International Civil Aviation Organization - coscapsa.org Accident Investig… · Web viewThis document provides a brief explanation on the material developed to assist States with

Model Accident Investigation Manual for

States with Limited Aviation Activity

Implementation Template

This document provides a brief explanation on the material developed to assist States with limited aviation activity and resources to meet their obligations related to the investigation of aircraft accidents and incidents, in accordance with the Chicago Convention and ICAO ANNEX 13. The outputs will also assist Member States efforts to comply with the best practices of the GLOBAL SAFETY INITIATIVE 4 - EFFECTIVE INCIDENT AND ACCIDENT INVESTIGATION contained in the ICAO GLOBAL AVIATION SAFETY PLAN and ISSG ROADMAP

Model Accident and Incident Investigation Table of Contents

CONTENTS

Introduction........................................................1 Purpose...............................................................32 Background.........................................................33 Accident and Incident Investigation Model Law and Regulations 44 Accident/Incident Investigation Organization and Procedures Manual 4

Organization and Structures...........................11 Designated & Trained Personnel........................12 Availability and Development of Investigators. .13 Accident and Incident Reporting........................24 Accident Investigation Response Plan................25 Accident Notification Procedures.......................26 Security of Aircraft Wreckage and Recorders....37 Impounding Records...........................................38 Equipment Maintained for Accident Investigation 39 Risk Assessment.................................................310 Notification of Other States..............................311 Accredited Representative Duties.....................312 Options Available To [STATE] For Accident Investigations 413 Accident Investigation Process for [STATE].....614 Funding of Investigative Activities..................715 [STATE] Reporting System and Database Management 716 Covers All Operations Within [STATE]............717 Standardized Format.........................................718 Contact information & Publication...................7

Policies and Procedures...................................11 Accident Notifications........................................12 ANNEX 13 Notifications of Other States.............13 Wreckage Security & Protection of the Recorders 24 Initial Actions at the Accident Scene..................25 Delegated Accidents...........................................36 Completing the On-Scene Investigation.............37 Reports................................................................48 Safety Recommendations...................................49 Additional Subjects.............................................4

Appendix A: Overview of Investigation Groups and Functions 12 Structures Group-................................................23 Operations Group-..............................................24 Powerplants Group.............................................25 Systems Group....................................................36 Maintenance Group............................................47 Survival Factors Group.......................................48 Airports & Emergency Response Group............49 Human Factors Group.........................................510 Aircraft Performance Group.............................511 Simple Investigation Group Organization........712 Sample Accident Investigation Timeline..........813 Accident Investigation Timeline In Practice....9

Appendix B: Notification Form....................10

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Model Accident and Incident Investigation Foreward

FOREWARD

1 Purpose

1.1 Aircraft accidents are, fortunately, rare occurrences. Advances in technology and training have greatly reduced the accident rate over the past years and air transport has become one of the safest modes of travel in most of the world. However, when an accident does occur, the State of Occurrence is faced with both maintaining the evidence of the accident and performing an independent and thorough investigation into the reasons for the accident. The State of Occurrence can expect that other States specified in ANNEX 13, such as the State of Manufacture and the State of the Operator, will have a detailed interest in the accident and those States will expect the actions by the State of Occurrence to conform to the procedures specified by ANNEX 13. Also, because of the increases in communications technology, the international news media will quickly be pressing the State of Occurrence for details on the accident and the investigation the State of Occurrence is doing. While the international news media does not understand the procedures in ANNEX 13, they do know what they have observed previously in other States and will expect an accident investigation similar to what they have seen in other States. States that are not prepared to initiate an investigation properly under ANNEX 13 run the risk of very negative international publicity.

1.2 The purpose of any aircraft accident investigation performed under ANNEX 13 is not to apportion blame or generate disciplinary measures. Instead, the investigation is an objective collection of the facts and circumstances surrounding the accident which can then be analyzed to generate safety improvements. The three main objectives of the investigation are:

a) Implement the Standards and Recommended Practices contained in ANNEX 13 to the Convention on International Civil Aviation (Chicago Convention)

b) Conduct independent and objective investigation of accidents and incidents in accordance with the State law and international best practices

c) Promote aviation safety through the investigation of accidents and incidents and the identification of safety deficiencies so that accidents may be avoided in future.

2 Background

2.1 The ICAO USOAP programme under the Comprehensive Systems Approach has identified that many States have not established legislation, regulations, policies, and procedures to meet their obligations related to ICAO ANNEX 13 and implement an effective investigation system. In addition, USOAP audits have established that many States have significant shortfalls in trained staff and lack independence in the conduct of accident and incident investigations.

a) It is recognized that States with limited aviation activity have a lower probability of an accident or a serious incident. Even if such States have established a fully capable Accident Investigation Bureau (AIB), it is challenging for the staff of the AIB to acquire the experience that would facilitate the conduct of investigations, particularly major investigations.

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b) States with limited resources will find it more difficult to establish and implement the critical elements of an aircraft accident and incident investigation system. However, since the State of Occurrence is responsible for any accidents in their territory, it is very important that those States establish procedures ahead of time to insure that those accidents are handled properly. There are several options discussed in this document which are available to all States but they are particularly helpful for States with limited resources. These options include delegating all or part of the investigation to another State, and the use of a Memorandum of Understanding (MOU) for cooperatively using regional resources or the resources of a single State for assistance in investigations. Such MOUs would, among other things, eliminate the duplication of efforts by States concerned. To this end, ICAO issued a model MOU in 2007 to be used by States in respect of aircraft accident and serious incident investigations. Such model MOU is available for States and can be found on the FSIX website (http://www.icao.int/fsix/ )

2.2 Reference Material

Mindful of different needs in States with regard to aircraft accident and incident investigations, ICAO has issued numerous associated guidance materials which States should be encouraged to refer to:

a) Guidance addressing the organization of an investigation, including the structure of an Accident Investigation Authority, is provided in the Manual of Aircraft Accident and Incident Investigation, Part I - Organization and Planning (Doc 9756);

b) Guidance addressing occurrence reporting is provided in the Manual of Aircraft Accident and Incident Investigation, Part IV - Reporting (Doc 9756);

c) Guidance on investigations as a whole is provided in the Manual of Aircraft Accident and Incident Investigation, Part III - Investigation (Doc 9756). It is noted that this Part has recently been updated.

3 Accident and Incident Investigation Model Law and Regulations

3.1 The Accident/Incident Investigation Model Law and Regulations should be adapted by States to enable them to fully implement the SARPs contained in ICAO ANNEX 13. In adapting these Laws and Regulations, States should take into account the national/local environment, including aspects of their legal and judicial systems that may limit their ability to fully meet some of the provisions contained in ICAO ANNEX 13, especially those contained in paragraph 5.12 therein. Use should also be made of relevant ICAO guidance material covered in items 2.4 and 2.5 above

4 Accident/Incident Investigation Organization and Procedures Manual

4.1 The content of the manual is based on the provisions of ICAO ANNEX 13 and the related guidance material. While this manual refers to “accidents”, the intent is that the same procedures will be used for incidents as well. This Model Accident and Incident Manual uses terms in a manner consistent with the definitions contained in ANNEX 13, chapter 1. Throughout ANNEX 13, the term “shall” is used to designate an ICAO Standard and the term “should” designates a Recommended Practice. In a similar manner, the use of the term “shall” in these manuals to designate essential investigative activities and “should” designates recommended investigative practices.

4.2 As it is recognized that it may not be feasible for States with limited aviation activity to establish and maintain a full time dedicated Accident Investigation Bureau, the manual describe the possible investigation organizations/structures to be in place by such States to ensure the best possible level of compliance with the provisions of ICAO ANNEX 13, and in particular to ensure independence in the conduct of accident and serious incident investigations.

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4.3 The system described in the manual may depend upon a State establishing a formal MOU with other States and/or organizations, either for the provision of technical assistance or for the delegation of some or all accident and serious incident investigations. The system described in the manuals may also depend upon a State entering into an agreement with other States to form a regional/sub-regional pool of aircraft accident and incident investigators (available to all these States), or even a regional/sub-regional aircraft accident and incident investigation authority.

4.4 The intent of this manual is not to duplicate the material contained in ANNEX 13 or the ICAO Manual of Aircraft Accident and Incident Investigation, but to provide an overview of the options available to States with limited aviation activity or resources for investigating accidents within their State that complies with ANNEX 13. This is done in the form of a generic template that can be customized by a State to fit individual situations.

4.5 Irrespective of any agreements a State may make with any other State or organization, the State of Occurrence will need to have trained staff available and procedures in place to ensure that the wreckage is secured and other evidence is maintained until the formal investigation begins. The Manual addresses the training options and qualifications for the technical staff that will be accomplishing these tasks. The Manual also provides the necessary policies, procedures and checklists to assist the relevant staff in fulfilling their duties, from the initial notification of the accident or incident, up through the completion of the final investigation report.

4.6 The manual can be used as a template by inserting the applicable data into the bracketed areas and modifying the text to comply with individual State requirements. Text that is in italics is a note that amplifies the preceding material, and can be left in the template or deleted as individual States prefer.

The following template items should be edited by the individual State as applicable:

[24 HOUR CONTACT INSTRUCTIONS]

[AGENCY MAINTAINING THE DATABASE].

[CONTACT INFORMATION FOR SAFETY REPORTING]

[DESIGNATED MANAGEMENT POSITION AT THE STATE ACCIDENT INVESTIGATION AUTHORITY]

[DESIGNATED MONETARY AMOUNT]

[DESIGNATED POSITION AT THE STATE INVESTIGATION AUTHORITY OR OTHER DESIGNATED PERSONNEL]

[DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY]

[DESIGNATED REPRESENTATIVE FOR THE STATE ACCIDENT INVESTIGATION AUTHORITY]

[DIRECTOR GENERAL FOR STATE ACCIDENT INVESTIGATION AUTHORITY]

[EXISTING MOUS, IF ANY, SHOULD BE ATTACHED TO THIS DOCUMENT]

[INVESTIGATION RUN WITH [STATE] IIC/FULL DELEGATION/PARTIAL DELEGATION/MOU/REGIONAL COOPERATION]

[LEGISLATION OR REGULATION REFERENCE]

[LOCATION]

[METHOD OF PUBLICIZING SAFETY REPORTING SYSTEM CONTACT DATA].

[NAME OF INDIVIDUAL OR ORGANIZATION]

[PROCEDURES FOR ACCESSING EQUIPMENT]

[SPECIFIC STATE LEGISLATION AND REGULATION REFERENCES]

[STATE ACCIDENT INVESTIGATION AUTHORITY]

[STATE DESIGNATED POSITION FOR THE STATE SAFETY INFORMATION DATABASE]

[STATE]

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Model Accident and Incident Investigation Organization & Structures

ORGANIZATION AND STRUCTURES

1 Designated and Trained Personnel

[STATE] shall have within [STATE ACCIDENT INVESTIGATION AUTHORITY] personnel that are both designated and trained to receive internal notifications within [STATE], as well as notifications to other States such as the State of Manufacturer and the State of the Operator. These personnel shall be prepared to ensure the security of evidence, including recorders, at an accident scene, as well as impounding the applicable operator and flight documents in a timely manner.

Note: The investigation of an aircraft accident requires very specific investigative skills. Even staff with extensive aviation backgrounds will not be able to effectively do an investigation without proper training and experience in the areas covered by the MANUAL OF AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION, PART III - INVESTIGATION (DOC 9756). However, personnel shall be designated and trained to handle, at a minimum, the initial aftermath of an accident.

2 Availability and Development of Investigators

[STATE] shall have a sufficient number of staff members designated as accident investigators, so that there shall be always at least one investigator available at any time. The training and experience required of these investigators is directly dependant on the extent of the investigation [STATE] intends to perform with [STATE] personnel.

2.1 Initial Training

At a minimum, these designated investigators shall have received at least two weeks of formal training on basic aircraft accident investigation procedures provided by a government accident investigation agency, university, or other comparable organization. This training is not intended to qualify the designated investigators as fully qualified investigators, but only to provide an overview of accident investigation sufficient for the designated investigator to perform the essentials duties listed in this manual. This function is not dependent on a single staff member; there always needs to be alternate staff available in cases where the primary investigator is not available.

Note: There are several investigator training programs sponsored by government

organizations, universities, and comparable organizations. Any of the programs that have a formal, structured curriculum covering the principles and procedures of basic aircraft accident investigation shall be sufficient for staff new to investigations provided the program follows the guidelines of ICAO CIRC 298, TRAINING GUIDELINES FOR AIRCRAFT ACCIDENT INVESTIGATORS. The accident investigation courses sponsored by some of the States with large accident investigation staffs are particularly recommended for [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY]. These courses, which are generally taught by active investigators from those States, expose the new [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] investigator to the principles of accident investigation. They also provide an opportunity for the new investigator to make personal contacts with investigators from other States that they may be working with in the future. Establishing this kind of personal relationship with other active investigators prior to an accident makes any actual post accident coordination much easier. It also provides an informal network of active investigators that can later be used to provide the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] with valuable technical expertise and insights.

2.2 Recurrent training

Recurrent training may consist of any or all of the following:

a) formal classroom training;

b) attending accident investigation seminars or workshops; or

c) on-the-job experience as an Investigator in Charge (IIC) or group chairman in an accident investigation or serious incident investigation.

While it is recommended that the recurrent training occur on an annual basis, the minimum recurrent training for an investigator to maintain the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] status is at least one week of training or experience every three years.

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Preference for recurrent training shall be given to regional workshops and other programs that involve the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] directly in the discussion of investigative techniques rather than attendance at programs that are not interactive.

3 Accident and Incident Reporting

[STATE] requires the mandatory reporting of accidents and incidents as specified in [SPECIFIC STATE LEGISLATION AND REGULATION REFERENCES]. All reported cases shall be immediately provided to [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY]. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall transmit this information to the [STATE DESIGNATED POSITION FOR THE STATE SAFETY INFORMATION DATABASE] in a timely manner.

4 Accident Investigation Response Plan

This Accident Investigation Response Plan for [STATE] is based upon [SPECIFIC STATE LEGISLATION AND REGULATION REFERENCES]. This plan has been approved by [DIRECTOR GENERAL FOR STATE ACCIDENT INVESTIGATION AUTHORITY] so it can be implemented immediately after an accident. This plan details the response to an accident or incident

a) within the territory of [STATE] ;

b) for an operator registered in [STATE] that has an accident or incident over international waters;

c) international accidents that [STATE] participates in under ANNEX 13;

d) communication procedures within [STATE] and with other States;

e) who is going to perform which functions during the investigations; and

f) how that process shall work, and who is responsible for accomplishing the various coordinations, if [STATE] decides to delegate many or all of the investigation functions

Note: Without this pre-planning and approval, even the best response plan will likely be ignored during the aftermath of an accident. Therefore, [Director General for State Accident Investigation Authority] has already approved of this plan prior to an accident so that the plan can be immediately implemented by the designated individuals when an accident or serious incident

occurs. While [STATE] shall have options for how to handle an accident based on the circumstances of that particular accident, the criteria for making that decision have been established ahead of time.

5 Accident Notification Procedures

The designated notification contact for [STATE] is [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] who can be contacted at [24 HOUR CONTACT INSTRUCTIONS]. The alternate notification contact is [NAME OF INDIVIDUAL OR ORGANIZATION] who can be contacted at [24 HOUR CONTACT INSTRUCTIONS]. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall use the notification checklist in APPENDIX B: NOTIFICATION FORM as a guideline to obtain as much information as possible during the initial notification.

5.1 Established Communication Procedures

The [STATE ACCIDENT INVESTIGATION AUTHORITY] within [STATE] shall establish communication procedures to insure that they always receive a timely notification of any accident. The [STATE ACCIDENT INVESTIGATION AUTHORITY] shall take the initiative to confirm that other organizations have current contact information for [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY], and know their responsibilities for reporting an accident. Notification procedures within the State shall be designed so that there is always an alternate means of communicating timely information from knowledgeable sources such as air traffic facilities, police, fire or other government organizations accident notification to the [STATE ACCIDENT INVESTIGATION AUTHORITY] in case the primary means of communication fails.

5.2 Internal Notifications & Notification of Other States

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] responsible for dealing with the accident investigation shall be responsible for notifying the applicable management people within [STATE ACCIDENT INVESTIGATION AUTHORITY], performing the initial actions to secure the wreckage, and doing the notifications of other States as required by ANNEX 13.

Note: The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] that receives an accident notification has the authority

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to speak for [STATE ACCIDENT INVESTIGATION AUTHORITY] and spend the amount specified in this manual, to insure that the initial stages of the investigation are done properly.

6 Security of Aircraft Wreckage and Recorders

Upon notification of an accident, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall confirm security of the wreckage in order to ensure that the following takes place:

a) The components of the aircraft remain in their original condition as much as possible so that perishable data might not be lost.

b) The wreckage is not disturbed once the rescue and fire fighting operations are completed.

c) Electrical power has been removed from all recorders so that information will not be lost.

7 Impounding Records

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall ensure that all aircraft, crew, and air traffic records are secured after being notified of an accident. Any records, either written or electronic, that may be related to the aircraft, crew, dispatch, weather, or air traffic shall be impounded for later access by the investigation team.

Note: Wreckage security and impounding records can be a difficult task. However, coordination with other government agencies and operators ahead of time can simplify this duty. It is not sufficient for the investigator to assume that someone else is going to take care of the aircraft wreckage security and other information like airmen records, maintenance records, dispatch documents and air traffic control information. The investigator needs to either personally confirm the security of these items or directly arrange for that security.

8 Equipment Maintained for Accident Investigation

The equipment available for accident investigation is stored at [LOCATION] and accessible by [PROCEDURES FOR ACCESSING EQUIPMENT]. The equipment maintained by the [STATE ACCIDENT INVESTIGATION AUTHORITY] is dependent upon the depth of the investigation contemplated by [STATE]. At a minimum, the following should be included:

a) a digital still camera;

b) communications equipment;

c) GPS; and

d) personal safety and protective equipment.

Note: A digital still camera shall be available for the preliminary documentation of the accident scene. These photographs can then also be transmitted in a timely manner to the accident investigation team.

9 Risk Assessment

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall do an initial risk assessment for the potential hazards associated with the investigation. This assessment shall be an objective review of the working conditions at the accident scene that can be provided to the investigation team. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall update that assessment as necessary as new information is received or conditions at the accident scene change that significantly change the risk assessment.

10 Notification of Other States

Anytime that there is an accident involving products or operators outside the State of Occurrence, the State of Occurrence is obligated to notify the other applicable States. ANNEX 13 provides a complete list of the States that need to be notified. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall give particular attention to timely notification of the States that may potentially be providing Accredited Representatives and Technical Advisors to assist in the investigation.

11 Accredited Representative Duties

When an accident involving a [STATE] operator (or other categories specified by ANNEX 13) occurs in another State, [STATE] shall provide an Accredited Representative as specified by ANNEX 13.

11.1 The Accredited Representative

a) serves as the link between States

b) represents his own government in the investigation

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c) collects information requested by the Investigator-In-Charge (IIC) for the State of Occurrence

d) provides information to his own State from the IIC

e) may designate Technical Advisors as appropriate to help support the investigation being done by the State of Occurrence

The Accredited Representative may also make submissions to the State of Occurrence on the report of the accident. The State of Occurrence may either incorporate the submission into the report or append it to their report if they disagree with the submission. While there may be some variation in the way ANNEX 13 is applied by various States, it is the basis for international cooperation in an accident investigation. It is highly desirable that States develop relationships with the other States that are likely to be providing Accredited Representatives before an accident happens.

11.2 The Technical Advisor

a) works for his Accredited Representative;

b) provides technical expertise; and

c) may provide testing, recorder, or simulator assistance.

Note: It is important to note that the coordination between States is always between designated government representatives serving as accredited representatives. The Technical Advisors are working for their respective Accredited Representative. Technical Advisors are there to provide technical expertise, testing facilities and recorder or simulator assistance. Even if an Accredited Representative does not travel to the State of Occurrence, the States of Manufacture and Operation are still obligated under ANNEX 13 to provide relevant information to assist in the investigation. This may involve the travel of the Technical Advisors even when the Accredited Representative doesn’t travel.

11.3 Actions

Under ANNEX 13, Accredited Representatives and Technical Advisors are entitled to do the following:

a) visit the site;

b) examine the wreckage;

c) obtain witness information;

d) have full access to all relevant evidence as soon as possible;

e) receive copies of pertinent documents;

f) participate in readouts of recorded media;

g) participate in follow-up activities;

h) participate in progress or analysis meetings; and

i) review draft reports.

12 Options Available To [STATE] For Accident Investigations

When an accident occurs in [STATE] there are a variety of options available to accomplish the accident investigation in accordance with ANNEX 13. This section outlines the options available and the criteria for choosing how the options are used.

12.1 Investigation Run By [STATE] IIC

This is the manner in which most large States with designated full time accident investigators perform investigations, and can be used by any State. The appropriateness of this choice depends on the size of the investigation, resources available to work on the investigation, the accident investigation expertise of the staff assigned to the investigation and the independent status of the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY]. [STATE] may exercise this option even if it is necessary to use extensive technical resources from other States under the ANNEX 13 guidelines or under existing MOUs.

12.1.1 Staff & Resources

A major investigation shall be run by [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] only when the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] currently meets at least the minimum training requirements specified in this manual and there is expertise from either other States or outside resources available to support the Investigator in Charge (IIC) on both investigative procedures and technical issues. However, for some less complex accidents and most incidents, [STATE ACCIDENT INVESTIGATION AUTHORITY] should provide the Investigator in Charge (IIC) for the investigation.

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Note: [STATE] shall only run a major investigation when there is legislation or specific regulations that give the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] independence in the conduct of the investigation, so that the investigation can be accomplished without political or organizational interference. Whenever [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] is functioning as the IIC in an accident investigation, the appropriate Accredited Representatives and Technical Advisors from the applicable States listed in ANNEX 13 shall be included in the investigation.

12.1.2 Authority of the Investigator In Charge (IIC)

Whenever [STATE ACCIDENT INVESTIGATION AUTHORITY] decides to control the investigation by designating [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] as the IIC of the investigation, the [STATE ACCIDENT INVESTIGATION AUTHORITY] has the authority to use whatever outside resources they deem necessary to assist the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] in accomplishing a thorough and independent investigation in accordance with ANNEX 13. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall be expected to use Accredited Representatives from other States for advice in the conduct of an investigation. The [STATE ACCIDENT INVESTIGATION AUTHORITY] may also use assistance under an MOU or non-government consultants to advise the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] on the accident investigation process. However, any non-government advisors shall be used in an advisory position only and shall not have any connection to any of the service providers involved in the accident or judicial activities. All resources that are used to actually manage an investigation shall be employees of [STATE] or another State.

12.2 Delegate the Entire Investigation to Another State

ANNEX 13 allows the State of Occurrence to delegate all of the investigation to another State if the other State agrees to do the investigation. In this situation, operational control of the investigation transfers to the State that has accepted the delegation; [STATE] shall still provide staff to support and facilitate the investigation. The responsibility for the investigation

and the issuance of a report of the investigation shall be with the State that accepted the delegation.

Note: While this option relieves [STATE] from most of the responsibility for the investigation, it also means that [STATE] does not have control of either the investigation or the final report that is produced from the investigation. This option shall only be used by [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] after receiving approval from [DIRECTOR GENERAL FOR STATE ACCIDENT INVESTIGATION AUTHORITY]

12.3 Delegate Portions of the Investigation to Another State

[STATE ACCIDENT INVESTIGATION AUTHORITY] can delegate any portion of the investigation to another State if the other State accepts the delegation. [STATE ACCIDENT INVESTIGATION AUTHORITY] maintains overall control of the investigation but gives responsibility for specific portions of the investigation to another State. A partial delegation can be valuable in the following situations:

a) There are potentially complex issues involved in doing the investigation;

b) [STATE] lacks technical expertise in a particular area(s); or

c) There is an accident with a [STATE] operator in international waters near the territory of another State.

Note: All delegations, either partial or complete, require the agreement of both States. While this can sometimes be a complex process, the partial delegation keeps [STATE] in control of both the overall investigation and the reports that are published at the end of the investigation..

12.4 Memorandum of Understanding (MOU)

[STATE] has the option to receive assistance from other States under a Memorandum of Understanding (MOU) that specifies who shall provide what assistance under what conditions. [EXISTING MOUS, IF ANY, SHOULD BE ATTACHED TO THIS DOCUMENT]. Any such MOUs define prior arrangements by [STATE], and are the manner that [STATE] intends to request assistance from other States. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall, after consulting with [DESIGNATED MANAGEMENT POSITION AT THE

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STATE ACCIDENT INVESTIGATION AUTHORITY] coordinate assistance from other States under these MOUs. With concurrence from the other State, the entire MOU or portions of the MOU may be used as necessary for a particular accident.

Note: It is very advantageous for [STATE] to determine ahead of time what expertise should be needed and where that expertise should come from to investigate an accident. The negotiations are always easier to do without the pressures that exist immediately after an accident. The Memorandum of Understanding with another State is a tool to objectively evaluate [STATE] needs for assistance during an accident investigation, and should provide the framework for both State’s actions. Any MOUs with the States of Manufacturer for the primary aircraft that operate in [STATE] are the first consideration since the States of Manufacture generally have extensive experience and expertise on the products manufactured in their State and are usually staffed with investigators familiar with major investigations. There is however, no limit on the number of MOUs that [STATE] can establish. Additional MOUs with States physically closer to [STATE] may also be advantageous.

Note: A model MOU is available for States and can be found on the FSIX website (http://www.icao.int/fsix/ ). This model should be customized to fit the specific needs of the States involved. The MOU should be general enough to cover most accident circumstances, but it needs to be specific enough to cover anticipated needs of [STATE]. Any MOU that essentially says that both States shall comply with ANNEX 13 is of very limited practical value.

12.5 Regional Cooperation

When there is an option for cooperatively using investigative resources on a regional level, [STATE] shall participate by sending [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] to regional investigator meetings and providing administrative support to the regional investigative efforts whenever possible. [STATE] shall

participate in both the development and use of investigative resources from other regional States. When investigators from other States in the regional cooperation program are used within [STATE], they shall be supported by [STATE] to perform independent and thorough investigations in the manner specified by ANNEX 13.

Note: ICAO strongly encourages cooperation between States on a regional level; this can be effectively applied in accident investigation. In a cooperative regional concept, the accident investigation resources of multiple States are available to be used on accidents in any of the individual States. Some States may have dedicated staff for accident investigations and/or staff that have experience in major accident investigations. These resources can be effectively shared at a regional level. This not only provides expertise to [STATE], but it provides additional experience for the designated regional investigators. There are distinct cultural and time advantages for [STATE] to have resources available from within this region. [STATE] shall cooperate in the development of a database of the investigative skills available in the region and establishing specific procedures for how those resources can be utilized in the region. Communication, independence of the Investigators, salary, and travel costs, if any, shall be established in the regional agreement. [STATE] anticipates that it will take extra work to establish and maintain a cooperative regional effort, but expects distinct practical advantages to [STATE] as an outcome.

13 Accident Investigation Process for [STATE]

All of the above options are available to [STATE], and [STATE] is not limited in the number of options that can be exercised during an accident investigation. Because of unique circumstances of any particular accident, [STATE] shall exercise the options as necessary to perform a thorough, independent and objective investigation required by ANNEX 13. However, because of the time critical nature of the decision making process after an accident, [STATE] has already established the following guidelines:

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[STATE] has determined that [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall be expected to implement [INVESTIGATION RUN WITH [STATE] IIC/FULL DELEGATION/PARTIAL DELEGATION/MOU/REGIONAL COOPERATION] as the normal process for a major accident in [STATE].

If that option is unavailable for any reason, the preferred alternative shall be [INVESTIGATION RUN WITH [STATE] IIC/FULL DELEGATION/PARTIAL DELEGATION/MOU/REGIONAL COOPERATION].

For some smaller accidents the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall implement [INVESTIGATION RUN WITH [STATE] IIC/FULL DELEGATION/PARTIAL DELEGATION/MOU/REGIONAL COOPERATION] as the normal process to investigate the accident.

For most incidents, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall implement [INVESTIGATION RUN WITH [STATE] IIC/FULL DELEGATION/PARTIAL DELEGATION/MOU/REGIONAL COOPERATION] as the normal process as part of the [STATE] accident prevention program.

Regardless of the option chosen, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall insure that the data collected during an investigation is protected and processed according to ANNEX 13 standards, unless [STATE] has filed a difference with ICAO.

14 Funding of Investigative Activities

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] is automatically authorized to spend up to [DESIGNATED MONETARY AMOUNT] to investigate any accident or incident approved for investigation by [DESIGNATED MANAGEMENT POSITION AT THE STATE ACCIDENT INVESTIGATION AUTHORITY].

15 [STATE] Reporting System and Database Management

[STATE] has established a voluntary safety reporting system and database that meets the ANNEX 13 standards in [LEGISLATION OR REGULATION REFERENCE].

16 Covers All Operations Within [STATE]

ANNEX 13 requires that [STATE] have a voluntary safety reporting system for collecting safety into a

database that is then analyzed for safety issues. While operators within [STATE] may operate voluntary reporting systems, these shall not substitute for a [STATE] reporting system and database. A voluntary reporting system being maintained by a service provider may be a part of the [STATE] reporting system if it is freely available to [STATE] for inclusion into the [STATE] database.

17 Standardized Format

The [STATE] database will be in a standardized format suitable for sharing with other States. The European Coordination Centre for Accident and Incident Reporting Systems (ECCAIRS) software is an example of a program that provides a database that is in a standardized format for sharing with other States.

18 Contact information & Publication

[CONTACT INFORMATION FOR SAFETY REPORTING] is available to all service providers in [STATE] to elicit contributions for the voluntary reporting system. This database is maintained and analyzed by [AGENCY MAINTAINING THE DATABASE]. Information in the database is publicized in [METHOD OF PUBLICIZING SAFETY REPORTING SYSTEM CONTACT DATA].

6-May-23 2-7

Model Accident and Incident Investigation Policies & Procedures

POLICIES AND PROCEDURES

1 Accident Notifications

1.1 Ensuring Timely Accident Information

Although the accident response plan has been coordinated with the expected sources of notification such as police, fire departments, airports and air traffic facilities; [STATE] may actually receive the initial information from other sources, such as the news media. In such cases, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall initiate contact with official sources listed above to confirm the information and get the most accurate information available.

1.2 Information to be Gathered During a Notification

APPENDIX B: NOTIFICATION CHECKLIST is a checklist of helpful items to collect during the initial notification. It is common for there to be inaccurate information supplied during the first few hours after an accident. However, once the basic details of the accident are confirmed, [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall not delay notifications to [STATE ACCIDENT INVESTIGATION AUTHORITY] contacts or making ANNEX 13 notifications.

1.3 Determination of [STATE] Role in the Investigation

As specified in the guidelines of Section 13 of [STATE] ACCIDENT & INCIDENT INVESTIGATION POLICIES, after the basic facts of the accident are determined, [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall make a determination as to the role of the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] in the investigation.

2 ANNEX 13 Notifications of Other States

Unless [STATE] chooses to do a complete delegation of the investigation to another State, or has specifically delegated the notification of other States process in a Memorandum of Understanding (MOU), there will need to be coordination between [DESIGNATED POSITION(S)

AT STATE ACCIDENT INVESTIGATION AUTHORITY] and Accredited Representatives from other States.

Timely communication between the State of the Manufacturer, the State of the Operator and other States via Accredited Representatives will be particularly important. The scope of the investigation will determine the number of persons the other States will send to the site of the accident or incident. It normally will not be possible for [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] to inform the other States of specific technical support requirements since the information is preliminary. However, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall provide all of the available preliminary information to the State of Manufacturer, State of Operator, and other applicable States.

2.1 The State of Manufacturer

Accredited Representatives from a State of Manufacturer and their Technical Advisors should have considerable experience in the investigation of their products, and bring appropriate team members for the investigation, based on the preliminary information provided them. If the initial team members that respond to the accident are not sufficient, additional resources can be added later in the investigation. The State of Manufacturer should provide, through the Accredited Representative, drawings, specifications and other data that can be used in the identification and evaluation of components.

2.2 State of Operator

The State of Operator should provide, through the Accredited Representative, historical documentation for the aircraft maintenance and procedures published by the company for operation of the aircraft.

2.3 Other States

While any of the States listed in ANNEX 13 are entitled to participate in the investigation, and

6-May-23 3-8


may potentially make significant contributions to the investigation, the State of Manufacture and the State of the Operator are typically the States that make the largest contributions. These States are usually able to provide engineering support.

Note: When assistance is requested under Annex 13 as part of an investigation solely to prevent recurrence of an accident or incident, then the assistance of the State of Manufacture, the State of the Operator and other States listed in Annex 13 should be provided at no cost to [STATE]. Therefore, it is important to keep the investigation done by [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] and any portions of the investigation delegated by [STATE ACCIDENT INVESTIGATION AUTHORITY] completely separate from any judicial investigations.

3 Wreckage Security & Protection of the Recorders

After notification of an accident the [DESIGNATED REPRESENTATIVE FOR THE STATE ACCIDENT INVESTIGATION AUTHORITY] will confirm or arrange security for the aircraft wreckage and the removal of electrical power to the aircraft recorders in order to maintain the evidence necessary for the investigation. If movement of any wreckage components needs to occur after rescue and firefighting operations have ceased, the [DESIGNATED REPRESENTATIVE FOR THE STATE ACCIDENT INVESTIGATION AUTHORITY] shall arrange for documentation of those components before they are moved. Coordination with local authorities shall be done to maintain security of the wreckage until representatives of the [STATE ACCIDENT INVESTIGATION AUTHORITY] are able to arrive at the scene.

Note: The [STATE ACCIDENT INVESTIGATION AUTHORITY] will want to have representatives at the scene of the accident in a timely manner to insure that the wreckage security is being maintained, recorders are secured, communications are established and proper preparations are being made for the arrival of the investigation team. For many incidents these actions can be initiated effectively from the [STATE ACCIDENT INVESTIGATION AUTHORITY] offices by individuals other than those responding to the scene. However for

most accidents, [STATE] should have additional staff available to the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] to assist in these procedures.

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall also ensure that any recorders in the aircraft wreckage are secured in their original condition for transportation to a suitable laboratory for read-out. If the recorders are in water at the accident scene, they shall be kept in water until delivery to the laboratory.

[STATE ACCIDENT INVESTIGATION AUTHORITY] may have the recorder readouts done by whomever they choose. However, the preferred location for the recorder readouts from accidents in [STATE] shall be the State of the Manufacturer for the aircraft involved in the accident. [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] will coordinate any [STATE] participation in the readout and the analysis of the recorders.

Note: An early decision where to have the recorders read out is important to the investigation. There are several States that have the capability to download the information from both flight recorders and voice recorders while protecting the sensitive nature of the information. [STATE] can, by mutual agreement, use any of those facilities under the guidance of ANNEX 13 ATTACHMENT D. While the State of Manufacturer and the State of the Operator are frequently both present wherever this read-out is accomplished, the State of the Manufacturer normally has the more experienced staff for the equipment, as well as an extensive library of data from similar aircraft. That data can be compared to the recorder that is being analyzed if the readout is done at that State’s facility

4 Initial Actions at the Accident Scene

4.1 Preliminary Determinations

Upon arrival at the accident scene, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] will make a preliminary assessment document of the general accident scene and make an assessment of the

6-May-23 3-9


potential safety issues. This includes, but is not limited to, weather conditions, terrain, environmental aspects, hazardous materials carried in the aircraft , or aircraft hazards from the aircraft wreckage itself, such as composite materials that have been exposed to fire and any hazards that exist at the accident scene that may affect the investigation team

4.2 Wreckage Diagramming and Documentation

A basic diagram of the wreckage site and preliminary observations should be documented by the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY].

Note: APPENDIX A: OVERVIEW OF INVESTIGATIONGROUPS AND FUNCTIONS contains an overview of what various specialists will be looking for during the investigation. This Appendix can also be used as a checklist for preliminary observations by a [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] doing an initial walk through of the wreckage as well as an overview of what to expect from the investigative team during the investigation.

4.3 Photo Documentation

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall photograph the wreckage and surrounding area as evidence for the investigation team. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall also collect any photos or videos taken by other agencies or witnesses of the accident, for later use by the investigation team. Especially valuable are photos or video taken of the aircraft near the time of the accident. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall use a digital camera to provide photographs to other investigators traveling to the scene in order to help them better prepare for the upcoming investigation.

These photographs should include the following:

a) an overview of the wreckage site taken from various angles around the wreckage;

b) ground scars to show the path of the aircraft;

c) final resting position of the aircraft; and

d) photographs of fire patterns, engine damage, cabin conditions and cockpit documentation as applicable.

5 Delegated Accidents

Even if [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] is not responsible for the on-scene investigation, they will observe and support the on-scene investigation.

5.1 Meetings

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall attend any progress or wrap-up meetings held during an investigation done under a delegation or an MOU.

5.2 Safety

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall actively participate in support of the investigation, as well as observe for any safety issues discovered during the investigation which may need action by [STATE].

5.3 Communication

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall communicate the progress of the investigation to [DESIGNATED MANAGEMENT POSITION AT THE STATE ACCIDENT INVESTIGATION AUTHORITY] on a daily basis.

6 Completing the On-Scene Investigation

At the completion of the on-scene investigation the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall ensure that the terms of any delegation or MOU are met, and aircraft components are designated either to be kept for further examination or to be released to the owner of the aircraft.

6.1 Documentation

All applicable factual observations by the investigation groups shall be documented and signed by the participants to the investigation. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall

6-May-23 3-10


obtain copies of photographs taken during the investigation, and monitor what each of the investigative groups has decided still needs to be accomplished by their group and what the tentative schedule is to accomplish those tasks. .

6.2 Follow-Up Investigations

The involvement of [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] in follow-up investigations away from the scene of the accident shall be coordinated on a case by case basis with [DESIGNATED MANAGEMENT POSITION AT THE STATE ACCIDENT INVESTIGATION AUTHORITY]. [STATE] may be represented at the recorder readouts as well as testing of components or interviews that may have significant information about the accident.

Note: Any work carried out at any manufacturer’s facilities should have direct supervision from either [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] or a government employee from another State. The Accredited Representative from the State of Manufacturer shall coordinate the testing of components for [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] or whoever has been delegated as the Investigator in Charge (IIC). If the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] doesn’t travel for the testing, the Accredited Representative can arrange for proper oversight of the testing, however the IIC shall specify what testing is required. Any examinations done at a manufacturing facility should always be supervised by investigators from the States involved in the investigation.

7 Reports

7.1 [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall confirm that a preliminary accident report is sent to ICAO and the specified States when the aircraft is over 2250 kg. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall confirm that draft accident reports are coordinated with other States as specified in ANNEX 13 and published as soon as possible unless that role has been delegated to another State. If [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] is writing the final reports, they should request assistance from other States or organizations for this task.

8 Safety Recommendations

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall confirm that any Safety Recommendations from the investigation are issued as necessary, and shall track the response(s) from the organizations or States receiving the recommendations unless this role has been delegated to another State.

9 Additional Subjects

9.1 Administrative Aspects of the Investigation

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] should assist other investigators coming to the accident scene under ANNEX 13, under a Memorandum of Understanding (MOU), or as part of a regional cooperation agreement. This assistance may be in areas such as arranging for visas, transportation or lodging after arriving in [STATE], or on-scene support such as establishing a command post or other administrative aspects necessary to directly support the investigation.

Note: Whenever investigators are coming from another State to support the investigation, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall coordinate with them on the administrative details necessary for a smooth commencement of the investigation.

6-May-23 3-11


While this will change for every investigation, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] should expect to assist in at least the areas listed above so that the investigation can be started quickly and carried out efficiently.

9.2 Judicial Aspects

If judicial authorities are involved in the investigation, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall coordinate with them to keep the safety investigation separate from the judicial activities, and shall arrange for the investigation team’s access to the wreckage, recorders and other investigative materials, if necessary.

9.3 Medical Aspects

For accidents in [STATE], the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall ensure that the following occurs:

a) An autopsy shall always be performed on fatally injured crew members with access to the controls of the aircraft ;

b) An autopsy shall always be performed on fatally injured crew member that may have had an involvement in either the accident or the post crash evacuation;

c) Toxicology samples shall always be taken on crew members; and

d) Toxicology samples shall always be taken on dispatchers, mechanics or air traffic controllers that were directly related to the accident aircraft.

9.4 News Media

Contacts with the news media shall be made only by [DESIGNATED POSITION AT THE STATE INVESTIGATION AUTHORITY OR OTHER DESIGNATED PERSONNEL]. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall brief investigators providing assistance from other States to not discuss the investigation with the news media unless specifically authorized by [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY].

9.5 Family Assistance

Family Assistance activities shall not be a part of the accident investigation; all Family Assistance activities shall be done separately from the accident investigation. However, the [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall cooperate with any Family Assistance activities being done within the guidance of ICAO CIRCULAR 285-AN/166 for providing timely and relevant information for the survivors and family members.

9.6 Interviews

The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall provide translators knowledgeable in the use of aviation terms for the interviews, as necessary. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall provide copies to the investigation team of any witness interviews done by organizations shortly after the accident. The [DESIGNATED POSITION(S) AT STATE ACCIDENT INVESTIGATION AUTHORITY] shall coordinate, as necessary, to arrange a location and time for the interviews of surviving crew members and other service providers related to the accident.

6-May-23 3-12

Model Accident and Incident Investigation Appendix A

APPENDIX A: OVERVIEW OF INVESTIGATION GROUPS AND FUNCTIONS

The investigation of an accident requires a Multidisciplinary (Team) Approach to document evidence in a systematic, thorough and objective manner. The investigation shall start in a general manner, covering all aspects of the operation, and then progressively narrow down as some areas are determined to not be as relevant to the accident. The investigation shall always consider all areas surrounding the operation, even if they don’t appear to have contributed to the accident. Only an objective review of the procedures and actions involved can eliminate an area from more thorough consideration. There is also the possibility that safety issues not directly related to the accident shall be found during the investigation of the areas not directly contributing to the accident.

The following checklist is intended to provide a [DESIGNATED REPRESENTATIVE FOR THE STATE ACCIDENT INVESTIGATION AUTHORITY] an overview of what to expect during an investigation when [STATE] has delegated portions of the investigation to another State. A more complete description of the accident investigation progress and the specific group functions is found in the MANUAL OF AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION, PART III - INVESTIGATION (DOC 9756).

The following group descriptions include the common duties assigned to that particular group. There are no requirements for a specific set of groups in every investigation, nor must the groups be organized in a particular manner. The investigative groups may be structured or combined by the Investigator in Charge (IIC) in any manner, as long as all applicable aspects of the accident are examined.

Two things are essential to be considered for membership in an investigative group:

(1) the individual can provide technical expertise to that group and

(2) the individual does not also have any role in the judicial aspects of the investigation.

There is no obligation for the Investigator in Charge (IIC) to include any certain people on the

groups, even if qualified, but typically the groups include the following:

a) representatives from the manufacturer;

b) service provider;

c) employee organizations; and

d) other organizations that can provide technical expertise needed by the investigation.

Each group should be led by a [STATE] employee familiar with the investigation management process.

Each of the groups shall also contribute to the overall assessment of the [STATE] Safety Programme as compared to the guidance contained in the SAFETY MANAGEMENT MANUAL (SMM) (DOC 9859). In addition to typical group evaluations, any accident investigation will include an evaluation of the following:

a) the effectiveness of the [STATE] voluntary and mandatory incident reporting systems;

b) use of safety databases; and

c) [STATE] actions to address potential issues identified by these systems.

In effect, the accident investigation is also an assessment of the Safety Management Systems (SMS) of Service Providers within [STATE], and of the [STATE] Safety Programme that provides oversight of these Service Providers. This is why it is critical that the investigation team have independence in the accident investigation.

6-May-23 APP A-13

Model Accident and Incident Investigation

2 Structures Group-

This group controls wreckage & site safety, as well as wreckage recovery. Typical actions would include the following:

Create a Wreckage Diagram

Identify and document Impact Marks

Identify and document Fire Patterns

Inspect Aircraft Integrity

Generate Mock-ups

3 Operations Group-

This group focuses on pilot action and procedures. The group wants to understand what did the crew do, why did they do that, and was company procedure followed.

Typical questions are similar to the following:

Did they respond with the appropriate procedure?

What procedure was performed?

Had the crew received training on that procedure?

When, how, and what training was received?

Is the procedure performed in line operations as trained?

This group can also be expected to investigate pilot qualifications. Information relevant to pilot qualification will be requested, such as the following:

Company training records

Violations, accidents, or incidents for the pilot

Regulator records for failures

Previous airline training records

Regulator oversight of operator

4 Powerplants Group

This group will investigate the following systems:

a) Engines/Propellers/APU;

b) Fuel Systems;

c) Evidence of Operation; and

d) Follow-up engine exams.

Some of the general indications they will be looking for are conditions as listed below:

6-May-23 APP A-14


4.2 General indications of high power in turbine engines

Ingestion of debris well into engine

Cases severely buckled/twisted

Compressor/turbine blades sheared/bent opposite direction of rotation

Shafts - twisted/sheared

4.3 General indications of low power in turbine engines

Less debris ingested

Blades bent in various directions

Shafts not twisted

Rotor blades intact – little damage

4.4 General indications of high power in Reciprocating Engines

Drive Shafts sheared or displaced

Significant Internal Damage

Gear Teeth Stripped

Rotating Parts Machined

Bending of Exhaust Stacks (hot)

4.5 General indications of rotation on Propellers

Chordwise scratches on the blade

Forward or “S” longitudinal bending along the blades

Leading Edge damage to the blades

Prop Tip separations

Slash marks left in trees or on the ground

4.6 Evidence of Fires

The fire, heat and smoke may leave behind patterns. These patterns are interpreted to determine the spread/propagation of the fire and the fire’s point of origin. This group will look at the wreckage for soot patterns or burn damage that correlates with in-flight airflow patterns versus ground fires.

5 Systems Group

The systems group will work to verify the integrity of the aircraft systems. Expected actions would include the following:

Verify and document systems settings

Perform off-site component tests

Obtain copies of cockpit documentation (if not done by operations group)

6-May-23 APP A-15


6 Maintenance Group

The Maintenance group will research and document the maintenance which has been performed on the aircraft. Expected areas of investigations are as follows:

General History of Aircraft

Clues from Previous Work

Research in Specific Areas

Operator Procedures

Government Oversight

Airworthiness Directives & Service Bulletins

Scheduled/Unscheduled Maintenance Activities

Trends in Write-ups

7 Survival Factors Group

This group will look at functions which directly influenced survival or non-survival after impact. Expected areas of investigation as follows:

Crash Injury Mechanisms

Performance of Evacuations

Performance Search & Rescue

Conduct Cabin Crew Interviews

Conduct Passenger Interviews

Determine Causes of Death (i.e. Impact, Thermal, Toxicological, G-Force)

Test Cabin Integrity

Evaluate Cabin Crew Performance

Performa Autopsies & obtain toxicology samples

8 Airports & Emergency Response Group

Some typical areas of investigation for this group are as follows:

Airway Facilities- Installation & Maintenance

Airport Certification Plan

Airport Emergency Plan

Airport Inspection History

Airport lighting and signage

Certification/Design

Personnel Qualifications/Training

Regulatory Oversight

6-May-23 APP A-16


8.1 Information from Air Traffic Services

Provide recorded data

Possible witnesses to the accident

Evaluate AT equipment and procedures used

Evaluate AT personnel workload & performance

8.2 Information about the weather at the time of occurrence

Define Environment

Wind, Temp, Density Altitude, Visibility, etc.

Obtain and note official observation sites, witnesses, CVR

Evaluate WX Services

Briefing Thoroughness

Forecast Accuracy

Dispatch Procedures

9 Human Factors Group

Human error is not the conclusion of an investigation but the beginning point. This group tries to work up what was known by the crew at the time of the event rather than looking at the accident solely from what happened. Some actions this group can be expected to take are as follows:

Document what person was doing in days before accident

Sleep/wake periods

Work/rest cycles

Major activities

Routine activities (e.g., meals)

Life events

Drug & Alcohol testing done in cooperation with medical staff

10 Aircraft Performance Group

This group can be expected to investigate and document the performance of the aircraft during the flight. This will include the following:

Determining and analyzing the flight path and attitude of the aircraft

Use of FDR, radar data and other recorded data

Weight & Balance

Overruns Undershoot accidents

Accuracy of FMS entries

Appropriateness of speeds selected

Possible Icing

Determination of windshear

6-May-23 APP A-17


Determination of wake turbulence

6-May-23 APP A-18


11 Simple Investigation Group Organization

Figure 1

6-May-23 APP A-19


12 Sample Accident Investigation Timeline

Figure 2

6-May-23 APP A-20


13 Accident Investigation Timeline In Practice

Figure 3 is a simplified example of how the timeline was used in a B737 runway overrun accident. Notice how dotted lines are used to relate latent conditions to the underlying reasons for the accident and how the dotted lines were used to connect related items.

The right side of the illustration shows the sequence of events that led up to the overrun.

Figure 3

Model Accident and Incident Investigation Organization/StructuresError: Reference source not found

APPENDIX B: NOTIFICATION FORM

Figure 4

6-May-23 APP A-22

Documents

International Civil Aviation Organization - coscapsa.org Accident Investig… · Web viewThis document provides a brief explanation on the material developed to assist States with