Wellington Branch Meeting

Safety Investigation at the New Zealand Civil Aviation Authorityby Jim Burtenshaw & Dan Foley


WHEN: Thursday 22 August, 5:30 for 6:00pm start
WHERE: Xero Building, corner of Wakefield St/Taranaki St,19-23 Taranaki St, Level 3, Wellington

"Hindsight is a wonderful thing but foresight is better, especially when it comes to saving life, or some pain!"
~William Blake

Aviation safety has seen major improvement over the last century due to the undertaking of safety investigations. The early focus was towards technical issues, with developments in design and manufacturing providing improved reliability.

As safety investigation matured the focus shifted towards understanding human error. Leading to crew resource management, CRM. We then began to understand that organisational latent factors were contributing to accidents. (Swiss cheese model).

Traditional investigation approaches are effective at identifying what barriers failed and what particular set of circumstances led to the accident.

As a risk-based regulator the CAA uses the themes and systems safety investigation (TSSI) methodology to help it understand complex problems.The Civil Aviation Authority of New Zealand (CAA) conducts approximately 300 event-based safety investigations annually from a reported 9500 occurrences. The benefits that can be gained from these event-based safety investigations however, have their limitations. It is considered greater safety benefits can be realised beyond the constraints of the causal chain of events. As such the CAA has developed a TSSI methodology.

As a regulator, the ultimate aim of the CAA is to improve aviation safety before accidents happen, rather than retrospectively after they occur. As such, the safety investigation unit at the CAA has been developing an approach that is more proactive rather than reactive. To this end we have developed the themes and systems safety investigation (TSSI) which complements and works simbiotically with the traditional event-based, Annex 13 type investigation which still forms a crucial part of our work. In this presentation, we outline the process of initiating and conducting proactive themes and systems safety investigations, and the benefits such investigations can deliver. We describe the TSSI approach and explore the indicators that point towhere such an approach is warranted. We provide practical examples of the application of the themes and investigation methodology the New Zealand aviation system.

Jim Burtenshaw (Yes Errol –Beau -Burten shaw is his farther) started his working life in the RNZAF has a Technician and completed his New Zealand Certificate of Engineering in Aeronautics. He then commissioned to engineering officer and completed two aeronautical engineering diplomas at the Royal Melbourne Institute of Technology. During Jim’s time in the RNZAF he completed two tours on Number 40 SQN and was seconded to the New Zealand Ministry of Defence to work in the Boeing 757 Upgrade Resident Project Team (RPT) in Alabama for three years. One of Jim’s engineering highlights of his career was designing, manufacturing, and operationally testing a camera pod on the centre line bomb rack of the A4K Skyhawk. Jim completed a Bachelor of Aviation Management Degree focusing on human factors and aircraft accident investigation, part-time whilst working in the RNZAF. In 2015 Jim retired as a Squadron Leader from the RNZAF, to take up his current role as Manager of the Safety Investigation Unit at the CAA. Since his time at the CAA Jim has influenced a number of safety initiatives including: the development of a combined wire safety message with Worksafe, the ACC, New Zealand Federated Farmers and the CAA, making the industry led Down To The wire (DTTW) campaign from a local based one to a National Based one, and the development of the CAA Themes and Systems Investigation Methodology. Jim is a member of the Royal Aeronautical Society and the International Society of Air Safety Investigators.

Dan Foley has spent 13 years as a Safety Investigator with the New Zealand CAA. He has a tertiary qualification in mechanical engineering, is a fixed wing aircraft instructor, Commercial Transport Pilot, and was an international calibration and commissioning pilot. He is a member of the International Society of Air Safety Investors. Dan co-developed the Civil Aviation Authority of New Zealand’s Themes and Systems Safety Investigation methodology. Dan’s work acknowledges that complex systems such as aviation, need to be explored from a different perspective to those traditionally used. His work has enabled aviation system risks to be identified, providing clarity and understanding of the risks.


Report by John Cook

Considering the size of the CAA in number of people, it was interesting to hear that there are only 9 safety investigators. I often wondered why they were not called air accident investigators in a similar way that the UK and USA refer to theirs; however, the presentation eluded to the fact that CAA is focussed on safety related to aviation systems as muchas it was involved in post crash investigations. This included the themes and systems safety investigation (TSSI) methodology that Jim Burtenshaw and Dan Foley focussed their presentation on.

In essence, they were using TSSI to move from the ‘ambulance at the top of the cliff’ scenario to a ‘fence’ between the regulator and the operator. The aim is to work closer with the operator and help, through data analysis, to show the operator likely areas of system failure that could lead to an accident or safety related incident. In other words, enable the operator to have more foresight rather than act in hindsight. It is also fortunate that the CAA is data rich across all of its operators.

Jim and Dan used many theories related to the human in the loop philosophy. They explained that the traditional approach to accident investigation was often outcome focussed. Within TSSI, the focus is on humans preventing accidents, where human error is a symptom. From a hindsight focussed approach, the aim is to understand why something happened. TSSI is a proactive approach. So event investigation is reactive and TSSI is proactive, taking a system-wide view to problem solving..EVENT –THEME –SYSTEM = problem intervention consequence on the system.

TSSI understands the problem from different perspectives and how the system really works.TSSI provides clarity to a problem, where human error is treated as a symptom and not a cause.This was an excellent presentationand a pre-cursor for a global presentation to a wider body of accident investigators in the Hague.For more information www.caa.govt.nz/resources/TSSI/index.html



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