This paper was published in two parts in the ISASI forum, October 1991 (24:3) and March 1992 (25:2). Reprints are available from the International Society of Air Safety Investigators, 107 E. See the Investigation QA Tutorial that accompanies this paper for implementation guidance and FAQs.
In his paper presented at the 1990 ISASI Seminar, Mr.
To avoid bias, the investigator must search for and attempt to accommodate every available item of surviving data before deciding its relevance.
(This process must include accommodation of the absence of expected data, which may in itself be a significant item of data! An investigator cannot append a smashed aircraft or component to the report.
The accident objects, conditions and properties must be observed, and the observations transformed into data in a format which documents accurately a description of what happened.
Data transformation is required to organize the data into a framework which will permit integration from numerous sources.
If an accident generates no data, you have no means for determining what happened. The fourth essential input is observations of the accident data.
However, it is critical that data not be filtered or discarded prior to hypothesis testing.
Early efforts to develop quality standards and controls required that needs be identified by direct observations of quality management efforts at the NTSB and other organizations.
The general systems model provides orderly guidance for observing quality control efforts.
The need was reinforced in other research during a review which identified investigation models and objectives in most major U. Government accident investigation processes, and an assessment of the quality of their results.
(Benner, 1983) This review of seventeen investigation program guidance documents disclosed little, if any, requirement for quality controls.