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Aviation safety experts have realized for some time that aircraft incidents and accidents almost always result from a series of events, each of which is associated with one or more cause factors. Thus, the cause of an accident or incident has many aspects. Some internationally accepted definitions in the context of the investigation of an aircraft accident or incident are listed below (ICAO, 1994):
Causes are actions, omissions, events, conditions, or a combination thereof, that lead to an accident or incident.
Accidents are occurrences associated with the operation of aircraft, from the time any person boards an aircraft with the intention of flight until the time all persons have disembarked, that results in one or more of the following:
A person is fatally or seriously injured.
The aircraft sustains damage or structural failure that adversely affects the structural strength, performance, or flight characteristics of the aircraft and would normally require major repair or replacement of the affected component.
The aircraft is missing or completely inaccessible.
Incidents are occurrences, other than accidents, associated with the operation of aircraft that affect or could affect the safety of operation.
The definition of cause given above takes into account the many events involved in an accident or incident. These events can be viewed as links in a chain. Investigations of some hull loss accidents in the United States have revealed as many as 20 links in the chain; the average is just under 4 links.1 For example, after an exhaustive technical and legal investigation into one controlled flight into terrain (CFIT) accident, an official commission concluded that at least 10 essential cause factors were involved.2 If any one of these 10 cause factors had not been present, or if some of the factors had occurred in a different order, the accident would not have happened. The most effective accident prevention strategy must take into account all the links in the chain of events that lead to incidents and accidents.
Subdividing an incident or accident into a chain of events reveals important information. If one more element is added to the chain in an incident, for example, the consequences of the incident might be much more serious, even resulting in an accident. Conversely, removing one link in the accident chain could substantially mitigate the consequences or, possibly, prevent all adverse consequences. In other words, from a safety management viewpoint the only meaningful difference between many incidents and accidents is the consequences.
For example, an aircraft may experience several abnormalities involving equipment malfunction, unexpected adverse weather conditions, and loss of situational awareness by the flight crew. As a result, the aircraft may take longer than expected to slow down after landing. If the aircraft happens to be landing at an airport with runways of the minimum required length with water hazards at the end, there could be a catastrophe. The resulting investigation might lead to a comprehensive review of procedures and systems related to approach and landing. If the same sequence of events happened at an airport with runways of the minimum required length but with a grassy field at the end, the aircraft might run off the end of the runway and experience minor damage and no crew or passenger injuries.