ABSTRACT
Accident investigation is a sense-making activity, a way of understanding events that frighten us, and, hopefully, finding ways to reduce the risk of those events in the future. Due to the disciplinary diversity, accident investigation is also a team activity, and the National Transportation Safety Board (NTSB) has developed an organizational framework based on these technical specialties to impose order on the process. Investigative work is divided up by working groups led by an investigator from each technical specialty. Air traffic control investigators examine air traffic operations in towers and centers. Aviation safety professionals have long recognized the need to look beyond pilot error to understand aviation safety issues. The commercial aviation safety team's efforts have been complementary to the rise of the safety management system, a paradigm that involves managing safety by measuring safety indicators so that it can be controlled like other business processes.
