The Tribune

By CAPTAIN RANDY BUTLER

Dear Editor,

The Tribune’s front-page reporting on the preliminary investigation into the fatal accident near San Andros on Independence Day understandably raises serious questions for the travelling public and the aviation community. The preliminary information establishes important facts about the aircraft’s final approach and impact sequence, but it does not yet determine why the accident occurred. That distinction should remain central to the public discussion.

A preliminary accident report is not a determination of probable cause, nor should it be used to assign responsibility to a pilot, operator, regulator, maintenance organisation, air traffic service provider or any other person or organisation before the investigation has been completed.

The Aircraft Accident Investigation Authority should be allowed to perform its responsibilities independently, professionally and objectively. Accident investigation serves an essential safety purpose - not the apportionment of blame, but establishing what occurred, understanding the circumstances and contributing factors, and identifying lessons capable of preventing recurrence. At the same time, prevention should not begin only when the final report is published.

The absence of a final ‘probable cause’ determination does not prevent the wider aviation system from examining whether existing surveillance information, occurrence histories, maintenance data, operational trends and other safety intelligence reveal risks that warrant attention now. A mature aviation safety system continually asks whether information already available to the state could reveal emerging risks. Accident and incident reports, surveillance findings, maintenance information, operational events, confidential safety reports and other safety data should not simply remain in separate files. Collectively, they should contribute to an integrated picture of national aviation risk.

This requires us to ask important questions:

* Are recurring accidents and incidents being analysed for common trends?

* Are operators receiving surveillance appropriate to their operations and risk profiles?

* Are aircraft maintenance and continuing airworthiness programmes being effectively monitored?

* Are inspectors sufficiently trained, experienced and resourced?

* When safety concerns are identified, is corrective action followed through and verified as effective?

* And are the regulator, accident investigation authority, air navigation services, airports and operators exchanging safety information effectively enough to recognise developing risks before they result in another serious occurrence?

These are not accusations against any organisation or individual. They are questions that an effective State Safety Oversight System should routinely ask of itself. Certification is an essential part of aviation regulation, but certification alone does not guarantee continuing safety performance. An Air Operator Certificate, Certificate of Airworthiness, licence or other approval confirms that established requirements have been satisfied at a particular point in the regulatory process.

The greater responsibility is ensuring that those standards continue to be met through effective surveillance, competent personnel, sound maintenance, training, operational discipline, occurrence reporting, risk analysis and timely corrective action. The tragedy in Andros should therefore encourage a broader national discussion focused not on premature blame, but on prevention.

The families who lost loved ones deserve a thorough and independent investigation. The aviation community deserves the opportunity to learn from its findings. And the travelling public deserves confidence that legitimate safety lessons are identified and acted upon. We owe those families something more meaningful than speculation. We owe them learning. We owe the travelling public effective oversight. And we owe future passengers and crews a commitment to use safety information before another accident occurs. The ultimate measure of an accident investigation should not simply be whether we eventually understand the accident that happened. It should be whether what we learned helps us prevent the next one.

Respectfully,

Captain Randy L. Butler, ATP principal consultant

Aviation Safety & Security Consultants Ltd

Former aviation safety inspector