Ethics & Good Practices in Accident Investigation & Judicial Proceedings

Air accident investigations and judicial proceedings take place and unfold differently. They belong to different cities, two different territories ruled by contending principles and goals. Accident investigations are, as a matter of fact, citizens of “Safety City,” whereas judicial proceedings are natives of “Justice City.” However, we can agree that trying to coordinate or, at least, connect these two cities is important towards achieving both safety and justice. I will explain the importance in making this connection and the challenges that this connection. I will focus on a different and, maybe, less conventional manner to interconnect safety investigations and the world of justice.

It is easy to spot the differences when comparing safety investigations with judicial proceedings, especially criminal ones, as they display different goals and tools.

The sole aim of accident investigation is to prevent future accidents and, consequently, avoid the apportion of blame or accountability. In contrast, the criminal process is part of the government’s response to a crime, part of a mechanism by which the state applies substantive criminal law to citizens (Ashworth, Redmayne, 2010). Therefore, to determine blame and accountability will be essential for the criminal process. The latter has a secondary aim similar in purpose to that of the accident investigation: prevent future accidents through deterrence. However, it is unanimously agreed that the true effectiveness of this effect is indeed limited (Lawrenson, Braithwite, 2018).

Technical investigations gather and analyse information. They determine the causes or contributing factors and, where appropriate, make consistent safety recommendations (Annex 13, investigation definition). In turn, the criminal process collects pieces of evidence and determines facts to indict and convict a culprit. Considering the existing differences, each procedure must be performed independent of any other procedure or authority; otherwise, intended goals are put at risk and will not be achieved. In this sense, independence is absolute and foundational to each and every function. Standard 3.2 of Annex 13 at the OACI Convention stipulates that states “shall establish an accident investigation authority that is independent from state aviation authorities and other entities that could interfere with the conduct or objectivity of an investigation.” Article 117.1 of the Spanish Constitution states that “Justice emanates from the people and is administered on behalf of the King by Judges and Magistrates who

are members of the judiciary, independent, irremovable, responsible, and subject only to the rule of law.”

Therefore, the questions at this stage are whether these two procedures should or should not coordinate and why. The need for both investigations to be coordinated is unanimously accepted by all parties involved. Despite their separate goals, both investigations look into the same reality, scenario, and facts through different lenses bringing about thoroughly different outcomes. They are, thus, doomed to share findings and cooperate for the sake of their respective objectives. Building trust in each other and in the ongoing performance of inquiries are therefore a must for both authorities.

The loss of mutual trust has negative consequences for technical and judicial investigations alike. This destructive effect works both ways, as it can be observed in the following examples. First example: The deletion of the last seconds of the recording from the Airbus A320111 cockpit voice recorder after the crash at Habsheim, near Mulhouse, on 26 June 1988, while it was under the BEA control and before it was delivered to the judicial authority, ended up ruining the reputation and trustworthiness of the technical authority. As a result, this was the last time that a technical investigation took precedence over a judicial investigation in France (TRÖGELER, 2014). On a related note, during the past two years, safety investigation reports have been used as evidence to convict in criminal proceedings conducted in Switzerland. Both can critically hinder future disposal of safety information (SHAHIDI, 2019).

It seems clear that it is in the interest of the parties in both types of investigations to cooperate and establish an adequate framework to coordinate. Nevertheless, it is still unclear how to best proceed with such coordination. I like thinking about it as if it were a 3D puzzle where we need to assemble a variety of pieces of different shapes and forms. Ethics and best practices are relevant to the final construction, which accommodates parts of the technical and the judicial investigations.

Ethics and best practices aligns with Just Culture. Only when positive norm regulation is enacted, and the concept becomes statute does Just Culture get interwoven into their very fabric. Thus, building this 3D puzzle requires ethics, Just culture, and best practices. Each one possesses their own context, so that it is possible for them to expand their horizons and become successfully connected.

Just Culture and ethics contribute to the definition of substantive criminal law. It is up to a society, through their institutions, to decide what conduct is unacceptable and deserving punishment. Criminal procedure rules should provide that the accused is gua-

ranteed a fair trial; whereas, safety investigation should implement good practices for the management of safety information and the protection of sources. Best practices should also prevent the use of information for purposes other than safety. This would create confidence in each procedure and facilitate the subsequent coordination of investigations, so that the puzzle is successfully assembled.

By respecting the principles and aims of each investigation, with mutual trust, progress can be made in two significant areas of the coordination of both processes. Initially, it will be necessary to coordinate access to the accident site, which may also include access to the collection of evidence and materials, conducting tests or ongoing analyses. Secondly, management of information also requires coordination. More precisely, it affects reports, drafts, notes, statements. Access to information for victims, relatives, and the media must also be part of these coordinated endeavors. Ethics, Just Culture principles, and best practices can be introduced and implemented through an array of instruments.

Legislation is vital to coordination. Norms are binding, despite their limitations, and, in that sense, they help in the effective implementation of best practices and Just Culture. Similarly, effectively implementing Memorandums of Understanding between technical and judicial authorities can advance such best practices and ensure successful coordination. Such MOUs have been developed between the accident investigation branches in the United Kingdom and the Crown Prosecution Service, the Dutch Safety Board and the Dutch Public Prosecution Service (OM), and the CIAIAC and the Ministry of Justice and the Judiciary Council in Spain. These agreements contain procedures and best practices that go further than regulating the specific instances of coordination during the investigation. Finally, education and training, as is the case of the seminars regularly conducted by APROCTA and EUROCONTROL, are essential to gain an understanding of ethics and best practices in safety so that they can be implemented.

In conclusion, I would like to highlight the importance of confidence and trust. We know the difference between the two types of inquiries. Although, it can be agreed that safety and judicial investigations share a common goal: confidence in the findings of the investigation. As a matter of fact, for those participating in the two processes, the purpose of coordinating ethics and best practices is to help ensure that they will provide protection, a sense of safety, and, eventually, the true facts related to the incident. If one of the procedures fails in achieving these goals, the coordination will subsequently fail too.

Summing up, if we are to attain the goals above explained, three different lines of action must be followed: 1. Assume that not everything can be regulated. That would stop the regulatory frenzy we live in and truly foster safety. 2. Make sure that professionals are properly trained, so that we can assess the strength involved in the education of professionals in excellence. 3. Introduce Just culture in two areas: restorative Just Culture checklist (Sidney Dekker) and mediation processes in criminal proceedings.

Both images: Irene Nadal Gómez, Ph. D

• Adela Cortina (2013), ¿Para qué sirve realmente la ética?, Paidós. • Andrew Ashworth, Mike Redmayne, (2010) The Criminal Process, Oxford (4th Edition). • Anthony J. Lawrenson, Graham R. Braithwaite, (2018) “Regulation or criminalisation: What determines legal standards of safety culture in commercial aviation?” Safety Science, Volume 102, Pages 251-262, https:// doi.org/10.1016/j.ssci.2017.09.024. (http://www.sciencedirect.com/science/article/pii/S0925753517316247) • Mildred Trögeler, (2014) “Criminalisation of air accidents and the creation of a Just Culture”, https://eala.aero/ wp-content/uploads/2014/05/Mildred-Tr%c3%aegeler-EALA-prize.pdf • Hassan Shahidi, (2019), “Criminalizing Accidents and Incidents Threatens Aviation Safety” https:// flightsafety.org/asw-article/criminalizing-accidents-and-incidents-threatens-aviation-safety/. y

z Photos (top and bottom) Slides from Irene Nadal Gómez's presentation at the 2020 Just Culture Workshop

Source: Sidney Dekker

Restorative Just Culture aims to repair trust and relationships damaged after an incident. It allows all parties to discuss how they have been affected, and collaboratively decide what should be done to repair the harm.

Have you acknowledged how the following parties have been hurt:

First victim(s) — patients, passengers, colleagues, consumers, clients Second victim(s) — the practitioner(s) involved in the incident Organization(s) — may have suffered reputational or other harm Community — who witnessed or were affected by the incident Others — please specify:………………………………….…………

First victim(s) — information, access, restitution, reassurance of prevention Second victim(s) — psychological first aid, compassion, reinstatement Organization(s) — information, leverage for change, reputational repair Community — information about incident and aftermath, reassurance Others — please specify:………………………………………………….…

First victim(s) — tell their story and willing to participate in restorative process Second victim(s) — willing to tell truth, express remorse, contribute to learning Organization(s) — willing to participate, offered help, explored systemic fixes Community — willing to participate in restorative process and forgiveness Others — please specify:…………………………………………………………

Forgiveness is not a simple act, but a process between people:

Confession — telling the truth of what happened and disclosing own role in it Remorse — expressing regret for harms caused and how to put things right Forgiveness — moving beyond event, reinvesting in trust and future together

Your response is restorative if you have:

Moral engagement — engaged parties in considering the right thing to do now Emotional healing — helped cope with guilt, humiliation; offered empathy Reintegrating practitioner — done what is needed to get person back in job Organizational learning — explored and addressed systemic causes of harm

Public Domain. By Professor Sidney Dekker—Griffith University, Delft University and Art of Work. sidneydekker.com

z Image: Irene Nadal Gómez shared this handout during her presentation at the 2020 Just Culture Workshop. You can download a high-res PDF of this checklist here.