When people hear that an airplane or helicopter crashed they begin to jump to conclusions. If the weather was stormy they speculate that weather played a role. If a witness reports a perception of a rough-running engine, they speculate that an engine failed. Jumping to conclusions is a less-than-scientific approach to determinations of cause. A successful and reliable mishap investigation requires a thorough and step-by-step approach to reach a scientifically-sound conclusion. An investigation must be pursued with honesty, integrity and trust. Clients, witnesses, and consultants need to know that sound investigation techniques will be utilized and evidence will be carefully preserved.
An initial investigation should determine basic operative facts of an incident and begin the process of preserving evidence. Factual information and physical evidence must be gathered quickly and carefully. After determining initial facts, a proper evaluation team must be assembled. The evaluation team will continue the information gathering process. In addition to ensuring the safe keeping of evidence, the team begins assembling a wide array of information from governmental, academic, scientific and other sources. Inspections of scenes and evidence are scheduled. Scientific evaluation, testing, and destructive testing take place. Test results are communicated. Timelines are assembled and cause and effect analysis begins. Pilot training, qualifications, decision making, performance, and skill are examined. Weather information is reviewed. Route, track, radar and communications information are reviewed. Maintenance information is scoured. Design documents, drawings and specifications are reviewed. Careful analysis leads to the scientific exclusion things that did not contribute to a mishap and to scientific proof of the cause of the mishap. Causes, and the contributing factors to causes, are determined.
The end result of a careful investigation and analysis is a determination of Root Cause. The Root Cause, or causes, are the basic causes that can be scientifically identified to have caused or contributed to cause an incident. In investigating an aviation mishap the determination of Root Cause can determine liability and can lead to reporting and recommendations so that other similar mishaps can be avoided in the future.