Piper PA-31-350 Chieftain VH-WGI, Launceston Tasmania, 17 September 1993

The main purpose for investigating air safety occurrences is to prevent aircraft accidents by
establishing what, how and why the occurrence took place, and determining what the
occurrence reveals about the safety health of the aviation system. Such information is used to
make recommendations aimed at reducing or eliminating the probability of a repetition of the
same type of occurrence, and where appropriate, to increase the safety of the overall system.
To produce effective recommendations, the information collected and the conclusions reached
must be analysed in a way that reveals the relationships between the individuals involved in the
occurrence, and the design and characteristics of the systems within which those individuals
operate.