“Our purpose is to improve aviation safety by determining the circumstances and causes of air accidents and serious incidents, and promoting action to prevent reoccurrence.”
As one of a series of interviews with interesting individuals in the aviation industry, Flight Training News met Crispin Orr, the head of the UK’s Air Accidents Investigation Branch (AAIB) at his office near Farnborough Airport.
The AAIB’s headquarters are approached via a foreboding black metal bridge which has seen better days. Perhaps it’s the knowledge that the wreckage of so many aircraft have been driven over that bridge – testimony to so many lives lost that makes the bridge look so unwelcoming. I announce my name and purpose. The security gates open to allow me into the AAIB’s compound, where I park my car and walk into the impressive modern offices. I complete a computerised questionnaire, my pass is issued and exactly on time, I’m greeted warmly by Crispin. “Hello David. How would you like your coffee?”
Crispin talks easily with all his staff. There are some 60 people working at the site and all reporting eventually to him. Covid has increased ‘hybrid’ working and the offices seem fairly empty although the work-load for the branch is still high. The coffee is poured and we then climb the open stairs to the first floor, past a large hanging model of a Nimrod and into his office.
Crispin is a modest, slightly self-effacing man and that is evident in the office’s furnishings with a few personal pictures on the wall, some military wings and a photograph of his family. Crispin is the perfect age for this position - mid fifties. He is married with two grown up daughters. He has maturity and a relaxed manner. He describes himself as a middle-ranking civil servant but this belies his actual standing, since he occupies an office of the very highest importance – Chief Inspector of Air Accidents for the whole of the United Kingdom, (and the Crown Dependencies and Overseas Territories).
Crispin’s background is impressive. His A levels in Maths, Physics and Chemistry led him to a 9-month engagement with the Army equivalent to the Officer Internship of today. This was followed by a degree in Engineering and Management at Durham University. There he joined the University Air Squadron, completing some 100 hours in the Bulldog trainer, flying out of RAF Leeming and from Teesside Airport.
(In later years, he would gain an MSc in Defence Technology from Cranfield University as well as post-graduate qualifications in Safety and Accident Investigation. He became a member of the Royal Aeronautical Society and the Society of Experimental Test Pilots. Crispin now holds the Chair of the European Civil Aviation Conference (ECAC) Group of Experts on Air Accident and Incident Investigation).
He fell in love with flying at University and decided a career in aviation was what he most wanted. He joined the Army where he knew his future would lead to the Army Air Corps and flying battlefield helicopters. Along that path, Crispin graduated from Sandhurst where perhaps he had learnt two of the key skills necessary for running the organisation he now heads – teamwork and leadership. Crispin was clear, though, that in the Army Air Corps one was a soldier first and a pilot second, because it was all about delivering an operational effect.
Crispin continued to fly the Gazelle and the Lynx, obtained command qualifications and flew in Germany and Northern Ireland. He later successfully applied to train at the world-renowned Empire Test Pilots’ School (ETPS) flying many different types of aircraft. He subsequently worked at the Rotary Wing Test and Evaluation Squadron (RWTES) at Boscombe Down following his successful graduation from ETPS in 1994. Learning the skills of a test pilot added another important string to his investigator’s bow.
Over the next 20 years he rotated through various appointments including command of a front-line operational squadron and command of the RWTES. Having investigated his first military air accident in 2003, he later jumped at the opportunity to head up the Military Air Accidents Investigation Branch, finding himself working at Farnborough leading investigations into air accidents across all three Services. In 2015 he established and was the first Head of the Defence Accidents Investigation Branch with an expanded remit to investigate maritime and land accidents, as well as air accidents. At the end of 2016, when the then head of the AAIB left to set-up the Healthcare Safety Investigation Branch, Crispin responded to the job advert for the Chief Inspector role and was delighted to be selected. And so in January 2017, he transitioned from military to civil service and moved upstairs to the prestigious AAIB, one floor above where he’d previously been employed by the military.
So what parts of Crispin’s history have contributed to his position today? His degree brought engineering knowledge; his army background brought teamwork and leadership; his test pilot experience enabled him to identify aircraft safety issues from one end of the telescope and his military accident investigations enabled him to look at accidents from the other end. The transfer from military to civilian was not a difficult one, and it is clear he could not have been more prepared or better suited to his current role.
Crispin’s demeanour is that of an approachable and confident man. He is modest besides, completely clear that the success of the AAIB doesn’t lie with him but rather with the whole team. He is quick to point out that within the Branch there are world experts in almost every area of accident investigation, all working under the Farnborough roof. This has made the AAIB a global centre of excellence which is recognised world-wide. The AAIB is frequently called on to assist with the investigation of accidents in other countries. Crispin points out that this is an important part of the role, because commercial air transport is an inherently international activity, and the effective investigation of accidents, wherever they occur, helps to improve aviation safety for the travelling UK public.
It is important for the aviation community to understand that, although they often work together, the AAIB and the CAA are very separate organisations, albeit each trying to improve safety, and each reporting to the Department for Transport.
Unlike the CAA, the AAIB is not a regulatory body. The AAIB makes recommendations to whichever organisation is best placed to take the necessary action to address the safety issue. This could be the aircraft manufacturer, or the operator, or the regulator.
The recipient is required to respond within 90 days to explain what has or will be done to address the recommendation and that response is published by the AAIB for all to see. Furthermore, the AAIB now monitors the progress of the action then taken in response to each recommendation and so the recommendations cannot be ignored or kicked into the long grass.
Crispin emphasised that the AAIB’s sole purpose is to improve aviation safety. It is not to attribute blame or liability for an accident. This is extremely important to encourage an openness in reporting. He was at pains to emphasise that ‘blame’ is not a word in the AAIB’s vocabulary. Incidents or accidents rarely have just one cause. It’s the AAIB’s purpose to identify the complex interaction of factors which may have caused or contributed to the accident, so that action can be taken to prevent a recurrence.
The analysis of human factors is an important part of this. Human performance is variable and imperfect. When mistakes or errors are made, it is important to understand why, because only then can the equipment, procedures or training be improved to help prevent those mistakes and errors being made again in the future.
Selection for the AAIB is thorough. Technical and soft skills are carefully examined before employment is offered and it is extremely rare for an appointment to go wrong. AAIB investigators fall into four specialist areas:- experts in Operations (pilots), Engineering, Human Factors and Data. All appointees will have significant aviation experience. Pilots will need an ATPL valid in the UK and some ten to fifteen years appropriate experience.
Soft skills are especially important as are an inquisitive nature and an ability to work in a team. All investigators will go through an extended training scheme starting at Cranfield University where a six-week safety and accident investigation course has been developed. But six weeks does not bring qualification and an investigator can expect to train for up to two years before they will be accredited and able to investigate unsupervised. Yes, the AAIB is an inclusive employer and welcomes diversity in all respects.
Each investigator is qualified eventually to investigate accidents involving any aircraft type, whatever their professional background. “This provides a freshness of approach” Crispin asserts, “whilst still being able to call upon the particular expertise of another investigator who might have more experience in that role.” Each specialist discipline maintains an on-call rota. “So if you are top of the list, you could potentially be deployed to any sort of occurrence – commercial air transport serious incident, general aviation fatal helicopter accident, or whatever. That’s one thing about this job, you never know what the next phone call will bring.”
Each investigation goes through a number of different phases culminating in consultation with affected parties before publication of the final report. The consultation is important to ensure the report is accurate and nothing has been missed or misrepresented. Crispin and his deputy review every report and provide final publication approval.
In answer to the question, “Is a good investigator made or born?” Crispin answered that some qualities, certainly the soft skills, one is probably born with, whilst the more technical aspects of the job can be learned. “To be a good investigator you have to have the knowledge, skills and experience, but also the aptitude and the right attitude.”
Liaising with accident victims and their families is a difficult and important part of the job. Again the AAIB treat this area of their job extremely cautiously and sensitively. Crispin is conscious too of the potential for psychological trauma within his own team when confronting some awful scenes and the Branch has an extensive Trauma Risk Management programme supported by experts in this field. “We all have a ‘well of resilience’.” he observed. “That well has only so much capacity and we must be careful to ensure that critical levels are not reached.” Physical health and fitness are also important. Aircraft sometimes crash in inaccessible areas and all investigators undertake remote terrain training in Snowdonia to maintain their ability to operate safely in such challenging environments.
The AAIB has for some years been pioneering the use of drones to gather photographic evidence at the accident site. Crispin believes the UK is also ahead of most other countries in their investigation of drone accidents, and this is becoming an increasingly important part of the job.
If anyone becomes aware of an accident or serious incident involving an aircraft, they have a legal responsibility to report it. There is a 24hr manned telephone line for such reports1. Not all accidents or incidents will receive the same attention from the AAIB. The level of inquiry applied will depend upon a number of factors including the nature of the operation, the seriousness of the occurrence and the scope for lessons to be learnt. The AAIB may simply record the details for statistical purposes, conduct a light touch investigation by correspondence or deploy a team to conduct a full field investigation. Other options include taking no further action or merely informing the relevant sporting association that oversees that type of recreational flying activity.
However, any accident involving fatalities will be investigated, including fatal accidents involving gliders, autogyros and drones. Investigation into autonomous and remotely piloted aircraft is expanding especially with the possibility of electric vertical takeoff and landing (eVTOL) flying machines carrying passengers or goods in urban environments in the not too distant future. Again, our AAIB is well advanced in its knowledge of these new forms of transport.
Not all accidents have to include a fatality to attract the AAIB’s attention. Keen aviators may remember the collapsed nose leg of the 787 at Heathrow. No-one died as a result, but the investigation was nevertheless considered worthwhile.
The AAIB will also investigate serious incidents i.e. occurrences which nearly resulted in an accident. Crispin remarks that “a great deal can be learned from the investigation of serious incidents, and in a sense they are ‘free lessons’ because the underlying safety issues can be identified and addressed before they result in an accident.”
AAIB investigators are not desk-tied observers of aviation-gone-wrong. Instead they are encouraged to fly at least two days a month. Ops Inspectors continue to fly with an airline or commercial helicopter operator. This can be from either seat but normally with a training Captain. This enables investigators to remain up-to-date on the latest equipment, procedures and operational challenges. Crispin emphasised that this is important too for the credibility of the teams.
It’s an absorbing role and many inspectors stay with the Branch until they retire. There is no specific retirement age and Crispin recalled that one inspector retired after forty-eight years of service with the AAIB! But that was exceptional and most of the current cohort of inspectors are in their 40’s and 50’s. It is a demanding role in many respects.
I was interested to learn whether the AAIB is influenced in its reporting either by politics or commercial pressures. Crispin’s response was swift. He maintained that no politician, senior official or industry leader had tried to direct or influence him during his five years as Chief Inspector “it would be a very short conversation if they did”. The branch is staunchly proud of its independence and impartiality and would never allow these things to be compromised. Have reports ever been challenged? Yes, of course and an addendum can be published if necessary. However, errors are normally identified and dealt with during the consultation process. If new and significant evidence comes to light after the report has been published, the investigation can be reopened.
“Has our leaving EASA impacted your job?” In essence, his answer is “no”. Accident investigation is conducted in accordance with a framework of standards and recommended practices set out in Annex 13 to the Chicago Convention to which almost every country is a signatory. Although the AAIB can no longer participate in certain European Union committees, it maintains very close relations with safety investigation authorities across Europe, and indeed across the world. “There is a worldwide community of air accident investigators dedicated to improving safety and we are continually sharing information and experience.” As mentioned, Crispin holds the chair of the European Civil Aviation Conference Group of Experts on Accident and Incident Investigation, which involves 44 European States and is unaffected by Brexit.
On that subject, Crispin explains that any accident involving British passengers (world-wide) is of interest to the UK AAIB. But, as is the norm in aircraft investigations, the state where the accident occurs is responsible for leading the investigation. The State of Occurrence will always invite the State of the Operator, the State of Registration, the State of Design and the State of Manufacture to participate in the investigation. And assistance can be sought from anyone with relevant information, expertise or facilities. Hence the AAIB is often invited to participate in foreign investigations and will do so, where possible, as the purpose is to improve the safety of international aviation.
Crispin stressed that investigators are a community and all work together to improve safety world-wide. Accident investigation authorities are not in competition. The aim is the same for everyone and each authority normally covers its own costs. Industry stakeholders will support investigations in any way they can as they also have a vested interest in understanding how they can improve the safety of their product or their operation. The AAIB also has a wide network of specialists who can be contracted to provide technical support, such as metallurgical examination, flight testing and research. When an aircraft crashes into the sea, the AAIB may commission a specialist survey vessel to help search for and survey the wreckage on the seabed using a remotely operated vehicle, as it did following the accident involving Emiliano Sala. These can be incredibly complex and expensive operations.
That all said, Crispin is a realist. He knows that accidents will never be completely eradicated. But, if he and his team can help to reduce the fatalities and injuries, the AAIB has succeeded. When asked if older pilots had more accidents, he indicated some concerns regarding pilots self-certifying their fitness particularly as they get older. He would also encourage every private pilot to fly regularly with an instructor to maintain and improve their skills. We discussed the age-old conundrum of experience versus age and he emphasised the need to demonstrate proficiency at whatever age.
Crispin emphasised that he regularly worked with his counterparts from different countries and all had the same passion for safety. When asked, how would he improve that safety, were he given total control, he stressed the value of an effective Safety Management System which must operate proactively at the very heart of the company. “Not just box ticking or form filling.” Outside of the commercial world, he would advocate that recreational pilots adopt a pseudo-professional approach to their flying, to preparation, to weather observance, to airspace and to sensible threat analysis. Private pilots should feel no less responsible for flying safely than their commercial partners and periodic practice with an instructor is essential to maintain proficiency.
Crispin asserted that every day at the AAIB is an interesting and a challenging one. The AAIB is in a very privileged position with all the resources and powers necessary to undertake truly independent accident investigation. With this independence comes massive responsibilities and in particular for the head of the section. There can be a lot of pressure when the team are undertaking a high-profile investigation which may have a profound effect on the futures of aircraft manufacturers, airlines and potentially individuals.
Crispin’s belief in team-work and the strength of his organisation resting in the contribution of every employee was inspiring to hear. His budget is adequate but he has to be careful to spend tax-payer’s money wisely and yet achieve the task. His respect and belief in his colleagues were obvious.
We’d spent three hours talking and not once did either of us look at the clock. We could have talked for another three. Crispin’s attitude and love of aviation is infectious as is his conscientious approach to his role. It was a privilege to meet such a dedicated and experienced professional and one we’re very fortunate to have heading up our own Air Accidents Investigations Branch. Yes, he does take work home and yes, he keeps his own licences current.
Thank-you Crispin for your transparency and Flight Training News wishes you every success for the future.
© David Hoy March 2022.