knowledge researchers have gained from the beginning, exploring the attributions of reports and knowing what diverse factors have predominated in different eras. Descriptive analyzes of air disaster investigation have two objectives: to identify the beginnings of a global safety culture resulting from evolution in operational safety and to relate the different eras to the attributions of air accident investigations.
Keyword : air accident, air disaster, aviation psychology, aviation safety, human factors, International Civil Aviation Organization (ICAO), operational safety, organizational factor, preventive measures, safety culture
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Aircraft Accident Investigation Board Pakistan. (2020). Preliminary Investigation Report, 20 May 2020, PIA, PK8303. https://caapakistan.com.pk/Upload/SIBReports/AAIB-431.pdf
Aircraft Accident Investigation Commission Ministry of Transport Japan. (1971). Final Report, 30 July 1971, All Nippon, flight 058. Aviation Safety. https://reports.aviation-safety.net/1971/19710730-1_B722_JA8329.pdf
Aircraft Accident Investigation Commission Ministry of Transport Japan. (1987). Final Report, 12 August 1985, Japan AirLines, flight 123. B3A. http://www.mlit.go.jp/jtsb/eng-air_report/JA8119.pdf
Aircraft Accident Investigation Commission Ministry of Transport Japan. (1996). Final Report, 26 April 1994, China AirLines, flight 140. Aviation Safety. https://reports.aviation-safety.net/1994/19940426-0_A306_B-1816.pdf
Arnau, M. (2021). ¿Qué son la Teoría de la Causalidad y la Pirámide de Bird? Proalt. https://www.proalt.es/teoria-de-la-causalidad-y-piramide-de-bird-que-son-y-de-que-nos-sirven/
BBC Mundo. (2013). Columbia: la tragedia que cambió el rumbo de la exploración espacial – BBC News Mundo. BBC Mundo News. https://www.bbc.com/mundo/noticias/2013/02/130131_ciencia_columbia_aniversario_tragedia_2003_nasa_jg
Bravo, P. (2016). La Historia de la Aviación – Revista Sucesos. http://www.librosmaravillosos.com/lahistoriadelaaviacion/index.html
Bridges, V. (1967). Historia de las Comunicaciones: Transportes Aéreos. Salvat S.A. de Ediciones.
Burrel, G. (Ed.) (1992). Crónica de la Aviación. Plaza y Janes.
Centro de Investigação e Prevenção de Acidentes Aeronáuticos. (2009). Final Report, 17 July 2007, TAM Linhas Aéreas, flight 3054. Aviation Safety. https://reports.aviation-safety.net/2007/20070717-0_A320_PR-MBK.pdf
Civil Aeronautics Board. (1950). Final Report, 7 June 1950, Strato. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2016/05/NC92857.pdf
Civil Aeronautics Board. (1952a). Final Report, 11 April 1952, PanAm, flight 526A. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/02/N88899.pdf
Civil Aeronautics Board. (1952b). Final Report, 16 December 1951, Miami AirLines. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/01/N1678M.pdf
Civil Aeronautics Board. (1954). Final Report, 14 February 1953, National AirLines. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/03/N90893.pdf
Civil Aeronautics Board. (1957). Final Report, 6 October 1955, TWA, flight 409. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/06/N30062.pdf
Civil Aeronautics Board. (1962). Final Report, 16 December 1960, United AirLines, flight 826. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/10/N8013U.pdf
Comisión Investigación de Accidentes e Incidentes de Aviación Civil España. (1977). Final Report, 27 marzo 1977, Pan Am y KLM, vuelo 4805.
Comisión Investigación de Accidentes e Incidentes de Aviación Civil España. (2011). Informe Final, 20 agosto 2008, SpanAir, vuelo 5022. https://www.mitma.gob.es/recursos_mfom/pdf/C4A41FC7-89D7-42C5-B5F1-7DC96ACD287F/105210/2008_032_A.pdf
Comisión Investigación de Accidentes e Incidentes de Aviación Civil España. (2021). Informe Técnico, 27 noviembre 1983, Avianca, vuelo 011. https://www.mitma.gob.es/organos-colegiados/ciaiac/publicaciones/informes-relevantes/a-0421983-informe-tecnico-del-accidente-sufrido-por-la-aeronave-boeing-747-283b-matricula-hk-2910-a-12-km-del-aeropuerto-de-madrid-barajas-el-dia-27-de-noviembre-de-1983
Commision of Inquiry of Canada. (1964). Final Report, 29 November 1963, TransCanada AirLines, flight 831. Aviation Safety. https://reports.aviation-safety.net/1963/19631129-0 CF-TJN.pdf
Commission of Inquiry of Suriname. (1989). Final Report, 7 June 1989, Suriname Airways, flight 764. B3A. https://www.baaa-acro.com/sites/default/files/2020-06/N1809E.pdf
Court of Inquiry of Karnataka. (1990). Final Report, 14 February 1990, Indian AirLines, flight 605. B3A. https://doi.org/10.1037/h0054879
Egyptian Ministry of Civil Aviation. (2006). Final Report, 3 January 2004, Flash AirLines, flight 604. Aviation Safety. https://reports.aviation-safety.net/2004/20040103-0_B733_SU-ZCF.pdf
Ethiopian Directorate of Aircraft Accident Investigations. (2020). Interim Investigation Report, 10 March 2019, Ethiopian AirLines, flight 302. Aviation Safety. https://reports.aviation-safety.net/2019/20190310-0_B38M_ET-AVJ_Interim.pdf
France Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2002). Final Report, 30 January 2000, Kenya Airways, flight 431. Aviation Safety. https://reports.aviation-safety.net/2000/20000130-1_A310_5Y-BEN.pdf
France Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2003). Final Report, 25 December 2003, Union des Transports Africains, flight 14. Aviation Safety. https://reports.aviation-safety.net/2003/20031225-0_B722_3X-GDO.pdf
France Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. (2012). Final Report, 1 June 2009, Air France, flight 447. Aviation Safety. https://reports.aviation-safety.net/2009/20090601-0_A332_F-GZCP.pdf
France Secretariat D’etat Aux Transports. (2021). Database, 3 March 1974, Turkish AirLines, flight 452. ASN. https://reports.aviation-safety.net/1974/19740303-1_DC10_TC-JAV.pdf
Goverment of India Ministry of Civil Aviation. (1997). Final Report, 12 November 1996, Saudi Arabian, flight 763. https://www.dgca.gov.in/digigov-portal/Upload?flag=iframeAttachView&attachId=130614975&mainAccidentReports
Goverment of India Ministry of Civil Aviation. (2010). Final Report, 22 May 2010, Air India, flight 812. Aviation Safety. https://reports.aviation-safety.net/2010/20100522-0_B738_VT-AXV.pdf
Grupo de Investigación de Accidentes Autoridad Civil Aérea Colombiana. (1996). Final Report, 20 December 1995, American AirLines, flight 96. B3A. https://www.baaa-acro.com/sites/default/files/2020-12/N651AA.pdf
Grupo de Investigación de Accidentes Autoridad Civil Aérea Colombiana. (2017). Final Report, 29 November 2016, LaMia, flight 2933. Aviation Safety. https://reports.aviation-safety.net/2016/20161128-0_RJ85_CP-2933.pdf
GTD Engineering System & Software. (2010). El primer accidente de avión. GTD Blog. https://www.gtd.es/es/blog/el-primer-accidente-de-avion
Hawkes, N. (1992). Vehículos. Debate.
Helmreich, R. L. (2006). Red alert. Flight Safety Australia, 10(5), 24–31.
Hubert, R. (1990). Database, 16 August 1954, Air Vietnam. B3A. https://www.baaa-acro.com/crash/crash-bristol-170-freighter-21e-pakse-47-killed
Hubert, R. (2021a). Database, 3 August 1975, Alia. B3A. https://www.baaa-acro.com/crash/crash-boeing-707-321c-near-agadir-188-killed
Hubert, R. (2021b). Database, 3 October 1972, Aeroflot Russian AirLines, flight 217. B3A. https://www.baaa-acro.com/crash/crash-ilyushin-ii-62-moscow-174-killed
Hubert, R. (2021c). Database, 11 October 1984, Aeroflot Russian AirLines, flight 3252. B3A. https://www.baaa-acro.com/crash/crash-tupolev-tu-154b-1-omsk-178-killed
Hubert, R. (2021d). Database, 19 September 1976, Turkish AirLines, flight 452. B3A. https://www.baaa-acro.com/crash/crash-boeing-727-2f2-near-isparta-154-killed
Institute for an Industrial Safety Culture. (2017). ¿Qué es la cultura de seguridad? ICSI Instituto Para Una Cultura de Seguridad Industrial. https://www.icsi-eu.org/es/revista/cultura-seguridad-definicion
Institute for an Industrial Safety Culture. (2021). Los atributos de una cultura de seguridad eficaz. ICSI Instituto Para Una Cultura de Seguridad Industrial. https://www.icsi-eu.org/es/revista/atributos-cultura-seguridad
International Civil Aviation Organization. (1944). Convention on International Civil Aviation. ICAO. https://www.icao.int/publications/Documents/7300_orig.pdf
International Civil Aviation Organization. (1951). ICAO Circular 18-AN/15, Aircraft Accident, Nº 1. https://archive.org/details/icao-circular-18-an-15-aircraft-accident-digest-no.-1/page/56/mode/2up
International Civil Aviation Organization. (1956). ICAO Circular: 56-AN/51, Nº 1, Report 20 July 1956, LAV, flight 253. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/07/YV-C-AMS.pdf
International Civil Aviation Organization. (1957). ICAO Circular 59-AN/54, Nº 5, Report 11 August 1957, Maritime Central Airways. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/07/CF-MCF.pdf
International Civil Aviation Organization. (1965). ICAO Circular 88-AN/74, no 18, Report 20 May 1965, Pia, flight 705. B3A. https://www.baaa-acro.com/sites/default/files/2018-02/AP-AMH.pdf
International Civil Aviation Organization. (1970). Doc. 6920 Manual of Aircraft Accident Investigation (4th ed.). https://www.slideshare.net/Aldo_Castro/doc-6920-manual-of-aircraft-accident-investigation
International Civil Aviation Organization. (2001). Anexo 13 al Convenio de Aviación Civil Internacional sobre Investigación de accidentes e incidentes de aviación, Novena edición (9th ed.). http://www.udi.edu.co/images/biblioteca/aeronautica/anexo13.pdf
International Civil Aviation Organization. (2006). Doc 9859-AN/474 Safety Management Manual (SMM) (1st ed.). ICAO.
International Civil Aviation Organization. (2009). Doc 9859-AN/474 Safety Management Manual (SMM) (2nd ed.). ICAO.
International Civil Aviation Organization. (2011). Doc 9756 Investigación de accidentes e incidentes de aviación. Parte III Investigación (1st ed.). ICAO. http://www.udi.edu.co/images/biblioteca/aeronautica/anexo13.pdf
International Civil Aviation Organization. (2012). Doc 9756 Investigación de accidentes e incidentes de aviación. Parte II Procedimientos y listas de verificación (1st ed.). ICAO. http://www.udi.edu.co/images/biblioteca/aeronautica/anexo13.pdf
International Civil Aviation Organization. (2013a). Doc-AN/474 Safety Management Manual (SMM) (3rd ed.). ICAO.
International Civil Aviation Organization. (2013b). Doc 9998 Política de la OACI sobre asistencia a las víctimas de accidentes de aviación y sus familiares (Primera edición). Mitma.
International Civil Aviation Organization. (2015). Doc 9756 Investigación de accidentes e incidentes de aviación. Parte I Organización y planificación (2nd ed.). ICAO. http://www.udi.edu.co/images/biblioteca/aeronautica/anexo13.pdf
International Civil Aviation Organization. (2016). Anexo 13 al Convenio de Aviación Civil Internacional sobre Investigación de accidentes e incidentes de aviación, Undécima edición (11th ed.). ICAO. https://www.icao.int/SAM/Documents/2017-SSP-JIAAC-ARG/Anexo13_Enm%2015_es.pdf#search=Anexo%2013
International Civil Aviation Organization. (2018). Doc 9859-AN/474 Safety Management Manual (SMM) (4th ed.). ICAO.
International Civil Aviation Organization. (2020a). Anexo 13 al Convenio de Aviación Civil Internacional sobre Investigación de accidentes e incidentes de aviación (12th ed.). ICAO. https://elibrary.icao.int/reader/229736/&returnUrl%3DaHR0cHM6Ly9lbGlicmFyeS5pY2FvLmludC9leHBsb3JlO21haW5TZWFyY2g9MS9wcm9kdWN0LWRldGFpbHMvMjI5NzM2?productType=ebook
International Civil Aviation Organization. (2020b). Anexo 17 al Convenio sobre Aviación Civil. Seguridad (Undécima edición). ICAO. https://elibrary.icao.int/reader/262960/&returnUrl%3DaHR0cHM6Ly9lbGlicmFyeS5pY2FvLmludC9leHBsb3JlO3NlYXJjaFRleHQ9YW5leG8lMjAxNzttYWluU2VhcmNoPTEvcHJvZHVjdC1kZXRhaWxzLzI2Mjk2MA%3D%3D?productType=ebook
International Civil Aviation Organization. (2020c). Doc 9756 Investigación de accidentes e incidentes de aviación. Parte IV Redacción de informes (3rd ed.). ICAO.
International Civil Aviation Organization. (2021). ICAO Web – Uniting Aviation. A United Nations Specialized Agency. https://www.icao.int/Pages/default.aspx
Italian Republic Ministry of Defense Board of Inquiry. (1960). Final Report, 26 June 1959, TWA, flight 891. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/09/N7313C.pdf
Junta de Investigación Accidentes Aviación Civil Argentina. (2000). Informe Final, 31 agosto 1999, Líneas Aéreas Privadas Argentinas S.A., vuelo 3142. Aviation Safety Network. https://reports.aviation-safety.net/1999/19990831-0_B732_LV-WRZ.pdf
Junta Investigadora de Accidentes de Aviación Civil del Ministerio Transporte y Comunicaciones de la Republica Bolivariana de Venezuela. (2005). Informe Final, 16 agosto 2005, West Caribbean Airways, vuelo 708. https://reports.aviation-safety.net/2005/20050816-0_MD82_HK-4374X.pdf
Komite Nasional Keselamatan Transportasi Republic of Indonesia. (2015). Final Report, 28 December 2014, Indonesia Air Asia, flight 8501. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2015/12/PK-AXC.pdf
Komite Nasional Keselamatan Transportasi Republic of Indonesia. (2017). Final Report, 16 August 2015, Trigana Air Service, flight 267. Aviation Safety. https://reports.aviation-safety.net/2015/20150816-0_AT43_PK-YRN.pdf
Komite Nasional Keselamatan Transportasi Republic of Indonesia. (2019). Final Report, 29 October 2018, Lion Mentari Airlines, flight 610.
Lombardo, O. M. (2020). Aviónica: Evolución de la Interfaz Hombre-Máquina. Vortexx. https://vortexxmag.com/avionica-evolucion-de-la-interfaz-hombre-maquina/
Martínez, A. (2016). Introducción al Sistema ADREP/ECCAIRS. ICAO. https://www.icao.int/SAM/Documents/2016-AIGARCM/P14-Introduccion al ECCAIRS.pdf
Marimón, L. (1973). Historia de la aeronáutica. Academia General del Aire.
Minister for Transport and Power of Ireland. (1963). ICAO Circular 71-AN/63, no 1, Report 10 September 1961, President AirLines. B3A. https://www.baaa-acro.com/sites/default/files/import/uploads/2017/11/N90773.pdf
Ministere des Transports France. (1983). Final Report, 1 December 1981, AdriaAvio, flight 308. Aviation Safety Network. https://reports.aviation-safety.net/1981/19811201-1_MD81_YU-ANA.pdf
Ministere des Travaux Publics et des Transports France. (1965). Final Report, 3 June 1962, Air France, flight 007. Aviation Safety Network. https://reports.aviation-safety.net/1962/19620603-0_B703_F-BHSM.pdf
Ministerio de Comercio e Industria España. (1971). Final Report, 3 July 1970, Dan Air, flight 1903. B3A. https://www.baaa-acro.com/sites/default/files/2018-07/G-APDN.pdf
Ministry of Communications and Works of Nicosia. (1967). ICAO Circular 88-AN/74, na 16, Report 20 April 1967, Globe Air. B3A. https://www.baaa-acro.com/sites/default/files/2018-04/HB-ITB.pdf
Ministry of Transport of Pretoria. (1968). Final Report, 20 April 1968, South Africa, flight 228. Aviation Safety Network. https://www.baaa-acro.com/sites/default/files/2018-05/ZS-EUW.pdf
Muñoz-Marrón, D. (2018). Factores Humanos en Aviación: CRM (Crew Resource Management-Gestión de Recursos de la Tripulación) [Human Factors in Aviation: CRM (Crew Resource Management)]. Papeles del Psicólogo, 39(3), 191–199. https://doi.org/10.23923/pap.psicol2018.2870
National Transportation Safety Board. (1983). Final Report, 9 July 1982, PanAm Airways, flight 759. NTSB. http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR83-02.pdf
National Transportation Safety Board. (1986). Final Report, 25 May 1979, American AirLines, flight 901. NTSB. http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR79-17.pdf
National Transportation Safety Board. (2004). Final Report, 12 November 2001, American Airlines, flight 587. Aviation Safety Network. https://reports.aviation-safety.net/2001/20011112-0_A306_N14053.pdf
National Transportation Safety Committee of Indonesia. (1997). Final Report, 26 September 1997, Garuda Indonesia, flight 152. Aviation Safety. https://reports.aviation-safety.net/1997/19970926-0_A30B_PK-GAI.pdf
Presidency of Civil Aviation Kingdom of Saudi Arabia. (1982). Final Report, 19 August 1980, Saudi Arabian Airlines, flight 163. B3A, 196. https://www.baaa-acro.com/sites/default/files/2021-05/HZ-AHK.pdf
Presidency of Civil Aviation Kingdom of Saudi Arabia. (1991). Final Report, 11 July 1991, Saudi Arabia, flight 2120. 93. https://reports.aviation-safety.net/1991/19910711-0_DC86_C-GMXQ.pdf
Ranter, H. (1999). Database, 17 March 1988, Avianca, flight 410. Aviation Safety Network. https://web.archive.org/web/20000816002233/http://aviation-safety.net/reports/880317-0.htm
Ranter, H. (2015). Flight safety foundation. https://aviation-safety.net
Ranter, H. & Lujan, F. (1996). Aviation safety network. https://aviation-safety.net/about/
Ranter, H. & Lujan, F. I. (2021a). Database, 2 January 1973, Nigeria Airways. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19860905-0
Ranter, H. & Lujan, F. I. (2021b). Database, 1 January 1978, Air India, flight 855. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19780101-1
Ranter, H. & Lujan, F. I. (2021c). Database, 9 January 2011, Irán Air, flight 277. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=20110109-0
Ranter, H. & Lujan, F. I. (2021d). Database, 9 May 1987, Polish Airlines, flight 5055. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19870509-0
Ranter, H. & Lujan, F. I. (2021e). Database, 14 August 1958, KLM, flight 607E. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19580814-0
Ranter, H. & Lujan, F. I. (2021f). Database, 16 March 1969, Avensa, flight 742. Aviation Safety Network.
Ranter, H. & Lujan, F. I. (2021g). Database, 16 September 1964, Aeroflot, flight 721. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19640902-0
Ranter, H., & Lujan, F. I. (2021h). Database, 31 March 1986, Mexicana de Aviación, flight 940. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19860331-1
Ranter, H. & Lujan, F. I. (2021i). Final Report, 4 February 1966, All Nippon, © 60. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19660204-0
Ranter, H. & Lujan, F. I. (2021j). Final Report, 28 sempriembre 1992, Pakistan International Airlines – PIA, flight 268. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19920928-0
Ranter, H. & Lujan, F. I. (2021k). Final Report, 19 May 1993, SAM Colombia, flight 501. Aviation Safety Network. https://aviation-safety.net/database/record.php?id=19930519-0
Rodríguez, A. (2012). Investigación de accidentes por el método del árbol de causas. Instituto Nacional de Seguridad e Higiene en el Trabajo. http://publicacionesoficiales.boe.es
Russian Interstate Aviation Committee. (2007). Final Report, 22 August 2006, Pulkovo Aviation Enterprise, flight 612. https://mak-iac.org/upload/iblock/9a7/Tu-154M_22-08-2006.pdf
Russian Interstate Aviation Committee. (2015). Final Report, 17 November 2013, Tatarstan, flight 9363. Aviation Safety Network. https://reports.aviation-safety.net/2013/20131117-0_B735_VQ-BBN.pdf
Taiwan Aviation Safety Council. (2002). Final Report, 25 May 2002, China AirLines, flight 611. Aviatio Safety. https://reports.aviation-safety.net/2002/20020525-0_B742_B-18255.pdf
The Royal Spanish Academy of Languages. (2020a). Accidente | Definición | Diccionario de la lengua española | RAE - ASALE. RAE. https://dle.rae.es/accidente
The Royal Spanish Academy of Languages. (2020b). Catástrofe | Definición | Diccionario de la lengua española | RAE - ASALE. RAE. https://dle.rae.es/catástrofe
Transportation Safety Board of Canada. (2003). Final Report, 2 September 1998, Swissair Transport Limited, flight 111. http://www.tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/a98h0003.pdf
VAIU. (2017). Pioneros de la aviación – Historia de la aviación – Hermanos Wright. https://vaiu.es/pioneros-de-la-aviacion-historia-de-la-aviacion-hermanos-wright/?cn-reloaded=1
World Health Organization. (2008). Glossary of Humanitarian Terms – ReliefWeb. https://www.who.int/hac/about/reliefweb-aug2008.pdf