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Aviation History
1948
1948 - 2056.PDF
672 Accident Investigation FLIGHT DECEMBER 2ND, 1948 category of accidents and that the proposed Board shouldhave a discretion to direct such an Investigation in other cases. For the reasons given below this cannot be accepted. As the Committee point out in paragraphs 33 and 80 of theReport, to require a public judicial investigation into every accident is unnecessary and would often be a waste of timeand effort. But the category defined in paragraph 80 and Recommendation X would involve holding public investiga-tions into the great majority of accidents, and would often mean employing an unnecessarily cumbersome and expensiveprocedure which would not be justified by the results. The Committee are themselves anxious to avoid this, as emphasizedin paragraphs 117 and 118. The analysis of accidents given in paragraph 1*9 of the Report covering a selected period isnot truly representative and does not reflect accurately what the Committee's recommendations would involve. The Com-mittee's proposal might necessitate holding some 30 or more public investigations a year, many of them into comparativelytrivial occurrences. The circumstances surrounding accidents to aircraft varyso infinitely that it is not possible to define a category for formal public investigations which would be satisfactory, prac-tical and reasonably logical. Each case must be decided in the light of all the attendant circumstances and the require-ments of the public interest. While it is considered that the right course is for the Minister to decide each case on itsmerits, it has been concluded, after a review of past practice, that there should be more Court Investigations in future andbelow are set out certain specific criteria to which the Minister will give particular attention in so deciding. With regard to the position of the Minister as an " interestedparty" and that of the Chief Inspector of Accidents, which are considered in paragraphs 41 to 49 of the Report, the diffi-culty which the Committee envisaged is theoretical rather than real, as appears from the categorical statements in paragraph 45of the Report. The exercise of what is in a sense a quasi- judicial discretion, in addition to his usual administrative andexecutive responsibilities, is part of the normal functions of a Minister of the Crown and the Committee do not contend thatthere is any risk that the Minister would exercise his discretion dishonestly and decline to direct a public investigation lestmisdeeds of his officers should come to light. Moreover, the fact that the Minister is answerable to Parliament for the exer-cise of his discretion is the best possible safeguard that it is properly exercised. Nor can it be seriously suggested that anInspector of Accidents might so fail in his duty as to conceal blameworthy conduct by employees of the Ministry. It is agreed that at a public investigation, the President ofthe Court should have the assistance of appropriate technical assessors if he so desires, but it is thought to be better thatthe assessors should be appointed ad hoc, rather than from a pre-selected panel, as proposed in recommendation IV. It isimportant that the most suitable persons according to circum- stances should be appointed and that the field of selectionshould not be restricted to a panel. It is not, therefore, pro- posed to accept Recommendations IV and XII. Parts of recommendations XIII and XVI, though with con-siderable modifications, have been incorporated into the new form of investigation procedure explained below. PROPOSED NEW PROCEDUREC OMPLAINTS about the present accident investigationprocedure have largely focused on criticisms: — (a) that too few Court Investigations have been held; (b) that the holding of Inspectors' Investigations in publicis not satisfactory; (c) that blame should not be allocated in Inspectors'Reports to persons who have not had an opportunity of cross-examining the witnesses on whose evidence they arefound to blame or who have not, as in the case of dead pilots, been able to put their case to the Inspector. To meet these points, a new procedure has been evolved.It is thought that this procedure will go far towards meeting the difficulties which the Committee had in mind, while avoid-ing the establishment of an elaborate, cumbersome and costly machine, and leaving the Minister's ultimate responsibility toParliament unimpaired. It has been decided to introduce the following procedure: — Preliminary (i) When the Inspector of Accidents has decided that anaccident requires investigation, he will proceed to make pre- liminary investigations forthwith. At the same time, public notice will be given that a preliminary investigation is takingplace into the cause of the accident, and that any persons interested who desire to make representations as to the cir-cumstances or causes of the accident should do so in writing within a time specified in the notice. (ii) As soon as possible after that time has elapsed, theInspector will report to the Minister indicating (a) whether the preliminary enquiries point to the possi-bility that serious negligence on the part of anybody, in- cluding manufacturer, operators, flying crew, trafficcontrol or otherwise, may have been a contributory cause- of the accident; or (b) whether there was a serious structural failure or;failure of equipment or any other notable occurrence which ought not to have occurred without serious negligence,(iii) On receipt of this preliminary report from the Inspec-' tor, the Minister will decide whether to instruct the Inspectorto complete his investigations to comply with a full] Inspector's Investigation, or to order a Court Investigation. 'In so deciding the Minister will have regard, amongst other! matters, to the criteria indicated above, and also the fol-lowing : — (a) whether the procedure of a public Court Investiga-tion would be more likely than a private enquiry to enable the cause of the accident to be determined; and (b) whether the accident itself was of a sufficientlyserious kind, or attended by other circumstances likely to" disturb public confidence either in the safety of travel by»air or in the manner in which the functions of the Ministry or of the operators are being conducted, regard being hadto any representations made by interested parties as pro- vided for in (i) above. Inspector's Investigations J (iv) Inspectors' Investigations will be held in private.(v) The Attorriey-General, as representing the public in- terest, will be entitled to intervene at any stage of an Inspec-tor's Investigation, if he thinks fit, in order to make representations or to cross-examine witnesses; to this endhe will be provided with a copy of any representations which have been made by interested parties. Arrangements willbe made to keep the Attorney-General informed of all Inspector's Investigations. (vi) Where there is any significant conflict of evidence onan important issue of fact, the Inspector will allow interested parties to cross-examine the witnesses in question, if hethinks that the interests of justice and fairness so require. (vii) The Inspector will not, in his Report to the Minister,attribute blame to any persons unless an opportunity has previously been given to such person, or, if he be dead, thento the legal personal representative of such person, of making any statement or giving any evidence and producing anywitnesses on his behalf, and, unless by reason of the absence of the witness overseas or other good cause it does not seemto the Inspector of Accidents reasonably practicable so to do, of questioning any witnesses from whose evidence itappears that such person was blameworthy. (viii) Where witnesses are being cross-examined before anInspector under (vi) or (vii) above, a representative of the Treasury Solicitor will sit with the Inspector to afford hiiBany legal advice or guidance he may require. (ix) The Inspector's power to summon witnesses and torequire the production of documents in Regulation 5 of the Air Navigation (Investigation of Accidents), 1922, will beextended to correspond with the powers of Court under Regulation 7 (3) (1) (b) of those regulations. (x) Regulation 6 (ii) of the 1922 Regulations (which em-powers an Inspector to include in his Report a recommenda- tion for the cancellation, suspension or endorsement of anylicence or certificate) will be revoked. (xi) Subject to (a), (b) and (c) of paragraph (xv) below.Reports of Inspectors' Investigations will continue to be published as soon as possible after presentation to theMinister as a matter of course when they fall within my predecessor's undertaking to the House of Lords of October24th, 1946, which is set out in Annex C to the Report of the Newton Committee. In addition, any other Report willbe published at the request of any interested party (xii) At any stage of an Inspector's Investigation or aftersuch an Investigation has been concluded, the Minister may order a Court Investigation if he considers the public interestso requires Court Investigations (xiii) These will be conducted by a President appointedfrom a panel of persons with legal qualifications nominated' Continued at foot of next page.) < 2b •••
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