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Session 11

Investigation Report

SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014

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Investigation Reports

� Preliminary Report

� Draft Final Report

� Final Report

� Format of reports

� Sending reports to ICAO

The Product: Final Report

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Road to Final Report

Preliminary Report

Interim statement(s)

Draft Final Report

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Final Report

Preliminary Report

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Distribution of Preliminary Report (1)

� Standard 7.1 – (Accident involving aircraft > 2,250 kg)

Preliminary Report must be sent by State conducting the

investigation to :

� State of Registry or State of Occurrence, as appropriate

� State of the Operator

� State of Design

� State of Manufacture

� State that provided information, significant facilities or

experts

� ICAO

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Distribution of Preliminary Report (2)

� Standard 7.2 – (Accident involving aircraft <= 2 250 kg

and involving airworthiness or matters considered to be of

interest to other States) Preliminary Report must be sent

by State conducting the investigation to :

� State of Registry or State of Occurrence, as appropriate

� State of the Operator

� State of Design

� State of Manufacture

� State that provided information, significant facilities or

experts

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� Standard 7.3 – In an ICAO working language

(English/French/Spanish/Russian/Chinese/Arabic)

� Standard 7.4 – Must be sent within 30 days, unless:

� Accident Data Report (ADREP) has been sent by that time

� To be sent as soon as possible

� Means: Fax, e-mail, airmail

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Distribution of Preliminary Report (3)

Draft Final Report

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Drafting of Final Report

Investigation

Draft Final Report issued for comments (60 days)

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Final Report completed and made public

Invitation for Comments

� Standard 6.3 - State conducting the investigation to invite

comments on Draft Final Report from:

� State that instituted the investigation

� State of Registry

� State of the Operator

� State of Design

� State of Manufacture

� States that participated

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Even if they did not participate in

the investigation

� Draft Final Report to be sent for comments through a

dated transmittal correspondence

� Must offer a 60-day comment period (from date of

transmittal correspondence)

Comments

� No comment � State conducting the

investigation will proceed to arrange for the

release of the Final report

� Comments received � State conducting the

investigation shall:

� Amend the draft Final Report to include the

comments if accepted, or

� Append the comments to the Final Report if this is

desired by the State providing the comments

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Final Report

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Distribution of Final Report

� Standard 6.4 – Final Report must be sent to:

� State that instituted the investigation

� State of Registry

� State of the Operator

� State of Design

� State of Manufacture

� States that participated

� State having suffered fatalities or serious injuries to its

citizens

� State that provided information, significant facilities or

experts14

Release of Final Report

� Release = Make Final Report public

= Make Final Report publicly available

� Standard 6.5 – In the interest of accident prevention, the State conducting the investigation of an accident or incident shall make the Final Report publicly available …

� As soon as possible

� By:

� Hardcopy

� Posting on Internet

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Format of Reports

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Format of Investigation Report

Title

Synopsis

1 Factual Information

2 Analysis

3 Conclusions

(a) Findings

(b) Cause(s)/Contributing factors/Significant factors

4 Safety Recommendations

5 Appendices

Detailed guidance in Part IV of ICAO Manual of Aircraft Accident and Incident Investigation (Doc 9756)

Objective of the Investigation

� To state the objective of the investigation in an

investigation report

The sole objective of the investigation of an

accident or incident shall be the prevention of

accidents and incidents.

It is not the purpose of this activity to apportion

blame or liability.

1. Factual Information

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2. Analysis

2.2 Flight operations

2.2.1 Crew qualifications

2.2.2 Operational procedures

2.2.3 Weather

2.2.4 Air traffic control

2.2.5 Communications

2.2.6 Aids to navigation

2.2.7 Aerodrome

2.3 Aircraft

2.3.1 Aircraft maintenance

2.3.2 Aircraft performance

2.3.3 Mass and balance

2.3.4 Aircraft instrumentation

2.3.5 Aircraft systems

2.4 Human factors

2.4.1

Psychological and physiological factors affecting the personnel involved

2.5 Survivability

2.5.1 Rescue and fire service response

2.5.2 Analysis of injuries and fatalities

2.5.3 Survival aspects20

2.1 General

3. Findings and Causes

Findings

Statements of all significant conditions, events or circumstances in the accident sequence

Must be supported by and directly related to the factual information and the analysis.

Commonly Used Findings(Doc 9756 Appendix 5to Chapter 1)

Causes

Events which resulted in injuries or damage.

An act, omission, condition or circumstance which if eliminated or avoided would have prevented the accident from happening.

Reasons why the accident occurred?

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Some States add Safety Actions

Title

Synopsis

1 Factual Information

2 Analysis

3 Conclusions

(a) Findings

(b) Cause(s)/Contributing factors/Significant factors

4 Safety Actions

5 Safety Recommendations

6 Appendices

Detailed guidance in Part IV of ICAO Manual of Aircraft Accident and Incident Investigation (Doc 9756)

Sending Reports to ICAO

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Preliminary Report

� Standard 7.1 – (Accident involving aircraft > 2 250 kg)

Must send to ICAO.

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Final Report

� Standard 6.7 – If State that has conducted an

investigation into an accident or incident, involving aircraft > 5,700 kg, has released a Final Report � send Final

Report to ICAO

Note – The Final Report sent to ICAO is to be prepared in one of the

working languages* of ICAO and in ICAO format, whenever practicable.

* English/French/Spanish/Russian/Chinese/Arabic

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Accident Data Report (ADREP)

� Standard 7.5 – (Accident involving aircraft > 2,250 kg)

State conducting the investigation to send ADREP to:

� ICAO

� As soon as possible after the investigation

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Incident Data Report

� Standard 7.7 – (Incident involving aircraft >2 250 kg) State

conducting the investigation to send ADREP to:

� ICAO

� As soon as practicable after the investigation

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Reports from Investigation Authorities

� Australian Transport Safety Bureau

(www.atsb.gov.au)

� French Bureau Enquêtes-Accidents (www.bea-

fr.org)

� Transportation Safety Board of Canada

(www.tsb.gc.ca)

� UK AAIB (www.aaib.gov.uk)

� US National Transportation Safety Board

(www.ntsb.gov)

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- End -

Session 11

Investigation Report

SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014