INTERNAL SAFETY INVESTIGATOR for
MO Management System

With the new MO SMS management system, key figures for the management of internal investigative activities on SAFETY enter the MO organization: the INTERNAL SAFETY INVESTIGATOR.

The new core of PART 145 at point 145.A.200 introduces the "Internal investigation" as a key safety management processes and the MO Safety Policy recognise the need for all personnel to cooperate with the compliance monitoring and internal investigations referred to under point (c) of AMC1 145.A.200(a)(3). The new SAFETY MANAGEMENT KEY PROCESSES is based also on Internal investigation. In line with its just culture policy, the MO organisation should 

• define how to investigate incidents such as errors or near misses, 

• in order to understand not only what happened, but also how it happened, 

• to prevent or reduce the probability and/or consequence of future recurrences (refer to AMC1 145.A.202). 

The scope of internal investigations should extend beyond the scope of the occurrences required to be reported to the competent authority in accordance with point 145.A.60, to include the (investigation) reports referred to in 145.A.202(b) "Internal safety reporting scheme". This approach should avoid concentrating the analysis on who was (were) directly or indirectly concerned by the events.

The MO nominated Safety Manager is responsible for ensuring the initiation and follow-up of internal occurrence investigations as indicated in the AMC1 145.A.30 (ca) )vii) and the Investigation process is part of the Organisation’s Safety Programme (as per GM1 145.A.30(e) 10.3).

The MO organisation, should assign responsibility to one or more suitably qualified persons with clearly defined authority, for coordinating action on airworthiness occurrences and for initiating any necessary further investigation and follow-up activity, as indicated in the AMC1 145.A.60. In the MOE at chapter 3.2 the MO define the "Internal safety reporting and investigations" process.

In line with ‘just culture’ as part of the safety policy, as per AMC1 21.A.139(c)(3) and (4), the MO should define how to investigate events such as :

• failure,

• malfunction, 

• defect, 

• error, 

• near miss, 

• hazard, 

• incident, 

• accident, 

• or other occurrence 

in order to understand not only what happened, but also how it happened, as well as to prevent or reduce the probability and/or the consequences of any future recurrence. 

The competency of a MO Safety Manager, as indicated in the GM4 145.A.30(e) d), should include, but not be limited to, an understanding of safety investigation techniques and root cause methodologies.

As indicated in the AMC1 145.A.202, each internal safety reporting scheme should ensure confidentiality and enable and encourage free and frank reporting of any potentially safety-related occurrence, including incidents such as errors or near misses, safety issues and identified hazards. This will be facilitated by the establishment of a just culture.

The internal safety reporting scheme should contain the following elements:

(1) clearly identified aims and objectives with demonstrable corporate commitment;

(2) a just culture policy as part of the safety policy, and related just culture implementation procedures;

(3) a process to:

(i) identify those reports which require investigation; and

(ii) when so identified, investigate all the causal and contributing factors, including technical, organisational, managerial, or human factors issues, and any other contributing factors related to the occurrence, incident, error or near miss that was identified;

(iii) if adapted to the size and complexity of the organisation, analyse the collective data showing the trends and frequencies of the contributing factors;

(4) appropriate corrective actions based on the findings of investigations;

(5) initial and recurrent training for staff involved in internal investigations;

(6) where relevant, the organisation should cooperate with the owner, operator or CAMO on occurrence investigations by exchanging relevant information to improve aviation safety.

The internal safety reporting scheme should:

(1) ensure the confidentiality of the reporter;

(2) be closed loop, to ensure that actions are taken internally to address safety issues and hazards; and

(3) feed into the recurrent training as defined in AMC3 145.A.30(e) whilst maintaining the appropriate confidentiality.

Feedback should be given to staff both on an individual and a more general basis to ensure their continued support of the safety reporting scheme.