What Is an Investigation in Aviation SMS?

The Essence of an Investigation

In aviation, where every second counts, an investigation is your forensic tool, dissecting incidents to reveal their roots and prevent recurrence. It’s a systematic process, grounded in ICAO Doc 9859 and FAA AC 120-92B, that examines hazards, near-misses, or incidents—be it a runway incursion or a maintenance oversight—to uncover causes and strengthen your Aviation Safety Management System (SMS). Whether you’re a new safety manager probing a hazard report or an accountable executive ensuring ICAO Annex 19 compliance, an investigation is your compass for navigating risks and building a safer operation.

Picture a detective at a crash site, piecing together clues—not to assign blame, but to forge wisdom. That’s an SMS investigation. It’s not about finger-pointing; it’s about extracting actionable insights from data, interviews, and training records to ensure your airline, airport, or MRO never faces the same threat twice.

Why Investigations Matter

The Heart of Safety Assurance

An investigation is the pulse of your SMS, turning chaos into clarity and risks into opportunities. It’s your key to unlocking compliance, fortifying safety culture, and driving continuous improvement. Without investigations, your SMS is blind to its weaknesses; with them, it’s a vigilant guardian of safety. Here’s why they’re critical:

• Ensure Compliance: Investigations align with SMS manual requirements, reducing audit findings by 70%, per 2025 industry benchmarks.
• Mitigate Risks: Root cause analysis cuts repeat incidents by 85%, as seen in a 2024 European airport’s SMS.
• Strengthen Culture: Transparent investigations boost safety culture engagement by 80%, per SMS Pro’s data, encouraging proactive reporting.
• Drive Improvement: Findings fuel lessons learned, enhancing safety assurance processes.
• Build Trust: Rigorous investigations signal to regulators and stakeholders that safety is your priority.

An investigation isn’t just a process—it’s your SMS’s truth-seeker, ensuring every incident becomes a stepping stone to excellence.

Anatomy of an Investigation

Components of a Robust Process

An SMS investigation is a disciplined, data-driven process, not a haphazard review. It’s a structured inquiry, typically documented in 300–500 words, that delivers actionable outcomes for audits and safety cases. Here’s what it entails, per ICAO and FAA standards:

• Incident Trigger: Starts with a hazard report, near-miss, or incident, like a maintenance error.
• Data Collection: Gathers evidence from logs, interviews, and training records.
• Root Cause Analysis: Uses tools like Bowtie analysis or 5 Whys to identify causes.
• Corrective Actions: Proposes corrective actions and preventive measures, tracked via SMS databases.
• Documentation: Records findings in lessons learned libraries for future reference.

It’s rigorous yet accessible, ensuring a safety manager or regulator can act on its insights immediately.

Real-World Impact

Investigations That Transformed Safety

In 2025, a North American MRO investigated a tool calibration error, using Bowtie analysis to pinpoint training gaps. The resulting corrective actions slashed maintenance errors by 80% and informed a safety case that aced a Transport Canada audit. In Asia, an airline’s investigation into a runway incursion uncovered signage issues, leading to a 70% drop in similar incidents after updating policies. A safety manager said, “Our investigations are our radar—they spot risks before they strike.” These cases prove investigations are the engine of SMS resilience.

Mastering Investigations

A Strategic Blueprint

Ready to make investigations your SMS superpower? Here’s your masterclass blueprint:

• Define Scope: Focus on specific incidents or hazards, aligning with SMS goals.
• Collect Data: Use SMS databases and hazard reports for evidence.
• Analyze Causes: Apply risk matrices and Bowtie analysis for precision.
• Implement Actions: Deploy control measures and track via KPIs.
• Share Findings: Distribute via newsletters or read files to boost culture.
• Integrate with Cases: Feed insights into safety cases for audit readiness.

For deeper strategies, explore our safety culture guide, manager tactics, risk mitigation strategies, or four pillars overview.