1.0 Event Investigation

1.1 Why Event Investigation is important

  1. Maintenance was the primary cause of 8.3% of the US accidents in the 1990s for 100+ passenger jets.

  2. A maintenance event started the accident chain in 26% of the worldwide accidents in 2003 for Western- and Eastern-built jets and turboprops.

  3. Worldwide ramp incidents cost $5 billion in 2004.

  4. Event investigation programs help to identify contributing factors to errors and violations and to create corrective actions to prevent future events.

  5. Event investigation is a method for sharing human performance issues within the organization.

  6. Event investigation is a key part of a Safety Management System, required by many National Aviation Authorities (NAAs).