procedures manual of aircraft accident

Procedure Manual of Accident/ incident investigation Issue I dated 21/11/2012 : of 32

PROCEDURES MANUAL

OF

AIRCRAFT

ACCIDENT/INCIDENT

INVESTIGATION

AIRCRAFT ACCIDENT INVESTIGATION BUREAU

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AMENDMENTS

The Manual will be reviewed by the Head of AAIB or in his absence by the authorized person

from time to time and he will be responsible for issuing the Amendments, if any, at least once

a year or as and when any information in this manual is incorrect, inconsistent or outdated.

The holders of the Manual will ensure that it is up to date.

RECORD OF AMENDMENTS

No. Date of Issue Date of insertion Signatures


INDEX

CHAPTER 1 DEFINITIONS

CHAPTER 2 AIRCRAFT ACCIDENT INVESTIGATION BUREAU

2.1 AIRCRAFT (INVESTIGATION OF ACCIDENTS & INCIDENTS) RULES 2012

2.2 STRUCTURE

2.3 FUNDING

CHAPTER 3 NOTIFICATION

3.1 GENERAL

3.2 NOTIFICATION/ ACKNOWLEDGEMENT 3.2.1 ACCIDENT OR SERIOUS INCIDENT IN THE INDIAN TERRITORY

3.2.2 ACCIDENTS OR SERIOUS INCIDENTS IN THE TERRITORY OF ANOTHER CONTRACTING

STATE TO A CIVIL AIRCRAFT WHERE INDIA IS EITHER STATE OF REGISTRY OR OPERATOR

OR MANUFACTURE OR DESIGN

3.2.3 ACCIDENTS OR SERIOUS INCIDENTS TO INDIAN REGISTERED CIVIL AIRCRAFT IN A NON-

CONTRACTING STATE OR OUTSIDE THE TERRITORY OF ANY STATE

3.3 APPOINTMENT OF ACCREDITED REPERSENTATIVES/ ADVISERS/ PARTICIPANTS/

OBSERVERS 3.3.1 INVESTIGATION CARRIED OUT BY AAIB (INDIA)

3.3.2 INVESTIGATION CARRIED OUT BY OTHER STATE

CHAPTER 4 PLANNING THE INVESTIGATION

4.1 GENERAL

4.2 PRELIMINARY INVESTIGATION

CHAPTER 5 SIZE AND SCOPE OF THE INVESTIGATION

5.1 GENERAL

5.2 ACCIDENT INVESTIGATION

5.3 INCIDENT INVESTIGATION

5.4 POWERS OF AIRCRAFT ACCIDENT INVESTIGATORS

5.5 POST-FIELD PHASE OF THE INVESTIGATION

CHAPTER 6 SUBMISSION OF REPORTS

6.1 GENERAL

6.2 RESPONSIBILITIES AS A CONTRACTING STATE

6.3 RESPONSIBILITIES AS A STATE CONDUCTING THE INVESTIGATION

CHAPTER 7 ADREP REPORTING

7.1 ACCIDENTS AND SERIOUS INCIDENTS

7.2 INCIDENTS TO AIRCRAFT OVER 5 700 KG

CHAPTER 8 ACCIDENT PREVENTION MEASURES

8.1 INCIDENT REPORTING SYSTEMS

8.2 DATABASE SYSTEMS

8.3 ANALYSIS OF DATA — PREVENTIVE ACTIONS

8.4 EXCHANGE OF SAFETY INFORMATION

APPENDICES


APPENDICES

Appendix A Aircraft (Investigation of accidentsand incidents) Rules 2012

Appendix B Oganisation Chart

Appendix B1 List of officials to be notified of serious incidents/ accidents

Appendix B2 In-house Procedures

Appendix C ICAO Reporting & Notification Checklist

Appendix C1 Format & content of Notification

Appendix C2 Initial notification form

Appendix D Addresses of aircraft accident investigation authorities

Appendix E Records to be segregated and sealed after occurrences

Appendix E1 Guidelines for On-Site Investigation

Appendix E2 Guidelines on Occupational Health and Safety

Appendix E3 Training Manual

Appendix E4 Guidelines for major Group investigation

Appendix F Format of Final investigation report

Appendix G Format of Preliminary investigation report

Appendix G1 Guidance on completing each section of the final report

Appendix H Format of the Preliminary data report

Appendix I Format of Accident data report (final)

Appendix J Procedure for Voluntary Reporting System


CHAPTER 1

DEFINITIONS& ABBREVATIONS

In addition to the definitions given in the Aircraft (Investigation of Accidents and

Incidents) Rules 2012, and unless there is anything repugnant in the subject or context, the

following definitions and abbreviations are used in the Manual:

DEFINITIONS

ABBREVATIONS

AAIB Aircraft Accident Investigation Bureau

AIC Aeronautical Information Circular

ALD Administration & Logistics Division of AAIB

ASC Air Safety Circular

CoI Committee of Inquiry

ID Investigation Division of AAIB

MoCA Ministry of Civil Aviation

PD Prevention Division of AAIB

TD Technical Division of AAIB


CHAPTER 2

AIRCRAFT ACCIDENT INVESTIGATION BUREAU 2.1 AIRCRAFT (INVESTIGATION OF ACCIDENTS & INCIDENTS) RULES 2012

2.1.1 In exercise of the powers conferred by Section 4 and 7 of the Aircraft Act 1934, the

Central Government has amended the Aircraft Rules 1937 and has notified the Aircraft

(Investigation of Accidents & incidents) Rules 2012 vide Gazette of India Notification

No. G.S.R. 535(F) dated 5th

July 2012. The Aircraft (Investigation of accidents and

incidents) Rules are at Appendix ‘A’.

2.1.2 The specifications concerning the State of the Operator are also applicable when an

aircraft is leased, chartered or interchanged and when India is not the State of Registry

and if functions and obligations of the State of Registry are discharged in part or in

whole in respect of Annex 13.

2.2 STRUCTURE

2.2.1 For the purposes of carrying out investigation into accidents, serious incidents and

incidents referred to in sub-rules (1), (2) and (4) of rule 5 of the Aircraft Rules 2012,

Ministry of Civil Aviation has set up a Bureau known as the Aircraft Accident

Investigation Bureau of India. The Bureau has started functioning with officers

familiar with aircraft accident investigation procedures. The Organisation structure is

at Appendix ‘B’. At present panel of expert investigators with appropriate experience

and training is being kept.

The Aircraft Accident Investigation Bureau has following functions, namely:

(a) obtaining preliminary report from any person or persons authorised either under

sub-rule (1) of rule 9 or under sub-rule(2) of rule 7 of the Aircraft (Investigation of

accidents and incidents) Rules 2012;

(b) assisting the Central Government in setting up of Committee of Inquiry and formal

investigation;

(c) to facilitate the investigation and administrative work of the Committees and

Courts, whenever necessary.

(d) processing of the reports of Courts and Committees of Inquiry received by the

Central Government, which includes –

(i) forwarding of the reports to the States for consultation

(ii) forwarding the report made public by the Central Government to the States

as required under Annex 13;

(iii)forwarding the report made public by the Central Government to ICAO if

the mass of the aircraft involved in accident or incident is more than 5,700

kg;

(e) follow-up the recommendations made by Courts and Committees of inquiry and to

ensure that are implemented by the concerned agencies;


(f) to process cases for a resolution by the Central Government of disputes between

the Bureau and any agency regarding implementation of a recommendation;

(g) to formulate safety recommendation on the basis of safety studies, including

induction of new technology to enhance safety, conducted from time to time.

(h) establish and maintain an accident and incident database to facilitate the effective

analysis of information on actual or potential safety deficiencies obtained,

including that from its incident reporting systems, and to determine any preventive

actions required;

(i) to process obligations of the Central Government under Annex 13 to the

Convention relating to International Civil Aviation signed at Chicago on the 7th

day of December, 1944 as amended from time to time; and

(j) any other functions, which the Central Government may ask the Bureau to perform

from time to time under these rules.

2.3 FUNDING

AAIB will be funded by the budgetary allocation from Ministry of Civil

Aviation. The procedure for supplementary funding exists based on the

requirements.


CHAPTER 3

NOTIFICATION

3.1 GENERAL

3.1.1 Under sub-rule (2) of rule 1 of the Aircraft (Investigation of Accidents & incidents)

Rules 2012, an accident or an incident to an aircraft is required to be notified by the

pilot-in-command of the aircraft or, if he be killed or incapacitated, by the owner, the

operator, the hirer or other person on whose behalf he was in command of the aircraft,

or any relevant person, as the case may be. This notification is to be sent to the

Aircraft Accident Investigation Bureau (hereinafter AAIB) and Director-General of

Civil Aviation as soon as is reasonably practicable but in any case not later than 24

hours after the person becomes aware of the accident or the incident. In the case of an

accident occurring in India, the information shall also be given to the District

Magistrate and the Officer-in-charge of the nearest Police Station of the accident and

of the place where it occurred.

3.1.2 Telephone, facsimile or e-mail is in most cases the most suitable and quickest means

available. More than one means of communication may be used. A control room has

been set up for the purpose which is manned 24 x 7 hrs. with following contact details

for the purpose of notification:

Phone numbers +9111 24610843, 24610848

Fax number +9111 24693963

e-mail [email protected]

3.1.3 Notification of incidents which may qualify as serious incidents and accidents shall

also be sent to all the officials as per Appendix ‘B1’.The telephonic notifications shall

be followed by written information on the above e-mail IDs. SMSes will not be taken

as a normal method of intimation as it lacks positive communication. In house

procedures to be followed on receipt of notification onwards are at Appendix ‘B2’.

3.1.4 The notification shall be in plain language and contain as much of the following

information as is readily available, namely :

(a) for accidents the identifying abbreviation ACCID, for incidents INCID;

(b) manufacturer, model, nationality and registration marks, and serial number of the

aircraft;

(c) name of owner, operator and hirer, if any, of the aircraft;

(d) qualification of the pilot-in-command, and nationality of crew and passengers;

(e) date and time of the accident or incident;

(f) last point of departure and point of intended landing of the aircraft;

mailto:[email protected]


(g) position of the aircraft with reference to some easily defined geographical point

and latitude and longitude;

(h) number of crew and passengers; aboard, killed and seriously injured; others,

killed and seriously injured;

(i) description of the accident or incident and the extent of damage to the aircraft so

far as is known;

(j) physical characteristics of the accident or incident area, as well as an indication

of access difficulties or special requirements to reach the site; and

(k) presence and description of dangerous goods on board the aircraft,

but notification shall not be delayed due to the lack of complete information.

NOTE : ICAO Reporting & Notification Checklist is at Appendix ‘C’, the

format & content may be seen at Appendix ‘C1’ & Initial notification

form at ‘C2’

3.1.5 If the details or, other known relevant information are omitted initially, such

information shall also be dispatched as soon as it is possible.

3.1.6 The notification as required above shall also be submitted to the Bureau by the

concerned –

(a) aerodrome operator;

(b) officer-in-charge of air traffic control unit and the watch supervisory officer of

air traffic control; and

(c) regional or the sub-regional officers of the Directorate General of Civil

Aviation.

NOTE: The Search and Rescue Service in India is coordinated by the Airports

Authority of India. Search and rescue (SAR) Manual of Air Traffic Services of

Airports Authority of India deals with the subject of Search and Rescue.

3.2 NOTIFICATION/ACKNOWLEDGEMENT

3.2.1 ACCIDENT OR SERIOUS INCIDENT IN THE INDIAN TERRITORY

3.2.1.1 On receipt of information/ notification about the occurrence/ serious incident/

accident, Administrative & Logistics Division, [hereinafter referred as (ALD)] under

the intimation to the Ministry of Civil Aviation shall notify the facts of the accident

or serious incident in the Indian territory, containing as much of the information

referred to in sub-rule (2) of the Aircraft Rules 2012 as may be available with a

minimum of delay and by the most suitable and quickest means available, to

(a) the State of Registry;


(b) the State of Operator;

(c) the State of Design;

(d) the State of Manufacture; and

(e) ICAO when the aircraft involved is of a maximum mass of over 2,250 kg or is a

turbojet-powered aeroplane.

3.2.1.2 While notifying the following information will also be added, namely

(a) an indication to what extent the investigation will be conducted by the Central

Government or is proposed to be delegated by the Central Government to another

State; and

(b) Identification of the originating authority and means to contact the person

investigating and the AAIB of India at any time.

3.2.1.3 If it comes to the notice of AAIB that the State of Occurrence is not aware of a

serious incident to an Indian registered aircraft or an aircraft operated by Indian

operator, notification of such an incident shall be forwarded to the State of Design,

the State of Manufacturer and the State of Occurrence. These States will be asked,

if they wish to appoint an Accredited Representative to participate in the

investigation, and if so, they will be assisted by the advisers.

3.2.1.4 In case the aircraft is registered with another contracting state, ALD, in addition,

shall forward as soon as possible and by the most suitable and quickest means

available the information of the accident or serious incident to the State of

Registry, the State of the Operator and ICAO. The State of the Operator shall also

be requested to intimate the presence and description of dangerous goods on board

the aircraft, if any.

3.2.1.5 A list of addresses of aircraft accident and incident investigation authorities can be

found in the Manual of Aircraft Accident and Incident investigation, Part I –

Organisation and Planning (Doc 9756). A copy of the list is attached for ready

reference. (Appendix ‘D’). All the officers of AAIB however should refer to the

Doc 9756 on regular basis and ensure that the latest addresses are available with

them.

3.2.1.6 The notification shall be in plain language and contain as much of the information

as is readily available but its dispatch shall not be delayed due to the lack of

complete information.

3.2.1.7 As soon as it is possible to do so, the details omitted from the notification as well

as other known relevant information shall be dispatched to the State of

Manufacture, the State of Design, State of Registry, the State of the Operator and

ICAO.


3.2.2 ACCIDENTS OR SERIOUS INCIDENTS IN THE TERRITORY OF ANOTHER

CONTRACTING STATE TO A CIVIL AIRCRAFT WHERE INDIA IS EITHER

STATE OF REGISTRY OR OPERATOR OR MANUFACTURE OR DESIGN

3.2.2.1 In case an Indian Registered Civil aircraft is involved in an accident or serious

incident in the territory of another contracting State, and information/ notification of

the accident/ serious incident is received from the State of Occurrence, ALD will

acknowledge the same to the State of Occurrence.

3.2.2.2 All relevant information including the information about the aircraft and flight crew

involved in the accident or serious incident will be collected from the regulatory

authority and ALD will provide it to the State of Occurrence.

3.2.2.3 The State of Occurrence shall, if applicable will be provided, at the earliest, details

of dangerous goods on board the aircraft.

3.2.3 ACCIDENTS OR SERIOUS INCIDENTS TO INDIAN REGISTERED CIVIL

AIRCRAFT IN A NON-CONTRACTING STATE OR OUTSIDE THE TERRITORY

OF ANY STATE

3.2.3.1 When the accident or the serious incident to an Indian registered Civil aircraft has

occurred in the territory of a non-Contracting State which does not intend to

conduct an investigation in accordance with ICAO Annex 13, investigation will be

carried out in cooperation with the State of Occurrence but, failing such

cooperation, investigation will be carried out with such information as is available.

3.2.3.2 As a State of Registry when an investigation is being conducted under the Aircraft

Rules into an accident or serious incident to Indian Civil Registered aircraft in the

Indian territory or in a Non Contracting State or outside the Territory of any State

notification shall be forwarded to the State of the Operator, the State of Design, the

State of Manufacture and the International Civil Aviation Organization as per

Annex 13.

3.2.3.3 In case the location of the accident or the serious incident to an Indian Civil

registered aircraft cannot definitely be established as being in the territory of any

State, the investigation shall be instituted and conducted by AAIB.

3.2.3.4 When any civil aircraft other than the Indian Civil Registered aircraft is involved in

any accident or serious incident in International waters and the location is nearest to

the Indian Territory, all assistance shall be provided as possible. Similarly in case

an Indian Civil Registered aircraft is involved in an accident or serious incident in

International waters request shall be made to the State nearest to the location to

provide assistance as possible.

3.2.3.5 In all these cases, the notification requirements will be fulfilled by ALD as in 3.2.1

above.


3.3 APPOINTMENT OF ACCREDITED REPERSENTATIVES/ ADVISERS/

PARTICIPANTS/ OBSERVERS/EXPERTS

3.3.1 INVESTIGATION CARRIED OUT BY AAIB (INDIA)

In case it is decided that the accident or serious incident is to be investigated by

Court or Committee of Inquiry (CoI) as per the Aircraft (Investigation of Accidents

& Incidents) Rules 2012, ID will put up on file to Ministry of Civil Aviation for

formation of the Court or CoI. Suitability of the expert investigator for the Court or

CoI from the available pool of investigators will be decided keeping in view that

there is no conflict of interest and the expert is readily available.

3.3.1.1 The State of Operator, Registry, Design or of Manufacturer (wherever applicable)

are entitled to appoint an accredited representative to participate in the

investigation. These States may appoint one or more advisers, to assist its

accredited representative. State whose nationals suffered fatal injuries during the

accident are entitled to appoint an expert.

3.3.1.2 When neither the State of Design, nor the State of Manufacture appoint an

accredited representative, organizations responsible for the type design and the final

assembly of the aircraft shall be invited by AAIB to participate.

3.3.1.3 When neither the State of Registry, nor the State of the Operator appoints an

accredited representative, Operator should be invited to participate, subject to the

procedures of the investigation.

3.3.1.4 Observer or participant status is a privilege granted by the State conducting the

investigation to a person having a direct interest in the investigation and who has

the expertise to contribute to achieving the objective of the investigation. The

persons representing a State department or agency, the aircraft owner and operator,

union or employee associations, the flight crew involved in the accident, if

needed, may be granted observer/ participant status.

3.3.1.5 When any documents or information is required for investigation purposes, or

aircraft component examinations is required to be carried out in the State of

Registry, the State of the Operator, the State of Design, the State of Manufacture, or

in any other State, matter will be taken up with the accredited representative of that

State and endeavour shall be made to ensure that the request is met in so far as it is

compatible with the policies of his Government.

3.3.1.6 All the participants from other States namely – advisers, experts, accredited

representatives, observer etc. will be provided with the letters by Head AAIB

clearly giving the powers and roles of these participants. Format of the letters are at

Appendix ‘K’


3.3.2 INVESTIGATION CARRIED OUT BY OTHER STATE

3.3.2.1 In case investigation of aircraft accident and serious incident is carried out by other

State where India is a State of Registry, Operator, Design or manufacture, the

intention to appoint an accredited representative shall be conveyed to the State

conducting the investigation. If such an accredited representative is appointed with

the prior approval of MoCA, the name and contact details as well as the expected

date of his arrival to the State of Occurrence will be provided to the State of

Occurrence. Advisers proposed by the operator or design organization to assist the

Accredited Representative will be intimated accordingly to the State conducting

investigation.

3.3.2.2 When specifically requested by the State conducting the investigation of an

accident to an aircraft over 2 250 kg to appoint an Accredited Representative, the

same shall be appointed.

3.3.2.3 When request for any documents or information for investigation purposes or

aircraft component examinations to be carried out in India is received, the

accredited representative will ensure that the request is met in so far as it is

compatible with the policies the Government.

3.3.2.4 AAIB officer who acts as an Accredited Representative from India and his advisers

for any accident or serious incident will ensure that the information relevant to

investigation of accident or serious incident is provided to the investigators and no

information regarding progress and findings of the investigation is divulged

without the express consent of State conducting the investigation.

3.3.2.5 If a request is received from any State conducting the investigation of an accident

or an incident following shall be provided to that State

After processing the request, all the information relevant to investigation and

available with India

Pertinent information of the facilities or services which have been, or would

normally have been, used by an aircraft prior to an accident or an incident

Pertinent information on any organization whose activities may have directly or

indirectly influenced the operation of the aircraft.

3.3.2.6 In case investigation of aircraft accident and serious incident is carried out by other

State where the citizens of India have suffered serious injuries or fatalities, an

expert shall be appointed and intention conveyed to the State conducting the

investigation, with the prior approval of MoCA.


CHAPTER 4

PLANNING THE INVESTIGATION

4.1 GENERAL

The following ICAO documents will be referred as guidance material wherever

required for the notification, investigation and reporting:

Annex 13 - Aircraft Accident and Incident Investigation - 9th edition (July 2001),

Amendment 11 (applicable November 2006) Doc 9756 - Manual of Aircraft Accident and Incident Investigation

o Part I - Organization and Planning – 1st edition, 2000 o Part III – Investigation o Part IV - Reporting – 1st edition, 2003

Doc 6920 - Manual of Aircraft Accident Investigation - 4th edition, 1970 Doc 9156 - Accident/Incident reporting Manual (ADREP Manual) - 2nd edition, 1987 Cir 285-AN/166 - Guidance on Assistance to Aircraft Accident Victims and their Families

– 2001 Cir 298-AN/172- Training Guidelines for Aircraft Accident Investigators –2003 Cir 314-AN/179 - Hazards at Aircraft Accident Sites – 2008

4.1.1 Liaison during the investigation with Civil Authorities, Police Authorities, Defence

Authorities, Hospitals, Ambulance Services, Fire Services and any other local

authority is of vital importance. In most cases aerodrome officials, local inhabitants

and/or police will probably be the first persons to arrive at the scene of an aircraft

accident. It is, therefore, extremely important to have cooperation of the police and

aerodrome officials to ensure the security of the wreckage. This prevents vital

evidence being lost by unnecessary interference with the wreckage before the arrival

of the investigation team.

4.1.2 If it is suspected that the aircraft may have carried dangerous cargo, special

precautions should be taken in placing personnel at a safe distance from the wreckage.

This is particularly important if a fire has occurred.

4.1.3 In accordance with ICAO Annex 13, if a request is received from the State of Design

or the State of Manufacture that the aircraft, its contents, and any other evidence

remain undisturbed pending inspection by an accredited representative of the

requesting State, all necessary steps shall be taken to comply with such request, so far

as this is reasonably practicable and compatible with the proper conduct of the

investigation; provided that the aircraft may be moved to the extent necessary to

extricate persons, animals, mail and valuables, to prevent destruction by fire or other

causes, or to eliminate any danger or obstruction to air navigation, to other transport or

to the public, and provided that it does not result in undue delay in returning the

aircraft to service where this is practicable.


4.1.4 The Officer Incharge of the Aerodromes closest to the site of accident shall assist in

coordination with Local Police Authorities and shall take immediately all reasonable

measures to protect the evidence until the arrival of the officer of AAIB or any other

authorized person.

4.1.5 All the documents relating to the aircraft shall be segregated and sealed by the

Operator and shall be handed over to authorized AAIB Officer, who shall determine

the adequacy of action as deemed appropriate and may seal any other documents etc.

pertinent to the investigation of the accident as any of the material could be of use to

the investigating authority. The broad outlines of the records, which should be

segregated and sealed, are at Appendix-‘E’.

4.1.6 Due to the importance of flight recordings, extreme care must be taken in handling the

recorders to prevent damage. Only fully qualified personnel should be assigned to

recover and handle the recorders. Handling and transportation of the flight recorders

from the accident site to the read-out facilities should be carried out preferably by an

officer of AAIB after ensuring that there is no further damage during transportation.

TD will immediately make arrangements for the read-out and inform Head AAIB.

4.1.7 In the event adequate facilities to read out the flight recorders are not available in

India, facilities made available by other States should be used, giving consideration to

the following:

a) the capabilities of the read-out facility;

b) the timeliness of the read-out; and

c) the location of the read-out facility.

Read-outs of flight recorder recordings should be carried out in the presence of

Chairman Court/ Committee of Inquiry.

4.1.8 The assistance of civil authorities, particularly that of local police is also necessary to

ensure that vital evidence is not lost. The authorized officer of AAIB shall co-ordinate

with the police authorities/ Local Government Authorities to initiate action to extricate

persons from the aircraft, to arrange for immediate first aid and medical attention, to

extinguish fire and removal of the persons dead or alive from the wreckage.

4.1.9 The officer In charge of Aerodrome shall ensure with the help of operator that the

Captain and the Co-pilot are immediately subjected to medical check up for the

consumption of alcohol. The doctor carrying out such a medical check up shall take

samples of blood, urine etc. required for detailed chemical analysis. In the event of

accident at an Airport, Breath Analyzer test, samples of blood, urine shall be taken at

the Airport Medical center wherever available.


4.1.10 In other cases where medical centers are not available at the airports or when the

condition of crew members require immediate hospitalization, Aerodrome In charge

with the help of police authorities if required, shall ensure that the sample of the blood,

urine etc are taken at the nearest hospital. These checks should be expeditiously

carried out without any loss of time. The sample should be suitably preserved and

handed over to authorized AAIB officer for the detailed laboratory examination.

4.1.11 In the event of death of the crewmembers, complete autopsy examination of fatally

injured flight crew and, subject to the particular circumstances, of fatally injured

passengers and cabin attendants is required to be carried out. These examinations shall

be expeditious and complete. The authorized officer of AAIB shall ensure that the

bodies are subjected to these examinations by police authorities. Till the AAIB

instructions on the subject are issued, Air Safety Circular 2 of 2010 may be referred.

4.1.12 If appropriate the Medical examination of the surviving crew, passengers and involved

aviation personnel, should be carried out by a physician, preferably experienced in

accident investigation. These examinations should be expeditious.

4.1.13 Additional Director General Medical Services (ADGMS) shall associate in the Post

Mortem(s) and he shall render the reports to the Court/ Committee of Inquiry.

NOTE 1 While rescuing the injured crewmembers, their identification and location in or

around the aircraft must be carefully observed and recorded. In case the pilot

and/or copilot are found dead, the necessary photographs must be taken in situ

prior to the removal. The removal action should be such as to cause minimum

of disturbance to the aircraft wreckage/parts and any such disturbance should

be fully recorded. The location of the passengers should also be recorded

immediately during rescue operation. However, removal of the injured to the

nearest hospital must not be delayed for want of formalities with regard to the

recording as stated above.

NOTE 2 Safe custody shall include protection against further damage, access by

unauthorised persons, pilfering and deterioration. All the parts of the aircraft

or relevant matter picked up from the wreckage should be preserved. The

aircraft parts or components which are suspected to have malfunctioned be

preserved for testing or examination in a thorough manner The positions at

which the flight data and voice recorders are found if installed on the aircraft

should be recorded on a sketch.


4.1.14 If, in the course of an investigation it becomes known, or it is suspected, that an act of

unlawful interference was involved, ID shall immediately initiate action to ensure that

the local administrative/ police authorities are informed.

4.2 PRELIMINARY INVESTIGATION

4.2.1 Rule 9 of the Aircraft (Investigation of accidents and incidents) Rules 2012 - requires

the Bureau to authorise any person including an officer of the Bureau to carry out

preliminary investigation to an accident or incident and to submit a preliminary report

to the Bureau in a specified format to assess the classification of the occurrence and

the expertise needed for detailed investigation under rules 11 or 12, of the Rules. if

considered expedient by the Central Government.

4.2.2 Head, AAIB and in his absence, Investigation Division (ID) will authorize an officer

of the Bureau or any other person to carry out the above said preliminary investigation.

Procedure to be followed for the onsite investigation is at Appendix ‘E1’.

4.2.3 The officer, for the purposes of investigation shall have power to require and enforce

the production of all books, paper, documents and articles which he may consider

necessary for the investigation, and to retain any such books, papers, documents and

articles until completion of the investigation. He shall have the access to examine any

aircraft and its components involved in the accident or incident, the place where the

accident or incident occurred or any other place, the entry upon and examination of

which appears necessary for the purpose of the investigation.

4.2.4 The preliminary investigation shall normally include the gathering, recording and

preliminary analysis of all relevant information on that accident or incident. Where

feasible, the officer shall visit the scene of the accident, examine the wreckage and

take statements from witnesses. The guidelines on Occupational Health and Safety

applicable to Aircraft Accident Investigations is at Appendix ‘E2’

4.2.5 In case of serious incidents the aircraft as a whole may not be required to be kept for

investigation purposes under the custody, however in case of accident particularly to

large transport aircraft, covered space may be required for keeping the accident

aircraft/ wreckage. The hangars space will be arranged at the airport nearest to the site

of occurrence, if required for the purposes to avoid any pilferage, damage or loss of

evidence.


CHAPTER 5

SIZE AND SCOPE OF THE INVESTIGATION

5.1 GENERAL

5.1.1 The investigation normally will include:

the gathering, recording and analysis of all relevant information on that accident

or incident;

if appropriate, the issuance of safety recommendations;

if possible, the determination of the causes and/or contributing factors; and

the completion of the Final Report.

5.1.2 The extent of the investigation will be carried out depending on the lessons expected

to be drawn from the investigation for the improvement of safety. The scope of the

investigation and the size and composition of the investigation team would be decided

by the:

injuries, deaths and damage to equipment, third parties and the environment;

identified and potential safety issues underlying the accident/incident;

the likelihood of recurrence, the probability of adverse consequences, and the

severity of adverse consequences;

accident and incident history related to the type of operation, size and type of

aircraft, the operator, manufacturer, and regulator; and

actual and potential deviations from industrysafetyand operational regulations,

standards, procedures and practices.

5.1.3 Formal Accident Investigation will be carried out into an accident involving a large

aircraft and usually involving fatalities. Committee of Inquiry will carry out

investigation into an incident involving any aircraft or into an accident involving a

small aircraft. Wherein it is felt that the causes are known and incident or accident is

of repetitive nature Small Investigation Reports will be prepared by a Committee of

the officers of AAIB. Following Matrix may be used as guidance for proposing

method of investigation.


Investigation

type

Occurrence type/ details

Formal

Investigation

A major catastrophic accident involving fatalities will be formally

investigated by Court of Inquiry. The Court will be ordered by

Ministry of Civil Aviation based on the nature of accident and

expertise available. The Court shall be assisted by various groups for

investigation. The completion of investigation may take 6 months or

more. Such an investigation will require additional budgetary

funding.

CoI (including

Group

Investigation)

In case the occurrence and investigation requires lot of onsite

activity, wherein CoI is immediately ordered. The CoI may be

assisted by various groups for investigation. The members of CoI are

taken from the pool of expert investigators available with AAIB. The

completion of investigation may take 3 months or more.

CoI Investigation of an occurrence which prima facie is non complex and

may be completed in less than 8 weeks by a small Committee of

Inquiry comprising mostly of AAIB officers.

Inquiry Officer An occurrence which has been assessed as limited scope factual

information based investigations (preliminary) as per Rule. This will

result in a small concise report and is prepared within 4 to 6 weeks.

5.1.4 Aircraft accident investigation is a specialized task which should be undertaken by

qualified investigators only. Aircraft Accident Investigation Bureau (AAIB) India has

been established recently. Earlier Air Safety Directorate of DGCA was carrying out

the functions and duties of investigation and prevention of accidents. Initially AAIB is

being manned by qualified and experienced investigators. As of now and in future, the

appropriately qualified personnel available with the AAIB will require training in the

accident investigation techniques in order to participate in or to conduct an aircraft

accident investigation. Training details/ requirements are at (Training Manual)

Appendix ‘E3’. Guidelines for major Group investigation are at Appendix ‘E4’.

5.2 ACCIDENT/ SERIOUS INCIDENT INVESTIGATION

5.2.1 The extent of the investigation and the procedure to be followed in carrying out such

an investigation shall be determined by ID, depending on the lessons it expects to draw

from the investigation for the improvement of safety.

5.2.2 The State of Registry, the State of the Operator, the State of Design, the State of

Manufacture and any other State that, on request, provides information, facilities or


experts will be usually represented by an accredited representative. These accredited

representatives will be entitled to:

Visit the scene of the accident

Examine the wreckage

Obtain witness information and suggest areas of questioning

Have full access to all relevant evidence as soon as possible

Receive copies of all pertinent documents

Participate in read-outs of recorded media

Participate in off-scene investigative activities such as component

examinations, technical briefings, tests and simulations

Participate in investigation progress meetings including deliberations

related to analyses, findings, causes and safety recommendations

Make submissions in respect of the various elements of the investigation.

5.2.3 Advisers also will be permitted to participate to the extent possible and as per the

obligations of Annex 13.

5.2.4 The experts from States which have special interest in an accident by virtue of

fatalities or serious injuries to its citizens will be entitled to:


Have access to the relevant factual information

Participate in the identification of the victims

Assist in the questioning surviving passengers who are citizens of the State

Receive a copy of the final report

5.2.5 In case an aircraft involved in an accident or a serious incident lands in Indian

Territory and the State conducting the investigation, requests than that State shall be

provided with the flight recorder records and, if necessary, the associated flight

recorders.

5.2.6 The Accredited representative and their advisers nominated by the States will have all

the right and privilege of access to, among others, the scene of the accident, the

relevant evidence and all pertinent documents.

5.2.7 Upon the arrival of an accredited representative, he will be provided with thorough

update on the investigation and copies of all relevant information/ pertinent

documents. The investigating chairpersons will be introduced to the accredited

representatives and their advisers, and are made aware of their rights and

responsibilities.


5.2.8 Advisers assisting accredited representatives w i l l be permitted, under the accredited

representatives’ supervision, to participate in the investigation to the extent necessary

to enable the accredited representatives to make their participation effective. In

addition, advisers may be invited to provide their expert knowledge to one or more

groups of the investigation.

5.2.9 In case a Committee of inquiry or the formal investigation (Court of inquiry) is

ordered by Government to carry out a particular serious incident or accident

investigation which normally takes some time to set up after the accident date, the

authorized person who had already commenced onsite investigation work shall on

instructions from Committee/Court of Inquiry wall assist the Committee or the Court

as the case may be with all the relevant factual information.

5.2.10 The Court/ Committee of Inquiry shall make a report to the Ministry of Civil Aviation

stating all relevant facts with regard to the accident and conclusions with regard to the

causes of the accident and adding any observations and recommendations which they

may think fit to make with a view to preservation of life and avoidance of similar

accidents in future.

5.2.11 ID on behalf of Head AAIB will review the report for accuracy of all the factual

material obtained during the investigation. At this stage if any problem regarding

investigation issues is there the same should be resolved or at least addressed to the

Court/ Committee of Inquiry.

5.2.12 Any judicial or administrative proceedings to apportion blame or liability will be

separate from these investigations.

5.3 INCIDENT INVESTIGATION

5.3.1 As per the Aircraft (Investigation of Incidents and Accidents) Rules 2012, the

Director-General may order the investigation of any incident or serious incident and

may appoint a competent and qualified person as Inquiry Officer for the purpose of

carrying out the investigation.

5.3.2 The Inquiry Officer shall make a report to the Director-General in the format as given

in Appendix ‘F’.

5.3.3 The Director-General shall forward the report of the Inquiry Officer to the Central

Government with such comments as the Director-General may think fit to make and

the Central Government may, at its discretion, make the whole or part of any such

report public in such a manner as it may consider fit.


5.4 POWERS OF AIRCRAFT ACCIDENT INVESTIGATORS

5.4.1 The investigation of aircraft accidents and incidents will be strictly objective and

totally impartial and must also be perceived to be so. The investigators including the

Court/ Committee of Inquiry and Inquiry Officer shall have the following powers:

(a) to require the attendance of any person by summons under his hand, whom

he thinks fit to call before him and examine for such purpose and to require

answers or returns to any inquiries he thinks fit to make;

(b) to require any such person to make and to sign a declaration regarding the

true nature of the statements made by him;

(c) to require and enforce the production of all books, paper, documents and

articles which he may consider necessary for the investigation, and to retain

any such books, papers, documents and articles until completion of the

investigation; and

(d) to have access to and examine any aircraft and its components involved in

the accident or incident, the place where the accident or incident occurred

or any other place, the entry upon and examination of which appears to the

investigator necessary for the purpose of the investigation.

5.4.2 The Court of Inquiry investigating into the causes of the accident shall have, for the

purpose of the investigation, all the powers of a Civil Court under the Code of Civil

Procedure, 1908 (5 of 1908) and without prejudice to these powers the Court may:-

(a) enter and inspect, or authorise any person to enter and inspect, any place

or building, the entry or inspection whereof appears to the Court requisite

for the purposes of the investigation; and

(b) enforce the attendance of witnesses and compel the production of

documents and material objects; and every person required by the Court

to furnish any information shall be deemed to be legally bound to do so

within the meaning of section 176 of the Indian Penal Code (45 of 1860).

5.5 POST-FIELD PHASE OF THE INVESTIGATION

5.5.1 Subsequent to the on site investigation, significant investigation work remains, and the

investigator must work diligently to maintain and manage the progress of the

investigation. In general, the post-field phase involves the continued collection and

validation of evidence; the examination of all pertinent personnel, company, aircraft,

facility, records; the examination of selected wreckage in the laboratory; the testing of

selected components and systems; the reading and analysis of recordings; the conduct


of further interviews; the determination of the sequence of events; the analysis of all

investigation information; and completion of technical and group reports, if any.

Guidance given in Doc 9756 should be followed for this phase of investigation.

5.5.2 It is always a challenge to ensure that the investigation continues to progress following

the field phase. To ensure the continued progress of the investigation, the investigator

should ensure that Investigations Management System Event Flow Chart is made and

followed as advised in Doc 9756.


CHAPTER 6

SUBMISSION OF REPORTS

6.1 GENERAL

6.1.1 The person authorized to carry out the preliminary investigation should submit the

report preferably within ten days of the accident or serious incident in the Performa

(Appendix‘G’). It shall contain the requisite information including any safety hazard,

either in human factor, Aircraft factor and/or any other relevant factor that is prima

facie evident during the early stages of investigation such as lack of piloting

proficiency if any or any unwarranted disregard of safety requirements, in case these

are obvious to enable framing and implementation of immediate corrective safety

measures.

6.1.2 The Committee of Inquiry or the Court is required to make a Final report (in English)

to the Central Government stating its findings as to the causes of the accident and the

circumstances thereof and adding any observations and recommendations with a view

to the preservation of life and avoidance of similar accidents in future. The format of

the Final Report in the Appendix ‘F’ should be used. Appendix‘G1’ contains detailed

guidance material on completing each section of the final report. However, it may be

adapted to the circumstances of the accident or incident.

6.1.3 The report should be self-contained in respect of its text. The body of the final report

should comprise the Factual Information; Analysis; Conclusions & Safety

Recommendations. The causes should include both the immediate and the deeper

systemic causes. The recommendations should be for the purpose of accident

prevention and any resultant corrective action. Photographs, sketches and evidence of

particular significance such as mandatory references should appear as Appendices to

the report.

6.1.4 In case after the investigation has been closed and report made public, any significant

evidence which was not in the knowledge of the Investigators comes to the knowledge

of AAIB, the same will be processed for its significance or relevance to the

investigation by representatives of ID, TD and PD. In case the information is significant

in nature and prima facie it is felt that the investigation is required to be reopened, the

file with relevant facts will be sent to MoCA for making the investigation open.

However, when the earlier investigation was not instituted by Indian Central

Government consent of the State shall be obtained which instituted the investigation.

6.1.5 Any preventive action that is considered necessary to be taken promptly to enhance

aviation safety at any stage of the investigation of an accident or incident, the same

shall be recommended to the appropriate authorities, including those in other States.


6.1.6 When appropriate, any safety recommendations arising out of investigations shall be

addressed to the accident investigation authorities of other State(s) concerned and,

when ICAO documents are involved, to ICAO.

6.2 RESPONSIBILITIES AS A CONTRACTING STATE

6.2.1 Head, AAIB will ensure that if a draft investigation report from the State conducting

the investigation is received for comments, the draft report or any part thereof, or any

documents obtained during an investigation of an accident or incident, shall not be

circulated, published or given access without the express consent of the State which

conducted the investigation, unless such reports or documents have already been

published or released by that latter State.

6.2.2 Similarly as and when safety recommendations are received from any contracting

State, the proposing State shall be informed of the preventive action taken or under

consideration, or the reasons why no action will be taken. In case it is agreed to

implement the recommendation, immediate follow up action will be taken by APD

with the concerned organisations and monitor its progress for speedy implementation.

6.3 RESPONSIBILITIES AS A STATE CONDUCTING THE INVESTIGATION

The following actions will be carried out by the ALD of AAIB. Officers will maintain

the records.

6.3.1 ACCIDENTS TO AIRCRAFT OVER 2,250 KG

When the aircraft involved in an accident is of a maximum mass of over 2,250 kg,

preliminary report shall be sent to:

a) the State of Registry or the State of Occurrence, as appropriate;

b) the State of the Operator;

c) the State of Design;

d) the State of Manufacture;

e) any State that provided relevant information, significant facilities or experts; and

f) the International Civil Aviation Organization.

6.3.2 ACCIDENTS TO AIRCRAFT OF 2,250 KG OR LESS

When the aircraft involved in an accident is of a maximum mass of 2,250 kg or less

and when airworthiness or any other matter considered to be of interest to other States

are involved, Preliminary Report shall be forwarded to:

a) the State of Registry or the State of Occurrence, as appropriate;


b) the State of the Operator;


d) the State of Manufacture; and

e) any State that provided relevant information, significant facilities or experts.

6.3.3 In all cases the Preliminary Report (also final report & other communication) shall be

submitted to appropriate States and to the International Civil Aviation Organization in

English.

6.3.4 The Preliminary Report shall be sent to the above mentioned States by facsimile,

e-mail, or airmail within thirty days of the date of the accident unless the

Accident/Incident Data Report has been sent by that time. When matters directly

affecting safety are involved, it shall be sent as soon as the information is available

and by the most suitable and quickest means available.

6.3.5 A copy of the draft Final Report shall be sent to all States that participated in the

investigation, inviting their significant and substantiated comments on the report not

later than 60 days. The draft Final Report of the investigation shall be sent for

comments to:

a) the State of Registry;

b) the State of the Operator with additional copy for Operator;

c) the State of Design with additional copy for organisation responsible for type

design; and

d) the State of Manufacture with additional copy for organisation responsible for

assembly of aircraft.

6.3.6 If the comments are received from the State concerned within sixty days of the date of

the transmittal letter, either the draft Final Report shall be amended to include the

substance of the comments received or, if desired by the State that provided

comments, the comments shall be appended to the Final Report. If no comments are

received within sixty days of the date of the first transmittal letter, the Final Report

shall be issued, unless an extension of that period has been agreed with the States

concerned.

6.3.7 A copy of the draft Final Report will also be sent, through the State of the Operator, to

the operator to enable the operator to submit comments on the draft Final Report.

6.3.8 A copy of the draft Final Report will also be sent, through the State of the Design and

the State of Manufacture, to the organizations responsible for the type design and the

final assembly of the aircraft to enable them to submit comments on the draft Final

Report.


6.3.9 The Final Report of the investigation of an accident shall be sent with a minimum of

delay to:

a) the State of Registry, in case of foreign registered aircraft

b) the State of the Operator, in case of foreign operator



e) any State having suffered fatalities or serious injuries to its citizens; and

f) any State that provided relevant information, significant facilities or experts.

6.3.10 The Final Report should be released in the shortest possible time and, if possible,

within twelve months of the date of the occurrence. If the report cannot be released

within twelve months, an interim report should be released on each anniversary of the

occurrence, detailing the progress of the investigation and any safety issues raised. In

order to provide relevant and timely information on the progress of the investigation to

the families and accident survivors, draft guidance on assistance to aircraft accident

victims and their families published by ICAO and draft ICAO policy on the subject be

referred. However before release of any such information, approval of competent

authority be taken.

6.3.11 When the investigation into an accident or an incident involving an aircraft of a

maximum mass of over 5 700 kg has been conducted and a Final Report has been

released, a copy of the Final Report shall also be sent to the International Civil

Aviation Organization.


CHAPTER 7

ADREP REPORTING

7.1 ACCIDENTS AND SERIOUS INCIDENTS

7.1.1 In accordance with Annex 13 – Aircraft Accident Investigation, States are required to

send preliminary data report to ICAO on all aircraft accidents, which involve aircraft

of a maximum certificated take-off mass of over 2,250 kgs. ALD shall compile the

data and send the same to ICAO as per the requirements. Some factual and

circumstantial information related to an accident normally will be available within the

first weeks of the investigation. All endeavours should be made to send the

Preliminary report within 30 days of the accident. Format of the Preliminary data

report is at Appendix ‘H’. The report of all accidents and serious incidents will be sent,

wherever applicable to

a) the State of Registry, in case of foreign registered aircraft

b) the State of the Operator, in case of foreign operator



e) any State having suffered fatalities or serious injuries to its citizens; and

f) any State that provided relevant information, significant facilities or

experts

7.1.2 Accident data report (final) in the format as given at Appendix ‘I’ should also be

compiled and sent to all concerned by ALD after approval of Head, AAIB, once the

investigation has been completed and final report approved. This data report should

provide accurate and complete information including factors, causes and safety

recommendations.

7.1.3 When the aircraft involved in an accident is of a maximum mass of over 2 250 kg,

Accident Data Report shall be sent, as soon as practicable after the investigation, to the

International Civil Aviation Organization also by ALD.

7.1.4 If a request is received from any State which had associated with the Investigation in

any manner, pertinent information additional to that made available in the

Accident/Incident Data Report will also be provided to those States.

7.2 INCIDENTS TO AIRCRAFT OVER 5 700 KG

7.2.1 There is no obligation for States to conduct an investigation into an incident. However

Rule 13 of the Aircraft Rules 2012 requires that the Director-General may order an

investigation of any incident or a serious incident involving Indian Civil registered

aircraft and may appoint a competent and qualified person as Inquiry Officer for the

purpose of carrying out the investigation. Further in case the Central Government


decides to investigate that incident or serious incident, the investigation ordered by

Director-General shall be closed and all relevant material shall be transferred to the

Court or the Committee appointed by the Central Government for its investigation.

7.2.2 Otherwise the Inquiry Officer shall make a report to the Director-General in the format

specified by the AAIB for investigation reports. The procedures are incorporated in the

Procedures Manual of Air Safety Directorate of DGCA.

7.2.3 In this regard when the aircraft involved in an incident is of a maximum mass of

over 5,700 kg and the investigation has revealed matters which might be of interest to

other States, Incident Data Report shall be sent, as soon as practicable after the

investigation, to the International Civil Aviation Organization.


CHAPTER 8

ACCIDENT PREVENTION MEASURES

8.1 INCIDENT REPORTING SYSTEMS

8.1.1 The procedure for mandatory occurrence reporting is elaborated in Chapter 5 of this

Manual. In order to facilitate collection of information on actual or potential safety

deficiencies the incident information and its investigation reports are mandatorily

required to be reported to AAIB by more than one organisations.

8.1.2 The voluntary incident reports are also required to be reported to AAIB in order to

facilitate collection of information on actual or potential safety deficiencies that may

not be captured by the mandatory incident reporting system. The details of the

Voluntary Reporting System are at Appendix ‘J’.

8.1.3 The voluntary incident reporting system established is totally non-punitive and afford

protection to the sources of the information.

8.2 DATABASE SYSTEMS

8.2.1 Based on the information received from the Mandatory occurrence reports, voluntary

reports, accident/ incident investigation reports, hazard reports etc. a database will be

maintained by the ALD Division of the AAIB. To facilitate the effective analysis of

information obtained from the above stated resources, the data will be kept in the excel

format till the software for data base system is developed. The data will then be kept in

standardized formats for analysis and to facilitate data exchange.

8.3 ANALYSIS OF DATA — PREVENTIVE ACTIONS

The information contained in accident/incident reports is reviewed with follow up on

recommendation. The database also will be utilised to have proper analysis of the

critical fields to determine any preventive actions required.

In the analysis of the information contained in the database, if safety matters

considered to be of interest to other States are identified, such safety information will

now be shared by AAIB with the Manufacturers so that same can be further forwarded

to other States as soon as possible.

In addition to safety recommendations arising from accident and incident

investigations, safety recommendations may result from safety studies, such safety

recommendations will also be addressed to concerned organizations.


In case it is observed that a particular matter may be of interest to other States, that

safety matter will be sent by AAIB to those States as soon as possible.

8.4 EXCHANGE OF SAFETY INFORMATION

The accident summaries are available on the website of AAIB and the APD is required

to have the analysis of data available with the ICAO website and implement the

lessons learnt from such analysis. Once the database based on the standardised

definitions, classification and formats becomes functional, the exchange of data will be

started with the help of COSCAP and ICAO.

ORGANISATION STRUCTURE

DDAED (TD) DDAS (ID)

Jt. GM

HEAD

AAIB

ADAS (ALD) Jt GM (PD)

ASO ASO

DELHI REGION CHENNAI REGION MUMBAI REGION

ID - Investigation Division

TD - Technical Division

PD - Prevention Division

ALD - Administrative & logistics

. Division

REGIONS

ASO

HEAD

AAIB


ORGANISATION STRUCTURE:

The functions of AAIB are such that there cannot be any water tight

divisions and duties may be allocated to officers across the divisions

depending on the requirement and expertise available. Following four

divisions exist in AAIB:

1. INVESTIGATION DIVISION (ID)

This Division consists of senior technical officers having at least 15 years

of experience in aircraft accident investigation. These officers act as

Chairman or team members of the Committee of Inquiries. Preliminary

investigations will be carried out by officers of this division. Review of

preliminary reports will be carried out to decide further actions. Junior

officers are posted in this division to have on job training (OJT). The

Division maintains a list of external experts for investigation.

2. TECHNICAL DIVISION (TD)

This Division

Carries out analysis of Flight Recorders at the Laboratory and be part

of the Flight Data Recorder Group for investigation, if required.

Is responsible for Technical Assistance from the testing of involved

components or failed structural parts.

Persons with relevant experience are employed for this Division.

Initially AAIB will be utilizing the existing Labs with the DGCA, in

addition to NAL, HAL, Air India FDR laboratory and facilities of

PHHL for readout and testing of components. As a policy, all the

avenues will be explored to test the components first in India to

maximum extent possible, before sending the components abroad.

3. ACCIDENT PREVENTION DIVISION (APD)

The Bureau is entrusted with the work of handling voluntary reports

and mandatory occurrence reports. These occurrences though are not

required to be investigated by Bureau but have to maintain record and

utilize the data for the purposes of safety studies and other preventive

work. Follow up on recommendation with preparation of reports,

facing technical audits by ICAO and other organizations, Interaction

and co-ordination with ICAO on Annex 13 & Annex 1, will be carried

out by this Division. The database design, analysis, review and

updation will also be required from time to time.

4. ADMINISTRATION & LOGISTICS DIVISION

The receipt of notification of an occurrence is the basis of all other

activities. Junior Technical officers may handle the notifications

received and take action as per the procedures laid down. The

investigation work will require lot of travelling by the officers

involving administrative handling of the activities involved. The

exigencies will require that the officer may have to proceed at short

notice. In addition matter subsidiary or incidental to aircraft accident

and incident investigation i.e. recruitment Rules, Personal record

keeping, Court cases, Parliament Questions, RTI, Cadre maintenance

and review, budget and expenditure, procurement of tool kits, official

accommodation & its maintenance etc. rests with this Division.

Work Allocation for Aircraft Accident Investigation Bureau

S.No. DESIGNATION WORK ALOTTED

1 DDG 1. Overall Supervision

2. Notification of Accident/Incident to

States/ICAO (Through ASO (S) – DDAS (RSP)

– DDG (BSR))

3. Process cases for resolution regarding

implementation of recommendations by

Committee of Inquiry. (DDAS will put note to

DDG)

2 DDAS 1. Preliminary Investigation.

2. Can be made member of Committee of Inquiry

for Investigation of Serious Incident/ Accident..

3. Will put up note to DDG regarding

implementation of recommendations by

Committee of Inquiry.

4. Process obligation of the Central Government

Under Annex 13.

5. Notification of Accident/Incident to

States/ICAO (Through ASO (S) – DDAS (RSP)

– DDG (BSR) ).

6. Parliament Questions.

3 Jt. GM (K) 1. Can be made member of Committee of Inquiry

for Investigation of Serious Incident/ Accident.

2. ATC, Aerodrome, CNS related matters.

4 ADAS (J) 1. Preliminary Investigation

2. Facilitate the investigation and administrative

work of Committee of Inquiry/formal

Investigation.

3. Establish and maintain an accident/incident

database.

4. Follow-up of official E-mail for reporting of

occurrences & updating web site.

5. Administrative Work of AAIB (Through ASO –

ADAS/SASO - DDAS– DDG).

6. Maintenance of AAIB office set-up.

5 ASO (S) 1. Preliminary Investigation.

2. Follow-up of Preliminary Report and putting up

note and notification for Committee of

Inquiry/Formal Investigation.

3. Updation of documents


database.


occurrences.

6 ASO (R) 1. Preliminary Investigation.

2. ADREP Summaries

3. Follow-up of recommendations made by

Committee of Inquiry and put up to DDAS for

further action.


database.


occurrences.

7 DDAED 1. Preliminary Investigation

2. investigation of Serious Incident/ Accident.


to carry for Investigation.

4. Assist the Committee of Inquiry in CVR/DFDR

Downloading/Analysis.

5. Assist the Committee of Inquiry in Material

Failure Analysis in DGCA Lab.

6. RTI Questions.

8 Jt. GM (N) 1. Can be made member of Committee of Inquiry


2. ATC, Aerodrome, CNS related matters.

3. Follow up action in connection with AAIB

office set-up.

4. Training of officers and experts

9 ADAS (D) 1. Preliminary Investigation (Southern Region).



10 ASO 1. Preliminary Investigation (Western Region).

ADAS 1. Preliminary Investigation (Northern Region).



3. Maintenance of AAIB office set-up.

APPENDIX ‘B1’

List of officers to be notified immediately on phone in addition to normal

notification in case of serious incidents and accidents

S. No Name Emails Contact No

1. Sh. G. Asok

Kumar, JS, MoCA

[email protected]

011 24617692

2. Ms. Puja Jindal.

Dir. MoCA

[email protected] 09968277301

3. Shri. B. S. Rai,

AAIB


4. Shri. R. S. Passi,

AAIB


5. Shri. N. S. Dagar,

AAIB

[email protected]

09811385422






APPENDIX ‘B2’

AAIB IN-HOUSE PROCEDURES

The object of a safety investigation is to identify and reduce safety-related risk.

AAIB investigations should determine and communicate the safety factors related

to safety matter being investigated. Though it is not a function of the AAIB to

apportion blame or determine liability but at the same time, an investigation report

must include factual material of sufficient weight to support the analysis and

findings. At all times the AAIB will endeavour to balance the use of material that

could imply adverse comment with the need to properly explain what happened,

and why, in a fair and unbiased manner.

As per the Aircraft (Investigation of accidents and serious incidents) Rules 2012,

AAIB is responsible for investigating serious incidents and accidents to civil

aircraft as well as participating in overseas investigations involving Indian Civil

registered aircraft. The AAIB will perform its functions in accordance with the

provisions of these Rules and where applicable, any relevant international

agreements.

As per Rule 8(3) of the above referred Rules, the Bureau is required to

discharge the following functions, namely

(a) obtaining preliminary report under rule 9 from any person or persons

authorised either under sub-rule (1) of rule 9 or under sub-rule(2) of rule

7;

(b) assisting the Central Government in setting up of Committee of Inquiry

and formal investigation under these rules;

(c) to facilitate the investigation and administrative work of the Committees

and Courts, whenever necessary.

(d) processing of the reports of Courts and Committees of Inquiry received

by the Central Government, which includes –

(i) forwarding of the reports to the States for consultation under sub-

rule (1) of rule 14;

(ii) forwarding the report made public by the Central Government

under sub-rule (2) of rule 14 to the States as required under Annex

13;

(iii) forwarding the report made public by the Central Government

under sub-rule (2) of rule 14 to ICAO if the mass of the aircraft

involved in accident or incident is more than 5,700 kg;

(e) follow-up the recommendations made by Courts and Committees of

inquiry and to ensure that are implemented by the concerned agencies;

(f) to process cases for a resolution by the Central Government of disputes

between the Bureau and any agency regarding implementation of a

recommendation;

(g) to formulate safety recommendation on the basis of safety studies,

including induction of new technology to enhance safety, conducted from

time to time.

(h) establish and maintain an accident and incident database to facilitate the

effective analysis of information on actual or potential safety deficiencies

obtained, including that from its incident reporting systems, and to

determine any preventive actions required;

(i) to process obligations of the Central Government under Annex 13 to the

Convention relating to International Civil Aviation signed at Chicago on

the 7th day of December, 1944 as amended from time to time; and

(j) any other functions, which the Central Government may ask the Bureau

to perform from time to time under these rules.

Rule 14 i.e. Consultation and Final Report requires that the Bureau shall forward a

copy each of the report received from either the Court under sub-rule (7) of rule 12

or Committee of Inquiry under sub-rule (6) of rule 11 to –

(a) the State of registry,

(b) the State of operator,

(c) the State of design,

(d) the State of manufacturer, and

(e) the State that participated in the investigation in accordance with sub-

rule (4) of rule 6, inviting their significant and substantiated

comments on the report within sixty days of its issuance.

Rule 18 i.e. Mandatory incident reporting system requires that the Aircraft

Accident Investigation Bureau shall establish a mandatory incident reporting

system to facilitate collection of information on actual or potential safety

deficiencies. Rule 19 Voluntary incident reporting system requires that the

Aircraft Accident Investigation Bureau shall establish a voluntary incident

reporting system to facilitate collection of information on actual or potential safety

deficiencies that may not be captured by the mandatory incident reporting system

and Rule 20 Maintenance of an accident and incident database requires that the

Aircraft Accident Investigation Bureau shall establish and maintain an accident

and incident database to facilitate the effective analysis of information on actual or

potential safety deficiencies obtained and shall from its incident reporting system

determine any preventive actions if required.

The In house procedures and the lines of reporting for carrying out the above

functions are given in the following sections and should be meticulously followed

and record maintained.

The AAIB is funded with an annual budget from the budget head of Ministry of

Civil Aviation for carrying out the investigation of aircraft accidents and serious

incidents. In case of need supplementary budget provisions will be asked for

particularly in case an accident occurs with a large number of passenger fatalities

and may require supplementary funding.

Notification

The initial information shall be assessed by ALD and take decision whether or not

to conduct an investigation. Once a decision is taken that an occurrence qualifies

for investigation by AAIB, ALD will immediately communicate the decision to ID

alongwith the information available. The Notification will be sent to the States

concerned and ICAO as in Chapter 5 of the Procedures Manual by ALD. ID will

then, based on the available information nominate preferably an officer from AAIB

or any other person who has already reached the site for carrying out the

preliminary investigation and submit the preliminary report to the ID. The person

so authorized will be immediately informed on phone followed by written

communication.

Classification & decision to investigate

All the officers of AAIB will keep their investigation field kit and essential

personal items ready for carrying out the preliminary investigation on site which

includes evidence gathering, safeguarding the evidences, retrieval of CVR and

DFDR, etc. It should be ensured that medicines if any are kept ready for few days

and separate batteries and/ or chargers for all the electronic equipments are ready

for operation. In case an officer will not be available for some period due to other

commitments, same will be informed to Head AAIB in advance.

On receipt of preliminary report, Group of officers of ID, TD & APD will classify

the occurrence for further investigation. The objective of classification is to

quickly identify and manage appropriately, those occurrences that require detailed

investigation including the allocation of resources. There may be occurrences

which may not be investigated but has got potential to contribute to aviation safety.

These will be recorded by the ALD in the database for future research and

statistical analysis.

One of the functions of AAIB is to formulate safety recommendation on the basis

of safety studies and establish and maintain an accident and incident database to

facilitate the effective analysis of information on actual or potential safety

deficiencies obtained, including that from its incident reporting systems, and to

determine any preventive actions required. In view of this the reports of occurrence

will be reviewed with following follow up actions:

A report of an occurrence that suggests that a safety issue may exist should

be investigated immediately. Investigation may lead to the identification of

the safety issue, including its significance, and provide the justification for

safety action.

In case it is felt that the investigation may not lead to the identification of

any unknown safety issue, basic details of an occurrence, based primarily on

the details provided in the initial occurrence notification will be recorded in

the database to be used in future safety analysis to identify safety issues or

safety trends. Such occurrences though not investigated immediately, but

may be the subject of a future investigation.

At times an occurrence may not warrant a full investigation but in that case

additional facts must be gathered for future safety analysis to identify safety

issues or safety trends. DGCA/ operator will be asked to render report on

that occurrence and database updated if any significant information is

received. The facts so gathered will be reviewed and if the issues are more

complex and warrant more detailed examination and analysis, full

investigation may be suggested

Preliminary ADREP will be filled in and sent to ICAO after getting it signed by an

officer of ALD and approved by Head AAIB. The reports may be submitted

electronically by visiting ICAO website or submission in non electronic format

should be sent to ICAO at the following address:

International Civil Aviation Organization

999 University Street, Montreal, Quebec H3C 5H7, Canada

Tel.: + 1 (514) 954-8219; Fax: + 1 (514) 954-6077; SITATEX:

YULCAYA

If the reports contain safety recommendations addressed to ICAO, the submission

to ICAO of the report must be accompanied by a letter to ICAO that outlines the

specific action proposed.

Priorities for investigating

The primary focus of AAIB is on enhancing safety, and in particular, those

aviation safety matters that may present a significant threat to public safety and are

the subject of widespread public interest. The significant attention therefore has to

be given to identifying systemic failures during investigation of serious incidents

and avoid catastrophic accidents which are often characterized by large numbers of

fatalities and serious injuries.

Many accidents may involve repetition of past occurrences where the contributing

factors are similar and the safety issues are well known. In these circumstances, the

likely safety benefits and lessons may not always justify full fledged investigations

by CoI with experts from panel. In those cases, Director ID, will based on the

preliminary report form a committee of AAIB officers. This committee will

prepare a report as per the format of final investigation report. The same will be

sent to Ministry of Civil Aviation for their approval. Data base will be updated for

future studies. At times however pattern of incidents may require thorough

investigation.

The following factors depending on the circumstances, will be considered while

taking a decision to investigate and at what level.

• anticipated safety value of an investigation, including the likelihood of

furthering the understanding of the scope and impact of any safety system

failures

• likelihood of safety action arising from the investigation, particularly of

national or global significance

• existence and extent of fatalities/serious injuries and/or structural damage to

aircraft /other infrastructure

• obligations or recommendations under international conventions

• nature and extent of public, interest, in particular the potential impact on

public confidence in the safety of aircraft operation

• existence of supporting evidence or requirements to conduct a special

investigation based on trends

• relevance to an identified and targeted safety program

• the risks associated with not investigating. In such a case it will be ensured

that a credible safety investigation is carried out by DGCA and report

rendered to AAIB.

• timeliness of notification

• training benefit for AAIB investigators.

Initiation of an investigation

In case it is decided that the accident or a serious incident is to be investigated by

Court or Committee of Inquiry (CoI) as per the Rules, ID will take up the matter on

file with Ministry of Civil Aviation for formation of the Court or CoI. Suitability of

the expert investigator from the available pool of investigators will be decided

keeping in mind that there is no conflict of interest and the expert is readily

available.

If the officer of AAIB has carried out the preliminary investigation he should

invariably be the part of CoI in appropriate capacity. In addition an AAIB officer

from ALD may also be designated for the co-ordination and follow up of that

particular investigation. The order of CoI should be immediately forwarded to the

Chairman and members of that Committee by ALD.

Normally the Order of CoI will contain the time duration by which the final

investigation report has to be submitted to the Central Government. If the report is

not submitted in time the Chairman CoI will send a formal request to Ministry of

Civil Aviation (Attn: Joint Secretary) asking for the extension required with

justification and status of investigation. He should also forward any interim

recommendation to enhance safety of aircraft operation.

Investigation Reports

On completion of investigation, the report will be submitted by the investigating

authority to Ministry of Civil Aviation as per the Format. It must be ensured that

the report has got following parts organised in accordance with international

standards and with AAIB procedures and guidelines.

Part 1: Factual information

Provides objective information that is pertinent to the understanding of the

circumstances surrounding the occurrence

Part 2: Analysis

Discusses and evaluates the factual information presented in Part 1 that the was

considered when determining its findings and safety actions.

Part 3: Findings

Based on the analysis of the factual information, presents the findings. The

findings can be from contributing safety factors; other safety factors; and other key

findings.

Part 4: Safety Recommendations

Based on the findings of the investigation, records the main local actions already

taken or being taken by the stakeholders involved, and recommends safety actions

required to be taken to eliminate or mitigate safety issues.

Part 5: Appendixes

Contains additional information that supports the report, for example, specialist

reports on materials failure or flight data analysis. Reports of less complex

investigations may not include safety action or appendixes.

On receipt of final report from Ministry of Civil Aviation, a copy of the final

report will be sent by ALD as per Rule 14 for consultation and inviting their

significant and substantiated comments on the report within sixty days of its

issuance to –

(a) the State of registry,

(b) the State of operator,

(c) the State of design,

(d) the State of manufacturer, and

(e) the State that participated in the investigation in accordance with sub-

rule (4) of rule 6,.

Group of officers of ALD, TD, ID and APD may go through the report for

checking its completeness regarding format etc. It will also be ensured that ICAO

13 SARP requirements are completely followed while writing the report. In the

meantime if any safety recommendation is given in the report which requires

immediate action by particular agency/ organisation, the recommendation will be

taken up with that agency/ organization.

All the actions in this paragraph will be initiated and co-ordinated by ALD. On

completion of 60 days of transmission of the final report, if any request is received

from the State for extension of time, the same will be brought to the knowledge of

Head AAIB along with the comments received from any State on the final report.

If request to extend the period is acceded to then that State will be informed of the

same. Comments received from various States will be deliberated through a

meeting chaired by Head AAIB wherein Chairman and members of the CoI or

Court will also be invited. If it is decided that the report requires amendment the

same will be carried out under intimation to Ministry of Civil Aviation or

otherwise the comments will be appended to the report and in all the cases the final

report will be sent back to Ministry of Civil Aviation for its public release.

In case after the investigation has been closed and report made public, any

significant evidence which was not in the knowledge of the investigators, comes to

the knowledge of AAIB, the same will be processed for its significance or

relevance to the investigation by representatives of ID, TD and PD. In case the

information is significant in nature and prima facie it is felt that the investigation is

required to be reopened, the file with relevant facts will be sent to MoCA for

making the investigation open. However, when the earlier investigation was not

instituted by Indian Central Government consent of the State shall be obtained

which instituted the investigation.

Follow up action on safety recommendations

Sub Rule 4 of Rule 8 of the Aircraft (Investigation of Accident & Incident)

Rules 2012 requires that AAIB may make procedures, not inconsistent with the

provisions of the Act and to carry out the purposes of these rules and the functions

referred to in sub-rule (3) of Rule 8. One of the functions is consolidation and

follow-up of safety recommendations made by the Committee of Inquiry and

Formal Investigation with the agencies required to implement the

recommendations and require action taken reports from these agencies.

On acceptance of the final report by the Government, the recommendations

contained in the final report will also be separately taken up by ALD with various

agencies/ organizations. When safety recommendations are issued, these clearly

focus on describing the safety issue of concern, rather than providing instructions

or opinions on a preferred method of corrective action. The organization to which

an AAIB recommendation is directed may assess the costs and benefits of any

particular means of addressing a safety issue.

When the AAIB issues a safety recommendation to a person, organisation or

agency, they must provide a written response within 90 days. That response must

indicate whether they accept the recommendation, any reasons for not accepting

part or all of the recommendation, and details of any proposed safety action to give

effect to the recommendation. If appropriate a meeting of all concerned will be

called by APD to discuss the recommendations and actions proposed by the

organizations for implementing these recommendations.

APD will compile all the pending recommendations and will take a monthly

review of the follow up. The recommendations which are pending for more than a

year will be brought to the knowledge of Ministry of Civil Aviation and if required

a meeting be convened at Ministry level to discuss these recommendations.

Central to the AAIB's investigation of transport safety matters is the early

identification of safety issues in the transport environment. The AAIB prefers to

encourage the relevant organisation(s) to initiate proactive safety action that

addresses safety issues. Nevertheless, the AAIB may use its power to make a

formal safety recommendation either during or at the end of an investigation,

depending on the level of risk associated with a safety issue and the extent of

corrective action undertaken by the relevant organisation.

The AAIB will also issue safety advisory notices suggesting that an organisation or

an industry sector consider a safety issue and take action where it believes it to be

appropriate. There is no requirement for a formal response to an advisory notice,

although the AAIB will publish any response it receives.

Terminology used in AAIB safety/ investigation reports

Occurrence: accident or serious incident.

Safety factor: an event or condition that increases safety risk. In other words, it is

something that, if it occurred in the future, would increase the likelihood of an

occurrence, and/or the severity of the adverse consequences associated with an

occurrence. Safety factors include the occurrence events (e.g. engine failure, signal

passed at danger, grounding), individual actions (e.g. errors and violations), local

conditions, current risk controls and organisational influences.

Contributing safety factor: a safety factor that, had it not occurred or existed at

the time of an occurrence, then either:

(a) the occurrence would probably not have occurred; or

(b) the adverse consequences associated with the occurrence would probably not

have occurred or have been as serious, or

(c) another contributing safety factor would probably not have occurred or existed.

Other safety factor: a safety factor identified during an occurrence investigation

which did not meet the definition of contributing safety factor but was still

considered to be important to communicate in an investigation report in the

interests of improved transport safety.

Other key finding: any finding, other than that associated with safety factors,

considered important to include in an investigation report. Such findings may

resolve ambiguity or controversy, describe possible scenarios or safety factors

when firm safety factor findings were not able to be made, or note events or

conditions which 'saved the day' or played an important role in reducing the risk

associated with an occurrence.

Safety issue: a safety factor particularly while carrying out safety studies, that:

(a) can reasonably be regarded as having the potential to adversely affect the

safety of future operations, and

(b) is a characteristic of an organisation or a system, rather than a characteristic

of a specific individual, or characteristic of an operational environment at a

specific point in time.

Safety issues are broadly classified in terms of their level of risk as follows:

Critical safety issue: associated with an intolerable level of risk and

generally leading to the immediate issue of a safety recommendation unless

corrective safety action has already been taken.

Significant safety issue: associated with a risk level regarded as acceptable

only if it is kept as low as reasonably practicable. The AAIB may issue a

safety recommendation or a safety advisory notice if it assesses that further

safety action may be practicable.

Minor safety issue: associated with a broadly acceptable level of risk,

although the AAIB may sometimes issue a safety advisory notice.

Safety at Site

The following minimum current vaccination will be required:

Hepatitis B

Tetanus

The following minimum Personal Protective Equipment is required:

Boots according to the site

Overalls including disposable overalls

Boot covers or gumboots (preferably steel toed)

Latex/Nitrile/Rubber Gloves

Leather riggers gloves

Safety Glasses/Goggles/Face Shield

Hearing Protection (Ear plugs)

Hard hat

Breathing protection apparatus

APPENDIX ‘C’

NOTIFICATION AND REPORTING CHECKLIST

Note.-- In this checklist the following terms have the meaning indicated below:

-- International occurrences: accidents and serious incidents occurring in the territory of a

Contracting State to aircraft registered in another Contracting State;

-- Domestic occurrences: accidents and serious incidents occurring in the territory of the State

of Registry;

-- Other occurrences: accidents and serious incidents occurring in the territory of a non-

Contracting State, or outside the territory of any State.

1. NOTIFICATION -- ACCIDENTS AND SERIOUS INCIDENTS

From For Send to Annex 13 reference

State of Occurrence International occurrences: All aircraft

State of Registry State of the Operator State of Design State of Manufacture ICAO (when aircraft over 2 250 kg)

4.1

State of Registry Domestic and other occurrences: Aircraft over 2 250 kg

State of the Operator State of Design State of Manufacture ICAO

4.7

State of Registry Domestic and other occurrences: Aircraft of 2 250 kg or less

Same as above, except ICAO

4.7.1

2. ACCIDENT REPORTING

Accidents wherever they occurred

From Type of report Concerning Send to Annex 13 reference

State conducting

the investigation

PRELIMINARY

REPORT Aircraft over 2 250 kg State of Registry or

State of Occurrence State of the Operator State of Design State of Manufacture State providing information, significant facilities or experts ICAO

6.1

Aircraft of 2 250 kg or

less Same as above, except ICAO 6.2

if airworthiness or

matters of interest

ACCIDENT DATA REPORT

Aircraft over 2 250 kg ICAO 6.6

FINAL REPORT All aircraft State instituting the

investigation State of Registry State of the Operator State of Design State of Manufacture State having interest because of fatalities State providing information, significant facilities or experts ICAO

6.10

6.12

3. INCIDENT REPORTING

Incidents wherever they occurred (when investigated)

From Type of report Concerning Send to Annex 13 reference

State conducting the investigation

INCIDENT DATA REPORT

Aircraft over 5 700 kg, if matters of interest to other States are involved

ICAO 6.7

INCIDENT INFORMATION

All aircraft, if matters of interest to other States are involved

Interested States 6.14

APPENDIX C1

Format and content

The notification shall be in plain language and contain as much of the following information as is

readily available, but its dispatch shall not be delayed due to the lack of complete information:

a) for accidents the identifying abbreviation ACCID, for serious incidents INCID;

b) manufacturer, model, nationality and registration marks, and serial number of the aircraft;

c) name of owner, operator and hirer, if any, of the aircraft;

d) name of the pilot-in-command;

e) date and time (local time or UTC) of the accident or serious incident;

f) last point of departure and point of intended landing of the aircraft;

g) position of the aircraft with reference to some easily defined geographical point and latitude

and longitude;

h) number of crew and passengers; aboard, killed and seriously injured; others, killed and

seriously injured;

i) nature of the accident or serious incident and the extent of damage to the aircraft so far as is

known;

j) an indication to what extent the investigation will be conducted or is proposed to be delegated

by the State of Occurrence;

k) physical characteristics of the accident or serious incident area; and

l) identification of the originating authority.

Note

The ICAO Manual of Aircraft Accident Investigation (Doc 6920) contains guidance material

concerning the preparation of notification messages and the arrangements to be made for their

prompt delivery to the addressee.

APPENDIX C2

ICAO Initial Notification Name, Organization and

contact information of

person/organization

submitting notification:

Name:

Title:

Organization:

Address:

Telephone:

Email: a) for accidents the identifying abbreviation

ACCID, for serious incidents INCID;

ACCID

(Accident)

INCID

(Serious Incident)

Incident

(optional)

b) manufacturer, model, nationality and

registration marks, and serial number of the

aircraft;

c) name of owner, operator and hirer, if any, of

the aircraft;

d) name of the pilot-in-command, and nationality

of crew and passengers;

e) date and time (local time or UTC) of the

accident or serious incident;

(dd/mm/yy) local date: / /

local time:

(dd/mm/yy) UTC date: / /

UTC time:

f) last point of departure and point of intended

landing of the aircraft;

Last point of departure:__________________________________________

Point of intended landing:_________________________________________

g) position of the aircraft with reference to some

easily defined geographical point and latitude

and longitude;

h) number of crew and passengers; aboard, killed

and seriously injured; others, killed and

seriously injured;

Persons on board _________crew _________pax

Fatal _________crew _________pax _________others

Serious Injury _________crew _________pax _________others

Minor _________crew _________pax _________others

i) description of the accident or serious incident

and the extent of damage to the aircraft so far

as is known;

j) an indication to what extent the investigation

will be conducted or is proposed to be

delegated by the State of Occurrence;

k) physical characteristics of the accident or

serious incident area, as well as an indication

of access difficulties or special requirements to

reach the site;

l) identification of the originating authority and

means to contact the investigator-in-charge and

the accident investigation authority of the State

of Occurrence at any time;

m) presence and description of dangerous goods

on board the aircraft. No Yes - If yes, UN #________________________

Operation Type

(If information is available)

Commercial Aviation

General Aviation

Schedule

Non-Scheduled

Passenger

Cargo

Level of damage to aircraft

(If information is available) Destroyed Substantial

Minor None

The State of Occurrence shall forward a notification of an accident or serious incident with a minimum of delay and by the most

suitable and quickest means available to: a) the State of Registry; b) the State of the Operator; c) the State of Design; d) the State

of Manufacture; and e) the International Civil Aviation Organization, when the aircraft involved is of a maximum mass of over

2 250 kg.

1

APPENDIX ‘D’

ADDRESSES OF ACCIDENT INVESTIGATION

AUTHORITIES

AFGHANISTAN President of Civil Aviation Operations Ministry of Civil Aviation and Tourism Ansari Watt, P.O. Box 165 Kabul Afghanistan Tel.: (873) 68 2341450 / 49 Fax: (873) 68 1280784 AFTN: OAKBYAYX Cable: CIVAVIA Kabul

ALBANIA Ministry of Public Works, Transport and

Telecommunication Directorate General of Civil Aviation Rruga Muhamet Gjollesha – Parku 1 Delegacioneve Pob 205, Tirana Albania Tel.: (355) 42-251220 (355) 68 212 1493 (outside office hours) (355) 42 343487 (24 hours) E-mail: [email protected] Fax: (355) 42-226232 SITA: TIATNXS AFTN: LATIYFYX Telex: 2124 ASTRAN AB

ALGERIA Ministère des transports Direction de l’Aviation civile et de la météorologie 119, rue Didouche Mourad Alger Algérie Tel.: (213) 2 74 06 81 (standard) (213) 2 74 76 30 (ligne Directeur directe) Fax: (213) 2 74 76 14 (213) 2 74 76 24 RSFTA: DAALYAYA SITA: ALGMTCR Telex: 66 129

ANDORRA National Civil Aviation Administration Département des Transports et de l’Énergie Ministère de l’Économie Carrer Prat de la Creu, 62-64 Andorra la Vella Andorra Tel.: (376) 875 700 Fax: (376) 861 519

ANGOLA Direcçao Nacional de Aviação Civil Rua Miguel de Melo No. 96, 6° Andar Caixa Postal 569 Luanda Angola Tel.: (244) 9232-49760 (Director General) (244) 9199-11200 / 9299-87740 (24 hours) Fax: (244) 2 39 05 29 AFTN: FNLUYAYX Telex: 4118 DNAC AN Cable: AERONAUTICA Luanda

ANTIGUA AND BARBUDA See Eastern Caribbean States ARGENTINA Junta de Investigaciones de Accidentes de Aviación Civil

(JIAAC) Avenida Belgrano 1370 – Piso 11 C1093AAO, Cuidad Autónoma de Buenos Aires Argentina Tel.: (54) 11 4382-8890 / 91 E-mail: [email protected] Tel./Fax: (54) 11 4317-6704 / 5 (54) 11 4381-6333 (24 hours) AFTN: SABAYAYX Website: www.jiaac.gov.ar

ARMENIA Flight Safety Inspection Department General Department of Civil Aviation Airport ―Zvartnots‖ Yerevan-0042 Armenia

ARUBA1

Department of Civil Aviation Sabana Berde 73-B Oranjestad Aruba Tel.: (297) 832665 General



2

Tel.: (374) 10 593 005 Tel./Fax: (374) 10 283 429 (24 hours) E-mail: [email protected] Fax: (374) 10 285 345 AFTN: UDDUYLYX

(297) 824330 (ext. 258) (297) 562-4040 (24 hours / 7 days mobile) E-mail: [email protected] Fax: (297) 823038 AFTN: TNCAYAYX Cable: CIVILAIR ARUBA

AUSTRALIA Australian Transport Safety Bureau (ATSB) P.O. Box 967, Civic Square Canberra A.C.T. 2608 Australia Tel.: (61) 2 6257-4150 (24/7 Notifications) (61) 2 6274-6464 (International liaison) E-mail: [email protected] (Notifications) [email protected] (International liaison) Fax: (61) 2 6274-6434 (Notifications) (61) 2 6274-6474 (International liaison) Website: http://www.atsb.gov.au

AUSTRIA Federal Office of Transport Accident Investigation Branch / Dept. Aviation P.O. Box 207 Lohnergasse 9/4 A-1210 Vienna Austria Tel.: (43) 1 27760-7700 (24 hours) E-mail: [email protected] Fax: (43) 1 27760-9299 Telex: 232 322 1155 Cable: 232 322 1155 Website: http://versa.bmvit.gv.at

AZERBAIJAN State Concern of Civil Aviation Azadlyg, Prospect 11 37000 Baku Azerbaijan Tel.: 994 12 93 44 34 Fax: 994 12 98 52 37 SITA: UBBZZJ2 AFTN: UBBUDDXX

BAHAMAS Accident Investigation Department Contact: Manager, Flight Standards Inspectorate P.O. Box N-975 Nassau-New Providence Bahamas Tel.: (242) 377 3445 (242) 376 7909 (24 hours / 7 days) E-mail: [email protected] [email protected] Fax: (242) 377 6060 AFTN: MYNNYAYX Telex: BS109 CADAIR BS Cable: CADAIR- BAHAMAS

BAHRAIN Assistant Undersecretary for Civil Aviation Ministry of Transportation Bahrain International Airport P.O. Box 586 Bahrain Tel.: (973) 32 3000 / 1000 Fax: (973) 32 5757 SITA: BAH APYF AFTN: OBBI YAYX Telex: 9186

BANGLADESH Civil Aviation Authority Flight Safety Kurmitola Dhaka 1206 Bangladesh Tel.: (880) 2 891122 Fax: (880) 2 893322 AFTN: VGHQYA Telex: 632210 CCAAB BJ Cable: CIVILAIR Dhaka

BARBADOS Technical Director — Aviation Air Traffic Services Building Grantley Adams International Airport Christ Church Barbados Tel.: (246) 428-09309 Fax: (246) 428-2539 AFTN: TBPBYAYX Cable: CIVILAV BARBADOS

BELARUS State Aviation Committee Civil Aviation Department 4 Ulitsa Aerodomnaya 220065 Minsk Belarus Tel.: (375) 172 225 392 Fax: (375) 172 227 728 AFTN: UMMDMAXX Cable: MSQDSB2








3

BELGIUM Bureau Enquêtes — Accidents Service Public Fédéral Mobilité and Transports Centre Communications Nord —2ème étage Rue du Progrès, 80 — Bte 5 1030 Bruxelles Belgique Tel.: (32) 2 277-4423 (32) 476 761-865 (24 hours) E-mail: [email protected] Fax: (32) 2 277-4260 Website: http://www.mobilit.fgov.be

BELIZE Civil Aviation Department Belize International Airport P.O. Box 367 Belize City Belize Tel.: (501) 25 2052 / 2014 Fax: (501) 25 2533 AFTN: MZBZYAYX Cable: CIVILAIR Belize

BENIN Direction de l’Aéronautique Civile B.P. 305 Cotonou Benin Tel.: (229) 30 10 98 / 99 AFTN: DBBBYAYX Cable: AEROCIVIL Cotonou

BERMUDA1

The Director of Civil Aviation Department of Civil Aviation 2 Kindley Field Road St. George, GE CX Bermuda Tel.: (441) 293 1640 Fax: (441) 293 2417 AFTN: TXKFYAYX Telex: 02903248 AVCIV BA Cable: AVCIV Bermuda

BHUTAN The Director Civil Aviation Division Ministry of Communication Royal Government of Bhutan P.O. Box 291, Thimphu Bhutan Tel.: (975) 2 22499 Fax: (975) 2 223639 / 22987 Cable: DIRCEVAVIATION Thimphu

BOLIVIA Ministerio de Obras Públicas, Servicios y Vivienda Viceministerio de Transportes Dirección General de Aeronáutica Civil Palacio de Comunicaciones Av. Mcal. Santa Cruz No. 1278 4° Piso La Paz Bolivia Tel.: (591) 3 339-5323 / 339-5331 (Santa Cruz) (591) 2 211-5519 (La Paz) E-mail: [email protected] Fax: (591) 3 339-5331 AFTN: SLLPYAYX Cable: AEROCIVIL La Paz Website: www.dgac.gov.bo

BOSNIA AND HERZEGOVINA Directorate of Civil Aviation – BDDCA Fehima efendije Čurčića 671000 Sarajevo Bosnia and Herzegovina Tel.: (387) 33 251 350 E-mail: [email protected] Fax: (387) 33 251 351 AFTN: LQBHYLYX

BOTSWANA The Director Department of Civil Aviation P.O. Box 250 Gaborone Botswana Tel.: (267) 365 5200 / (267) 312 062 E-mail: [email protected] Fax: (267) 353 709 / (267) 303 348 AFTN: FBHQYAYX Cable: AVIATION GABORONE

BRAZIL Centro de Investigaçáo e Prevençáo de Acidentes

BRUNEI DARUSSALAM Director of Civil Aviation



http://www.dgac.gov.bo/



4

Aeronauticos — CENIPA SHIS — QI 05 — Área Especial 12 LAGO SUL Brasilia — DF — CEP 71615-600 Brasil Tel.: (55) 61 3365 1008 / (55) 61 3364 8800 E-mail: [email protected] Fax: (55) 61 3365 1004 AFTN: SBBRYLYX Telex: 0611152 CENIPA SBBR Website: http://www.cenipa.aer.mil.br

Ministry of Communications Brunei International Airport Bandar Seri Begawan BB2513 Brunei Darussalam Tel.: (673) 2-330 142 E-mail: [email protected] Fax: (673) 2-331 706 AFTN: WBSBYAYX Telex: 2267 DCA BU Cable: CIVILAIR BRUNEI

BULGARIA Aircraft Accident Investigation Unit 9, Diakon Ignattii Street Sofia 1000 Bulgaria Tel.: (359) 2 940 98 63 E-mail: [email protected] Fax: (359) 2 988 57 50 SITA: SOFTOYA AFTN: LBSFYAYX Telex: 22640 AVINS BG Cable: AVINS Sofia

BURKINA FASO Direction de l’Aviation Civile B.P. 1158 Ouagadougou 01 Burkina Faso Tel.: (226) 30 64 88 / (226) 31 63 32 Fax: (226) 31 45 44 AFTN: DFFVYAYX

BURUNDI Directeur de la Régie des Services Aéronautiques B.P. 694 Bujumbura Burundi Tel.: (257) 22.3707 / (257) 21.8656 Fax: (257) 22.3428 AFTN: HBBAYAX Telex: 5190 AERO BDI Cable: MINITPTBU-BUJUMBURA

CAMBODIA State Secretariat of Civil Aviation 62 Preach Norodom Blvd. Phnom Penh Cambodia Tel.: (855) 12 810-330 / 878-192 / 456-443 (24 hours) Fax: (855) 23 223-511 SITA: PNHVAYA AFTN: VDPPYAYX Cable: DACK Phnom Penh

CAMEROON Direction de l’Aviation Civile Yaoundé Cameroun Tel.: (237) 30 3090 Fax: (237) 30 3362 AFTN: FKKYYAYX Telex: 8214 KN Cable: Aérocivile Yaounde

CANADA Transportation Safety Board of Canada 200 Promenade du Portage Place du Centre, 4th Floor Hull, Quebec K1A 1K8 Canada Tel.: (1) 819-994-4252 (1) 819-997-7887 (24 hour) E-mail: [email protected] Fax: (1) 819-953-9586 Website: http://www.tsb.gc.ca

CAPE VERDE Agencia de Aviação Civil – AAC Av. Cidade de Lisboa, no. 34 CP 371 Cidade da Prala Ilha de Santiago Cabo Verde Tel.: (238) 2 603430 (238) 989-9491 / 993-8396 (24 hours) E-mail: [email protected]

CAYMAN ISLANDS1

Director of Civil Aviation P.O. Box 277G George Town Grand Cayman West Indies Tel.: (1) 345 949-7811 Fax: (1) 345 949-0761 AFTN: MWCRYAYX






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Fax: (238) 2 611075

Telex: 4458 CIVAV CP

CENTRAL AFRICAN REPUBLIC Direction Générale de l’Aviation Civile et de la Météorologie B.P. 941 et 224 Bangui République Centrafricaine Tel.: (236) 61 53 16 Fax: (236) 61 49 18 AFTN: FEFVYAYX Telex: 5209 RC Cable: MINITRANS-BANGUI

CHAD Direction de l’Aviation Civile B.P. 96 N’Djaména Tchad Tel.: (235) 516 231 AFTN: FTTVYAYX

CHILE Dirección General de Aeronáutica Civil Miguel Claro 1314 Providencia, Santiago Chile Tel.: (56) 2 439-2376 (56) 2 09 138-9949 (Director’s mobile) (56) 2 439-2224 / 2550 (24 hours) E-mail: [email protected] / [email protected] Fax: (56) 2 436-8142 AFTN: SCSCYAYX Telex: 490532 DAITA CL

CHINA General Administration of Civil Aviation of China 155 Dongsi Street West Beijing 100710 China Tel.: (86) 10 6409-1908 (business hours)

(86) 10 6401-2907 (24 hours / 7 days) E-mail: [email protected] Fax: (86) 10 6405-2829 AFTN: ZBBBYAYX Telex: 22101 CAXT CN Cable: 22101 CAXTCN

CHINA, MACAO SPECIAL ADMINISTRATIVE

REGION Civil Aviation Authority Alameda Dr. Carlos D’Assumpção, 336-342 Centro Comercial Cheng Feng, 18˚ andar Macau China Tel.: (853) 2851-1213 (853) 6232 2999 (24 hours) E-mail: [email protected] Fax: (853) 2833-8089 AFTN: VMMCYAYI Website: www.aacm.gov.mo

COLOMBIA Grupo Investigación de Accidentes Unidad Administrativa Especial de Aeronáutica Civil Avenida El Dorado #103 -23 Oficina 204 Bogotá, D.C. Colombia Tel.: (57) 1 266-3068 (57) 1 350-554-8381 / 0958 (24 hours mobile) E-mail: investigació [email protected] Fax: (57) 1 266-3940 AFTN: SKBOYAYX Telex: 044620 DAAC CO

COMOROS Direction Générale de l’Aviation Civile et de la Météorologie B.P. 72 Moroni Comores Tel.: (269) 744 245 / 730 447 E-mail: [email protected] Fax: (269) 731 030 / 735 063 AFTN: FMCNYAYX Telex: K0241 PUBLICKO

CONGO Direction Générale de l’Agence Nationale de l’Aviation civile B.P. 128 Brazzaville Congo Tel.: (242) 82 40 90 (242) 82 80 61 Fax: (242) 82 40 90 AFTN: FCBVYAYX Telex: 5388 KG

COOK ISLANDS Department of Civil Aviation

COSTA RICA Dirección General de Aviación Civil







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P.O. Box 61 Rarotonga Cook Islands Tel.: (682) 22 810 Fax: (682) 28 816 AFTN: NCRGYAYX Telex: 62052 AVARUA

Ministerio de Obras Públicas y Transporte Sección AIG Apartado Postal 5026-100 San José Costa Rica Tel./Fax: (506) 290 0664 (Attn.: R. G. Gamboa Sandoval) E-mail: [email protected] SITA: SJOTOYA AFTN: MRSJYAYX Telex: 2926 DGAC

CÔTE D’IVOIRE Agence Nationale de l’Aviation Civile (ANAC) 07 B.P. 148 Abidjan 07 Côte d’Ivoire Tel.: (225) 27 74 24 / (225) 27 90 04 Fax: (225) 27 63 46 AFTN: DIAVYAYX Telex: 43452 ANAM CI

CROATIA Agency for Aircraft Accident and Serious Incident Investigation Prisavlje 14 10000 Zagreb Croatia Tel.: (385) 1 616-9168 E-mail: [email protected] Fax: (385) 1 616-9068 AFTN: LDZGYAYX

CUBA Dirección de Seguridad Aeronáutica y Operaciones Instituto de Aeronáutica Civil de Cuba Calle 23, No. 64 Vedado Ciudad de la Habana 4 Cuba 10600 Tel.: (53) 7 838-1115 (53) 7 838-1120 / 1132 (24 hours) E-mail: [email protected] /

[email protected] [email protected] (24 hours) Fax: (53) 7 838-4575 (53) 7 834-4553 (24 hours) SITA: HAVSACU AFTN: MULHYLYX Telex: 511737 A CIV CU

CYPRUS Air Accident and Incident Investigation Board Alpha Building Block A – 1st floor Pindarou 27 Street 1060 Nicosia Cyprus Tel.: (357) 404166/3/4/5 (357) 9935 6060 / 9963-3500 / 9933-5492 (mobile) E-mail: [email protected] [email protected] SITA: NICTOYA AFTN: LCNCYAYX Cable: 6055CIVAIR CY

CZECH REPUBLIC Air Accidents Investigation Institute Director Beranových 130 199 01 Prague 9 Czech Republic Tel.: (420) 225 115 426 (420) 724 300 800 (24 hours) E-mail: [email protected] Fax: (420) 225 115 430 Website: http://www.uzpln.cz

DEMOCRATIC PEOPLE’S REPUBLIC OF KOREA Director General General Administration of Civil Aviation Sunan District Pyongyang Democratic People’s Republic of Korea Tel.: (850) 2 381 8108 Fax: (850 2) 381 4625 SITA: FNJEDJS AFTN: ZKKKYAYX Telex: 5471 JS KP Cable: CIVILAIR Pyongyang

DEMOCRATIC REPUBLIC OF THE CONGO Direction de l’Aéronautique Civile Ministère des Transports et Communications Building Ontara, boulevard du 30 juin B.P. 3304

DENMARK Accident Investigation Board Langebjergvaenget 21 DK-4000 Roskilde Denmark









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Kinshasa/Gombe République démocratique du Congo Tel.: (243) 24 21710 Cable: CIVILAIR KINSHASA

Tel.: (45) 38 71 10 66 (24 hours) E-mail: [email protected] Fax: (45) 38 71 92 31 Website: http://www.aib.dk

DJIBOUTI Direction de l’Aviation Civile et de la Météorologie B.P. (204) 250 Djibouti République de Djibouti Tel.: (253) 340169 / 341647 Fax: (253) 355975 AFTN: HFFFYAYX Telex: 5871 PRESIDEN DJ

DOMINICAN REPUBLIC Comisión Investigadora de Accidentes de Aviación Junta de Aviación Civil Calle José Joaquín Pérez no. 104, Gazcue Santo Domingo República Dominicana Tel.: (1) 809 689-4167 E-mail: [email protected] Fax: (1) 809 221-8616 AFTN: MDCDYFYX Cable: DIRACIV-SANTO DOMINGO

EASTERN CARIBBEAN STATES Directorate of Civil Aviation of Eastern Caribbean States P.O. Box 1130 Factory Road St. John’s Antigua Tel.: (1) 809 462-0907 E-mail: [email protected] Fax: (1) 809 462-4145 AFTN: TAPAYAYX Telex: 2089 CIVILAV AK Website: http://www.oecs.org/DCA_WEBsite/ contacting_the_dca.htm

ECUADOR Junta Investigadora de Accidentes Dirección General de Aviación Civil Seguridad de Vuelo Av. Colón E5-56 y Rábida Quito Ecuador Tel.: (593) 2-223-8981 (593) 2-330-1497 (24 hours) (593) 9-350-5927 (Mobile) E-mail: [email protected] Fax: (593) 2-223-8981 (593) 2-330-1534 (24 hours) AFS: SEQUZXSM Telex: 22710 DACUIO ED

EGYPT Central Department of Aircraft Accident Investigation and Prevention Civil Aviation Authority Ministry of Transport and Communications P.O. Box 52, Cairo Airport Road Cairo Egypt Tel.: (20) 2 634 9068 / (20) 2 666 850 E-mail: [email protected] Fax: (20) 2 247 0351 SITA: CAIXYYF AFTN: HECAYAYX Cable: TYARAN-CAIRO

EL SALVADOR Autoridad de Aviación Civil Boulevard del Ejercito Nacional KM 9 1/2 Aeropuerto de Ilopango San Salvador El Salvador Tel.: (503) 2295-0265 / (503) 2295-0406 / (503) 2295-

0433 ext. 128 (503) 7729-7690 (mobile 24 hours) E-mail: [email protected] Fax: (503) 2296-6349 / (503) 2295-0406 AFTN: MSSSYAYX / MSSSYOYX Cable: AEROCIVIL San Salvador

EQUATORIAL GUINEA Ministerio de Transportes y Comunicaciones Dirección General de Transportes y Aviación Civil Calle Arallia, N˚ 22 Malabo (Bioko-Norte) República de Guinea Ecuatorial Tel.: (240) 9 3231 / (240) 9 2062 Fax: (240) 9 3313 AFTN: FGSL YD YX

ERITREA Director General Civil Aviation Authority Sematat Avenue Street No. 172 P.O. Box 252 Asmara Eritrea Tel. (291) 1 124335 (Director General) (291) 1 127250 (Air Navigation Division)







8

Telex: GE913101 PUBMBO Cable: DIRAVIACIVIL MALABO

PBX: (291) 1 123090 / 127222 E-mail: [email protected] Fax: (291) 1 124334 SITA: ASMCAYA AFTN: HHAAYAYX

ESTONIA Ministry of Economic Affairs and Communications Emergency Management Department Harju 11 Tallinn 15072 Estonia Tel.: (372) 625-6313 E-mail: [email protected] Fax: (372) 631-3660 AFTN: ULTTYAYX

ETHIOPIA Civil Aviation Authority P.O. Box 978 Addis Ababa Ethiopia Tel.: (251) 1 610277 / 180359 E-mail: [email protected] Fax: (251) 1 612533 SITA: ADDYAYF AFTN: HAABYAYX Telex: 21162 CIV AIR ET Cable: CIVILAIR Addis Ababa

FIJI Civil Aviation Authority of Fiji Private Mail Bag Nap 0354 Nadi Airport Fiji Tel.: (679) 672 1555 (679) 999 5201 (after hours) E-mail: [email protected] / [email protected] Fax: (679) 672 1500 Website: http://www.caafi.org.fj

FINLAND Accident Investigation Board Sörnäisten rantatie 33 C FIN-00580 Helsinki Finland Tel.: (358) 9 1606 7643 E-mail: [email protected] Fax: (358) 9 1606 7811 AFTN: EFHKYAYX Telex: 12-1247 AVIA SF Website: http://www.onnettomuustutkinta.fi

FRANCE Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation civile Bâtiment 153 Aéroport du Bourget 93350 Le Bourget France Tel.: (33) 1 49 92 72 00 (33) 1 48 35 86 54 (Emergency 24 hours) E-mail: [email protected] Fax: (33) 1 49 92 72 03 AFTN: LFPSYLYX Telex: 203591 F Website: http://www.bea-fr.org

GABON Secrétariat Général à l’Aviation Civile et Commerciale B.P. 2.212 Libreville Gabon Tel.: (241) 76 38 95 / (241) 73 08 28 Fax: (241) 73 08 25 AFTN: FOOVYAYX Telex: 5352 GO Cable: AVIACIVIL Libreville

GAMBIA Gambia Civil Aviation Authority Banjul International Airport Yundum, P.O. Box 285 Banjul Gambia Tel.: (220) 472831, 82167 / 71 Fax: (220) 472190 AFTN: GBYDYAYX Telex: 2295 MINWOCOM GV Cable: CIVILAIR BJL

GEORGIA Head of Air Transport Department Ministry of Transport 28 Rustaveli Avenue 380008 — Tbilisi Georgia Tel.: (995) 32 93 30 92 Fax: (995) 32 98 96 30 SITA: TBSDMSU AFTN: UGGUDD








9

GERMANY Federal Bureau of Aircraft Accidents Investigation Hermann-Blenk-Str. 16 38108 Braunschweig Germany Tel.: (49) 531 3548 0 E-mail: [email protected] Fax: (49) 531 3548 246 Telex: 952749 ACCID D Website: http://www.bfu-web.de

GHANA The Director General Ghana Civil Aviation Authority Private Mail Bag Kotoka International Airport Accra Ghana Tel.: (233) 21 776171 E-mail: [email protected] Fax: (233) 21 773293 SITA: ACCATYA AFTN: DGAAYAYX Telex: 94 2336 GHACAA GH Cable: AIRCIVIL ACCRA

GREECE Hellenic Republic Ministry of Transport and Communication Air Accident Investigation and Aviation Safety Board Ex. American Base Building 221 Helliniko 167 01 Athens Greece Tel.: (30) 210 960 8090 (30) 6973-430405 / 430406 (24 hour) E-mail: [email protected] Fax: (30) 210 961-7137

GUATEMALA Dirección General de Aeronáutica Civil Aeropuerto Internacional ―La Aurora‖ Zona 13 Guatemala, Centro América Tel.: (502) 2 331 0311 / 9484 Fax: (502) 2 331 4840 AFTN: MGGTYAYZ Telex: 3120 ACIVIL GU Cable: DAEROCIVIL Guatemala

GUINEA Ministère de l’Équipement Direction Nationale de l’Aviation Civile B.P. 95 Conakry République de Guinée Tel.: (224) 45 34 57 / 45 19 28 Fax: (224) 41 35 77 AFTN: GUCYYAYX Telex: 22349 MITRANS Cable: AVIACIVIL CONAKRY

GUINEA-BISSAU Direction Générale de l’Aviation Civile C.P. 77 Bissau Guinée-Bissau Tel.: (245) 21 30 03 / 21 39 61 AFTN: GGOVYAYX Cable: AEROCIVIL Bissau

GUYANA Civil Aviation Authority 82 Premniranjan Place Prashad Nagar Georgetown Guyana Tel.: (592) (592) 225-6822 E-mail: [email protected] Fax: (592) 225-6800 AFTN: SYGCYAYX

HAITI Office National de l’Aviation civile Aéroport International de Port-au-Prince B.P. 1346 Port-au-Prince Haiti Tel.: (509) 46 052 Fax: (509) 46 0998 AFTN: MTEGYAYX Telex: CIVILAV ITT 2030465

HONDURAS Junta de Prevencion e Investigación de Accidentes e Incidentes Aereos

HONG KONG1

Civil Aviation Department Queensway Government Offices, 46th Floor





10

Dirección General de Aeronáutica Civil Apartado Postal 30145 Tegucigalpa, M.D.C. Honduras Tel.: (504) 234-2507 (COCESNA – 24 hours) (504) 233-4489 (COFAH – 24 hours) Tel./Fax: (504) 233-3683 (DGAC) AFTN: MHTGYTYX Website: www.dgachn.org

66 Queensway Hong Kong China Tel.: (852) 2867 4332 (852) 2910-6821 (24 hours) E-mail: [email protected] Fax: (852) 2810-0093 (852) 2910-1177 (24 hours) AFTN: VHHHYAYX Website: www.cad.gov.hk

HUNGARY Transportation Safety Bureau (TSB) P. O. B. 62 H-1675 Budapest Hungary Tel.: (36) 1 294 5529 (36) 1 296 9504 (36) 30 931-0832 (mobile) Fax: (36) 1 296 9520 AFTN: LHBPYLYX

ICELAND Aircraft Accident Investigation Board Hus FBSR Flugvallarvegi 101 Reykjavik Iceland Tel.: (354) 511 1666 (0800 – 1600 hrs) (354) 660 0336 (24 hour) E-mail: [email protected] Fax: (354) 511 1667 AFTN: BICAYAY Website: http://www.rnf.is

INDIA AIRCRAFT ACCIDENT INVESTIGATION

BUREAU

MINISTRY OF CIVIL AVIATION

Phone numbers +911124610843, 24610848

Fax number +9111 24693963 e-mail [email protected]

INDONESIA National Transportation Safety Committee Gedung Karya, 7th Floor Ministry of Transport Merdeka Barat No. 8 Jakarta 10110 Indonesia Tel.: (62) 21 351 7606 (62) 21 381 1308 ext. 1497 E-mail: [email protected] Fax: (62) 21 351 7606 AFTN: WIIXYAYX Telex: 49482 CIVAIR IA Cable: CIVILAIR JAKARTA Website: www.dephub.go.id/knkt

. IRAN (ISLAMIC REPUBLIC OF) Ministry of Roads and Transportation Civil Aviation Organization Mehrabad International Airport P.O. Box 13445-1798 Tehran Islamic Republic of Iran Tel.: (98) 21 6602-5230 / 6602-5238 / 4465-9349 E-mail: [email protected] Fax: (98) 21 4465-9348 AFS: OIIIYAYX Telex: 213889 EPDIR Cable: CIVILAIR, TEHRAN Website: http://www.cao.ir

IRAQ Directorate of Flight Safety General Establishment of Civil Aviation P.O. Box 23006 Baghdad International Airport Baghdad Iraq Tel.: (964) 1 8863999 (ext. 28278) Fax: (964) 1 8880178 SITA: SDAYAYD AFTN: ORBSYDYX Telex: 212500 YIA IK Cable: SDA

IRELAND Air Accident Investigation Unit (AAIU)

ISRAEL Ministry of Transport






11

Department of Transport 44 Kildare Street Dublin 2 Ireland Tel.: (353) 1 604 1293 E-mail: [email protected] Fax: (353) 1 604 1514 AFTN: EIDWYAYX Website: http://www.aaiu.ie

Chief Investigator P.O. Box 120 Ben Gurion International Airport 70100 Israel Tel.: (972) 3-975-1380 (972) 50-621-2329 (24 hours mobile) E-mail: [email protected] Fax: (972) 3-760-4442 AFTN: LLADYAYX Telex: 381000 CAATS IL Cable: MEMTEUFA-BENGURION AIRPORT-ISRAEL

ITALY Agenzia nazionale per la sicurezza del volo Via A. Benigni, 53 00156 Rome Italy Tel.: 39 068 207 8219 / 39 068 207 8200 Fax: 39 068 273 672

JAMAICA Civil Aviation Authority 4 Winchester Road Kingston 5 Jamaica Tel.: (876) 960-3965 / (876) 920-2280 E-mail: [email protected] Fax: (876) 920-0194 AFTN: MKJKYAYX Cable: CIVAV JA

JAPAN Director-General Secretariat of the Aircraft and Railway Accidents Investigation Commission Ministry of Land, Infrastructure and Transport 2-1-2, Kasumigaseki, Chiyoda-ku Tokyo 100-8918 Japan Tel.: (81) 3 5253 8813 E-mail: [email protected] Fax: (81) 3 5253 1677 AFTN: RJTDYAYA Cable: KOKUKYOKU-TOKYO Website: http://www.motnet.go.jp/araic/index.html

JORDAN Civil Aviation Authority Aircraft Accident Investigation Unit (AIU) P.O. Box 39257 Amman 11104 Jordan Tel.: (962) 6 445 2027 / (962) 6 489 2282 (962) 6 445 1140 E-mail: [email protected] Fax: (962) 6 445 1141 SITA: AMMXYA AFTN: OJAMYAYX Telex: 21325 CIVAIR JO Website: http://www.jcaa.gov.jo/ air_accident_investigation.asp

KAZAKHSTAN Ministry of Transport and Communications Civil Aviation Committee 47, Kabanbai batyr Avenue 010000 Astana Kazakhstan Tel.: (7) 7172-242605 (0900 – 1830) Fax: (7) 7172-243165 AFTN: UACDYAYD

KENYA The Chief Inspector of Accidents Directorate of Civil Aviation P.O. Box 30163 Nairobi Kenya Tel.: (254) 2 822950 (ext. 238) Fax: (254) 2 822195 AFTN: HKNCYAYD Telex: KE 25239 DCA HQ Cable: DIRECTAIR

KIRIBATI The Director of Civil Aviation Ministry of Information, Communications and Transport P.O. Box 277 Bikenibeu, Tarawa Kiribati

KUWAIT Directorate General of Civil Aviation P.O. Box 17 SAFAT Kuwait 13001 Kuwait Tel.: (965) 2 476-5815






12

Tel.: (686) 28092 / 26003 Fax: (686) 28280 / 26193 AFTN: NQTAYF Telex: KI77022 Cable: MINCOM TARAWA

(965) 2 476-2755 Fax: (965) 2 476-5796 SITA: KWIASYA/KWIDDYA/KWIAPYA AFTN: OKAAYAYX Cable: CIVAIR KUWAIT

KYRGYZSTAN Interstate Aviation Committee 22/2/1 Bolshaya Ordynka Str. 119017 Moscow Russia Tel.: (7) 495 953-1244 Fax: (7) 495 953-3508 / 1600 E-mail: [email protected] Website: www.mak.ru

LAO PEOPLE’S DEMOCRATIC REPUBLIC Department of Civil Aviation Wattay International Airport P.O. Box 119 Vientiane Capital Lao People’s Democratic Republic Tel.: (856) 21 512161 / 512163 E-mail: [email protected] Fax: (856) 21 520237 / 512044 AFTN: VLAOYAYX Cable: AVIACIVIL Vientiane

LATVIA Transport Accident and Incident Investigation Bureau Brivibas Street 58, Room 209 LV-1011 Riga Latvia Tel.: (371) 6728 8140 E-mail: [email protected] Fax: (371) 67 283 339 AFTN: UMRUYAYX Telex: 161100 PTB SJ 1237 AVTO

LEBANON Directorate General of Civil Aviation Beirut International Airport Khalde Lebanon Tel.: (961) 1 628195 / 6 / 7 (961) 3 032443 E-mail: [email protected] Fax: (961) 1 629010 AFTN: OLDDYAYX SITA: BEYXYYF Telex: LE20314 DGACLN LE Cable: CIVILAIR, BEIRUT

LESOTHO Directorate Civil Aviation P.O. Box 629 Maseru 100 Lesotho Tel.: (266) 312499 Fax: (266) 310188 AFTN: FXMMYAYX Telex: 4321 LO Cable: CIVILR

LIBERIA Directorate of Civil Aviation Ministry of Transport P.O. Box 9041-1000 Monrovia 10 Liberia Tel.: (231) 22 66 91 Fax: (231) 22 75 15 AFTN: GLRBYAYX Telex: 44384 MINTRANS

LIBYAN ARAB JAMAHIRIYA Civil Aviation and Meteorology Higher Institute P.O. Box 84116 Tripoli Libyan Arab Jamahiriya Tel.: (218) 21 3615994 / 3330256 Fax: (218) 21 3615995 SITA: TIPYAXS-TIPTOYA AFTN: HLLTYAYX Telex: 20353 CALLY Cable: SIRECTAIR TRIPOLI BYA

LITHUANIA Ministry of Transport Chief Investigator of Aircraft Accidents and Incidents Gedimino Av. 17 LT-01505 Vilnius Lithuania Tel.: (370) 5 239 3907 E-mail: [email protected] Fax: (370) 5 212 4335

LUXEMBOURG Ministère des Transports

MADAGASCAR Ministère des Transports et de la Météorologie






13

Direction de l’Aviation Civile 19-21, Boulevard Royal Boîte postale 590 L-2938 Luxembourg Tel.: (352) 478-4413 / 14 Fax: (352) 467-7790 AFTN: ELLXYAYX Telex: 1465 CIVAIR LU Cable: CIVILAIR-LUX

Direction de l’Aviation Civile B.P. 921 Anosy Antananarivo 101 Madagascar Tel.: (261) 20 22 35689 (261) 20 22 28418 (261) 20 22 44757 Fax: (261) 20 22 30444 AFTN: FMMDYAYX

MALAWI Director of Civil Aviation Private Bag 322, Capital City Lilongwe 3 Malawi Tel.: (265) 780 577 E-mail: [email protected] Fax: (265) 784 986 AFTN: FWHQYAYX Telex: 44736 AVIATION MI Cable: AVIATION-LILONGWE

MALAYSIA Chief Inspector of Air Accidents Ministry of Transport Department of Civil Aviation Level 1 – 4, Podium Block 27, Persiaran Perdana, Precinct 4 Federal Government Administrative Centre 62618 Putrajaya Malaysia Tel.: (60) 3-8871-4000 Fax: (60) 3-8871-4069 AFTN: WMKKYAYX Telex: PENAWA MA 30128 Cable: CIVIL KUALA LUMPUR

MALDIVES Civil Aviation Department Ministry of Transport and Civil Aviation 2nd Floor, Huravee Building Ameer Ahmed Magu Malé 20-05 Maldives Tel.: (960) 324 986 / 324 983 E-mail: [email protected] Fax: (960) 323 039 AFTN: VRMMYAYX Telex: 66034 CIVAV MF

MALI Direction Nationale de l’Aéronautique Civile Ministère des Travaux Publics et des Transports B.P. 227 Bamako Mali Tel.: (223) 22 55 24 Fax: (223) 22 61 77 AFTN: GABVYAXY Cable: AVIACIVIL Bamako

MALTA Department of Civil Aviation Luqa Airport Luqa Cmr 02 Malta Tel.: (356) 222 936 / (356) 249 170 Fax: (356) 239 278 AFTN: LMMLYAYX Telex: 1654 CAMLT MW Cable: CIVILAIR MALTA

MARSHALL ISLANDS Directorate of Civil Aviation P.O. Box 1114 Majuro 96960 Marshall Islands Tel.: (692) 247 3889 Fax: (692) 247 7615 / 3888

MAURITANIA Ministère de l’Équipement et des Transports Direction de l’Aviation civile Boîte Postale 91 Nouakchott Mauritanie Tel.: (222) 253 337 / (222) 535 78 Fax: (222) 535 78

MAURITIUS Department of Civil Aviation S.S.R. International Airport Plaine Magnien Mauritius Tel.: (230) 603-2000 E-mail: [email protected] Fax: (230) 637-3164




14

SITA: NKCYAYX AFTN: GQNVYAMR Cable: MINITRANSPORTS Nouakchott

SITA: MRUXTYF AFTN: FIMPYAYX Telex: 4896 DCAMAU

MEXICO Dirección General de Aeronáutica Civil Secretaría de Comunicaciones y Transportes Providencia No. 807 — 6˚ piso Colonia del Valle Codigo Postal 03100 México, D.F. Mexico Tel.: (52) 55 5 523 33 77 Fax: (52) 55 5 523 72 07 AFTN: MMMXYAYX Telex: 1764154 ACIAME

MICRONESIA (FEDERATED STATES OF) Division of Civil Aviation Administration Department of Transportation, Communications and Infrastructure P.O. Box PS-2 Palikir, Pohnpei, FM 96941 Federated States of Micronesia Tel.: (691) 320 2865 E-mail: [email protected] Fax: (691) 320 5853 AFTN: PTPNYAYX Telex: 729-6807

MONACO Service de l’Aviation Civile Héliport de Monaco MC-98000 Monaco La Principauté de Monaco Tel.: (377) 98 98 87 11 (office hours) (33 6) 07 93 28 38 (out-of-office hours) Fax: (377) 98 98 87 08 AFTN: LNMCYAYX Telex: 469525 MONAVI

MONGOLIA Air Accident Investigation Bureau Mongolia Ministry of Road, Transportation, Construction and Urban Development of Mongolia Chinggis Khaan International Airport Ulaanbaatar 34 Mongolia Tel.: (976) 11 282095 E-mail: [email protected] Fax: (976) 11 379974 AFTN: ZMUBYAYX

MOROCCO Bureau d’enquêtes et d’analyses des accidents d’aviation civile Avenue Maâ El Aynaine B.P. 1073 Agdal, RP Rabat Maroc Tel.: (212) 5 37 67 94 41 / 42 (212) 6 60 18 18 70 (24 hours) Fax: (212) 5 37 77 30 74 AFTN: GMMRYAYA

MOZAMBIQUE National Civil Aviation Administration P.O. Box 227 Maputo Mozambique Tel.: (258) 1 465416 Fax: (258) 1 465415 AFTN: FQHQYAYX Telex: 6-175 SEAC MO Cable: AERONAUTICA-MAPUTO

MYANMAR Department of Civil Aviation Headquarters Building Yangon International Airport P.O. Box 11021 Mingaladon Yangon Myanmar Tel.: (95) 1 665 637 / 635 996 Fax: (95) 1 665 124 / 6078 AFTN: VYYYYAYX Telex: 21228 CIVAIR BM

NAMIBIA Directorate of Aircraft Accident Investigation Ministry of Works, Transport and Communication Private Bag 13341 6719 Bell Street, Snyman Circle Windhoek Namibia Tel.: (264) 61 208 8411 / 05 / 10 (264) 81 242 9279 (mobile) Fax: (264) 61 238 884 AFTN: FYHQYAYX

NAURU Director of Civil Aviation Civil Aviation Authority Government Office Yaren District

NEPAL Director General of Civil Aviation Civil Aviation Authority Babar Mahal Kathmandu



15

Nauru, Central Pacific Tel.: (674) 444 3113 Fax: (674) 444 3117 AFTN: ANAUYAYX Telex: 33081 Cable: GOVNAURU

Nepal Tel.: (977) 1-262387 / 262518 E-mail: [email protected] Fax: (977) 1-262516 AFTN: VNKTYAYX Telex: 2553 DCA NP Cable: AIRCIVIL

NETHERLANDS ANTILLES1

Directorate of Civil Aviation Seru Mahuma Z/N Curaçao Netherlands Antilles Tel.: (599) 9 839-3319 (599) 9 839-3518 (24 hours) E-mail: [email protected] Fax: (599) 9 868-9924 AFTN: TNCCYAYX Telex: 1102 DCA NA Cable: CIVILAIR-CURAÇAO

NETHERLANDS Dutch Safety Board P.O. Box 95404 2509 CK The Hague Netherlands Tel.: (31) 70 333 70 00 (31) 800 6353 688 / (31) 70 333 7072 (24 hours) E-mail: [email protected] Fax: (31) 70 333 70 77 AFTN: EHGVYLYS Website: www.safetyboard.nl

NEW ZEALAND The Chief Executive Officer Transport Accident Investigation Commission 11 Cigna House 40 Mercer Street P.O. Box 10-323 Wellington 6143 New Zealand Tel.: (64) 4-473-0199 (24 hours) (64) 4-473-3112 E-mail: [email protected] Fax: (64) 4-499-1510 AFTN: NZHOYAYX Cable: CIVAIR NZ Website: http://www.taic.org.nz

NICARAGUA Dirección General de Aeronáutica Civil Ministerio de Transporte y la Construcción KM 11½ Carretera Norte Managua Nicaragua Tel.: (505) 2 276-8580 E-mail: [email protected] / [email protected] Fax: (505) 2 276-8588 AFTN: MNMGYAYX Telex: 1308 AEROCIVIL

NIGER Direction de l’Aviation Civile Ministère des Transports B.P. 727 Niamey Niger Tel.: (227) 72 32 66 / 67 Fax: (227) 74 17 56 SITA: DRRVSITX AFTN: DRRVYAYX Telex: MINTRANS 5249 NI Cable: AVIACIVILE Niamey

NIGERIA Accident Investigation Bureau Nnamdi Azikiwe Airport P.M.B. 7009 Area 1 Abuja Nigeria Tel.: (234) 9 8100420 (234) 9 8100421 (234) 9 8100422 (234) 9 8033174991 E-mail: [email protected] Fax: (234) 9523 2113 / 1603 AFTN: DNLLYAYX Telex: 26567 FCAA NG SITA: LOSXSYF

NORWAY Accident Investigation Board Norway P. O. Box 213 N-2001 Lillestrøm

OMAN Directorate General of Civil Aviation and Meteorology Seeb International Airport P.O. Box 1, Postal Code 111








16

Norway Tel.: (47) 63 89 63 00 (47) 63 89 63 20 (24H) E-mail: [email protected] Fax: (47) 63 89 63 01 AFTN: ENCAYAYX Cable: 71032 ENFB N Website: http://www.aibn.no

Muscat Oman Tel.: (968) 519 210 / 519 315 E-mail: [email protected] Fax: (968) 510 122 AFTN: OOMSYAYX Telex: 5418 DGCAOMAN ON Cable: CIVAIR MUSCAT

PAKISTAN Headquarters, Civil Aviation Authority Terminal-1, JIAP Karachi-75200 Pakistan Tel.: (92) 21 924 8720 E-mail: [email protected] Fax: (92) 21 924 8722 Telex: 29534 DGCAA PK SITA: KHIAPXX to DG HQCAA AFTN: OPHQYAYX

PALAU Ministry of Commerce and Trade P.O. Box 1471 Koror Palau 96940 Tel.: (680) 488 1116 / 587 2111 E-mail: [email protected] Fax: (680) 587 3521 / 2222

PANAMA Jefatura de la Unidad de Prevención e Investigación de

Accidentes Autoridad Aeronáutica Civil Panama 0816-03073 Panama Tel.: (507) 501-9134 E-mail: [email protected] Fax: (507) 501-9317 AFTN: MPTOYAYX Telex: 2057CIVILAV PA Website: www.aeronautica.gob.pa

PAPUA NEW GUINEA Chairman Accident Investigation Commission – PNG Paulus Dowa P.O. Box 1265 Mt Hargen, Western Highlands Papua New Guinea Tel.: (675) 542-2833 (24 hrs) (675) 688-4156 (mobile) Fax: (675) 542-2861 AFTN: AYPYYAYX Telex: 22203 NE

PARAGUAY Centro de Investigación y Prevención de Accidentes Aeronáuticos Dirección Nacional de Aeronáutica Civil Aeropuerto Internacional ―Silvio Pettirossi‖ Luque Paraguay Tel.: (595) 21 645-599 (595) 21 646-114 (24 hrs) E-mail: [email protected] Fax: (595) 21 645-599 AFTN: SGASIPAX Web: www.dinac.gov.py

PERU Dirección General de Aeronáutica Civil Ministerio de Transportes y Comunicaciones Avenida 28 de Julio #800 Lima-1 Peru Tel.: (511) 433 7800 / 433 3166 Fax: (511) 433 2808 AFTN: SPLIYAYD-SPLIYAYX Telex: 25511 PE DIGECOM Website: http://www.mtc.gob.pe

PHILIPPINES Civil Aviation Authority of the Philippines Ninoy Aquino Avenue corner MIA Road Pasay City 1301 Metro Manila Philippines Tel.: (63) 2 879-9110 / 2 / 3 (OPCEN) E-mail: [email protected] Fax: (63) 2 834-0143 / 831-6215 AFTN: RPLLYAYX

POLAND Ministry of Transport State Commission of Aircraft Accident Investigation

(SCAAI) 4/6 Chalubinskiego 00-928 Warsaw Poland Tel.: (48) 22 630-11-31 (48) 22 630-11-42 (48) 500 233 233 (24 hours - event notification)








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E-mail: [email protected] Fax: (48) 22 630-11-43 SITA: WAWGILO

PORTUGAL Gabinete de Prevençao e Investigação de Acidentes com Aeronaves (GPIAA) Praça Duque de Saldanha, n.˚ 31, 4˚ 1050-094 Lisboa Portugal Tel.: (351) 91 519-2963 (24 hours) (351) 21 273-9230 (general) (351) 21273-9250 (director) E-mail: [email protected] Fax: (351) 21 273-9260 AFTN: LPPTYLYX Website: www.gpiaa.gov.pt

QATAR Department of Civil Aviation and Meteorology P.O. Box 3000 Doha Qatar Tel.: (974) 426262 Fax: (974) 429070 AFTN: OTBDYAYX Telex: 4306 CIVAIR DH Cable: CIVILAIR DOHA

REPUBLIC OF KOREA Aviation and Railway Accident Investigation Board Ministry of Construction and Transportation 281, Gonghang-Dong Gangseo-gu, Seoul Republic of Korea 157-815 Tel.: (82) 2 6096-1017 (82) 2 6096-1030 (24 hours) E-mail: [email protected] Fax: (82) 2 6096-1031 AFTN: RKSLYLYX Website: http://www.araib.go.kr

REPUBLIC OF MOLDOVA State Administration of Civil Aviation Investigation Bureau Airport MD 2026 Chisinau Republic of Moldova Tel.: (373) 2 524064 / 525766 (373) (0) 799 91 307 / 793 00 351 (mobile) E-mail: [email protected] info@caamd Fax: (373) 2 529118 / 529190 AFTN: LUKKYGYX

ROMANIA Ministry of Transport Direction of Air Transport Investigation 38 Dinicu Golescu Blvd., Sector 1 010873 Bucharest Romania Tel.: (40) 21 319-6185 (40) 750 032-401 E-mail: [email protected] Fax: (40) 21 312-4791 (40) 750 032-493 SITA: BUHYARO AFTN: LRBBYAYA Telex: 11181 AIRBUHR

RUSSIAN FEDERATION Federal Aviation Authorities of Russia State Oversight Flight Safety Department 37 Leningradsky Prospect 125167 Moscow Russian Federation Tel.: (7) 095 155-5784 Fax: (7) 095 155-5535 SITA: MOWYASU AFTN: UUUFYLY Interstate Aviation Committee Air Transport Accident Investigation Commission Building 22/2/1 Bolshaya Ordynka Street 109017 Moscow Russian Federation Tel.: (7) 095 951-1686 Fax: (7) 095 953-1145 AFTN: UUUUZXDD

RWANDA Direction de l’Aéronautique B.P. 898 Kigali Rwanda Tel.: (250) 75971

SAINT-PIERRE ET MIQUELON1

Service de l’Aviation Civile Blvd de Port-en-Bessin B.P. 4265 Saint-Pierre 97500 Saint-Pierre et Miquelon Telex: 914439 DDE SPM






18

Fax: (250) 72971 AFTN: HRYRYAYX Cable: DIRAVIAMET Kigali

AFTN: LFVPYAYX Cable: AVIACIVIL Saint-Pierre

SAMOA Ministry of Transport: Civil Aviation, Marine and

Shipping P.O. Box 1607 Apia Samoa Tel.: (685) 23 290 / 2 E-mail: [email protected] Fax: (685) 20 048 AFTN: NSFAYD Telex: 21 MALO SX Cable: MALO APIA

SAN MARINO Ministry of Communications and Transport Via A. di Suberchio 47898 Cailungo San Marino Tel.: (378) 549 992 345

SAO TOME AND PRINCIPE Direction de l’Aviation Civile C.P. 97 Sao Tomé Sao Tomé-et-Principe Tel.: (239 2) 241450 (INAC Administration) (239 2) 225860 (Head of Investigation Commission) (239 9) 903178 (Mobile) Fax: (239 2) 225118 AFTN: FPSTYA Telex: 245 DAC ST Cable: AERONAUTICA São Tomé

SAUDI ARABIA Safety Department General Authority of Civil Aviation P.O. Box 887 Jeddah 21421 Saudi Arabia Tel.: (966) 2 640-685-5515 / 5491 Fax: (966) 2 685-5507 AFTN: OEJDYAYX Telex: 601093 CIV AIR SJ Cable: CIVIL AIR JEDDAH

SENEGAL Direction de l’Aviation Civile B.P. 8184 Aéroport de Dakar-Yoff Sénégal Tel.: (221) 20 04 03 Fax: (221) 20 39 67 AFTN: GOO YAYX Telex: 51206 SG Cable: AVIACIVIL SENEGAL

SERBIA Civil Aviation Directorate Aircraft Accidents Investigations Department Omladinskih brigada 1 11070 Beograd Serbia Tel.: (381 11) 313-2516 (381 64) 803-3509 (381 11) 228-6415 (24 hours) E-mail: [email protected] Fax.: (381 11) 311-7518 / 7579 AFTN: LYBNYLYX Website: www.cad.gov.rs

SEYCHELLES Directorate of Civil Aviation P.O. Box 181 Victoria Mahé Seychelles Tel.: (248) 373 001 / 373 533 E-mail: [email protected] Fax: (248) 384 009 AFTN: FSIAYNYX Telex: 2239 DCA SZ Cable: DIRECTAIR SEYCHELLES

SIERRA LEONE Director of Civil Aviation Ministry of Transport and Communications Ministerial Office Block George Street Freetown Sierra Leone Tel.: (232) 22 22106 / 26191 Fax: (232) 22 228 488 AFTN: GFLLYA Telex: SE3574 Cable: AIRCIVIL Freetown



http://www.cad.gov.rs/


19

SINGAPORE Air Accident Investigation Bureau of Singapore Changi Airport Post Office P.O. Box 1005 Singapore 918155 Tel.: (65) 6541-2796 / 3042 (65) 9826 2359 (Mobile) Fax: (65) 6542 2394 AFTN: WSSSYAYX Telex: RS 21231 AVIATEL Cable: AIRCIVIL Website: http://www.mot.gov.sg

SLOVAKIA Civil Aviation Administration M.R. Stefanik Airport 823 05 Bratislava Slovakia Tel.: (421) 918 382 059 / 060 / 061 (mobile numbers) E-mail: [email protected] Fax: (421) 2 3303 4077 SITA: BTSTOYA AFTN: LZIBYIYX, or LZIBYIYP Telex: 92264 MDSR SK

SLOVENIA Ministry of Transport Aircraft Accident and Incident Investigation Division Langusova 4 SI-1535 Ljubljana Slovenia Tel.: (386) 1 478-8155 E-mail: [email protected] Fax: (386) 1 478-8189 AFTN: LJLAYAYX Website: http://www.mzp.gov.si/

SOLOMON ISLANDS Civil Aviation Division Ministry of Culture, Tourism and Aviation P.O. Box G20 Honiara Solomon Islands Tel.: (677) 36561 / 3 Fax: (677) 36775 AFTN: AGGHYAYX Telex: 66470 HQ Cable: CIVILAIR Honiara

SOMALIA Somali Civil Aviation Authority Flight Safety Division P.O. Box 1737 Mogadishu Somalia Tel.: (252) 1 20203 AFTN: HCMMYAYX Telex: 3033 MINTRAS Cable: CIVAIR Mogadishu

SOUTH AFRICA Civil Aviation Authority Accidents Investigations Department Private Bag X 73 Halfway House 1685 South Africa Tel.: (27) 11 545 1000/1050 E-mail: [email protected] Fax: (27) 11 545 1466 Website: http://www.caa.co.za

SPAIN Comisión de Investigación de Accidentes e Incidentes de Aviación Civil Ministerio de Fomento C\Fruela, 6 — 1ª planta 28011 Madrid Spain Tel.: (34) 91 597 89 60 E-mail: [email protected] Fax: (34) 91 463 55 35 AFTN: LEACYAYX Telex: 27702 CIAIR E Website: http://www.ciaiac.es

SRI LANKA Civil Aviation Authority Supreme Building No. 64, Galle Road Colombo 03 Sri Lanka Tel.: (94) 11 233-3447 E-mail: [email protected] Fax: (94) 11 242-4540 AFTN: VCCCYAYX Cable: AIRCIVIL Colombo Website: http://www.caa.lk

SUDAN Air Accident Investigation Central Directorate Civil Aviation Authority P.O. Box 430 Khartoum Sudan Tel.: (249) 15 577-5152

SURINAME Permanent Secretary Ministry of Transport, Communications and Tourism Prins Hendrikstraat 26-28 Paramaribo Suriname Tel.: (597) 420 100 / 420 422






20

(249) 91 291-9213 (mobile) E-mail: [email protected] Fax: (249) 15 577-5150 AFTN: HSSSYAYG Telex: 22650 DGACA ASD

E-mail: [email protected] Fax: (597) 420 425 / 420 100 AFTN: SMPBYAYX Telex: 148 CIVPBM SN Cable: CIVILAIR

SWAZILAND Ministry of Public Works and Transport Directorate of Civil Aviation Swazi Bank Building P.O. Box 58 Mbabane 4100 Swaziland Tel.: (268) 48683 E-mail: [email protected] Fax: (268) 48682 AFTN: EDMBYQ Telex: 2104 WD

SWEDEN Accident Investigation Board P.O. Box 12538 S-102 29 Stockholm Sweden Tel.: (46) 8 5088-6200 E-mail [email protected] Fax: (46) 8 5088-6290 Website: http://www.havkom.se

SWITZERLAND Bureau d’enquêtes sur les accidents d’aviation Aéropôle 1 Route de Morens CH-1530 Payerne Switzerland Tel.: (41) 26 662-3300 (41) 333 333-333 (24-hour — ask for AAIB) E-mail: [email protected] Fax: (41) 26 662-3301 Website: http://www.bfu.admin.ch

SYRIAN ARAB REPUBLIC Directorate General of Civil Aviation P.O. Box 6257 Damascus Syrian Arab Republic Tel.: (963) 11 3331306 Fax: (963) 11 2232201 AFTN: OSDIYAYX Telex: 411928 CIVAIR SY

TAJIKISTAN Aircompany ―Tajik Air‖ 734006 Dushanbe Titova Str. 32/1 Tajikistan Tel.: (7) 3772 212247 Fax: (7) 3772 510041 / 218685 SITA: DYUWW7J AFTN: UTDDTJKW

THAILAND Aircraft Accident Investigation Committee Flight Standards Bureau Department of Civil Aviation 71 Ngarmduplee, Rama IV Road Bangkok 10120 Thailand Tel.: (66) 2 287 3198 (66) 2 286 0594 / 286 0506 (24 hours) Fax: (66) 2 286 2913 / 287 3186 (24 hours) AFTN: VTBAYAYX Telex: 22720 BKKRCC TH Cable: CIVILAIR Bangkok

THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA Aircraft Accident Investigation Commission Luj Paster 23-1/3 1000 Skopje The former Yugoslav Republic of Macedonia Tel.: (389) 2 3148-408 / 415 (RCC, 24 hours) (389) 70 344-899 (RCC, 24 hours) Fax: (389) 2 3148-263 (RCC, 24 hours) SITA: SKPAPYF; SKPOCYF (RCC) AFTN: LWSKYSYX (RCC)

TOGO Direction de l’Aviation Civile B.P. 2699 Lomé Togo Tel.: (228) 263 740 (228) 265 574 Fax: (228) 260 860 AFTN: DXXXYAYX

TONGA TRINIDAD AND TOBAGO






21

Ministry of Civil Aviation P.O. Box 845 Queen Salote Road Nuku’alofa Tonga Tel.: (676) 24 144 (676) 24 045 Fax: (676) 24 145 AFTN: NFTNYAYX Telex: 66269 PRIMO TS Cable: CIVILAIR TONGA

Quality Assurance and Accident Investigation South Airport Terminal Building Golden Grove Road Piarco Trinidad and Tobago Tel.: (1) (868) 669 4251

TUNISIA Ministère du Transport Direction Générale de l’Aviation Civile BP 179 – 2035 Tunis CEDEX Tunisie Tel.: (216) 71 806-522 (216) 71 848 000 ext. 34657 (after business hours) Fax: (216) 71 806-469 (216) 71 752-022 / 753-327 (after business hours) SITA: TUNXYXH / TUNOAXH AFS: DTTVYAYX Cable: CIVILAIR TUNIS

TURKEY Directorate General of Civil Aviation Ministry of Transport Bosna Hersek Cad., ( 90.Sok) No: 5 06510 Emek Ankara Turkey Tel.: (90) 312 212 4635 Fax: (90) 312 212 4684 SITA: ANKYXYA AFTN: LTAAYAYX Telex: 44659 CAD TR

TURKMENISTAN Department of Transport and Communications National Civil Aviation Administration Chary Nurymov Street, 3a 744000 Ashgabad Turkmenistan Tel.: (993) 12 35 10 52 / 511804 Fax: (993) 12 35 44 02 SITA: ASBTCT5 AFTN: UTAUYAYX Telex: 228 118 AKHAL RU

TURKS AND CAICOS ISLANDS1

Department of Civil Aviation Grand Turk Turks and Caicos Islands Tel.: (1) 649 946 2138 Fax: (1) 649 946 1185

UGANDA The Managing Director Civil Aviation Authority P.O. Box 5536 Kampala Uganda Tel.: (256) 414-352-000 / 312-352-000 (256) 414-320-905 / 892 (24 hours) E-mail: [email protected] Fax: (256) 414-321-401 AFTN: HUENYAYX Cable: 61508 CAA UGA Website: www.caa.co.ug

UKRAINE Independent Aircraft Accident Investigation Department State Aviation Administration Prospect Peremogy 14 01135 Kyiv Ukraine Tel.: (380) 44 461-5551 (24 hours) E-mail: [email protected] Tel./Fax: (380) 44 486-4271 AFTN: UKKAPLXX

UNITED ARAB EMIRATES General Civil Aviation Authority P.O. Box 6558 Abu Dhabi United Arab Emirates

UNITED KINGDOM Air Accidents Investigation Branch Department of Transport Farnborough House Berkshire Copse Road Aldershot



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Tel.: (971) 2 444 7666 E-mail: [email protected] Fax: (971) 2 499 1599 / 405 4485 AFTN: OMAEYAYX

Hants GU11 2HH United Kingdom Tel.: (44) 1252 510300 (44) 1252 512299 (accident line) E-mail: [email protected] Fax: (44) 1252 376999 AFTN: EGGCYLYX Telex: 858119 ACCINV G Website: http://www.aaib.gov.uk

UNITED REPUBLIC OF TANZANIA The Chief Inspector of Accidents Ministry of Communications and Transport Accident Investigation Branch P.O. Box 2819 Dar es Salaam United Republic of Tanzania Tel.: (255) 22 2115079 (255) 22 2115080 E-mail: [email protected] Fax: (255) 22 2118905 AFTN: HTDQYAYA Telex: 41120 DIRECTAIR Website: http://www.aviationauthority.org

UNITED STATES National Transportation Safety Board 490 L’Enfant Plaza East, SW Washington, DC 20594 United States Tel.: (1) 202-314-6290 (24 hours) E-mail: [email protected] Fax: (1) 202-314-6293 AFTN: KRWAYAYL Cable: TRANSAFETY Washington, DC Website: http://www.ntsb.gov

URUGUAY Oficina de Investigación y Prevencion de Accidentes e

Incidentes de Aviación Av. Wilson Ferreira Aldunate 5519 - Aeropuerto Internacional de Carrasco, Canelones Uruguay Tel.: (598) 2 601-4851 (598) 2 604-0408 INT. 5172 (598) 9961-1290 (24 hours) E-mail: [email protected] Fax: (598) 2 601-4851 AFTN: SUMUCAR UY 2228 Telex: DINACIA UY23412 Cable: AEROCIVIL — MONTEVIDEO Website: www.dinacia.gub.uy

UZBEKISTAN State Inspection of the Republic of Uzbekistan for Flight Safety Oversight (Gosavianadzor) 73B Nukus Street Tashkent 100015 Uzbekistan Tel.: (998) 71 120-0060 254-3571 E-mail: [email protected] / [email protected] Fax: (998) 71 254-1482 / 120-0065 SITA: TASDDHY, TASCAHY AFTN: UTTAYAYX, UTTAYAYR Telex: 116169 POLET

VANUATU Director of Civil Aviation Pacific Building Private Mail Bag 068 Port-Vila Vanuatu Tel.: (678) 22819 Fax: (678) 23783 SITA: VLICBYA AFTN: NVVVYAYX Telex: 1040 VANGOV

VENEZUELA Direccion de la Junta Investigadora de Accidentes de Aviacion Civil Av. Francisco Miranda Torre MINFRA, Piso 20 Chacao, Caracas 1060 Venezuela Tel.: (58) 0212 201-5410 / 5491 (58) 0426 517-8259 (Emergency accident/incident

reporting) E-mail: [email protected] /

[email protected] Fax: (58) 0212 201-5545 AFTN: SVCCLALX










23

Telex: 24626 MTCAC VC Cable: DIGETRAERO-CARACAS Website: www.infraestructura.gob.ve

VIET NAM Director General Civil Aviation Administration Gia Lam Airport Hanoi Viet Nam Tel.: (84) 4 827-3384 (84) 4 827-1992 (24 hours) (84) 9128-19130 (mobile) E-mail: [email protected] Fax: (84) 4 827 1913 (84) 4 873-2291 (24 hours) SITA: HANCFVN AFTN: VVVVYAYX Telex: 412242 BGTVT VT

YEMEN Civil Aviation and Meteorology Authority Civil Aviation Sector P.O. Box 7251 Sana’a Yemen Tel.: (967) 1 337166 E-mail: [email protected] Fax: (967) 1 326811 AFTN: OYSNYAYX Cable: CIVILAIR

ZAMBIA The Director Department of Civil Aviation P.O. Box 50137 Ridgeway Lusaka Zambia Tel.: (260) 1 253 149 E-mail: [email protected] Fax: (260) 1 251 841 AFTN: FLHQYFDYQX Telex: 42280 ZA Cable: AVIATION LUSAKA

ZIMBABWE Civil Aviation Authority Karigamombe Centre, 16th Floor Samora Machael Ave. Private Bag 7716 Causeway Harare Zimbabwe Tel.: (263) 4 756 418 / 9 (263) 4 765 751 E-mail: [email protected] Fax: (263) 4 756 748 SITA: HREXTYF AFTN: FVHAYZYX Telex: 4738 ZW





APPENDIX ‘E’

SEGREGATION AND SEALING OF DOCUMENTS IN CASE OF AN

AIRCRAFT ACCIDENT OR SERIOUS INCIDENT :

The following are the broad outlines of the records which should be

segregated and sealed as soon as possible after the accident occurs:

a) Air Traffic Services:

i) Log books of all the relevant ATS including Radar Units.

ii) All messages pertaining to the aircraft including data like flight

progres strips, etc.

iii) All messages detailing information passed to the aircraft.

iv) Log books of all ATS vehicles employed for search and

rescue, fire fighting and visits to the site of accident etc. Note: The

vehicle log book should be sealed after relevant entries are made.

These entries should be made immediately on return from the

operation.

b) Aeronautical Communication Service:

i) All tapes containing messages exchanged with the aircraft.

ii) All tapes containing messages exchanged/communicated regarding

alerting, search and rescue and fire fighting etc.

iii) All messages regarding the aircraft.

iv) Relevant records/log books of all the Navaids used just prior to accident.

v) The dairy of Duty Officer of Communication Centre.

c) Rescue and Fire Fighting Services:

i) The occurrence book of the Fire Fighting unit concerned.

ii) Log books of the vehicles engaged in the search and rescue and actual

fire fighting operations.

Note: These books should be sealed after necessary entries have been

made regarding completion of rescue and fire fighting operations.

d) Meteorological Department (Aviation);

i) All records pertaining to Metars, TAFORS & ROFORS, Specis &

weather warning which could be of relevance to the aircraft involved.

ii) All records forming basis of the information regarding Metars, Tafors

and Rofors.

iii) The special weather observation recorded immediately after the accident.

iv) Log books of the Duty Officers at different positions.

e) Documents of aircraft:

i) All documents including log books regarding, maintenance, servicing

etc. of aircraft should be segregated and sealed by the Operator and

handed over to the Aircraft Accident Investigator or his representative.

ii) Documents such as aircraft file, flight reports, performance reports and

concessions granted if any.

f) Fuel Sample:

The sample of fuel/oil uplifted should be preserved by the fuel vendor. A separate

fuel/oil sample should also be collected and sealed by Aircraft Accident

Investigator or his representative.

The list is not exhaustive and investigators may include other items also.

APPENDIX ‘E1’

GUIDELINES ON ON SITE INVESTIGATION

1 AIM OF ON-SITE INVESTIGATION

The aim of the on-site investigation is to collect as much evidence as possible before the

wreckage has been disturbed. Sometimes the time available for an on-site investigation

may be limited by factors outside the control of Investigation Personnel, such as weather,

or a hazardous location. You should concentrate on collecting relevant evidence rather

than trying to analyse the occurrence on-site.

2 ON ARRIVAL AT THE SITE

The Investigating Personnel must complete the following immediately on arrival at the

site:

2.1 Check with the Police whether there has been any disturbance of the wreckage during any

rescue operations and record the extent of the disturbance.

2.2 You may require that the site is not disturbed by persons such as the land owner,

aerodrome owner or local authority agencies. Pursuant to the Aircraft Rules, it is however

an offence for a person to hinder, or prevent, access by an authorised person to a place to

which access is necessary. You need to be mindful of the normal functional use of the

occurrence site.

2.3 Review arrangements for guarding the site and impress on any guards the importance of

their duties, in order to:

Prevent disturbance of the wreckage

Protect and preserve, where possible, any impact marks made by the aircraft

Admit only those persons or vehicles authorised.

3 PRECAUTIONARY MEASURES

Observe the following precautionary measures:

3.1 If the site has been attended by emergency services any fire has probably been extinguished.

As long as there is fuel in the wreckage and ignition sources for example, batteries

precautions must be taken to prevent an outbreak of fire. In particular you should check that

electrical power is not still applied to any system which could cause a hazard to personnel for

example, radiation from a radar transmitter. Fire appliances should be kept at hand as long as

the risk remains. If residual fuel has to be drained from the aircraft as a precautionary

measure, the quantity removed and from which tank(s) it was removed must be recorded.

3.2 During subsequent examination of the wreckage beware of further fire/explosion hazard by

may be present at the site, particularly after a fire has occurred, are associated with the

following:

Inflated tyres

Compressed springs

Hydraulics/pneumatics

Oleos

Igniters

Oxygen systems - fixed and portable

Fire extinguishers

Evacuation chutes

Flares

Life rafts and jackets

Composite materials.

3.3 Dangerous cargo may have been in the aircraft. This may be confirmed by the aircraft

operator. In this case examination of the wreckage must not commence until there is

confirmation by an expert that the site is safe for personnel to work in. This applies

particularly to radioactive or biological cargo. Remember that fire or impact may have

damaged protective packaging of dangerous cargo thus rendering them most hazardous and

difficult to recognise, especially if labeling has been destroyed or has come off.

4 INITIAL SURVEY OF THE SITE

4.1 The primary considerations at this time are to establish:

A probable flight path

Impact angle

Impact speeds

Whether or not the aircraft was under control

Whether structural failure occurred prior to impact.

4.2 A check that all of the major components of the aircraft, particularly the extremities, are

present at the accident site will provide a good indication (though not a completely

reliable one) of whether or not structural failure contributed to the occurrence. You

should be aware that items of wreckage may be submerged, buried or otherwise

concealed.

4.3 Proceed as follows when carrying out the initial survey:

4.3.1 After discussions with the police (or other local authority in charge) carry out a

preliminary survey. Do not attempt a detailed examination at this stage. The aim is to

obtain as complete and clear a picture as possible of the circumstances under which the

accident occurred.

4.3.2 Establish the point of initial contact with the ground or other objects and then follow the

subsequent path of the aircraft by searching for marks or scars on the ground, on

buildings, trees, shrubs, rocks, etc.

4.3.3 Take into account the general state of the wreckage including location of items of

wreckage, contents of the aircraft and location of survivors and bodies. The wreckage

itself should not be moved or disturbed.

4.4 The impressions gained during the general survey of the wreckage and the knowledge

gained of the terrain will assist in planning further investigation and assessing priorities

in the work to be undertaken.

5 SITE RECORDS

All physical evidence and deductions made for various aspects from the

wreckage/aircraft must be recorded. This would be most useful during later analysis of

the occurrence. Additionally, a pocket-sized notebook will be convenient for recording

details at the accident site. This should be retained for later reference.

6 ACCIDENT LOCATION

Determine and record the precise location of the accident site. This can be a problem in

remote, rugged terrain where ground features are scarce. A Global Positioning System

(GPS) receiver would be useful for this purpose. Determine the site elevation and

significant terrain gradient as both may be relevant to the accident. A surveyor may later

be engaged to provide this information if it cannot be determined from maps and other

sources.

7 EVIDENCE

o Review the arrangements for guarding the site when making the preliminary survey

of the entire accident scene. Use this opportunity to re-emphasise to all concerned that

the pieces of wreckage must not be moved or disturbed. Since the preservation of

impact marks is very important, careful note should be made of all ground marks so

that guard arrangements may be amended where necessary to provide additional

security.

o Ensure that all aspects of the wreckage trail are preserved until they have been

photographed and their description and location have been recorded. This includes

such items as marks and scars upon trees or rocks, location of pieces of wreckage,

and location of bodies or human remains.

o Ensure that flight recorders are immediately retrieved and kept in safe custody for

analysis purposes.

8 PRESERVATION OF EVIDENCE

8.1 In carrying out an occurrence investigation, officers will be required to handle various

articles, which may be required as evidence (in the form of exhibits) in various

proceedings. These articles may consist of documents or aircraft components or material.

You must, therefore:

Ensure that the integrity of these potential exhibits is preserved.

As a general rule, handle evidence as little as possible.

Retain the item as closely as possible in its original condition.

Make immediate arrangements for appropriate preservation and safe storage. This

may include oiling, greasing, wrapping or sealing.

Note: Investigators collecting parts should not attempt to match fracture surfaces together,

because of the damage that can be caused to those surfaces.

9 COLLECTION AND HANDLING OF FLUID SAMPLES AS EVIDENCE

9.1 Fuel and other fluid samples require special consideration. If there is any likelihood of

the fluid samples being required as evidence, they should be obtained in accordance with

the following procedures:

9.2 If possible, three samples should be taken in the presence of the person giving

permission.

9.3 Each sample should, if possible, be placed in an identical sample bottle.

The sample bottles should then be security sealed.

Each bottle should be marked with the source, date, time and place of the taking of

the sample and should be signed by the officer concerned.

The three sample bottles should then be distributed as follows:

o One to the owner or, with the owner’s permission, an agent, pilot in command

or the person responsible for the maintenance

o One for analysis

o One to be retained as a control.

If it is not possible to comply with the above conditions, try to obtain a sample in the best

way the circumstances allow.

10 RELEASE OF WRECKAGE :

10.1 There should be no pressure to release all of the on-scene wreckage. Often it is better to

arrange for wreckage removal and storage and to retain control of the wreckage in case

there is a need to examine it later.

10.2 When on-site investigation has been completed the aircraft wreckage should be handed

over to the owner or their representative so that salvage/clean-up operations can

commence. It is essential to obtain a receipt for the evidence. You must record the

movement of that evidence.

10.3 In case of an occurrence to an aircraft registered in other contracting State, the aircraft, its

contents or any parts thereof shall be released by AAIB as soon as they are no longer

required in the investigation, to any person or persons duly designated by the State of

Registry or the State of the Operator, as applicable.

10.4 For this purpose access to the aircraft, its contents or any parts thereof, shall be facilitated

provided that, if the aircraft, its contents, or any parts thereof lie in an area within which it

is impracticable to grant such access, removal shall be affected to a point where access

can be given.

11 PERSONAL EFFECTS

Record the position of personal effects found at the site of an occurrence. Hand them to

police, obtaining a receipt for significant items, when no longer required for the

investigation and make a record of this.

12 ALLOCATION OF TASKS

After the initial survey in case groups have been formed for investigation purposes, the

Chairman Court/ Committee of Inquiry assigns the investigation tasks to the members of

the team(s), having regard to their special qualifications and to the initial assessment of

the priorities of gathering factual information relating to the accident. The importance of

timely discussion with other groups when key evidence is discovered should be

emphasised. Additionally, regular meetings of the groups should be held to review the

progress of work and to permit a free interchange of ideas and information by group

members. Investigators will often be working in unpleasant conditions, and the group

leaders should impose realistic targets for individual members. All investigators should

be permitted reasonable rest periods.

13 PHOTOGRAPHS

Take photographs as soon as possible after the occurrence and before the wreckage is

moved or disturbed. Where bodies are present, photographs are desirable before removal.

Photograph impact marks as a first priority, preferably during the initial walk-through of

the site, as these may be obliterated by later activity at the accident site. Good

photographs furnish the best possible record of an occurrence site. Since many

photographs will be taken, it is essential that they are labeled and indexed in some way to

assist later analysis. A simple title-board written with a felt pen and sheet of paper can be

used to identify close-up photographs. Note that some recent cameras provide the facility

not only to date/time-stamp each photo, but to also digitally enter a caption. Photographs

should cover general views of the scene from four directions and also back along the

wreckage trail to the first point of contact. A good coverage of the wreckage in the

condition in which it is found and before it is disturbed is essential. Record the location

and direction of each photograph, paying particular attention to the following:

Engine(s), before anything is moved, showing details of condition and damage from all

angles, to include:

o Engine control lever positions at the engines

o Engine components, and accessories

o Engine instrument readings and positions of control levers and switches.

Note: While important, these indications and settings are easily affected by forces of the

crash and are not always conclusive indications of positions at the time of impact.

o Instrument settings and readings

o Position of controls in the cockpit

o Radio settings

o Autopilot setting

o Fuel selectors

o Switch positions

o Undercarriage and flap selector positions

o Engine control lever positions

o Position of flap jacks, undercarriage jacks, latches

o Control surface positions

o Trim tab settings

o Suspicious breakages or bends

o Propeller/rotor blades showing pitch positions

o Fire damage

o Impact marks

o Seats and seat belts.

Consider also any photographs or video imagery taken by witnesses.

14 WRECKAGE

14.1 WRECKAGE DISTRIBUTION CHART

After you have made your initial study of the general scene of the accident and taken

photographs, your first step in the actual investigation is usually that of plotting the

distribution of the wreckage from a convenient datum. This task must be carried out

carefully and accurately, as the study of the completed chart may later suggest possible

failure patterns or sequences. You will refer to it frequently during the investigation and

it will supplement your written report. In most accidents the chart should record the

following:

o Locations of all major components, parts and accessories Freight

o Locations at which any accident victims were found

o The initial contact markings and other ground markings, with suitable reference to

identify the part of the aircraft or component responsible for the marking

o If terrain features appear to have a bearing on the accident or on the type or extent of

structural damage they too should be noted

o Pertinent dimensions, descriptive notes and also the locations from which

photographs were taken add to the completeness of the chart.

14.2 EXAMINATION OF IMPACT MARKS AND DEBRIS

Determine which part of the aircraft impacted first. This can usually be done by locating

the marks of the first impact of the aircraft, and examining the distribution of the

wreckage. The path of the aircraft may be deduced by careful examination of ground

marks or scars on trees, etc. Wing tips, propellers or landing gear leave telltale marks or

torn-off parts at points of contact with fixed objects. Ground scars used in conjunction

with height of broken trees will assist in establishing angle, attitude and speed at impact.

From these marks it is usually possible to form a preliminary mental picture of :

o The direction, angle and speed of descent

o Whether it was a controlled or uncontrolled descent

o Whether the engines were under power at the time of impact

o Whether the aircraft was structurally intact at the point of first impact.

14.3 WRECKAGE IN THE WATER

Investigation at times may involve an aircraft which has ended up in water. Recovery

may be expensive and time-consuming and this has to be weighed up with the likely

benefit to be achieved. Wreckage in salt water can deteriorate quickly, particularly

magnesium and, to a lesser extent, aluminum parts. As this process accelerates on

exposure to air, wreckage collected from salt water must be washed thoroughly with fresh

water as soon as it is raised. Further preservation action will be required for any

components that must be subjected to metallurgical examination. Water-displacing fluid,

oil or inhibited lanolin may be used as an interim preservative solution. Components such

as CVR and flight-data recorders should not be dried but kept in fresh water until a

specialist can assume responsibility.

15 OPERATIONS INVESTIGATION

15.1 OVERVIEW OF OPERATIONS INVESTIGATION

The Operations Investigation is concerned with facts relating to the history of the flight

and to the activity of the flight crew before and during the occurrence. The major areas

involved in the Operations Investigation are:

o Crew histories

o Flight planning

o Weight and balance

o Weather

o Air traffic services

o Communications

o Navigation

o Aerodrome facilities

o Aircraft performance

o Compliance with relevant instructions

o Examining witness statements

o Determination of final flight path

o Sequence of flight.

There is a close link between the work in the Operations Investigation and that in other

investigation areas — for instance, the flight path of the aircraft as constructed from air

traffic control and witness statements should be compared with that derived from flight

recorders. Such corroboration, whenever possible, constitutes one of the principles of a

properly executed investigation, namely, cross-checking the validity of information from

one source against information on the same subject from a different source.

15.2 CREW HISTORIES

A study of all the facts pertaining to the crew forms an important part of both the

Operations and Human Factors investigations. Because these two aspects are closely

related, a high degree of coordination in the collection and evaluation of the relevant facts

is required to achieve the best possible use of the information collected. The crew

histories should cover their overall experience, their activities, especially during the 72

hours prior to the occurrence, and their behaviour during the events leading up to the

occurrence.

15.3 FLIGHT PLANNING

A flight plan may have been prepared and filed with air traffic services. This will provide

the data such as the route, cruising altitudes and timings. It may also provide fuel load

and fuel consumption etc, which may need to be examined in detail and correlated to the

actual flight path. Commercial operators often have flight planning sections, which

prepare all flight plans, and will have a copy of the flight plan even if one is not available

in the aircraft. In the case of occurrences involving navigation factors or fuel

consumption questions, it may be necessary to check flight plans and navigation logs to

ensure that the data from which the flight plans were derived were relevant to the

particular circumstances of the intended flight, such as weather, aircraft type and model,

cruising altitude etc. In the case of light aircraft operated on private and training flights, it

will be useful to ascertain the crew’s intentions regarding the flight and any manoeuvres

planned.

15.4 WEIGHT AND BALANCE

A weight and balance sheet based on the planned flight may have been prepared.

Commercial flights generally use a standard form for these calculations. In the case of

light aircraft, a weight and balance sheet is rarely prepared. Since weight, balance and

load are critical factors that affect aircraft stability and control, especially in light aircraft,

considerable effort should be made to deduce the most probable weight of the aircraft at

the time of the occurrence, having regard to the flight time since take-off. It will be

necessary to check flight manual load data sheets, fuel records, freight and passenger

documentation to arrive at a final estimate. Elevator trim settings may give a clue to the

centre of gravity at the time of the occurrence.

15.5 WEATHER

Weather conditions at the time of the occurrence may be obtained from actual

observations or by a post-flight analysis requested from the Indian Meteorological

Department.

15.6 AIR TRAFFIC SERVICES

Circumstances of an occurrence may require that an operations or air traffic specialist be

included to investigate these aspects of an occurrence. This person is responsible for

establishing, recording and verifying the accuracy of all information relevant to Air

Traffic Services in connection with the flight. These include the following:

o Relevant AIPs

o NOTAM

o Aeronautical Information Circulars (AICs)

o Flight plan

o Flight plan and departure messages

o Various progress strips

o R/T transcripts

o Radar plots

o Manual of Air Traffic Services (MATS)

o ATS procedures

o ATS software.

The various functions exercised by Air Traffic Services such as ground movement

control, departure control, area control, approach control and aerodrome control may

enable to trace the progress of the flight from the planning stage up to the occurrence.

15.7 COMMUNICATIONS

Communications between aircraft and ATS are normally recorded. ATS tapes relevant to

the accident are to be removed and sealed immediately. Since the tapes are recycled

every 30 days, an immediate request must be made to ATS if access to them is required.

15.8 NAVIGATION

The navigational equipment carried in the aircraft should be checked against the aircraft

records and the remains of the navigational equipment recovered from the wreckage. The

serviceability and performance of navigation aids which may have been in use should be

checked. This may include comments from other users. The possibility of use of Global

Positioning System (GPS) must also be considered. The adequacy of current maps and

charts and the currency of the charts used in the aircraft should be checked.

15.9 AERODROME FACILITIES

The status of aerodrome facilities used by the aircraft may have to be examined and

verified. Assistance of an Aerodrome Personnel in this part of the investigation should be

taken as this is his/her area of expertise.

15.10 AIRCRAFT PERFORMANCE

The basic source of information concerning aircraft performance is the Flight

Manual/Operations Manual, the amendment status of which is important. While this

information will prove to be adequate for normal investigation purposes in most cases, it

may be necessary, in some instances, to examine the data from which the Flight Manual

performance is determined, to establish its validity to the particular circumstances of the

occurrence. This will require consultation with the manufacturer.

15.11 COMPLIANCE WITH INSTRUCTIONS

A necessary part of the operational investigation is to establish whether particular

directives were complied with. The directives should also be examined to establish

whether, in the light of the accident, they were proper and adequate for ensuring safety of

operations, and whether they were presented in a format easily understood. In examining

these matters it is important to distinguish what material has mandatory effect and what is

advisory. The directives may have many different forms including the following:

o Flight Manual

o Operations Manual

o NOTAM

o Aeronautical Information Publications (AIP)

o Aeronautical Information Circulars

o Aircraft Manufacturer’s Notices

o Airworthiness Directives

o Maintenance Control Manual

o Maintenance System.

15.12 STATEMENTS OF WITNESSES

Witness Statements may be used in conjunction with evidence obtained from other

sources of operational information. You may then have to go back to witnesses to resolve

discrepancies. When statements from witnesses’ conflict with each other and with

evidence obtained from other sources, you may need to re-interview the witness in

question to try to resolve the discrepancies.

15.13 DETERMINING THE FINAL FLIGHT PATH

The reconstruction of the last stage of the flight, that is, the accident phase, necessitates

close cooperation between the various groups or individuals involved in the investigation.

If a separate group has been set up for Operations Investigation, this becomes its primary

concern. The intention should be to build up a complete picture of the final events as they

occurred, in proper sequence, and to evaluate their interrelationships. The period of time

to be covered will depend on the circumstances. Generally, the period should commence

when the flight departs from normal (safe) operation and should terminate when the

inevitability of the accident is indisputably apparent. This may or may not always be the

point of impact — for example, in the case of an in-flight break-up.

15.14 SEQUENCE OF FLIGHT

Although the investigation will focus on the occurrence, it is usually desirable to discuss

the development of the entire sequence of the flight.

16 FLIGHT RECORDERS

The term ‘Flight Recorders’ encompasses three separate and distinct types of airborne

recorders: the Flight Data Recorder (FDR), the Cockpit Voice Recorder (CVR) and

Quick Access Recorder (QAR).

16.1 RECORDER TYPES

16.1.1 FLIGHT DATA RECORDER

The FDR, often referred to as the ‘flight recorder’, or Digital Flight Data Recorder

(DFDR), is a system for recording the values of defined basic flight parameters in

relation to a time base. The number of parameters recorded varies from aircraft type to

aircraft type. The parameters recorded for a particular aircraft can be obtained from the

operator. The digital recorders in use in the majority of aircraft have a limited recording

cycle of 25 (operating) hours. If they are required for investigation, prompt action is

required to ensure their removal from the aircraft. Although FDRs are built to withstand

rough handling, including shock, immersion in water and fire, and are internally shielded,

they should be handled with care until they are handed over for analysis by specialist. No

attempt should be made to open them or apply electrical power to any cables or sockets.

Keep them away from any radiation (radar source) or strong magnetic fields.

16.1.2 COCKPIT VOICE RECORDER

The CVR is a system for recording cockpit crew conversations (and ambient noises) via a

multi-directional microphone, the cockpit intercommunications system, the Public

Address system and radio-telephone (R/T) communications.

16.1.3 QUICK ACCESS RECORDER

The QAR, or Flight Data Acquisition Unit, is a recorder installed in some aircraft which

uses the same information sources as the impact-protected DFDR.

16.1.4 AIR TRAFFIC SERVICE RECORDINGS

Communications with Air Traffic Services are normally recorded and may be made

available provided the tapes are requested before they are recycled through the system

(after 30 days). If an opportunity to listen to a communications tape is made available, do

not only listen to any spoken words but also listen to background noises. While

background noises are often difficult to discern, different sounds — for example, stall

warning, undercarriage warning, horn or fire warning bells — may be heard. Other

sources of communications evidence should not be overlooked although some may not be

recorded. Other aircraft on the frequency and ground stations monitoring it may be

useful. When appropriate, communications on the operator’s communication network

should also be investigated. Continuous recordings are made of communications on ATS

frequencies as well as radar data. These tapes are re-used after a period. This period,

usually 15 to 30 days, is to ensure that they are available for any investigations. For

Radar tapes ATS needs to be advised as soon as possible, so that relevant tapes can be

removed from circulation.

17 STRUCTURAL INVESTIGATION

17.1 OVERVIEW OF AIRCRAFT STRUCTURE INVESTIGATION

The aircraft structure investigation concentrates on the airframe, including primary and

secondary structure, lift and control surfaces. When investigating an accident caused by

structural failure of the airframe or system, study the wreckage and evaluate separated

components and fractured surfaces. Failure of the airframe structure, fittings,

attachments, and other components are sometimes obscured by the ensuing accident.

However, these may have been the primary cause of in-flight disintegration or ground

impact in an out-of-control situation. Knowledge of the history of the flight, prevailing

weather conditions, aircraft behaviour, and the probable type of air loads sustained during

flight manoeuvres will assist in determining failure areas.

17.2 RECONSTRUCTION OF WRECKAGE

Reconstruction is employed for specific components such as a wing panel, tail surface or

control system, although in some instances it has been necessary to reconstruct almost all

major components. Reconstruction is performed in two stages:

Stage 1 Identify the various pieces and arrange them in their relative positions

Stage 2 Examine in detail the damage to each piece, and establish the relationship

of this damage to the damage on adjacent or associated pieces.

The latter is the chief purpose of reconstruction

17.2.1 PRELIMINARIES

Before commencing reconstruction work,

1. Photograph the entire site and wreckage.

2. Complete the wreckage distribution chart.

3. Inspect and make notes on the manner in which the various pieces were first found, by

walking around the site.

17.2.2 IDENTIFICATION OF PIECES

The difficulty in reconstructing a component, such as a wing, lies in identifying the

various pieces of wreckage. If the wing has broken up into a few large pieces, the task is

relatively simple. If, on the other hand, the wing has broken into a number of small pieces

as a result of high impact speed, reconstruction can be extremely difficult. The most

positive means of identification are:

o Part numbers which are stamped on most aircraft parts, which can be checked against

the aircraft parts catalogue

o Colouring (either paint or primer)

o Type of material and construction

o External markings

o Rivet or screw size and spacing.

17.2.3 RECONSTRUCTION ON-SITE

Collect parts from the suspected area, identify them and then arrange them on the ground

in their relative positions. Lay out major components such as the wing, tail and fuselage

in plan form for ease of later examination. Note, however, that if the suspected area is at

the junction of the major components, these areas are sometimes reconstructed

separately. For ease of examination, lay out individual cable runs with their associated

bell cranks, idlers and quadrants separately. If significant markings are found on any of

these latter items, corresponding markings must be sought out in the relative positions in

the wing, fuselage etc.

18 EXAMINATION OF THE AIRCRAFT STRUCTURE

Specific components or items may require additional examination and the same be got

examined at appropriate Laboratories of National Aeronautical Lab, Bangalore or

Directorate of Research & Development of DGCA or other approved facilities. When

carrying out a detailed examination of an aircraft’s structure, specialists should be

consulted for:

o Properties of metals and fracture analysis - Materials Evaluation Facility

specialists

o Basic causes and contributing factors associated with in-flight structural failures

of major components - Engineering Specialists

o Specific evidence that can be obtained by studying the scores, smears,

indentations and other markings, both at the impact site and on aircraft parts -.

Engineering Specialists

18.1 AIRFRAME

The first priority during the preliminary examination at the accident site is to determine if

a structural failure occurred before impact. To do this, the first step is to separate impact

damage from in-flight structural failure damage. Valuable information can be gathered

from a study of the various smears and scores found on different parts of the wreckage.

Where possible, study these before the wreckage is disturbed, since movement of the

wreckage may destroy clues or create misleading ones.

18.2 MAINPLANES, FUSELAGE AND TAIL UNIT

One of the primary aims when examining the structure is to determine whether there is

evidence that any part of the structure was not in its correct relative position at the time of

impact. Components such as cables, pulleys, hinges and tab mechanisms must be

examined to determine whether the failure of any of these items was caused by wear,

inadequate maintenance or impact.

18.3 UNDERCARRIAGE

Examine the selector, link mechanism, up and down locks and position of the operating

jacks or actuating cylinders to ascertain whether the undercarriage was up or down. If the

gear had failed or separated, note the direction of the force which caused the failure or

separation.

19 POWER PLANT INVESTIGATION

19.1 OVERVIEW OF POWERPLANT INVESTIGATION

The failure or malfunction of one or more power plants may be the cause of an

occurrence. For this reason it is essential that a careful examination of the power plants

and their associated components be made to determine whether they are involved as a

causal or predominant factor in the particular occurrence under investigation. The

purpose of powerplant investigation and analysis is to determine:

o The condition of the engine at the time of impact

o The engine power or thrust at the time of impact or failure

o The sequence of failure and cause of any engine malfunction or failure.

The powerplant investigation should include a carefully detailed documentation of all

evidence, to include:

o A comprehensive survey of the impact site and extent of wreckage distribution,

o length and depth of ground impact scars and craters,

o consistency and hardness of the terrain, and

o the slope of the impact area.

This information will already have been recorded during the initial site inspection. Any

additional details that the power plant investigation turns up should be added as overlays

to the original site plan and wreckage-distribution chart, and later copied to the original.

An inventory of the engine(s) to ensure that all engine parts, components, and accessories

are accounted for and aligned with each respective engine.

19.2 PROCEDURE FOR EXAMINING ENGINE COMPONENTS AND SYSTEMS

Follow this procedure when examining various engine components and systems.

Check the original Site Plan and Wreckage Distribution Chart for the geographical

location and scatter pattern of all engine, parts and accessories, and correct where

necessary.

Note the identity and location of any part that may be moved (or removed from the crash

site for any reason), altered, or affected by rescue, salvage, or weather conditions.

Note in particular:

o Evidence of case penetration

o Burn-through damage

o Ruptured fuel or oil lines

o Loose fittings

o Any items that are suspected to be of foreign origin.

Collect any fuel, oil, and hydraulic fluid samples to minimise post-impact contamination

or loss of the limited quantities that may remain.

Note: Where powerplant failure occurs and fuel contamination is a suspected cause, not only

should samples of fuel be obtained from the aircraft system, but an immediate

investigation should be made of the fuel servicing and storage facilities at the last

refuelling point.

Examine the fuel system, including:

All filters, screens and pumps

Check tanks and cells

Fuel lines and valves.

Examine propeller(s) for:

Impact damage and overall condition

impact, overspeed, malfunction, or fatigue breakage. Blade angle is a

function of power being delivered by the engine. Therefore, blade angle

may be one method that can be used to establish engine power or thrust.

As a rule, propellers under high power at impact can be expected to bend

or curl forward at the tips, while under low power, the blades should curl

rearward at the tips. Windmilling or stationary blades should be bent

rearward.

20 SYSTEMS INVESTIGATION

20.1 OVERVIEW OF SYSTEMS INVESTIGATION

Systems Investigation covers investigating and reporting on:

Hydraulics

Electrics and electro-pneumatics

Vacuum

Pressurisation and air conditioning

Ice and rain protection

Instruments

Air data computer

Flight director

Stall warning

Radio and navigation systems

Autopilot

Fire detection system

Oxygen system.

There is inevitably a degree of overlap with systems covered under sections relating to

structures and power plants. The technical information necessary to enable a detailed

analysis of individual aircraft systems/components should be obtained from the

Manufacturer/ Operator.

20.2 INVESTIGATING AIRCRAFT SYSTEMS

Each aircraft system must be accorded the same degree of importance regardless of the

circumstances of the occurrence. There is no way to determine adequately the

relationship of any system to the general area without a thorough examination. Data

developed by the examination of one system may be helpful in proving or disproving the

integrity of other systems. The examination of the system will generally involve more

than examination of components in-situ. It can involve the functional testing, under

laboratory conditions, of an individual component, or of the complete system using off-

the-shelf duplicates of the component or system. Computer software fitted in some

modern aircraft may be recovered and operated in a simulator to determine its role in the

occurrence. For each system that you investigate:

Obtain from the aircraft manufacturer or from the operator, appropriate detailed

schematic diagrams or working drawings to determine what components are included

in each system. The diagrams will also be helpful in analysing the effect of a

malfunctioning component on the rest of the system.

Make every effort to account for all the components. Each system can be broken

down into six areas as shown below. This should assist in accounting for components.

These areas are:

Supply

Pressure

Control

Protection

Distribution

Application.

Documentation of components should include:

Nomenclature

Component manufacturer’s name

Part number

Serial number

Specification number (where provided).

Some components having the same part number may be used in various parts of the same

system, especially in the hydraulic and pneumatic systems. It may be necessary to obtain

listings showing actual location of these components in the system by serial number. The

positions of switches and controls in the cockpit, together with the found (as-is) position

of any moving parts will have been photographed during the initial stages of the

investigation. Obtain copies of these photographs and crosscheck the readings on all

available instruments. If the original photographs are not ready, take an additional set of

photographs to supplement your documentation.

21 MAINTENANCE INVESTIGATION

21.1 OVERVIEW OF MAINTENANCE INVESTIGATION

The purpose of the maintenance investigation is to review the maintenance history of the

aircraft in order to determine:

Information that could have some bearing on the occurrence, or which could point to

a particular area of significance for regulatory investigation and action

Whether the aircraft has been maintained in accordance with the specified standards

Whether, having regard to information gained during the investigation, the specified

standards are satisfactory.

21.2 SECURE AIRCRAFT AND MAINTENANCE DOCUMENTATION

Following notification of the commencement of a regulatory investigation of an aircraft

occurrence, secure the related documents by applying to the operator to hand over the

following:

Aircraft log books

A copy of the current, and if possible, expired Maintenance Releases

Maintenance work-packages and any other appropriate certification documentation.

Approved Maintenance System, or the applicable accepted maintenance schedule for

the aircraft.

21.2.1 AIRCRAFT LOG BOOKS AND MAINTENANCE RELEASE

Inspect the aircraft log books and both current and expired maintenance releases to

ascertain the following information:

The operating history of the airframe, engines, and associated components; the hours

flown, cycles, landings, and, where appropriate, the status of any life-limited

components

The history of accidents, incidents, defects and irregular or abnormal operations

which have been reported or which become known during the investigation and any

subsequent rectification or other action taken

Whether all required maintenance, including applicable Airworthiness Directives,

have been carried out

That all modifications incorporated have been accomplished in accordance with

approved data

Whether the aircraft history has been entered in the log books in accordance with the

applicable log book instructions.

21.2.2 MAINTENANCE DOCUMENTATION

In addition to an inspection of the aircraft documentation, an examination of the

maintenance organisation’s work packages and any other certification documentation

relating to maintenance should be undertaken to determine:

That all maintenance and modifications has been carried out on the aircraft by

authorised or approved persons

That all the maintenance carried out was certified-for in accordance with applicable

legislation by authorised or approved persons If the maintenance system has been

followed correctly Record any discrepancies or omissions.

ANNEXURE „E2‟

OCCUPATIONAL HEALTH AND SAFETY APPLICABLE TO AIRCRAFT

ACCIDENT INVESTIGATIONS

It is recognised that safe working environment which is without any risk to health should be

maintained for all engaged in accident investigation & wreckage examination. The following

guidelines apply to all who are likely to face exposure to potentially infectious or injurious

substances or objects when conducting occurrence investigations. Everyone has a

responsibility to ensure that he or she works safely, and so protects others in the workplace.

Adherence to the work practices described, together with the use of appropriate personal

protective equipment, will reduce on-job risk for all exposed to accident site hazards.

Application of the procedures set out herein will ensure that:

Everyone is given relevant and up-to-date information to enable them to make

responsible decisions when faced with possible exposure to conditions that may pose a

safety or health hazard.

Measures are taken to safeguard health and, where exposure does occur, to provide

appropriate levels of treatment and counseling to minimise long-term effects arising from

the exposure.

Because of the specialised health and safety risks arising from accident investigation tasks,

these procedures should be applied wherever and whenever necessary.

1 Pathological Hazards

Contact with human and animal remains and body fluids is a serious health hazard

because of the risk of bacterial, viral and fungal contamination. Exposures to pathogens

are unpredictable and since infection can be transmitted through direct contact with the

eyes, nose and mouth (mucous membranes), an open cut, dermatitis rash/chafed skin, or

open skin sore, it is required that General Precautions be taken by all while working on-

site where the potential for exposure exists.

2 General Precautions

General precautions shall be observed to minimise exposure to infectious materials. Risk

reduction precautions shall include the following:

Direct contact with any potentially infected wreckage or soil should be avoided.

Until properly protected, any investigative procedure on potentially infected wreckage or

soil, which might tend to splash, spray, generate droplets or otherwise disperse

contaminated particulate matter should be avoided.

Do not eat, drink, smoke, apply lip balm or skin cream, or handle contact lenses while in

those areas defined as bio-hazard areas.

Use antiseptic hand towel immediately after leaving the bio-hazard area and removing

personal protective equipment.

Wash your hands with antiseptic soap and running water as soon as feasible after using

the antiseptic towels.

Any personal investigative equipment, (cameras, notebooks, etc.) which may become

contaminated with infectious materials shall be examined and either decontaminated or

disposed of as appropriate, prior to removal from the bio-hazard area.

Wash your skin or flush mucous membranes with water as soon as feasible following

contact of your body areas with potentially infectious materials.

No one with a pre-existing condition that would facilitate the spread of a blood-borne

pathogen for example, open hand or facial cuts, skin rashes, open sores will be permitted

access to the bio-hazard area.

3 Bio-hazards

Biohazards are blood-borne pathogens that cause disease in humans. They are

microorganisms which, when they enter human blood, can cause disease in humans.

Infectious pathogens can be found in fatally injured persons as well as injured survivors.

These pathogens include, but are not limited to:

Hepatitis B Virus (HBV)

Human Immunodeficiency Virus (HIV)

Malaria

Meningococcal bacterium

Lyme Disease

Queensland Tick Typhus

Ross River Fever

Syphilis

Tetanus.

The General and workplace infection control procedures apply to both HBV and HIV.

Infection transmission of other pathogens are interrupted by the procedures adopted for

HBV/HIV.

HIV

HIV affects the immune system, weakening it to the point where the individual becomes

more susceptible to other infections - for example, pneumonia, tuberculosis or cancers. In the

early and mid-1980s, it was generally believed that the HIV virus would not survive long

outside the body, Recent studies have changed this thinking. In some cases, dried plasma

held at room temperature retained infective virus for more than three days. No cases of insect

transmission are presently known. A vaccination against HIV infection is not available to

date.

HBV

Hepatitis B virus causes inflammation of the liver, and may result in an individual becoming

an HBV carrier with the potential to infect others. Liver failure and death can follow

infection. HBV can remain viable outside the human body for some days and can exist in

dried blood/body fluids. The disease, because of its abundance in a given infected blood

sample, relative to HIV, is potentially many times more infective and therefore the greater

site risk. The best defence against Hepatitis B infection is vaccination. Should a known

exposure occur it is usual medical practice to give a Hepatitis B Immuno Globulin (HBIG)

injection within 24 hours.

Malaria

Except for one strain of malaria, human malarias are generally not life threatening, but

produce a repetitive series of shaking chills and rapidly rising temperatures followed by

profuse sweating over several days. Relapses may occur at irregular intervals and the

infection may persist for upwards of 50 years. Transmission is by the bite of an infective

mosquito. Personal protection on the work-site will be achieved by regular use of insect

repellent containing diethyltoluamide (DEET), in addition to wearing the protective clothing

provided.

Meningococcal Meningitis

A bacterial infection characterised by fever, delirium and possible coma, intense headache,

nausea and often a stiff neck. Case fatality rates have been reduced from 50% to less than

10%, by modem therapy nevertheless prompt treatment is required. Transmission of the

disease is by direct contact, including respiratory droplets from the nose and throat from

infected persons. Wearing a partial face respiratory mask as for HIV/HBV exposure provides

necessary protection.

Lyme Disease

A tick-bone disease characterised by fever, fatigue and a distinctive skin lesion. Encephalitis

or meningitis are possible. Quite a while after the skin rash occurs, swelling and pain in the

large joints, primarily the knees, will occur in untreated patients. Chronic arthritis can result.

Transmission occurs mainly in summer from tick bite after the tick has fed for several hours.

The same insect repellent used for the malarial mosquito, when applied to shirtsleeves and

pants legs has proven to be effective.

Queensland Tick Typhus

A tick home disease which causes mild to severe fever. Transmission is similar to Lyme

Disease and similar protective measures apply.

Ross River Fever

A viral disease carried by kangaroos, other marsupials and wild rodents. Transmission to

man is by mosquito bite. This disease is characterised by fever, (although fever may be

absent), arthritis in the wrist, knee, ankles and small joints of the extremities. A rash on the

trunk and limbs usually accompanies the arthritis. The disease is self-limiting. Protection

from mosquito bite (as for Malaria) is the accepted prevention method.

Syphilis

This disease can occur concurrently with HIV infection and is spread in a similar way,

namely through contact with infectious body fluids and secretions. Syphilis is characterised

by skin lesions and a rash involving the palms and soles. As the disease develops it attacks

the central nervous system and cardiovascular system. Transmission of infection will be

interrupted by procedures adopted for HIV protection.

Tetanus

An acute disease characterised by painful muscular contractions primarily around the jaw and

neck followed by contractions of the trunk muscles. Around the world, case fatality rates

range between 30% and 90%. The disease is introduced into the body through a puncture

wound contaminated with soil, street dust etc. Often the wound is unnoticed or too trivial for

medical consultation. Active immunity can be obtained from an immunisation which lasts

nominally 8 to 10 years. Tetanus control is best achieved by active immunisation since it is

rarely possible to recover and identify the organism at an infection site.

4 General Work Practice Controls

All accident sites are potentially hazardous areas and entry to the site should be in

accordance with the provisions of the Procedures Manual on the subject. Controls may be

revised once potential hazards have been eliminated.

5 Personnel on Site

To limit exposure to potentially hazardous situations, only personnel who have a need to

be on-site as part of the investigation team should be allowed access to the occurrence

site, and then too, only for the minimum possible period. The aircraft manufacturer and

operator may be requested to advise on possible hazards associated with the aircraft or its

cargo. As part of the on-site safety process, pre-entry briefings will be conducted for all

personnel entering the occurrence site.

6 General Precautions

Personal safety at the occurrence site is a combination of common sense and proper

procedures. One must exercise caution and use all appropriate protective devices when

working at the occurrence site and should not work alone at an occurrence site unless the

site location and circumstances adequately provide for his or her personal safety.

7 Work in Confined Spaces

A confined space at an occurrence site is defined as a tank, fuselage segment, crater,

trench or other enclosure, not designed for human occupancy except for the purpose of

performing work, and which has one or more of the following conditions:

A limited number of openings for entry or exit

Poor natural ventilation

An oxygen deficient atmosphere

Airborne hazardous substances.

Before anyone enters a confined space a qualified person must confirm that the space is

safe. Appropriate rescue equipment must be available. An additional person must be

appointed to closely monitor the confined work-site and be ready to rescue the person

inside immediately, should the need arise.

8 Isolated Sites

One should not normally work alone at an isolated occurrence site. An isolated site is

defined as one which would involve more than two hours travel time to an appropriate

medical facility, or which would otherwise present difficulties if immediate removal of

an investigator were necessary.

9 Physical Condition

Everyone is responsible for ensuring that they are fit enough to endure the sometimes

arduous conditions found at an occurrence site and should be aware of the effects of

fatigue long before exhaustion sets in. In addition to being aware of the current condition

of the site, one needs to be aware of the condition of the participants in the investigation.

The symptoms of heat exhaustion are a pale face, cold sweat and shallow breathing. Heat

exhaustion is considered to be shock from exposure to heat. Place the individual on their

back in a shady spot, elevate their feet and loosen tight clothing. Apply cool, wet clothes.

Symptoms of heatstroke are red, hot, dry skin; high body temperature; rapid pulse; slow

and noisy breathing; confusion or unconsciousness. This condition is serious and must be

treated immediately. Seek shade, place the individual on their back and undress down to

the underwear. It is especially important to cool the head. Have the individual drink fluids

and rest.

10 Overview of Hazardous Materials

Adhere to the following guidelines:

Assume that hazardous materials are present at the occurrence site. Suspect all freight,

mail, and passenger baggage until positively identified. Always assume that pressure

vessels are explosive until rendered inert.

Before examining any wreckage, perform a personal site-safety check. If a danger has not

or cannot be neutralised, use alternative methods for gathering evidence such as

photography, photogrammetry, or witnesses. Aircraft always contain hazardous materials

such as fuel, oil and hydraulic fluid. When possible, clean any serious contamination of

fuel and lubricant from the wreckage using a detergent wash and rinse, and when

necessary, an approved absorbent. Be aware of the ever-present danger of fire and

explosion when cleaning contaminated wreckage. Burning or smouldering aircraft

interiors and modern composite materials emit noxious and highly toxic gases and

possibly carcinogenic particles.

11 Radioactive Material

As soon as possible after the notification of an occurrence, one should determine if

radioactive materials were on board the aircraft, either as cargo, equipment or as part of

the aircraft structure. This information must be obtained from the aircraft operator.

Although a member of the crew, if unhurt, and not suffering from shock, may also be

able to provide this information, it is better to obtain such information from a person or

agency that has not been traumatised. If it is established that radioactive material is in the

wreckage, inform all personnel involved in the investigation and take adequate

precautionary measures to avoid undue exposure of the investigation group to the

contaminated area until expert advice is obtained.

12 Chemical Hazards on Site .General

Chemical injury can occur through simple atmospheric contamination and exposure, or

by physical contact of toxic and corrosive substances. Modern synthetic agricultural

chemicals used in aerial spraying applications are often toxic and carcinogenic. When it

is suspected that there is possible chemical contamination, restrict admittance to the

occurrence site until a qualified chemical hazard authority has released the site. The local

Fire Department or Police will be able to contact such an authority. If necessary,

quarantine the area until cleared by appropriate experts. Use absorbent materials such as

sand or commercial neutralising agents to confine a spill.

Caution

Consumption of alcohol before or after exposure to chemicals may aggravate their side-

effects.

13 Agricultural Chemicals

Use caution when approaching the wreckage and occurrence site of any aircraft used in

the aerial application of chemical compounds. In such a situation, exposure to toxic

substances is a very real hazard. Among the multitude of fertilisers, pesticides,

insecticides, herbicides, rodenticides, fungicides and nematocides currently available for

aerial application, many are toxic to humans and readily absorbed through the skin.

Fertilisers and crop nutrients may cause skin, eye and lung irritation, but generally do not

cause serious or permanent damage.

Do not approach the wreckage of an agricultural aircraft until the chemicals on board

have been positively identified by an authority on chemical hazards, and appropriate

precautions have been taken.

14 The following provides general guidelines on the personal protective equipment to be

used by accident investigators at the accident site. The protective equipment may also be

required when performing off-site examinations and tests on wreckage parts.

Disposable latex gloves. Latex gloves should be durable even though they are to be

worn under work gloves. All latex gloves should be properly disposed of prior to

leaving the accident site.

Work gloves. Work gloves should be as durable as practical and provide the hand,

wrist and forearm with puncture and abrasion protection. Leather, nitrile and Kevlar

gloves are commonly used. All three types should be disinfected or properly disposed

of prior to leaving the accident site.

Face masks. Face masks should cover the nose and mouth. Masks come in disposable

and reusable configurations and should be disinfected or properly disposed of prior to

leaving the accident site.

Protective goggles. Protective goggles should enclose the eyes by sealing around the

top, bottom and sides. Common safety glasses are not acceptable. Goggles should be

fitted with one-way check valves or vents to prevent fogging and should be

disinfected or properly disposed of prior to leaving the accident site.

Disposable protective suits. Protective suits should be durable and liquid-resistant and

should fit properly. If possible, they should have elastic-type hoods and elastic pant

cuffs. Duct tape can be used to alter the suits and to patch tears. Protective suits

should be properly disposed of prior to leaving the accident site.

Disposable shoe covers and protective boots. Disposable shoe covers made of

polyvinyl chloride (PVC) or butyl rubber are recommended. Leather, rubber or

Gortex work boots are also acceptable. Disposable shoe covers and protective boots

should be disinfected or properly disposed of prior to leaving the accident site.

Disinfection chemicals. Two chemical types are commonly used to disinfect personal

protective equipment. Rubbing alcohol of 70 per cent strength is effective and is

available in towelettes, as well as in large hand towels. The most effective

disinfectant solution is a mixture of common household bleach and water, with one

part bleach to ten parts of water. Never mix alcohol and bleach.

Biological hazard disposal bags. Biological hazard disposal bags must be used for

disposal of contaminated personal protective equipment. The bags are red or orange

and are labelled “Biological hazard”. For transport, the disposed material should be

double bagged.

All the Regional and Headquarter officers should follow the above requirements strictly

whenever they are carrying out investigations.

1

APPENDIX ‗E3‘

TRAINING MANUAL

FOR

(OFFICERS AND EXPERTS)

GOVERNMENT OF INDIA

MINISTRY OF CIVIL AVIATION AIRCRAFT ACCIDENT INVESTIGATION BUREAU

ISSUE I DATE OF ISSUE 21/11/2012

2

GOVERNMENT OF INDIA

MINISTRY OF CIVIL AVIATION


TRAINING MANUAL

1 INTRODUCTION

Aircraft accident investigation is a specialized task which should be

undertaken by qualified investigators only. Aircraft Accident

Investigation Bureau (AAIB) India has been established recently. Earlier

Air Safety Directorate of DGCA was carrying out the functions and

duties of investigation and prevention of accidents. Initially AAIB is

being manned by qualified and experienced investigators from DGCA.

Since the outcome of an accident investigation is largely dependent upon

the aviation knowledge, skills and experience of the assigned aircraft

accident investigators, they should have:

an understanding of the depth of investigation that is necessary in order

for the investigation to conform with the legislation, regulations and other

requirements.

a knowledge of aircraft accident investigation techniques;

an understanding of aircraft operations and the relevant technical areas of

aviation;

the ability to obtain and manage the relevant technical assistance and

resources required to support the investigation;

the ability to collect, document and preserve evidence;

the ability to identify and analyse pertinent evidence in order to determine

the causes and, if appropriate, make safety recommendations; and

the ability to write a final report that meets the requirements of the

accident investigation.

In addition to technical skills and experience, an accident investigator

requires certain personal attributes. These attributes include integrity and

impartiality in the recording of facts; ability to analyse facts in a logical

3

manner; perseverance in pursuing inquiries, often under difficult or trying

conditions; and tact in dealing with a wide range of people who have

been involved in the traumatic experience of an aircraft accident.

2 AAIB INVESTIGATORS – QUALIFICATIONS & EXPERIENCE

The recruitment experience requirements for senior levels in the AAIB

are civil aircraft accident investigation as per the obligation of ICAO

Annex 13. However at entry level officers with experience &

qualification in various fields of aviation will be recruited with a knack

for qualitative and investigative analysis. Qualification in the legal and

statistical analysis field will be desirable qualification. In addition a panel

of experts will be kept with above type of experience. When assigned to

an accident investigation, such personnel will be relieved of their regular

duties as and when required for the investigation.

As of now and in future, the appropriately qualified personnel available

with the AAIB will require training in the accident investigation

techniques in order to participate in or to conduct an aircraft accident

investigation. These personnel will have considerable practical

experience in aviation as a foundation on which to build their

investigation skills such as a pilot, aeronautical engineer or aircraft

maintenance engineer. Personnel qualified in flight operations,

airworthiness, air traffic management, or aviation related management

will also be provided accident investigator training, since accident

investigations will often involve specialized areas. It will be ensured at all

times that those selected for training as investigators understand the

aviation infrastructure and are able to relate to the many different areas of

aviation.

An accident involving a general aviation or small commuter aircraft,

depending on the conditions may be investigated by a Committee of

Inquiry comprising of two persons or at times small reports prepared by a

single investigator. Most likely, the investigators will be drawn from a

panel of experts maintained with the AAIB. The experts should have at

least attended the introductory ―Aircraft Accident Investigation course‖

covering the procedures as per ICAO Annexure 13. In these

investigations, it is desirable for operations investigator to have some

4

technical experience and for an engineering investigator to have some

operational experience. In addition, the investigators should have a

comprehensive understanding of the interrelationship of each of the

supporting services that are necessary to operate an aircraft in the aviation

environment.

3 TRAINING GUIDELINES

3.1 GENERAL

Aircraft accident investigators require different levels of experience,

knowledge and training according to the particular role to which they are

assigned. AAIB officers will be imparted training commensurate with

their responsibilities as an accident investigator, group leader,

investigator-incharge, accredited representative or expert. The panel of

experts will be imparted training to act as advisers, experts or specialist.

The training guidelines and course will be planned in such a way that the

investigators receive appropriate levels of training and will enable them

to perform efficiently in any of the roles assigned to them.

Training a person for aircraft accident investigation involves several

phases. These phases include initial training, on-the-job training, a basic

accident investigation course and an advanced accident investigation

course supplemented by specialized courses. While on-the-job training is

an ongoing process that continues for many years, there will be sufficient

time intervals between each formal course to allow the investigator to

consolidate the information and the techniques learned.

Formal courses are designed to complement on-the-job training by

exposing the AAIB officers to a cadre of expert investigators. The experts

conducting the training will be from those with experiences in a particular

area of accident investigation i.e. aviation medicine physicians,

psychologists, aeronautical engineers and manufacturers‘ representatives.

Structured courses in aircraft accident investigation will also be

conducted by AAIB as and when required.

5

3.2 PHASE 1 — INITIAL TRAINING

Every officer on joining AAIB will be imparted initial training. In case

very few officers join the training may be imparted in parts. The aim of

the initial training is to familiarize new investigators with the legislation

and with the procedures and requirements of the AAIB. The following

subjects are included in the initial training or indoctrination:

a) Administrative arrangements

Aircraft Act & Aircraft (Investigation of Accidents and Incidents) Rules

2012;

International agreements (including Annex 13 — Aircraft Accident and

Incident Investigation);

Memoranda of understanding with other organizations;

Liaison arrangements with local authorities;

Structure of the AAIB;

Aircraft accident investigation procedures manual;

Definitions and accident classification;

Equipment and tools;

Transport arrangements;

Ethics and conduct; and

Expenditure control.

b) Initial response procedures

Procedures for calling after occurrence;

Notification of other Indian authorities and organizations;

Securing of records, recordings and samples;

Photography

Handling of Flight Recorders

Accident site jurisdiction and security;

Investigator safety including psychological stress;

Recovery of human remains;

Requests for autopsies; and

Family assistance.

6

c) Investigation procedures

On site investigation;

Preservation of evidences;

Authority and responsibility;

Size and scope of the investigation;

Investigation management;

Use of specialists;

Parties to the investigation, accredited representatives, advisers and

observers; and

Release of information to the news media.

d) Reports

Preliminary report;

Final report including aspect of reopening;

Submission of reports and ADREP;

Follow up on recommendations;

3.3 PHASE 2 — ON-THE-JOB TRAINING

Following the initial training, on-the-job training will be imparted to

officers. During this second phase, they will practice the procedures and

tasks covered in the initial training, and gain familiarity with

investigation techniques. This training will also familiarize them with the

investigation tasks at the accident site, the collection of factual

information, the analysis of the factual information and the development

of the final report. The on-the-job training will be carried out by

associating with the on going investigations with one of the experienced

investigators and will not be limited to one investigation.

3.4 PHASE 3 — BASIC ACCIDENT INVESTIGATION COURSES

After completing the phase 1 and phase 2 of the initial training, the

officer who is under training will attend a basic accident investigation

course as soon as is practicable, preferably within the first year of

7

recruitment. A basic course will have syllabus that includes the subjects

at Annexure I.

3.5 PHASE 4 ADVANCED ACCIDENT INVESTIGATION COURSES

AND ADDITIONAL TRAINING

Once an officer gains experience as a trained investigator, he will be sent

for an advanced accident investigation course where he can update his

knowledge of the basic techniques and increase his knowledge in special

areas relevant to accident investigations. Additionally they will be called

upon to investigate accidents involving a variety of aircraft types, thereby

getting an opportunity to have a basic knowledge of most of the major air

transport aircraft types that are operated in India. In this regard the

officers will be asked to undergo aircraft technical training courses at

manufacturers and operators facilities. Preferably, such aircraft type

courses which include specialized technology transport category aircraft

(i.e. aircraft equipped with a glass cockpit, fly-by-wire systems and

aircraft which contain composite materials in their structure).

Investigators with a technical or engineering background will attend the

aircraft type courses for technical/ maintenance personnel. Similarly,

investigators with a pilot background will attend the aircraft type courses

for pilots, which could include introductory flight training in a flight

simulator.

In accordance with Annex 13, the State of Design and the State of

Manufacture participate as accredited representatives in investigations

involving the type of aircraft that are designed or manufactured in their

State. Although the accredited representatives are usually accompanied

by expert advisers from the design organization and the manufacturer, it

will be ensured that the investigators, who are appointed as accredited

representatives have a basic knowledge of the aircraft designed or

manufactured in India.

Efforts will also be made to impart other additional training to officers by

sending them to attend conferences and seminars conducted by aircraft

accident investigation organizations, such as the International Society of

Air Safety Investigators (ISASI), IAF. The officers will be deputed to

major investigations as observers.

8

3.6 ADVANCED COURSE

Most topics covered in the basic course will also apply to advanced

courses, but the instructors will vary their treatment of these topics to suit

the purpose of the course and the experience level of the officers for that

batch. In general, an advanced course is desirable for preparing an

investigator for the responsibilities of group leader or investigator-in-

charge of a major investigation. Such a course will aim to give the

investigator an understanding of and some competence in the

organization of a major accident investigation.

In addition to the review of the organization of a major investigation,

topics that will be discussed include:

the provision of family assistance to those involved in an accident;

relations with the media;

an introduction to methods for cataloguing a large number of fragments

of wreckage;

management of a large accident site for security, safety and protection of

the personnel;

preparation of briefings and answers to formal questions for members of

government;

the methods of undertaking investigations that involve both civil and

military aircraft; and

liaison with the law enforcement authorities in accidents involving

unlawful interference.

techniques used to investigate accident damaged systems that involve

specialized technologies such as glass cockpit, fly-by-wire systems, GPS,

and enhanced ground proximity warning systems (EGPWS);

reconstruction of evidence recorded in damaged solid state recorders;

the use of virtual video presentations in large structural reconstructions of

wreckage; and

the use of computer simulations and programmes for flight simulators to

recreate aspects of the aircraft‘s flight path which are of interest to the

investigation.

9

3.7 SPECIALTY COURSES

AAIB will contact the manufacturers of systems for specialty courses,

since most manufacturers have their own accident investigators and

support personnel that are familiar with the systems and the investigation

techniques required to extract the information stored in the systems.

Similarly for other speciality courses arrangements will be made with

other State authorities. Specialty courses will be introduced to an officer

at any stage after a basic course. The courses would augment the skills

and knowledge acquired by the inspector in order to meet the needs of a

particular area of accident investigation that is relevant to his assigned

duties.

For topics such as helicopter accident investigation, gas turbine engine

accident investigation, accident survival aspects, fires and explosions,

Human Factor investigation, family assistance and media relations, they

are generally extensive enough to warrant a short course of their own

with a specialized syllabus.

Description of the systems involving specialized technologies (such as

glass cockpit, fly-by-wire systems, GPS, electronic flight instrument

system (EFIS) and EGPWS) is usually provided during aircraft type

courses. However, aircraft type courses do not include the investigation

aspects nor the investigation techniques of such complex systems.

Extensive information can be obtained from memory chips and other

solid state electronic circuits used in new technology systems.

Increasingly, the investigation techniques for solid state electronic

circuits are covered in accident investigation courses.

3.8 RECURRENT TRAINING

i. All officers of AAIB will be provided a recurrent training once in three

years period.

ii. The curriculum for a recurrent training may be from 3 to 5 days and

will aim to update the knowledge of participants with latest techniques,

amendments in procedure manual, technologies, regulations etc.

iii. The recurrent training will be conducted in house by senior officers to

whom specific topics will be assigned by Head AAIB.

10

iv. Recurrent training of empaneled experts will be carried out every three

years. In addition to the the training of AAIB officers, case histories of

important/complex investigations will be discussed and analysed.

v. For the sake of logistic convenience recurrent training of AAIB

officers and empaneled experts will be combined.

3.9 TRAINING RECORDS

ALD will maintain training dossiers of all AAIB officers and

empaneled experts. All officers and experts should also keep updated

records of their training. It will be the responsibility of officers/experts

to provide copies of certificates of training by them to ALD for

maintenance of records.

11

ANNEXURE - I

ACCIDENT INVESTIGATION BASIC COURSE GUIDELINES

Basic aircraft accident investigation courses will cover the following topics:

the responsibilities of the States involved, as defined in Annex 13 —

Aircraft Accident and Incident Investigation;

the accident site considerations, such as security, hazards, safety

precautions, wreckage diagramming, collection of evidence and control

of access;

the investigators‘ personal equipment and protective clothing;

the examination and recording of the wreckage and witness marks;

the range of apparatus available for recording evidence;

witness interview techniques;

the full range of in-flight recorders and ground-based recorders;

the determination of the time and origin of any aircraft fires;

crashworthiness and survival aspects;

the properties and the modes of failure of materials used in the aircraft

structure;

the design of aircraft systems and likely modes of failure;

aerodynamics and aircraft performance;

the examination of power plants;

human performance;

aviation medicine and pathology; and

the methodology of report writing.

Detailed breakdown of the topics that will be covered

General Introduction.

The first phase of a course will introduce to the history of aircraft accident

investigation, the development of the international agreements on the

conduct of investigations, and the Standards and Recommended Practices

(SARPs) adopted by ICAO and its Contracting States in the field of aircraft

accident investigation. The applicable international agreements and SARPs

are contained in Annex 13 — Aircraft Accident and Incident Investigation

12

to the Convention on International Civil Aviation. Relevant guidance

material from the Manual of Aircraft Accident Investigation (Doc 6920)

and Manual of Aircraft Accident and Incident Investigation (Doc 9756)

will be used for training. A review of these documents and their salient

points will be done so that the investigator knows where to find the

information on the relevant topics. General guidance will also be given on

the investigation of accidents involving unlawful interference and

inaccessible or missing aircraft.

Accident notification procedures

The trainees will be introduced to the accident notification systems and the

appropriate responses to be expected from each State and organization that

are notified. This introduction will cover the ways on how the notification

of the occurrence of an accident initiates the process of an investigation. It

will also cover the support to be provided to the accident investigation

authority in the State of Occurrence by the State of Registry, the State of

the Operator, the State of Design, the State of Manufacture, and any other

States that are involved by virtue of the number of their nationals involved

in the accident or are involved by providing a permanent base for the

investigation due to their proximity to an accident site. They will be made

aware of the requirements of Annex 13 in relation to this phase of an

investigation. Preparation for overseas travel in the form of passports and

visas and airport airside passes will be reviewed, as will be the benefits of

access provided by the international agreements inherent in Annex 9 —

Facilitation.

Investigation management

The introduction will cover the role of the investigator, the skills he will

need to acquire, and the accident investigation process. He will be made

aware of the value of assessing the availability of resources (such as

funding, personnel, equipment and buildings) as well as the planning for

the investigation of a major accident beforehand. He will be given

guidelines for determining the appropriate size and scope of an

investigation, the differences between the management of large and small

investigations, and the type of circumstances in which assistance from

specialists will contribute to the success of the investigation. An

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appreciation of the realities of the limits imposed by the resources available

and the optimum use of those resources will be discussed. The value of

memoranda of understanding with departments and organizations that

might be involved in an investigation will also be addressed.

Investigators’ equipment

The equipment to be used during investigations will be determined not only

by availability and cost but also by the means available to transport it to the

site. Information on the use of contemporary aids such as global

positioning systems (GPS) and data links back to base, as well as on the

use of basic items such as compasses and inclinometers will be made

available. Instruction on the proper method of taking samples of aircraft

fluids and the appropriate containers will also be included.

Accident site safety

The safety of personnel at an aircraft accident site is of paramount

importance and must be understood by participants of an investigation. An

investigator is a valuable resource and it is important that he is protected

and well equipped to do his work in the field with as little risk as is

practicable and with the optimum efficiency. Aircraft accidents frequently

occur in adverse weather conditions in areas of inhospitable terrain such as

mountainsides, swamps and deserts, or in adverse climatological conditions

involving ice or fierce heat. The need to take appropriate measures to

protect those on the site against exposure to the elements, to any hazardous

cargo or dangerous materials released from the aircraft, and against injury

or infection must be understood.

There are medical risks and hazards from the aircraft wreckage itself and

they must be explained to the investigators. Another subject that will be

covered is how to deal with psychological stress of investigators and other

personnel with exposure at an accident site. Disease is an ever-present risk

and inoculations against such risks as hepatitis, malaria and tetanus are

essential.

The use of protective equipment against airborne and blood borne

pathogens will be demonstrated. Utilities such as gas mains, electricity

transmission lines and main transport routes require special consideration.

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Finally, a plan for aid and rescue in the event of an accident involving

personnel at the site is required by many occupational health and safety

organizations and is also dictated by common sense.

Protection of evidence

To establish a suitable environment for a competent examination of the

area and the accident debris, measures should be taken to protect the

wreckage from fires, meteorological hazards and souveniring. The need to

give priority to recording transient evidence, securing light objects that

may be lost in the wind, and recording ground scars and other site

markings that may become obliterated will be addressed. The conduct of

interviews with the rescue personnel will also be discussed in order to

facilitate the determination of the movement of items of wreckage, which

they may have caused inadvertently.

Initial action at the accident site

The trainee will be given a thorough understanding of the numerous

considerations that should be taken into account at the accident site. With

some exceptions such as accidents involving missing aircraft or resulting in

wreckage that is inaccessible, the accident site is the primary area of

investigation. The methods of apportioning time effectively, prioritizing

the types of information to be gathered, plotting the position of surface

marks, and identifying and plotting the position of items of wreckage, as

well as the preparation for the removal of any exhibits to a secure site are

important considerations that the investigator should become familiar with

from the outset.

Information gathering techniques

The trainee will be introduced to the methods of gathering and reviewing

relevant documentation and procedures; the interview techniques used for

different types of witnesses; the transcription of air traffic services and

other recordings; and the review of aerodrome facilities, emergency

services responses and meteorological data.

Communication and recording media

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The various media available for communicating to and from an accident

site and for recording the evidence at the accident site and throughout the

investigation are essential elements of an investigation course. Digital

video cameras and digital cameras, standard film photography, laptops and

hand-held computers with connections via telephones to sources of

information of immediate use at the accident site, and tape recorders are all

useful for recording the available information as accurately and rapidly as

is practicable. As each type of equipment is evolving rapidly, it will be an

essential subject in the training of an investigator.

Witness interviews

The range of witnesses varies with physical condition, nature of

involvement, and differences in ethnic backgrounds. They will also vary in

their value based on their understanding of the required information and

their proximity to the scene. They may be a visual witness who saw an

event or an aural witness who heard a sound or relevant conversation. The

preparation for interviews, information to be gleaned from body language,

the relative positioning of the interviewer and interviewee, preparation of

the questions to be asked, the use of open questions, the art of listening and

general conduct of the interview, the use of recorders such as video

cameras and tape recorders, the value of written statements and signed

transcripts will be considered. The precautions to be taken when

interviewing the injured or persons in ill health, the young, the aged, and

hostile witnesses as well as the use of experts in the field of inquiry will be

discussed.

Recorders

In addition to the flight recorders, there are many other forms of recorders

used in the aviation industry, from the security cameras on the aerodrome

perimeter fence to the maintenance recorders in the aircraft, each with

potential use to an investigator. The value of each form of recorder, the

methods of interpreting and downloading the information, and the sources

of readout will be in the course syllabus. Equally, the value of

manufacturer‘s expertise in recovering information from damaged

recorders (such as global positioning receivers, solid-state flight recorders

and inertial navigation unit components) will be explored. Another aspect

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of importance is the means of locating the flight recorders and recovering

them from locations that are difficult to reach. Recorders at air traffic

services facilities, particularly those that record radar returns, will be the

subject of study and guidance regarding their potential use to an

investigation.

Examination of relevant maintenance documents

The maintenance history of the aircraft is established primarily from the

records held by the operator. However, the investigator must learn to

establish whether the maintenance, inspection procedures and servicing

that are recorded as having been completed have in fact been carried out,

and he must also learn to determine the adequacy of the specified

maintenance procedures.

Fires and explosions

The evidence available to distinguish an in-flight fire or explosion from

post-accident fires forms a valuable lesson that will be passed on to the

trainees. The means of determining the ignition source and the fuel supply

of a fire are important. It is necessary to teach about the effectiveness of

fire fighting measures available on board the aircraft and the means for

preventing post accident fires during an investigation.

Survival aspects

The chances of occupants surviving an accident can be assessed and the

means to do so will be given. They will know the formulae for impact force

calculations and the various forms of attenuating impact forces. A

discussion on the limits of human tolerance to heat and impact forces is

worthwhile, as are the effects of toxic by-products of the accident

environment. The efficiency of the rescue and fire fighting services,

standard pre-flight passenger briefing spiels, restraint systems, seat

anchorages and aids to egress from the aircraft are items that will be

studied under this heading. It is also very important to review the factors

that affect the occupants‘ chances of surviving the accident. The means of

determining the after effects of a fire on the occupants and the fire‘s

impediment to passenger evacuation will be discussed, as must the

availability of such items as smoke hoods and smoke goggles. An

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understanding of the methods used to protect the aircraft occupants from

the impact forces and post-impact effects (such as thermal stress and water

immersion) is very important for the accident investigator. He must be able

to assess the effectiveness of the methods and make recommendations

which will provide better protection for the occupants in the future.

Structures

As the basis for the examination of the wreckage, the study of structures is

an area of prime interest to the investigator. The study of structures will

comprise metallurgy, fibre reinforced plastics and timber structures, stress

analysis and the strength of these materials. It will also include the various

modes of failure and the characteristics of such failures in the materials

used in aircraft structures.

The methods of failure analysis, reconstruction of areas of interest in the

airframe, and the evidence of the various modes of failure are important

considerations. The various types of flight controls and landing gear

structures will also be studied under this heading. This section of the

syllabus will cover the advanced equipment used in the study of failure

mechanisms, the preparation of samples for examination by such

equipment, and the methods for comparative testing of similar materials.

The study of structures also provides a platform for introducing the means

of wreckage trajectory analysis. Every effort will be made to provide

examples of the various failure modes in materials used in aircraft

construction.

Systems

Aircraft systems vary from mechanical controls that are still found in

general aviation aircraft to the fly-by-wire systems already extant in wide-

bodied transport aircraft. There are a wide variety of systems that the

investigator should become familiar with in general terms. However, the

focus will be on the resources available to assist the investigator in the

event of an accident involving a complex system and on common causes of

system failure that might be experienced. A lead to system health can often

be found in past maintenance records or on-board recorders. In general

terms, fuel, hydraulic, pneumatic, electrical, pressurization, flight control,

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instruments, navigation, autopilot and instrument systems will be

discussed. Other topics that will be considered include software failures in

airborne computers and the adequacy of the protection against catastrophic

events ensuing from such failures.

Aerodynamics

The common areas of aerodynamics that frequently assume importance in

an investigation are those related to performance and in-flight structural

failure caused by overload or flutter. A review of basic aerodynamics and

the means of detecting failure from aerodynamic factors will be included in

the investigator‘s basic training. The topics of engine failure recognition

speed, V1 and V2, climb gradient, over-speed, engine-out performance,

icing and stability also deserve special attention.

Power plants

The detailed analysis of power plants is normally the subject of a separate

course and is usually carried out in conjunction with the engine

manufacturer‘s representatives. Nevertheless, the explanation of the basic

principles of reciprocating and turbine engines has a place in basic and

advanced investigation courses. The same is true with regards to the

analysis of damage to propellers and helicopter rotors, and a general

overview of methods of evaluating damage to determine if further

investigation of the particular propeller or engine is warranted. For

example, propellers and turbines can give a worthwhile indication of an

absence of engine power at the time of impact. This is another subject in

which examples of failures and accident damage form an essential part of

the course.

Rotary wing aircraft

A general introduction to the principles of flight for helicopters and their

control systems is relevant. However the subject of investigating helicopter

and other rotary wing aircraft accidents will be a separate specialty course.

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Organizational information

Organizational and management information is a section of the final report

format and it concerns the organizations and the management involved in

influencing the operation of the aircraft. The organizations include, for

example, the operator; the air traffic services, airway, aerodrome and

weather service agencies; and the regulatory authority. Conducting a

review of the organizational structure and functions as well as the

management policies and practices of the agencies, authorities and aircraft

operator involved is a subject that will be covered. For example, an

investigator should have the competence to review an aircraft operator‘s

management functions, policies and practices in their entirety. There are

many aspects of the supervisory process which may have a direct bearing

on the accident, such as acceptance of inadequate flight crew

qualifications; deficient guidance material; maintenance shortcuts;

improper crew rostering; failure to provide proper training in aircraft type;

shortcomings in crew resource management; and unreasonable pressure to

complete schedules on time.

The methods of investigating management and organizational aspects of an

organization to determine the presence of any risk factors or other

shortcomings is a requirement of a well-rounded accident investigation

course. An examination of the means of supervision is very important and

will include a review of orders, regulations, manuals and independent

audits as well as the performance of supervisors, instructors and company

management.

Human performance

No accident investigation can be complete without a thorough

consideration of Human Factors issues involved. The demands of the

environment and the aircraft on the human often approach the

physiological and psychological limits of the flight crew, maintenance and

servicing crews, air traffic services personnel and other personnel required

to support aircraft operations.

The study of human limitations, communications, fatigue, decision-making

processes, flight crew health and the information available from post-

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mortem examinations are vital components of this section of an

investigation course. An examination of the handling of the aircraft will

encompass the areas of operations and training.

The area of operations includes the man-machine relationship and the

actions or lack of actions in the events leading to the accident. The

investigation in this area covers specifically how the flight crew members

reacted, analysed and attempted to cope with the complexities of the flight.

The area of training will cover the extent and adequacy of the training

relevant to the accident flight. The Manual of Civil Aviation Medicine

(Doc 8984), the Human Factors Training Manual (Doc 9683), the Human

Factors Guidelines for Air Traffic Management (ATM) Systems (Doc

9758) and the Human Factors Guidelines for Safety Audits Manual (Doc

9806) are references which will be used in this section of the training.

Determination of the flight crew’s suitability for the flight

The flight crew members are required to meet certain licensing, training

and experience requirements before conducting any flight. In addition, they

must be fit for their duty and the complement of the crew must be

appropriate. Familiarity with the flight crew documentation and

requirements is essential. Fitness of the flight crew for the flight can be

considered as part of several Human Factor considerations and will be

explained in detail.

Methods of analysing the factual information gathered

There are several structured procedures for analysing the evidence and

facts determined during the investigation. Knowledge of these procedures

will enable the investigator to establish whether further investigation is

required in order to complete the investigation or to test any hypotheses

that the investigation team is considering.

Report writing

Report writing is an integral responsibility of an accident investigator.

ICAO has developed a format for writing reports that leads logically from

the history of the flight to the safety recommendations. There is a minimum

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of duplication and a full consideration of aspects of the flight that are

relevant to the improvement of safety. Knowledge of this format and

process gives the investigator a sound basis for drafting the final report,

including the formulation of appropriate safety recommendations.

The news media and public relations

Almost any aircraft accident is of interest to the news media and will to

some extent involve the investigator-in-charge in public relations activities.

There are two aspects to this subject: the information made available to the

public, and the more specialized approach to the survivors and the families

of those involved in an accident. The importance of keeping others

informed on the progress of an investigation, while not speculating as to

causes and protecting the privacy of those who assist with sensitive

information, must be explained to investigators. The Guidance on

Assistance to Aircraft Accident Victims and their Families (Cir 285) is a

sound basis for addressing this subject and will be used during training.

APPENDIX E4

GUIDELINES FOR MAJOR/ GROUP ACCIDENT INVESTIGATION

In a major accident investigation, a substantial team of investigators is usually

necessary to cover all aspects of the occurrence. The C o u r t m a y t ak e a s s i s t an ce

o f ex p e r t s o r ex p e r t g r o u p s as required, to cover various functional areas of the

investigation. Normally, off icers of AAIB will head the various working groups.

The membership of such groups may include, as appropriate, other investigators

e v e n f r o m the investigation authorities of the States involved in the occurrence,

as well as experts from the operator and the manufacturers of the aircraft, power plant

and accessories, who can contribute their technical knowledge and experience to the

investigation. The number of groups, and the number of personnel assigned to each

group, will depend on the type and complexity of the accident.

In some investigations, the apparent causes/contributing factors may become

evident early in the investigation. In such situations, the subsequent prime

investigative effort may then be channeled to good effect into a relatively narrow but

specialized area. Nevertheless, it will still be necessary to investigate all factors that

might have contributed to the accident and to eliminate those factors that did not. In

situations wherein the causes are not readily apparent, the investigation must progress

steadily through all aspects of the occurrence, and this type of situation may require

substantive effort of many groups of investigators working in a balanced and coordinated

manner.

1 SMALLER INVESTIGATIONS OF INCIDENTS AND ACCIDENTS

1.1 In the case of incidents and non-major accidents, the investigative effort required in

terms of manpower and resources may be proportionately smaller than that required

for a major accident. In such situations, the smaller investigation will be handled by

Committee of two investigators. One trained investigator will be the Chairman assisted

by one or more subject-matter experts.

1.2 Most investigations into serious incidents will be conducted by a small

investigation Committee from AAIB.

1.3 Even in small investigations, the degree of individual effort and diligence in accurately

recording the facts and developing the analysis and conclusions must be of the same high

standards as for major accident investigations.

2 INVESTIGATION RESPONSIBILITIES

2.1 GENERAL

2.1.1 AAIB has overall responsibility for the o r g a n i z a t i o n o f investigation and the

investigation report, including ensuring that the investigation receives adequate

resources. Once a Court/ Committee has been formed, the day to day conduct of the

investigation will be the responsibility of the Chairman of the Court/ Committee.

2.1.2 The Court/ Committee will keep MoCA apprised of any major shift in the size and

scope of the investigation and of any other situations that may result in a significant

change to the resources required for the investigation.

2.1.3 The chairman Court/ Committee of Inquiry will be responsible for the day-to-day

management and conduct of the investigation. During the pre-field phase, the h e must

determine the human, technical and financial resources needed for the investigation

and must establish the need of additional experts. During the field phase, he is

responsible for the conduct and control of the investigation, including defining the

scope of factual information to be gathered. During the later phases of the

investigation, when the significance of the established facts is under consideration,

the he must consolidate the group reports, analyse the information, and draft the Final

Report.

2.1.4 H e w i l l liaise and coordinate investigation activities with other organizations,

agencies and parties; enter into necessary informal agreements to facilitate the

coordination; recognize and authorize observer/participant status; and, in the absence

of established standards, procedures or instructions, take appropriate action, as

necessary. Head AAIB will be the investigation spokesperson.

2.1.5 He will have authority over all the members of the investigation team during the field phase

of the investigation while they are away from their usual place of work. He will take care of

travel expenses and overtime, approving leave, authorizing the issuance of equipment, to

give out contracts and to engage in other necessary financial commitments.

2.2 SUPPORT COORDINATORS

2.2.1 Officer of AAIB will be delegated to act as support coordinator and will support the

C o u r t / C o m m i t t e e in all endeavours, act in direct support of the investigation

process, and liaise with different groups, organizations and States. He will also assist the

t e a m in coordinating internal and external support for investigators in the field and in

keeping the States and various agencies involved in the occurrence informed as to the

progress of the investigation.

2.2.2 If needed an officer of AAIB will also be made Site Safety Coordinator to ensure that

all the activities at the accident site are properly coordinated with specific emphasis on

site security and site safety. This role should include, but not necessarily be limited to,

the following:

a) reviewing the cargo manifest and working with local safety officials as necessary;

b) conducting an initial assessment of the circumstances of the accident site(s), the

geography and condition of the site(s), and the hazards that exist, including biohazards;

c) defining the boundary(ies) of the site(s) required for the investigation, and the hazardous

zones within the site(s);

d) on behalf of the investigation authority assuming responsibility for the custody of the

site(s);

e) taking action to mitigate the risks within the site(s), to the degree possible;

f) determining the safety equipment and safety procedures for investigators operating on the

site; and

g) establishing and maintaining the safety of operations and of personnel at the accident

site(s).

2.3 INVESTIGATION GROUPS

2.3.1 GENERAL

In case of major investigation concept of group investigation will be followed.

Depending on the circumstances of the occurrence and the number of qualified

personnel available to carry out the investigation, some groups may be combined

and/or some groups may be eliminated altogether. The C o u r t will ultimately

determine the team composition. A group chairperson will be responsible for all the

activities of his group for the whole period of the investigation. Normally, the activities

of the various groups cease when their group reports are completed and submitted to the

Court.

2.3.2 Operations Group

The Operations Group is responsible for collecting the facts concerning the history of

the flight and the flight crew activities before, during and after the accident/incident.

This includes the man-machine relationship and the actions or inactions present in the

events surrounding the accident. It also includes flight planning, dispatch, mass and

balance, weather and weather briefing, radio communications, air traffic services,

navigation facilities, en-route stops, refuelling, flight experience, flight checks and

general information concerning the flight crew. It also includes all aspects of training

received and an assessment of the adequacy of this training; the level of supervision,

including orders, regulations and manuals; and, the performance of supervisors,

instructors and company management. The medical history of the flight crew,

including any recent illnesses, psychological factors, rest periods, and activities,

particularly during the twenty-four hours prior to the accident, should be determined.

This latter aspect of the investigation should be coordinated with the Medical/Human

Factors Group. The Operations Group should also determine the flight path prior to the

accident or incident. In this effort, it is essential to coordinate with the Witness Group,

the Flight Recorder Group, and the Site Survey Group. There are occasions when it is

desirable to form additional groups to take over some of the functions of the Operations

Group.

2.3.4 Medical/Human Factors Group

Support regarding the investigation of medical and human factors issues normally

would be achieved by assigning the subject-matter experts to the investigation group(s)

requiring such assistance. A separate Medical/Human Factors Group would only be

formed when there is a requirement to conduct an in-depth examination of the aero

medical, crash injury, and/or human performance issues.

For human factors issues, this group would be responsible for gathering and analysing

evidence on the general physical, physiological and psychological conditions, the

environmental factors, and the organizational and management factors that might have

adversely affected the crew or other individuals in the performance of their duties. The

investigation of human factors should be conducted whenever human performance

may have contributed to the occurrence, which could include the performance of,

among others, cabin crew, air traffic controllers, maintenance crew, engineers, regulatory

officials, decision-makers and management.

For medical issues, this group would be responsible for gathering and analysing

evidence associated with the pathological, aviation-medical and crash-injury aspects of

the investigation, including the identification of the crew, their location at the time of

the accident, and by reviewing their injuries, their position and their activity in the

cockpit at the time of the impact. This group will cover matters involving autopsies of

crew and passengers, as appropriate, not only to identify the victims and to assist in

legally determining the cause of death, but also to obtain all possible medical evidence

which may be of assistance in the investigation. The group will also investigate the

design factors related to human engineering that may have contributed to the

causes of the accident, the survival aspects, and the crashworthiness of the aircraft

contributing to the injury or death of the occupants.

The functions of the Medical/Human Factors group must be closely coordinated with the

Operations Group, Air Traffic Services/Airports Group, Witness Group, Recorders

Group, Maintenance and Records Group, Structures Group and Crashworthiness

Group.

2.3.5 Witness Group

The Witness Group is responsible for contacting and interviewing all survivors of the

flight, and all persons who may have seen or heard some portion of the flight, or

who may have knowledge concerning the flight or of the weather conditions at the

time of the accident. The group's activity can range from questioning relatively few

witnesses to a door- to-door activity covering great distances along the flight path in

which hundreds of possible witnesses are interviewed. Information concerning observed

positions, heights, altitudes, sounds, aircraft behaviour and in-flight disintegration can

be gathered in this manner. The location of witnesses at the time of the accident should

be plotted on a suitable map of the area. Whilst interviewing witnesses, close

coordination must be maintained with the Operations Group, the Flight Recorder

Group and the Site Survey Group in determining the flight path. In some

instances, interpretation and translation facilities have to be provided for the interview

of witnesses.

2.3.6 Flight Recorders Group

The Flight Recorders Group is responsible for examining and analysing the on-board

and ground-based flight recorders, including the flight data recorders, cockpit voice

recorder(s), and cockpit airborne image recorders. The Group will arrange through the

Investigator-in-charge for their read-out. The calibration of the parameters in the flight

data recorder must be taken into consideration in the interpretation of such read-

outs; this work will often require coordination with manufacturers, vendors, or the

operator(s) to ensure proper conversion of the parameters. The results of the read-outs

must be closely coordinated with the Operations Group and such other groups as the

circumstances indicate.

Due to the importance of flight recordings, extreme care must be taken in handling the

recorders to prevent damage.

In the event adequate facilities to read out the flight recorders are not available in India,

facilities made available by other States should be used, giving consideration to the

following:

a) the capabilities of the read-out facility;

b) the timeliness of the read-out; and

c) the location of the read-out facility.

Read-outs of flight recorder recordings should be carried out in the presence of Chairman

Court/ Committee of Inquiry.

The Flight Recorders Group may also be responsible for recovery and analysis of

information contained on other aircraft computers (for example, flight management

systems, traffic collision avoidance system, and terrain awareness and warning

system), on memory units containing satellite navigation information, and on other

portable electronic recording devices that can store some data related to the accident.

The group may also be responsible for collecting and synchronizing flight data, audio

and video information stored on ground-based devices.

2.3.7 Meteorology Group

When the weather is an important factor in an accident, a separate Meteorology Group,

composed of meteorology and operations specialists, can best serve the investigation.

The Meteorology Group should be responsible for the collection and compilation of

meteorological data pertinent to the accident, including both surface and upper air

reports of actual conditions, pilot reports, recorded meteorological data, as well as

forecasts of anticipated conditions prepared and issued by the agencies involved.

This group would also be responsible for investigating the systems, sensors,

equipment and processes used to generate and provide weather information. Of

necessity, the Meteorology Group must maintain close coordination with other groups,

particularly the Operations Group, the Air Traffic Services/Airports Group and the

Witness Group.

2.3.8 Air Traffic Services and Airport Group

When air traffic services or navigation aids are involved in the occurrence, the Air

Traffic Services and Airport Group, which should include air traffic services

specialists, should be established. This group should be responsible for the review of

the records of the air traffic services units concerned, including radar screen recordings,

the radio communication and telephone line voice recordings; and, for the

verification that written transcripts of voice communications are consistent with the

recordings. This group should provide, when appropriate, a reconstruction of the history

of the flight based on air traffic services information. In addition, the Group should

determine the operating status of pertinent navigation aids, communications

equipment, radar, transponder equipment, computers, and other equipment; and,

should provide technical data on all such equipment and its operation, whenever

it is deemed necessary.

When applicable, this group should investigate the operational status of the airport,

pertinent navigational aids, communications equipment, radar, transponder equipment,

and computers, and provide technical data on all such equipment and its operation.

2.3.9 Survivability Group

When required, the Survivability Group will be established to investigate the

evacuation, the crash response, the firefighting, the survival and the rescue issues.

The activities of this group include an examination of the respective equipment and

of the manner in which it was used. Close coordination with the Human Factors

Group, Operations Group and Cabin Safety Group will be required. This group could

also logically be a sub-group of the Medical/Human Factors Group.

2.3.10 Cabin Safety Group

The Cabin Safety Group is responsible for thoroughly exploring all the aspects of the

accident related to the actions of the passengers and cabin crew members. This will

normally include the following aspects: passenger/crew member survivability factors;

company policies and procedures as they relate to passenger/crew member safety;

industry policies, procedures and regulations; and flight attendant training with respect to

operational safety issues.

2.3.11 Maintenance & Records Group

Maintenance and Records Group is responsible for reviewing the maintenance

records to ascertain the maintenance history of the aircraft regarding adequacy of

inspection, malfunctions that might be related to the occurrence, flight time on the

aircraft, engines and components, and the flight time since overhaul. These activities are

normally performed at the maintenance base of the operator. The function of this group

involves close coordination with the other technical investigation groups, the State of

Registry and the operator. This group is also responsible for reviewing recovered

technical flight documents. Close coordination with the Operations Group will be

required.

2.3.12 Systems Group

The Systems Group is responsible for the detailed examination of all systems and

components, among others hydraulics, pneumatics, electrical and electronics, radio

communication and navigation equipment, air conditioning and pressurization, ice

and rain protection, cabin fire extinguishers, and oxygen. The examinations will include

determination of the condition and operational capabilities of components. It is important

that all system components be accounted for, within reason. The examination includes

determination of the positions of associated controls and switches, as well as the

identification and downloading of data contained in built-in test equipment. This group

must coordinate its activities with the Flight Recorders, Operations, Site Survey,

Maintenance and Records, Structures and Powerplants groups.

2.3.13 Structures Group

The Structures Group is responsible for collecting and analysing the facts and

evidence related to the airframe and flight controls. If the wreckage is scattered, the

Group’s first concern is to locate and identify as many sections, components and parts

as possible and to plot their positions on a wreckage distribution chart.

A reconstruction of the aircraft structure may be necessary, and this task could vary from

laying out various pieces of wreckage on a flat area to the more complicated re-assembly

of all available pieces in position on a framework. This procedure is most often used for

in-flight break-up, in-flight fire and explosion type accidents. The main purpose of such

a reconstruction is to identify the point of initial failure and to establish the

progression of the break-up pattern. Close cooperation with the Site Survey Group is

usually required.

2.3.14 Powerplants Group

The Powerplants Group is responsible for collecting and analysing the evidence related to

the engine(s), including fuel and oil systems, propeller(s) and powerplant controls. The

initial work of this group may be carried out in conjunction with the Structures Group

and the Site Survey Group in the locating and plotting of wreckage. All powerplant fires

should be investigated. This group is also responsible for determining the type of fuel

used, the possibility of fuel contamination, and the effectiveness of the powerplant fire

extinguisher system. The functions of this group must be coordinated with the Site

Survey, Structures, Systems, Flight Recorders and Operations Groups.

2.3.15 Site Survey Group

The Site Survey Group is responsible for producing, in pictorial and graphic format, a

description of the accident site, showing the location and distribution of the wreckage,

human remains and other associated items, such as impact marks. This group must

establish a probable flight path, an impact angle and impact speed. The activities of this

group are linked to the Aircraft Performance Group, Structures Group and Recorders

Group.

2.3.16 Crashworthiness Group

Crashworthiness Group is responsible for determining the survivability issues for

all aircraft occupants. The activities of this group will overlap with those of the

Structures Group, Site Survey Group, Survivability Group, Flight Recorders Group and

Witness Group. This group is often a sub-group of the Structures Group.

APPENDIX F

FORMAT OF THE FINAL REPORT

Title. The Final Report begins with a title comprising: name of the operator;

manufacturer, model, nationality and registration marks of the aircraft; place and

date of the accident or incident.

Synopsis. Following the title is a synopsis describing briefly all relevant

information regarding: notification of accident to national and foreign authorities;

identification of the accident investigation authority and accredited representation;

organization of the investigation; authority releasing the report and date of

publication; and concluding with a brief résumé of the circumstances leading to the

accident.

Body. The body of the Final Report comprises the following main headings:

1. Factual information

2. Analysis

3. Conclusions

4. Safety recommendations each heading consisting of a number of subheadings as

outlined in the following.

Appendices. Include as appropriate.

Note.— In preparing a Final Report, using this format, ensure that:

a) all information relevant to an understanding of the factual information, analysis

and conclusions is included under each appropriate heading;

b) where information in respect of any of the items in 1.— Factual information is

not available, or is irrelevant to the circumstances leading to the accident, a note

to this effect is included under the appropriate subheadings.

1. FACTUAL INFORMATION

1.1 History of the flight. A brief narrative giving the following information:

Flight number, type of operation, last point of departure, time of departure

(local time or UTC), point of intended landing.

Flight preparation, description of the flight and events leading to the

accident, including reconstruction of the significant portion of the flight

path, if appropriate.

Location (latitude, longitude, elevation), time of the accident (local time or

UTC), whether day or night.

1.2 Injuries to persons. Completion of the following (in numbers):

Injuries Crew Passengers Others

Fatal

Serious

Minor/None

Note.— Fatal injuries include all deaths determined to be a direct result of injuries

sustained in the accident.

1.3 Damage to aircraft. Brief statement of the damage sustained by aircraft in the

accident (destroyed, substantially damaged, slightly damaged, no damage).

1.4 Other damage. Brief description of damage sustained by objects other than the

aircraft.

1.5 Personnel information:

Pertinent information concerning each of the flight crew members including:

age, validity of licences, ratings, mandatory checks, flying experience (total

and on type) and relevant information on duty time.

Brief statement of qualifications and experience of other crew members.

Pertinent information regarding other personnel, such as air traffic services,

maintenance, etc., when relevant.

1.6 Aircraft information:

Brief statement on airworthiness and maintenance of the aircraft (indication

of deficiencies known prior to and during the flight to be included, if having

any bearing on the accident).

Brief statement on performance, if relevant, and whether the mass and centre

of gravity were within the prescribed limits during the phase of operation

related to the accident. (If not and if of any bearing on the accident give

details.)

Type of fuel used.

1.7 Meteorological information:

Brief statement on the meteorological conditions appropriate to the

circumstances including both forecast and actual conditions, and the

availability of meteorological information to the crew.

Natural light conditions at the time of the accident (sunlight, moonlight,

twilight, etc.).

1.8 Aids to navigation. Pertinent information on navigation aids available,

including landing aids such as ILS, MLS, NDB, PAR, VOR, visual ground aids,

etc., and their effectiveness at the time.

1.9 Communications. Pertinent information on aeronautical mobile and fixed

service communications and their effectiveness.

1.10 Aerodrome information. Pertinent information associated with the

aerodrome, its facilities and condition, or with the take-off or landing area if other

than an aerodrome.

1.11 Flight recorders. Location of the flight recorder installations in the aircraft,

their condition on recovery and pertinent data available therefrom.

1.12 Wreckage and impact information. General information on the site of the

accident and the distribution pattern of the wreckage; detected material failures or

component malfunctions. Details concerning the location and state of the different

pieces of the wreckage are not normally required unless it is necessary to indicate a

break-up of the aircraft prior to impact. Diagrams, charts and photographs may be

included in this section or attached in the Appendices.

1.13 Medical and pathological information. Brief description of the results of the

investigation undertaken and pertinent data available therefrom.

Note.— Medical information related to flight crew licences should be included in

1.5 — Personnel information.

1.14 Fire. If fire occurred, information on the nature of the occurrence, and of the

fire fighting equipment used and its effectiveness.

1.15 Survival aspects. Brief description of search, evacuation and rescue, location

of crew and passengers in relation to injuries sustained, failure of structures such as

seats and seat-belt attachments.

1.16 Tests and research. Brief statements regarding the results of tests and

research.

1.17 Organizational and management information. Pertinent information

concerning the organizations and their management involved in influencing the

operation of the aircraft. The organizations include, for example, the operator; the

air traffic services, airway, aerodrome and weather service agencies; and the

regulatory authority. The information could include, but not be limited to,

organizational structure and functions, resources, economic status, management

policies and practices, and regulatory framework.

1.18 Additional information. Relevant information not already included in 1.1 to

1.17.

1.19 Useful or effective investigation techniques. When useful or effective

investigation techniques have been used during the investigation, briefly indicate

the reason for using these techniques and refer here to the main features as well as

describing the results under the appropriate subheadings 1.1 to 1.18.

2. ANALYSIS

Analyse, as appropriate, only the information documented in 1. — Factual

information and which is relevant to the determination of conclusions and causes.

3. CONCLUSIONS

List the findings, causes and contributing factors established in the investigation.

The list of causes should include both the immediate and the deeper systemic

causes.

Note : The Final Report format presented in this Appendix may be adapted to the

circumstances of the accident or incident. Thus, States may use either “causes” or

“contributing factors”, or both, in the Conclusions.

4. SAFETY RECOMMENDATIONS

As appropriate, briefly state any recommendations made for the purpose of

accident prevention and identify safety actions already implemented.

APPENDICES

Include, as appropriate, any other pertinent information considered necessary for

the understanding of the report.

APPENDIX G

FORMAT OF THE PRELIMINARY REPORT


1.1 History of the flight. A brief narrative giving the following information:

Flight number, type of operation, last point of departure, time of departure

(local time or UTC), point of intended landing.

Location (latitude, longitude, elevation), time of the accident (local time or

UTC), whether day or night.

1.2 Injuries to persons. Completion of the following (in numbers):

Injuries Crew Passengers Others

Fatal

Serious

Minor/None

Note.— Fatal injuries include all deaths determined to be a direct result of injuries

sustained in the accident.

1.3 Damage to aircraft. Brief statement of the damage sustained by aircraft in the

accident (destroyed, substantially damaged, slightly damaged, no damage).

1.4 Other damage. Brief description of damage sustained by objects other than the

aircraft.

1.5 Personnel information:

Pertinent information concerning each of the flight crew members pertinent

to flight

Pertinent information regarding other personnel, such as air traffic services,

maintenance, etc., when relevant.

1.6 Aircraft information:

Brief statement on airworthiness and maintenance of the aircraft (indication

of deficiencies known prior to and during the flight to be included, if having

any bearing on the accident).

1.7 Meteorological information:

Natural light conditions at the time of the accident (sunlight, moonlight,

twilight, etc.). Brief statement on the meteorological conditions if relevant to

accident

1.8 Aids to navigation. Pertinent information on navigation aids available,

including landing aids such as ILS, MLS, NDB, PAR, VOR, visual ground aids,

etc., and their effectiveness at the time.

1.9 Communications. Pertinent information on aeronautical mobile and fixed

service communications and their effectiveness.

1.10 Aerodrome information. Pertinent information if any.

1.11 Flight recorders. Location of the flight recorder installations in the aircraft,

their condition on recovery and dtatus of data readout.

1.12 Wreckage and impact information. General information on the site of the

accident and the distribution pattern of the wreckage; detected material failures or

component malfunctions.

1.13 Medical and pathological information. Brief description of the results of the

investigation undertaken if any and pertinent data available therefrom.

1.14 Fire. If fire occurred, information on the nature of the occurrence, and of the

fire fighting equipment used and its effectiveness.

1.15 Survival aspects. Brief description of location of crew and passengers in

relation to injuries sustained, failure of structures such as seats and seat-belt

attachments.

2. Progress of Investigation

Status and progress of investigation. Any preventive action proposed at this stage

based on information documented in factual information.

Part IV. ReportingChapter 1. The Final Report IV-1-5

APPENDIX G1

Appendix 1 to Chapter 1FORMAT AND CONTENT OF THE FINAL REPORT

To enable the Final Report to be presented in a convenientand uniform manner, a standardized format is contained inthe Appendix to Annex 13. Detailed guidance oncompleting each section of the Final Report is providedbelow.

INTRODUCTION (Title and Synopsis)

The title of the Final Report should contain the followinginformation: name of the operator; manufacturer, model,nationality and registration marks of the aircraft; and placeand date of the accident.

The introduction should contain brief information on thenotification of the accident to national and foreignauthorities, the identification of the accident investigationauthority conducting the investigation, the accreditedrepresentation from other States and brief information onthe organization of the investigation. The authorityreleasing the report, as well as the date of release, shouldalso be given.

The introduction should contain a synopsis which brieflydescribes the accident. It should provide an overview of theaccident flight, a statement of why the accident happenedand a brief summary of the injuries and damage. Thesynopsis could be described as an executive summary ofthe Final Report and should usually not exceed one page inlength.

The title page, or the inside cover, may contain a statementon the accident prevention objective of the investigationand the Final Report. It may also be stated that it is not thepurpose of the investigation and the Final Report toapportion blame or liability. For example, the followingtext may be considered: “In accordance with Annex 13 tothe Convention on International Civil Aviation, it is not thepurpose of aircraft accident investigation to apportionblame or liability. The sole objective of the investigationand the Final Report is the prevention of accidents andincidents.”

The introduction may also contain a statement regardingthe responsibility for implementing the safety recommen-dations. For example, the following text may beconsidered: “Unless otherwise indicated, recommendations

in this report are addressed to the regulatory authorities ofthe State having responsibility for the matters with whichthe recommendation is concerned. It is for those authoritiesto decide what action is taken.”

The introduction should contain a reference to the time ofday used in the report, and the differential between localtime and Co-ordinated Universal Time (UTC).

A table of contents, a list of abbreviations used in the reportand a list of appendices will enhance the readability of thereport.


This part of the Final Report is descriptive in character andshould be a comprehensive record of the facts andcircumstances established in the investigation. When theinvestigation was conducted by groups, the report shouldcomprise a consolidation of the relevant information fromthe group reports. Supporting documents, such asphotographs, diagrams, relevant parts of flight recorderreadouts and technical reports, should be included orappended to the report. However, only those documents, orportions thereof, which are required to support the facts,analysis and conclusions should be appended to the FinalReport.

The collection of Human Factors information is an integralpart of the investigation. Thus, the Human Factors infor-mation should be integrated into the appropriate areas ofthe factual part of the report, rather than being placed undera separate heading. Human Factors information should bepresented in a language that is consistent with thepresentation of the other factual information.

The factual information part of the Final Report shouldcontain a description of all the events and circumstancesdirectly related to the occurrence. The sequence shouldbegin as far back in time as is necessary to include thesignificant events which preceded the accident. This partalso contains all factual information, i.e. informationresulting from direct verification, which is essential for thedevelopment of the analysis, conclusions and safetyrecommendations. The significance of the facts should not

1

IV-1-6 Manual of Aircraft Accident and Incident Investigation

APPENDIX G1

be explained in the factual information part. Suchdiscussions should be presented in the analysis part.

1.1 History of the flight

1.1.1 The history of the flight describes the significantevents which preceded the accident, in chronological orderwhen this is practicable. The information is usuallyobtained from sources such as flight records, flight datarecorders, cockpit voice recorders, air traffic servicesrecords and recordings, and witness accounts. Theinformation should be correlated to local time, or UTC ifthe flight involved more than one time zone. Theinformation presented in this section of the report should bebased on established facts. Usually the flight number, thetype of operator and operation, the crew briefing and flightplanning, the departure point and time of departure, and thepoint of intended landing will be given, followed by adescription of the events leading to the accident, includingnavigational details and relevant radio communications. Itis important to give a description of the flight and thepertinent events as they occurred, including areconstruction of the significant portion of the flight path,if appropriate. Evidence which facilitated the reconstructionof the sequence of events, such as witness accounts, cockpitvoice recorder and air traffic services transcripts, should bementioned.

1.1.2 In the history of the flight section, the objectiveis to enable the reader to understand how the accidenthappened but to avoid any analysis of why the accidentoccurred.

1.1.3 With regard to the location of the occurrence,include:

— the latitude and longitude, as well as a geographicalreference to a well-known location (such as 75 kmsouth of XYZ);

— the elevation of the accident site;

— time of the occurrence in local time (and UTC if theflight crossed time zones); and

— whether it was day, dawn, dusk or night.

1.2 Injuries to persons

1.2.1 Table 1-1 should be completed in numbers.

1.2.2 Fatal injuries include all deaths determined to bea direct result of injuries sustained in the accident. Seriousinjury is defined in Chapter 1 of Annex 13. For statisticalpurposes, ICAO classifies a fatal injury as an injury whichresults in death within thirty days of the accident. Theheading “Others” in the table refers to persons outside theaircraft who were injured in the accident. When theaccident involves a collision between two aircraft, aseparate table should be used for each aircraft.

1.2.3 Also, the nationalities of the passengers and thecrew should be listed by stating the number of fatalities andserious injuries for each nationality.

1.3 Damage to aircraft

1.3.1 This section should contain a brief statement ofthe damage sustained by the aircraft in the accident

Table 1-1. Injuries to persons

Injuries Crew Passengers Total in the aircraft Others

Fatal

Serious

Minor Not applicable

None Not applicable

TOTAL

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APPENDIX G1

(destroyed, substantially damaged, slightly damaged, or nodamage). A detailed description of damage to relevantaircraft components and systems should be included inSection 1.12 — Wreckage and impact information.

1.4 Other damage

1.4.1 Make a brief statement of damage sustained byobjects other than the aircraft, such as buildings, vehicles,navigation facilities, aerodrome structures and installations,and any significant damage to the environment.

1.5 Personnel information

1.5.1 Provide a brief description of the qualifications,experience and history for each flight crew member (pilot,co-pilot and flight engineer) including age, gender, type andvalidity of licences and ratings; flying experience (totalhours), types flown and hours on the type; hours flown inthe last 24 hours, 7 days and 90 days prior to the accident;results of recent training and mandatory and periodicchecks; experience on route and aerodrome involved in theaccident; relevant information on duty time and rest periodsin the 48 hours prior to the accident; significant medicalhistory and medical checks. Also, state the positionoccupied by each flight crew member and identify who wasflying the aircraft.

1.5.2 When relevant to the accident, give a briefstatement of the duties and responsibilities of the cabincrew, as well as their qualifications, experience andtraining. For example, these details would be relevant if theaccident involved an evacuation of the aircraft.

1.5.3 When relevant to the accident, include a briefstatement of the validity of licences and ratings, thequalifications and experience of air traffic servicespersonnel, including age, gender, position manned, totalexperience (in years), and details of experience specific tothe position manned. Details of training and pertinentchecks should be included, as well as duty times and restperiods in the 48 hours prior to the occurrence.

1.5.4 When relevant to the accident, information onmaintenance personnel and other personnel involved shouldinclude qualifications, experience, time on duty, shift workrosters, workload and the time of the day.

1.5.5 Use sub-headings, as appropriate, to organizethe information in this section.

1.6 Aircraft information

1.6.1 When relevant to the accident, provide a briefstatement of the airworthiness and maintenance of theaircraft including the following information:

— General information: Aircraft manufacturer andmodel, serial number and year of manufacture;nationality and registration marks, validity of theCertificate of Registration; name of the owner andthe operator; and validity of the Certificate ofAirworthiness;

— Aircraft history: Total flying hours sincemanufacture, since overhaul, and since last periodicinspection. Include relevant information onmaintenance log and maintenance documentation,compliance (or otherwise) with airworthinessdirectives, manufacturer service bulletins andaircraft modification status;

— Helicopters: Main rotor and tail rotor types andserial numbers. When relevant, include total time,time since overhaul, time since inspection, andcertificated time and cycle limits for relevantcomponents;

— Engines and propellers: Engine manufacturer andmodel, position on the aircraft and engine or enginemodule serial numbers; engine overhaul period ifan engine failure occurred; and total hours, hourssince overhaul and hours since last inspection, foreach engine. If relevant, provide the sameinformation for the propellers;

— Fuel: Type of fuel used and type of fuel authorized.Also, state the amount of fuel on board and how itwas determined, its specific gravity and itsdistribution in the fuel tanks;

— Accessories: In respect of any component whichfailed, give details of the manufacturer, type,model, part and serial number, certificated time andcycle limits, and operating time since manufactureand since overhaul;

— Defects: List any technical defects in the aircraft,engine or accessories which were discovered duringthe investigation or recorded in the appropriate logand not cleared. Indicate whether the defects wererecurring and whether the flight was permissibleunder the aircraft master minimum equipment list.If there were no defects, make a statement to thateffect; and

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APPENDIX G1

— Aircraft load: The maximum certificated take-offmass and landing mass, actual take-off mass, andmass at the time of the occurrence should be given.Also, state the certificated limits for the centre ofgravity of the aircraft, and the centre of gravity attake-off and at the time of the occurrence. Includea description of the operator’s loading controlsystem, the load distribution and its security, andhow the details of the aircraft mass and centre ofgravity were established.

1.6.2 Describe any aircraft part or system which hada bearing on the accident. Similarly, describe operationalprocedures, performance limitations and other aircraftrelated circumstances which played a role in the accident.The objective is to enable the reader to fully understandhow the accident happened.

1.6.3 The availability, serviceability and use oftransponder, airborne collision avoidance system (ACAS)and traffic alert and collision avoidance system (TCAS),ground proximity warning system (GPWS) and terrainawareness warning system (TAWS), should be stated. Therelevant systems should be discussed in detail for near-collisions, mid-air collisions, approach and landingaccidents and controlled flight into terrain accidents.

1.7 Meteorological information

1.7.1 Provide a brief statement on the relevantmeteorological conditions, including the forecast and actualweather, together with an appreciation of the weather inretrospect. When relevant to the occurrence, the followinginformation should be included:

— Describe when, where and how the pilot obtainedweather information;

— Weather forecast: Route and aerodrome forecastsavailable to the pilot, and details of any weatherbriefing obtained by the pilot prior to departure orreceived en route;

— Weather observations at the time and place of theoccurrence including precipitation, ceiling,visibility, runway visual range, wind speed anddirection, temperature and dewpoint;

— Actual weather on the route of the flight, includingweather observations, SIGMETs, pilot reports andwitness accounts;

— A general view of the weather situation (synopticweather);

— Weather radar recordings, satellite photos, low-levelwind shear alert system (LLWSAS) data, and otherrecorded meteorological information; and

— Natural light conditions at the time of the accident,such as day (sunlight or overcast), twilight (dawn ordusk; when relevant, the time of sunrise or sunset atthe applicable altitude should be included), night(dark or moonlight) and when relevant, the positionof the sun relative to the direction of the flight.

1.7.2 The amount of meteorological information to beincluded in this section depends on the significance of themeteorological factors in the occurrence. A detaileddescription of the forecast and weather observations isappropriate for a weather-related occurrence whereas abrief summary of the weather is appropriate when theweather was not a factor.

1.8 Aids to navigation

1.8.1 Include relevant information on navigation andlanding aids available, such as global navigation satellitesystem (GNSS), non-directional radio beacon (NDB), veryhigh frequency omnidirectional radio range (VOR),distance measuring equipment (DME), instrument landingsystem (ILS), and visual ground aids, as well as theirserviceability at the time of the accident.

1.8.2 When relevant, include pertinent information onequipment on board the aircraft, such as autoflight system,flight management system (FMS), global positioningsystem (GPS), and inertial navigation system (INS),including their serviceability. Relevant maps, charts,approach plates and radar recordings should also bediscussed and included in, or attached to, the report.

1.9 Communications

1.9.1 Describe the communication facilities availableto the flight crew and their effectiveness. Describe thecommunications with the air traffic services and othercommunications relevant to the flight, including referenceto communication logs and transcripts of recordings. Whenessential to the analysis and understanding of theoccurrence, pertinent extracts from the transcripts of airtraffic services communications recordings should beincluded in this section or attached to the report.

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APPENDIX G1

1.10 Aerodrome information

1.10.1 When the occurrence took place during take-off or landing, include information concerning theaerodrome and its facilities. When relevant, include thefollowing information:

— Name of aerodrome, location indicator, referencepoint (latitude/longitude) and elevation;

— Runway identification, runway markings, runwaylength and slope, length of overrun, andobstructions;

— Runway conditions, such as pavement texture andgrooving, rubber deposits, presence of water, slush,snow, ice, friction coefficient and braking action;

— Lighting, such as runway, taxiway and stopwaylighting; and visual aids, such as visual approachslope indicator system (VASIS) and precisionapproach path indicator (PAPI);

— Runway inspection programmes and inspectionscarried out; and

— Bird and wildlife programmes.

1.10.2 If the aircraft was taking off from, or landingon, an area other than an aerodrome, relevant informationon the take-off or landing area should be given.

1.10.3 This section should be divided into departureaerodrome information and destination aerodromeinformation, if both aerodromes were pertinent to theoccurrence.

1.11 Flight recorders

1.11.1 Provide the particulars for each flight recorder,such as manufacturer, model, number of parametersrecorded, recording medium and duration of the recording.The recorders would include flight data recorders (FDR),cockpit voice recorders (CVR), quick access recorders,engine parameter recorders, video recorders, non-volatilememory chips in aircraft systems, and other on-board orground-based recorders.

1.11.2 Describe the condition of the recorders onrecovery, in particular their exposure to fire and impactforces. If the flight recorder(s) could not be recovered, thereasons should be explained. If data was not recorded or

could not be extracted, describe the reasons for themalfunction or loss of data. Include techniques used toextract data and any problems encountered. If the recordersoperated properly, a short statement to this effect should bemade and the pertinent data presented.

1.11.3 In this section, provide information recordedby the flight recorders. Because of the length of a flightdata recording read-out report, include here or in anappendix to the Final Report only those parts of the read-out reports which are pertinent to the analysis and findings.

1.11.4 Transcripts from the cockpit voice recordingsshould be included in the Final Report or its appendicesonly when essential to the analysis and understanding ofthe occurrence. Parts of the recordings not essential to theanalysis shall not be disclosed. Chapter 5 of Annex 13contains provisions pertinent to transcribed voicerecordings and should be taken into account when it isconsidered necessary to include such transcripts in the FinalReport or its appendices.

1.11.5 If the aircraft was not required to be equippedwith flight recorders, a statement along the following linesmay be used: “The aircraft was not equipped with a flightdata recorder or a cockpit voice recorder. Neither recorderwas required by the relevant aviation regulations.”

1.12 Wreckage and impact information

1.12.1 Provide a general description of the site of theaccident and the distribution pattern of the wreckage,including the final portion of the flight path, the impactpath, the impact sequence and the location of impactimpressions on the ground, trees, buildings and otherobjects. The impact heading, aircraft attitude (pitch, rolland yaw) and aircraft configuration at impact should begiven. When relevant, the terrain surrounding the site of theaccident should be described. Relevant wreckage dis-tribution diagrams, charts and photographs should beincluded in this section or appended to the report. Thelocation and the state of the major parts of the wreckageshould be presented. In case of an in-flight break up of theaircraft, a detailed description of the wreckage distributionshould be provided.

1.12.2 In major accident investigations, it might benecessary to present the examination of the wreckage andthe technical investigations under appropriate sub-headingsin this section, such as structures, power plants,instruments, flight controls and systems. The descriptionsunder each sub-heading should embrace the significant

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APPENDIX G1

facts determined by the group which was responsible forthe detailed investigation. Under appropriate sub-headingsalso include the relevant results of special technicalinvestigations, examinations and laboratory tests, and thesignificance of the results obtained (see also Section 1.16— Tests and research). When relevant, the technicallaboratory and test reports should be appended to the FinalReport.

1.12.3 It is important to include all pertinent materialfailures and component malfunctions, and to indicatewhether they occurred prior to or at impact. It is essentialthat failed or malfunctioning components which aredeemed to be significant to the accident be described. Adetailed description of all wreckage components is notnecessary; describe only components considered to berelevant or which required examination and analysis. Theinclusion of drawings of components and photographs ofspecific failures will enhance the Final Report. Suchdrawings and photographs could be presented together withthe appropriate text or as an appendix.

1.13 Medical and pathological information

1.13.1 Describe the results of the medical andpathological investigations of the flight crew. Medicalinformation related to flight crew licences should beincluded under Section 1.5 — Personnel information.When relevant to the accident, the medical investigationmay also concern the cabin crew members, passengers andground personnel.

1.13.2 The results of the pathological andtoxicological examinations concerning injuries, detection ofdisease and factors which impaired human performance,such as carbon monoxide, oxygen deficiency, alcohol andother drugs, should be stated. If alcohol and drugs aredetected, their effects on human performance as determinedby medical experts should be presented in this section.

1.13.3 Describe the pathological evidence ofsignificance to the survival investigation such as therelationship of injuries and pathological evidence to thedeceleration forces, aircraft attitude at impact, seat designand attachments, seat belts (see also Section 1.15 —Survival aspects), break-up of the aircraft structure, smokeinhalation, decompression and any evidence of preparationfor an emergency situation, such as forced landing, ditchingand unlawful interference.

1.13.4 Given the provisions of Annex 13, Chapter 5with regard to medical and private records, particular care

should be taken that such information is disclosed in theFinal Report only when pertinent to the analysis andconclusions of the accident.

1.13.5 If the medical examinations indicate that theperformance of flight crew members was not degraded, asentence along the following lines may be used: “Therewas no evidence that physiological factors or incapacitationaffected the performance of flight crew members.”

1.14 Fire

1.14.1 If a fire or an explosion occurred, give a briefdescription of whether the fire started in flight or afterground impact. For in-flight fires, describe the effectivenessof the aircraft fire warning systems and the aircraft fireextinguishing systems. The determination of the origin of afire, source of ignition, fuel source, duration, severity andeffects on the aircraft structure and the occupants usuallyrequires an analysis of the facts and indications, and shouldtherefore be dealt with in the analysis part of the FinalReport. This section should describe the factual informationwhich was established in the investigation related to the fireand which should then be discussed and analysed in theanalysis part.

1.14.2 For fires on the ground, describe thepropagation and the extent of the fire damage. The responsetime of the rescue fire service, access to the accident site bythe rescue fire service vehicles, the type of fire fightingequipment used, the type of extinguishing agent and theamount that was used and its effectiveness should also bedescribed.

1.14.3 The effect of the fire on the evacuation andsurvivability of the occupants should be described inSection 1.15 — Survival aspects.

1.14.4 If there was no fire, a sentence along thefollowing lines may be used: “There was no evidence offire in flight or after the impact.”

1.15 Survival aspects

1.15.1 Give a brief description of the search andrescue activities. When applicable, include informationregarding the serviceability and effectiveness of theemergency locator transmitters.

1.15.2 The location of crew members and passengersin relation to injuries sustained should be stated. The failure

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APPENDIX G1

of structures, such as seats, seat belts and overhead binsshould be described. Also, the use and effectiveness ofsafety equipment should be reported. Aspects pertinent tothe crashworthiness of the aircraft should be addressed, aswell as occupant survivability in relation to impact forcesand fire.

1.15.3 If an evacuation was conducted, a descriptionof the following information is usually included:

— first notification of an accident to the emergencyservices and the response time;

— emergency lighting in the aircraft (installation,activation, functioning and failures);

— communications;

— passenger behaviour and carry-on baggage;

— emergency exits (types of exits and their use);

— evacuation slides (types of slides, activation andtheir use);

— injuries sustained in the evacuation; and

— post-evacuation events.

1.16 Tests and research

1.16.1 Describe the results of any tests and researchundertaken in connection with the investigation. Flighttests, simulator tests and computer modelling of aircraftperformance are examples of the type of information thatshould be included in this section. Relevant details ofresearch that is used to support the analysis should also beincluded.

1.16.2 The results of examinations of aircraft andengine parts may alternatively be included in Sections 1.6— Aircraft information, 1.12 — Wreckage and impactinformation or 1.16.

1.17 Organizational and management information

1.17.1 When relevant to the accident, providepertinent information on any organization and its manage-ment whose activities may have directly or indirectlyinfluenced the operation of the aircraft. The organizationsto be addressed in this section could include:

— operator;

— maintenance organizations;

— air traffic services;

— aerodrome administration;

— meteorological services;

— aircraft manufacturer;

— certification and licensing authority; and

— regulatory authority.

1.17.2 When deficiencies in the organizationalstructure and functions had a bearing on the accident, theinformation could include, but need not be limited to, thefollowing factors:

— safety culture;

— resources and financial viability;

— management policies and practices;

— internal and external communications; and

— certification, safety oversight and regulatoryframework.

1.17.3 When relevant, provide pertinent informationconcerning the operator, such as type and date of issuanceof the air operator certificate, types of operationsauthorized, types and number of aircraft authorized for use,and authorized areas of operation and routes. Also, includeinformation concerning any deficiencies found in theoperator’s company operations manual and other operatordocumentation, when the deficiencies had a bearing on theaccident.

1.18 Additional information

1.18.1 Give relevant information and facts, notalready included in Sections 1.1 to 1.17, which are essentialto the development of the analysis and conclusions parts ofthe Final Report.

Note.— Ensure that the factual information part of theFinal Report contains all the technical data which isessential to the analysis and conclusions parts of the report.

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1.19 Useful or effective investigation techniques

1.19.1 When useful or effective investigationtechniques have been used during the investigation, brieflydescribe the main features of these techniques and theirpertinence to future investigations. However, the data andthe results obtained as they relate to the accident, should beincluded under the appropriate Sections 1.1 to 1.18. Thefull report on the use of these techniques may be includedas an appendix to the Final Report.

2. ANALYSIS

2.1 In the analysis part of the Final Report, thesignificance of the relevant facts and circumstances whichwere presented in the factual information part should bediscussed and analysed in order to determine which eventscontributed to the accident. There might be a necessity torepeat the description of some of the evidence alreadypresented in the factual information part, however, theanalysis should not be a restatement of the facts. Also, nonew facts should be introduced in the analysis part. Thepurpose of the analysis is to provide a logical link betweenthe factual information and the conclusions that provide theanswer to why the accident occurred.

2.2 The analysis part should contain an evaluation ofthe evidence presented in the factual information part andshould discuss the circumstances and events that existed ormay have existed. The reasoning must be logical and maylead to the formulation of hypotheses which are thendiscussed and tested against the evidence. Any hypothesiswhich is not supported by the evidence should beeliminated; it is then important to clearly state the reasonswhy a particular hypothesis was rejected. When ahypothesis is not based on fact but is an expression ofopinion, this should be clearly indicated. As well, thejustification for sustaining the validity of a hypothesisshould be stated and reference should be made to thesupporting evidence. Contradictory evidence must be dealtwith openly and effectively. Cause-related conditions andevents should be identified and discussed. The discussionin the analysis should support the findings and theimmediate and systemic causes of the accident.

2.3 Also, discuss and analyse any issue that came tolight during the investigation which was identified as asafety deficiency, although such issue may not havecontributed to the accident.

2.4 Because the Final Report is often drafted as theinvestigation progresses and several investigators (all the

groups in a major investigation) will contribute to theanalysis part of the report, the development of an outlineand sub-headings for the analysis part will ensure that theinvestigators know their drafting assignments. Such anoutline will also indicate to the investigators how the sub-headings will come together in forming the analysis part ofthe Final Report. An example of such an outline is providedin Table 1-2.

3. CONCLUSIONS

This part should list the findings and the causes establishedin the investigation. The conclusions are drawn from theanalysis. However, it is essential to maintain the samedegree of certainty in a conclusion as was established in theanalysis. For example, if the discussion in the analysisindicates that an event or circumstance was likely, then thefinding should contain the same qualifier (likely).

3.1 Findings

3.1.1 The findings are statements of all significantconditions, events or circumstances in the accidentsequence. The findings are significant steps in the accidentsequence, but they are not always causal or indicatedeficiencies. Some findings point out the conditions thatpre-existed the accident sequence, but they are usuallyessential to the understanding of the occurrence. Thefindings should be listed in a logical sequence, usually in achronological order.

3.1.2 All findings must be supported by and directlyrelated to the factual information and the analysis. No newfactual information should be introduced in the findings.

3.1.3 It is customary to report on certain conditions inevery investigation, such as the validity of licences, thetraining and experience of the flight crew members, theairworthiness and maintenance of the aircraft, the loadingof the aircraft, and whether there was a pre-impact failure.The following findings are typical of what is usuallyincluded:

— The flight crew members were licensed andqualified for the flight in accordance with existingregulations;

— The maintenance records indicated that the aircraftwas equipped and maintained in accordance withexisting regulations and approved procedures;

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Table 1-2. Example outline for the analysis part

EXAMPLE OF SUB-HEADINGS IN THE ANALYSIS PART

An aircraft impacts the ground short of the runway during an instrument approach in marginal weather. Some of theoccupants are killed or injured. Based on these few facts, the investigator-in-charge can identify many of the areas tobe investigated and analysed. At an early stage of the investigation, the investigator-in-charge is able to allocatedrafting assignments to the investigators for tentative sub-headings in the analysis part, as follows:

2.1 General

2.2 Flight operations

2.2.1 Crew qualifications2.2.2 Operational procedures2.2.3 Weather2.2.4 Air traffic control2.2.5 Communications2.2.6 Aids to navigation2.2.7 Aerodrome

2.3 Aircraft

2.3.1 Aircraft maintenance2.3.2 Aircraft performance2.3.3 Mass and balance2.3.4 Aircraft instrumentation2.3.5 Aircraft systems

2.4 Human Factors

2.4.1 Psychological and physiological factors affecting the personnel involved

2.5 Survivability

2.5.1 Rescue fire service response2.5.2 Analysis of injuries and fatalities2.5.3 Survival aspects

The tentative sub-headings in the analysis part may require adjustments as the investigation progresses, but the listidentifies the major areas that should be covered in the analysis. The list is a good starting point as it indicates to theinvestigators where each drafting assignment for the sub-headings will fit into the analysis part as a whole.

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— The mass and centre of gravity of the aircraft werewithin the prescribed limits; and

— There was no evidence of airframe failure or systemmalfunction prior to the accident.

3.1.4 Significant events and factors that wereinvestigated in detail, but eliminated in the analysis, shouldalso be stated in the findings. For example, findings such as“flight crew fatigue was not a factor in the accident” and“there was no malfunction of the elevator control system”should be considered when a comprehensive investigationwas made into these aspects. Areas of ambiguity should beidentified and stated, for example, “the investigation wasunable to establish whether the pilot-in-command or the co-pilot was the pilot flying the aircraft at the time of theaccident”.

3.1.5 Some States present the causes of the accidentseparately from the findings under their own heading.Other States indicate in the list of findings which of thefindings were causes of the accident, for example by addingafter such a finding “(causal factor)” or “(contributoryfactor)”.

3.1.6 Examples of frequently used findings inaccident reports are listed in Appendix 5 to Chapter 1.

3.2 Causes

3.2.1 Causes are those events which alone, or incombination with others, resulted in injuries or damage. Acause is an act, omission, condition or circumstance whichif eliminated or avoided would have prevented theoccurrence or would have mitigated the resulting injuries ordamage.

3.2.2 The determination of causes should be based ona thorough, impartial and objective analysis of all theavailable evidence. Any condition, act or circumstance thatwas a causal factor in the accident should be clearlyidentified. Seen together, the causes should present apicture of all the reasons why the accident occurred. The listof causes should include both the immediate causes and thedeeper or systemic causes. No new information should beintroduced in the causes. The causes should be presented ina logical order, usually chronological order, bearing inmind that it is essential that all the causes be presented. Thecauses should be formulated with preventive action in mindand linked to appropriate safety recommendations.

3.2.3 Some States list the causes, usually sequentiallyas they occurred, without attempting to prioritize thecauses. Other States would prioritize the causes by usingterms such as primary causes and contributing causes.

3.2.4 When certain of a cause, a definite statementshould be used; if reasonably sure of a cause, a qualifyingword such as “probable” or “likely” should be used. Thecauses statement is usually a reiteration of statements madeat or near the end of the analysis and in the findings. Forexample, if the analysis and the findings state that a cause-related event or circumstance was “probable”, then thecauses statement should contain the same qualifier(probable).

3.2.5 When there is insufficient evidence to establishwhy an accident occurred, there should be no hesitation instating that the causes remain undetermined. In manyinstances, the most likely scenario could be stated providedthat a qualifier, such as “likely” or “probable” is included.However, a list of possible causes should not be given.

3.2.6 The causes should be formulated in a waywhich, as much as practicable, minimizes the implication ofblame or liability. Nevertheless, the accident investigationauthority should not refrain from reporting a cause merelybecause blame or liability might be inferred from thestatement of that cause. An example of a formulation of thecauses is given in Table 1-3.

4. SAFETY RECOMMENDATIONS

4.1 In accordance with Annex 13, the sole objectiveof the investigation of an accident shall be the preventionof accidents and incidents. Therefore, the determination ofappropriate safety recommendations is of utmostimportance. The safety recommendations are actions whichshould prevent other accidents from similar causes orreduce the consequences of such accidents. In order toensure that appropriate action is taken, each safetyrecommendation should include a specific addressee. Thisis usually the appropriate authority of the State which hasresponsibility for the matters with which the safetyrecommendation is concerned.

4.2 Annex 13 requires that at any stage of theinvestigation of an accident, the accident investigationauthority of the State conducting the investigation shallrecommend to the appropriate authorities, including thosein other States, any preventive action that is considerednecessary to be taken promptly to enhance aviation safety.The interim safety recommendations made during the

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Table 1-3. Example of causal statements

EXAMPLE OF FORMULATION OF CAUSES

One accident — same causes

The causes of this accident were: The causes of this accident were:

• the failure of airport management to identify andcorrect poor runway drainage;

• the known and uncorrected lack of runway drainage;

• the failure of the air traffic controllers to informthe flight crew that there was standing water on therunway;

• lack of communication between the ATC and theflight crew regarding the degenerated runwaycondition;

• the flight crew’s mismanagement of the aircraft’sairspeed; and

• the aircraft crossing the threshold 16 knots aboveVref; and

• the flight crew’s mismanagement of thrustreversers.

• the late application of reverse thrust.

Note. — The causal statement to the left implicates three groups of persons -— the flight crew, the airportmanagement and the air traffic controllers. Since the formulation of causes should not be blame-setting in nature,the statement on causation should focus on functions that in the example case were not performed at the level requiredfor safe operation. Such a functional statement logically leads to corrective or preventive measures that should berecommended to prevent future accidents.

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investigation may be presented in the safetyrecommendations part of the Final Report. Also, thepreventive actions taken in response to the interimrecommendations should be presented, as well as any otherpreventive actions taken by the appropriate authorities andthe industry, such as changed operating procedures by theaircraft operator and the issuance of service bulletins by themanufacturer. Some States present the interim safetyrecommendations and describe the preventive actions takenin the factual information part, Section 1.18, in lieu ofincluding this information in the safety recommendationspart. Publishing the preventive actions taken in the FinalReport has significant accident prevention value for thoseinvolved in similar operations.

4.3 A safety recommendation should describe thesafety problem and provide justification for safety actions.An example of a recommendation is given in Table 1-4.Attention should be focussed on the problem rather than thesuggested solution. Consideration should be given towhether a safety recommendation should prescribe aspecific solution to a problem or whether therecommendation should be flexible enough to allow theaddressee latitude in determining how the objective of therecommendation can be achieved. A safety recommen-dation should identify what actions to take, but leave scope

for the authorities responsible for the matters in question todetermine how to accomplish the objective of therecommendation. This is particularly important if all thesalient facts are not available and additional examination,research and testing appears necessary. In addition, theaccident investigation authority may lack the detailedinformation and experience required to evaluate thefinancial, operational and policy impacts on the addresseeof specific and detailed recommendations.

4.4 During aircraft accident investigations, safetyissues are often identified which did not contribute to theaccident but which, nevertheless, are safety deficiencies.These safety deficiencies should be addressed in the FinalReport. Some States include safety recommendations notrelated to the causes of the accident in the safetyrecommendations part of the Final Report. Other Stateshave adopted means other than the Final Report to notifythe appropriate authorities of safety deficiencies that are notrelated to the accident, although the actions taken areusually described in the Final Report.

4.5 In summary, the safety recommendations shouldinclude a convincing presentation of the safety problem withthe attendant safety risks deriving from it, as well as arecommended course of action for the responsible authority

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to take in order to eliminate the unsafe condition. The safetyrecommendations should identify what action is required, butshould leave considerable scope for the implementingauthority to determine how the problem will be resolved.

APPENDICES

The appendices should include, as appropriate, anypertinent information considered necessary to understandthe report, such as a glossary, supporting technical reports,accident site diagrams, photographs and flight recorderdata. Graphics and diagrams should have a professional

appearance and should show only the information requiredfor understanding the report. The appendices should benumbered and listed in the table of contents. The followingis a list of appendices commonly found in a Final Report:

— communications transcripts;— flight data recorder readouts;— flight plan and loadsheet;— technical investigation reports;— pertinent pages from manuals and handbooks;— pertinent maintenance records;— maps and diagrams; and— photographs.

Table 1-4. Example of a safety recommendation

EXAMPLE OF THE WORDING OF A SAFETY RECOMMENDATION

Consider the following safety recommendation:

“ICAO should establish a working group to clarify the international Standards and Recommended Practices inAnnex 14 regarding the marking of runway centrelines in relation to co-located threshold markings and turn-around areas.”

In accordance with the guidance above, the addressee (in this example ICAO) should be given sufficient latitudein determining how to achieve the objective of the recommendation. It should be left to ICAO to determine howthe work is to be undertaken, e.g. working group, consultant or panel. A general statement, such as “internationalrequirements” could also be used, thus leaving it to ICAO to determine whether Standards, RecommendedPractices and/or guidance material would be appropriate to meet the objective of the recommendation. Based onthe foregoing reasoning, the following formulation of the safety recommendation would be preferable:

“The (accident investigation authority) recommends that ICAO re-examine the international requirements inAnnex 14 regarding the marking of runway centrelines in relation to co-located threshold markings and turn-around areas.”

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APPENDIX ‘K’

FORMAT OF LETTER (on letter head) TO BE GIVEN TO ACCREDITED

REPERSENTATIVES, ADVISERS, EXPERTS, OBSERVERS ETC.

(TO WHOM SO EVER IT MAY CONCERN)

Subject: ACCIDENT / SERIOUS INCIDENT TO AIRCRAFT

OPERATED BY ON AT .

Shri/ Capt. is an accredited representative/ adviser/ observer/ expert for

the subject accident/ serious incident and will have the following powers (*) during the

conduct of investigation:


Examine the wreckage

Obtain witness information and suggest areas of questioning

Have full access to all relevant evidence as soon as possible

Receive copies of all pertinent documents

Participate in read-outs of recorded media

Participate in off-scene investigative activities such as component

examinations, technical briefings, tests and simulations

Participate in investigation progress meetings including deliberations

related to analyses, findings, causes and safety recommendations.

Make submissions in respect of the various elements of the investigation.

He/ She may be permitted to carry out the above functions.

(B. S. Rai)

DDG

(*) Delete whichever is not applicable