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a year or as and when any information in this manual is incorrect, inconsistent or outdated.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

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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

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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

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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

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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;

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(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.

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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 opsctrl@aai.aero
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;

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(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;

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(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.

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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.

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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’

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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.

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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.

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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.

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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.

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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.

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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.

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Investigation Occurrence type/ details
type
Formal A major catastrophic accident involving fatalities will be formally
Investigation 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 In case the occurrence and investigation requires lot of onsite
Group activity, wherein CoI is immediately ordered. The CoI may be
Investigation) 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

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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:

 Visit the scene of the accident


 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.

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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.

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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

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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.

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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.

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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;

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b) the State of the Operator;
c) the State of Design;
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.

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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
c) the State of Design;
d) the State of Manufacture;
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.

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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
c) the State of Design;
d) the State of Manufacture;
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

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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.

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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.

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 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.

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ORGANISATION STRUCTURE

HEAD
AAIB
Jt. GM

DDAS (ID) DDAED (TD) Jt GM (PD) ADAS (ALD)

ASO
ASO ASO
ID - Investigation Division

TD - Technical Division

PD - Prevention Division
HEAD ALD - Administrative & logistics
AAIB . Division

REGIONS

DELHI REGION CHENNAI REGION MUMBAI REGION


AIRCRAFT ACCIDENT INVESTIGATION BUREAU

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
4. Establish and maintain an accident/incident
database.
5. Follow-up of official E-mail for reporting of
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.
4. Establish and maintain an accident/incident
database.
5. Follow-up of official E-mail for reporting of
occurrences.

7 DDAED 1. Preliminary Investigation


2. investigation of Serious Incident/ Accident.
3. Can be made member of Committee of Inquiry
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


for Investigation of Serious Incident/ Accident.
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).


2. Can be made member of Committee of Inquiry
for Investigation of Serious Incident/ Accident.

10 ASO 1. Preliminary Investigation (Western Region).

ADAS 1. Preliminary Investigation (Northern Region).


2. Can be made member of Committee of Inquiry
for Investigation of Serious Incident/ Accident.
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 asok.kumar@nic.in 011 24617692
Kumar, JS, MoCA
2. Ms. Puja Jindal. Pujajindal.moca@nic.in 09968277301
Dir. MoCA
3. Shri. B. S. Rai, bsrai.dgca@nic.in 09871935864
AAIB
4. Shri. R. S. Passi, rsp.dgca@nic.in 09868206370
AAIB
5. Shri. N. S. Dagar, nsdagar@aai.aero 09811385422
AAIB
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: State of Registry 4.1
All aircraft State of the Operator
State of Design
State of Manufacture
ICAO (when aircraft
over 2 250 kg)
State of Registry Domestic and other occurrences: State of the Operator 4.7
Aircraft over 2 250 kg State of Design
State of Manufacture
ICAO
State of Registry Domestic and other occurrences: Same as above, 4.7.1
Aircraft of 2 250 kg or less except ICAO

2. ACCIDENT REPORTING

Accidents wherever they occurred

From Type of report Concerning Send to Annex 13


reference
State conducting PRELIMINARY Aircraft over 2 250 kg State of Registry or 6.1
the REPORT State of Occurrence
investigation State of the Operator
State of Design
State of Manufacture
State providing information,
significant facilities or experts
ICAO
Aircraft of 2 250 kg or Same as above, except ICAO 6.2
less
if airworthiness or
matters
of interest
ACCIDENT Aircraft over 2 250 kg ICAO 6.6
DATA REPORT
FINAL REPORT All aircraft State instituting the 6.10
investigation
State of Registry
State of the Operator
State of Design
State of Manufacture 6.12
State having interest
because of fatalities
State providing information,
significant facilities or experts
ICAO

3. INCIDENT REPORTING

Incidents wherever they occurred (when investigated)

From Type of report Concerning Send to Annex 13


reference
State conducting the INCIDENT Aircraft over 5 700 kg, if ICAO 6.7
investigation DATA REPORT matters of interest to other
States are involved
INCIDENT All aircraft, if matters of Interested States 6.14
INFORMATION interest to other States are
involved
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 Name:
contact information of Title:
person/organization Organization:
submitting notification: Address:

Telephone:
Email:
a) for accidents the identifying abbreviation ACCID INCID Incident
ACCID, for serious incidents INCID; (Accident) (Serious 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 (dd/mm/yy) (dd/mm/yy)


accident or serious incident; local date: / / UTC date: / /
local time: 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 Persons on board _________crew _________pax
and seriously injured; others, killed and Fatal _________crew _________pax _________others
seriously injured; 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 No Yes - If yes, UN #________________________


on board the aircraft.
Operation Type Commercial Aviation Schedule Passenger
(If information is available)
General Aviation Non-Scheduled Cargo
Level of damage to aircraft Destroyed Substantial
(If information is available)
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.
APPENDIX ‘D’

ADDRESSES OF ACCIDENT INVESTIGATION


AUTHORITIES
AFGHANISTAN ALBANIA
President of Civil Aviation Operations Ministry of Public Works, Transport and
Ministry of Civil Aviation and Tourism Telecommunication
Ansari Watt, P.O. Box 165 Directorate General of Civil Aviation
Kabul Rruga Muhamet Gjollesha – Parku 1 Delegacioneve
Afghanistan Pob 205, Tirana
Tel.: (873) 68 2341450 / 49 Albania
Fax: (873) 68 1280784 Tel.: (355) 42-251220
AFTN: OAKBYAYX (355) 68 212 1493 (outside office hours)
Cable: CIVAVIA Kabul (355) 42 343487 (24 hours)
E-mail: genci.resuli@dgca.gov.al
Fax: (355) 42-226232
SITA: TIATNXS
AFTN: LATIYFYX
Telex: 2124 ASTRAN AB

ALGERIA ANDORRA
Ministère des transports National Civil Aviation Administration
Direction de l’Aviation civile et de la météorologie Département des Transports et de l’Énergie
119, rue Didouche Mourad Ministère de l’Économie
Alger Carrer Prat de la Creu, 62-64
Algérie Andorra la Vella
Tel.: (213) 2 74 06 81 (standard) Andorra
(213) 2 74 76 30 (ligne Directeur directe) Tel.: (376) 875 700
Fax: (213) 2 74 76 14 Fax: (376) 861 519
(213) 2 74 76 24
RSFTA: DAALYAYA
SITA: ALGMTCR
Telex: 66 129
ANGOLA ANTIGUA AND BARBUDA
Direcçao Nacional de Aviação Civil See Eastern Caribbean States
Rua Miguel de Melo No. 96, 6° Andar ARGENTINA
Caixa Postal 569 Junta de Investigaciones de Accidentes de Aviación Civil
Luanda (JIAAC)
Angola Avenida Belgrano 1370 – Piso 11
Tel.: (244) 9232-49760 (Director General) C1093AAO, Cuidad Autónoma de Buenos Aires
(244) 9199-11200 / 9299-87740 (24 hours) Argentina
Fax: (244) 2 39 05 29 Tel.: (54) 11 4382-8890 / 91
AFTN: FNLUYAYX E-mail: info@jiaac.gov.ar
Telex: 4118 DNAC AN Tel./Fax: (54) 11 4317-6704 / 5
Cable: AERONAUTICA Luanda (54) 11 4381-6333 (24 hours)
AFTN: SABAYAYX
Website: www.jiaac.gov.ar

ARMENIA ARUBA1
Flight Safety Inspection Department Department of Civil Aviation
General Department of Civil Aviation Sabana Berde 73-B
Airport ―Zvartnots‖ Oranjestad
Yerevan-0042 Aruba
Armenia Tel.: (297) 832665 General

1
Tel.: (374) 10 593 005 (297) 824330 (ext. 258)
Tel./Fax: (374) 10 283 429 (24 hours) (297) 562-4040 (24 hours / 7 days mobile)
E-mail: fsid@aviation.am E-mail: dca-aua@setarnet.aw
Fax: (374) 10 285 345 Fax: (297) 823038
AFTN: UDDUYLYX AFTN: TNCAYAYX
Cable: CIVILAIR ARUBA

AUSTRALIA AUSTRIA
Australian Transport Safety Bureau (ATSB) Federal Office of Transport
P.O. Box 967, Civic Square Accident Investigation Branch / Dept. Aviation
Canberra A.C.T. 2608 P.O. Box 207
Australia Lohnergasse 9/4
Tel.: (61) 2 6257-4150 (24/7 Notifications) A-1210 Vienna
(61) 2 6274-6464 (International liaison) Austria
E-mail: atsbasir@atsb.gov.au (Notifications) Tel.: (43) 1 27760-7700 (24 hours)
atsbinfo@atsb.gov.au (International liaison) E-mail: fus@bmvit.gv.at
Fax: (61) 2 6274-6434 (Notifications) Fax: (43) 1 27760-9299
(61) 2 6274-6474 (International liaison) Telex: 232 322 1155
Website: http://www.atsb.gov.au Cable: 232 322 1155
Website: http://versa.bmvit.gv.at
AZERBAIJAN BAHAMAS
State Concern of Civil Aviation Accident Investigation Department
Azadlyg, Prospect 11 Contact: Manager, Flight Standards Inspectorate
37000 Baku P.O. Box N-975
Azerbaijan Nassau-New Providence
Tel.: 994 12 93 44 34 Bahamas
Fax: 994 12 98 52 37 Tel.: (242) 377 3445
SITA: UBBZZJ2 (242) 376 7909 (24 hours / 7 days)
AFTN: UBBUDDXX E-mail: hadderley.fsi@gmail.com
dmajor.fsi@gmail.com
Fax: (242) 377 6060
AFTN: MYNNYAYX
Telex: BS109 CADAIR BS
Cable: CADAIR- BAHAMAS

BAHRAIN BANGLADESH
Assistant Undersecretary for Civil Aviation Civil Aviation Authority
Ministry of Transportation Flight Safety
Bahrain International Airport Kurmitola
P.O. Box 586 Dhaka 1206
Bahrain Bangladesh
Tel.: (973) 32 3000 / 1000 Tel.: (880) 2 891122
Fax: (973) 32 5757 Fax: (880) 2 893322
SITA: BAH APYF AFTN: VGHQYA
AFTN: OBBI YAYX Telex: 632210 CCAAB BJ
Telex: 9186 Cable: CIVILAIR Dhaka

BARBADOS BELARUS
Technical Director — Aviation State Aviation Committee
Air Traffic Services Building Civil Aviation Department
Grantley Adams International Airport 4 Ulitsa Aerodomnaya
Christ Church 220065 Minsk
Barbados Belarus
Tel.: (246) 428-09309 Tel.: (375) 172 225 392
Fax: (246) 428-2539 Fax: (375) 172 227 728
AFTN: TBPBYAYX AFTN: UMMDMAXX
Cable: CIVILAV BARBADOS Cable: MSQDSB2
2
BELGIUM BELIZE
Bureau Enquêtes — Accidents Civil Aviation Department
Service Public Fédéral Mobilité and Transports Belize International Airport
Centre Communications Nord —2ème étage P.O. Box 367
Rue du Progrès, 80 — Bte 5 Belize City
1030 Bruxelles Belize
Belgique Tel.: (501) 25 2052 / 2014
Tel.: (32) 2 277-4423 Fax: (501) 25 2533
(32) 476 761-865 (24 hours) AFTN: MZBZYAYX
E-mail: luc.blendeman@mobilit.fgov.be Cable: CIVILAIR Belize
Fax: (32) 2 277-4260
Website: http://www.mobilit.fgov.be

BENIN BERMUDA1
Direction de l’Aéronautique Civile The Director of Civil Aviation
B.P. 305 Department of Civil Aviation
Cotonou 2 Kindley Field Road
Benin St. George, GE CX
Tel.: (229) 30 10 98 / 99 Bermuda
AFTN: DBBBYAYX Tel.: (441) 293 1640
Cable: AEROCIVIL Cotonou Fax: (441) 293 2417
AFTN: TXKFYAYX
Telex: 02903248 AVCIV BA
Cable: AVCIV Bermuda

BHUTAN BOLIVIA
The Director Ministerio de Obras Públicas, Servicios y Vivienda
Civil Aviation Division Viceministerio de Transportes
Ministry of Communication Dirección General de Aeronáutica Civil
Royal Government of Bhutan Palacio de Comunicaciones
P.O. Box 291, Thimphu Av. Mcal. Santa Cruz No. 1278
Bhutan 4° Piso
Tel.: (975) 2 22499 La Paz
Fax: (975) 2 223639 / 22987 Bolivia
Cable: DIRCEVAVIATION Thimphu Tel.: (591) 3 339-5323 / 339-5331 (Santa Cruz)
(591) 2 211-5519 (La Paz)
E-mail: dgacbol@entelnet.bo
Fax: (591) 3 339-5331
AFTN: SLLPYAYX
Cable: AEROCIVIL La Paz
Website: www.dgac.gov.bo

BOSNIA AND HERZEGOVINA BOTSWANA


Directorate of Civil Aviation – BDDCA The Director
Fehima efendije Čurčića 671000 Sarajevo Department of Civil Aviation
Bosnia and Herzegovina P.O. Box 250
Tel.: (387) 33 251 350 Gaborone
E-mail: occurrence@bhdca.gov.ba Botswana
Fax: (387) 33 251 351 Tel.: (267) 365 5200 / (267) 312 062
AFTN: LQBHYLYX E-mail: tmeshesha@gov.bw
Fax: (267) 353 709 / (267) 303 348
AFTN: FBHQYAYX
Cable: AVIATION GABORONE

BRAZIL BRUNEI DARUSSALAM


Centro de Investigaçáo e Prevençáo de Acidentes Director of Civil Aviation
3
Aeronauticos — CENIPA Ministry of Communications
SHIS — QI 05 — Área Especial 12 Brunei International Airport
LAGO SUL Bandar Seri Begawan BB2513
Brasilia — DF — CEP 71615-600 Brunei Darussalam
Brasil Tel.: (673) 2-330 142
Tel.: (55) 61 3365 1008 / (55) 61 3364 8800 E-mail: dca@pso.brunet.bn
E-mail: notifica@cenipa.aer.mil.br Fax: (673) 2-331 706
Fax: (55) 61 3365 1004 AFTN: WBSBYAYX
AFTN: SBBRYLYX Telex: 2267 DCA BU
Telex: 0611152 CENIPA SBBR Cable: CIVILAIR BRUNEI
Website: http://www.cenipa.aer.mil.br

BULGARIA BURKINA FASO


Aircraft Accident Investigation Unit Direction de l’Aviation Civile
9, Diakon Ignattii Street B.P. 1158
Sofia 1000 Ouagadougou 01
Bulgaria Burkina Faso
Tel.: (359) 2 940 98 63 Tel.: (226) 30 64 88 / (226) 31 63 32
E-mail: nkostov@caa.bg Fax: (226) 31 45 44
Fax: (359) 2 988 57 50 AFTN: DFFVYAYX
SITA: SOFTOYA
AFTN: LBSFYAYX
Telex: 22640 AVINS BG
Cable: AVINS Sofia

BURUNDI CAMBODIA
Directeur de la Régie des Services Aéronautiques State Secretariat of Civil Aviation
B.P. 694 62 Preach Norodom Blvd.
Bujumbura Phnom Penh
Burundi Cambodia
Tel.: (257) 22.3707 / (257) 21.8656 Tel.: (855) 12 810-330 / 878-192 / 456-443 (24 hours)
Fax: (257) 22.3428 Fax: (855) 23 223-511
AFTN: HBBAYAX SITA: PNHVAYA
Telex: 5190 AERO BDI AFTN: VDPPYAYX
Cable: MINITPTBU-BUJUMBURA Cable: DACK Phnom Penh

CAMEROON CANADA
Direction de l’Aviation Civile Transportation Safety Board of Canada
Yaoundé 200 Promenade du Portage
Cameroun Place du Centre, 4th Floor
Tel.: (237) 30 3090 Hull, Quebec K1A 1K8
Fax: (237) 30 3362 Canada
AFTN: FKKYYAYX Tel.: (1) 819-994-4252
Telex: 8214 KN (1) 819-997-7887 (24 hour)
Cable: Aérocivile Yaounde E-mail: airops@tsb.gc.ca
Fax: (1) 819-953-9586
Website: http://www.tsb.gc.ca

CAPE VERDE CAYMAN ISLANDS1


Agencia de Aviação Civil – AAC Director of Civil Aviation
Av. Cidade de Lisboa, no. 34 CP 371 P.O. Box 277G
Cidade da Prala George Town
Ilha de Santiago Grand Cayman
Cabo Verde West Indies
Tel.: (238) 2 603430 Tel.: (1) 345 949-7811
(238) 989-9491 / 993-8396 (24 hours) Fax: (1) 345 949-0761
E-mail: dgeral@acivil.gov.cv AFTN: MWCRYAYX
4
Fax: (238) 2 611075 Telex: 4458 CIVAV CP

CENTRAL AFRICAN REPUBLIC CHAD


Direction Générale de l’Aviation Civile et de la Direction de l’Aviation Civile
Météorologie B.P. 96
B.P. 941 et 224 N’Djaména
Bangui Tchad
Tel.: (235) 516 231
République Centrafricaine AFTN: FTTVYAYX
Tel.: (236) 61 53 16
Fax: (236) 61 49 18
AFTN: FEFVYAYX

Telex: 5209 RC
Cable: MINITRANS-BANGUI

CHILE CHINA
Dirección General de Aeronáutica Civil General Administration of Civil Aviation of China
Miguel Claro 1314 155 Dongsi Street West
Providencia, Santiago Beijing 100710
Chile China
Tel.: (56) 2 439-2376 Tel.: (86) 10 6409-1908 (business hours)
(56) 2 09 138-9949 (Director’s mobile) (86) 10 6401-2907 (24 hours / 7 days)
(56) 2 439-2224 / 2550 (24 hours) E-mail: yf_mao@caac.gov.cn
E-mail: dir.dpa@dgac.cl / ccam@dgac.cl Fax: (86) 10 6405-2829
Fax: (56) 2 436-8142 AFTN: ZBBBYAYX
AFTN: SCSCYAYX Telex: 22101 CAXT CN
Telex: 490532 DAITA CL Cable: 22101 CAXTCN

CHINA, MACAO SPECIAL ADMINISTRATIVE COLOMBIA


REGION Grupo Investigación de Accidentes
Civil Aviation Authority Unidad Administrativa Especial de Aeronáutica Civil
Alameda Dr. Carlos D’Assumpção, 336-342 Avenida El Dorado #103 -23
Centro Comercial Cheng Feng, 18˚ andar Oficina 204
Macau Bogotá, D.C.
China Colombia
Tel.: (853) 2851-1213 Tel.: (57) 1 266-3068
(853) 6232 2999 (24 hours) (57) 1 350-554-8381 / 0958 (24 hours mobile)
E-mail: aacm@aacm.gov.mo E-mail: investigació n.accide@aerocivil.gov.co
Fax: (853) 2833-8089 Fax: (57) 1 266-3940
AFTN: VMMCYAYI AFTN: SKBOYAYX
Website: www.aacm.gov.mo Telex: 044620 DAAC CO
COMOROS CONGO
Direction Générale de l’Aviation Civile et de la Direction Générale de l’Agence Nationale de l’Aviation
Météorologie civile
B.P. 72 B.P. 128
Moroni Brazzaville
Comores Congo
Tel.: (269) 744 245 / 730 447 Tel.: (242) 82 40 90
E-mail: dgacm@snpt.kn (242) 82 80 61
Fax: (269) 731 030 / 735 063 Fax: (242) 82 40 90
AFTN: FMCNYAYX AFTN: FCBVYAYX
Telex: K0241 PUBLICKO Telex: 5388 KG

COOK ISLANDS COSTA RICA


Department of Civil Aviation Dirección General de Aviación Civil

5
P.O. Box 61 Ministerio de Obras Públicas y Transporte
Rarotonga Sección AIG
Cook Islands Apartado Postal 5026-100
Tel.: (682) 22 810 San José
Fax: (682) 28 816 Costa Rica
AFTN: NCRGYAYX Tel./Fax: (506) 290 0664 (Attn.: R. G. Gamboa Sandoval)
Telex: 62052 AVARUA E-mail: concorde@sol.racsa.co.cr
SITA: SJOTOYA
AFTN: MRSJYAYX
Telex: 2926 DGAC

CÔTE D’IVOIRE CROATIA


Agence Nationale de l’Aviation Civile (ANAC) Agency for Aircraft Accident and Serious Incident
07 B.P. 148 Investigation
Abidjan 07 Prisavlje 14
Côte d’Ivoire 10000 Zagreb
Tel.: (225) 27 74 24 / (225) 27 90 04 Croatia
Fax: (225) 27 63 46 Tel.: (385) 1 616-9168
AFTN: DIAVYAYX E-mail: dinko.vodanovic@caacro.hr
Telex: 43452 ANAM CI Fax: (385) 1 616-9068
AFTN: LDZGYAYX

CUBA CYPRUS
Dirección de Seguridad Aeronáutica y Operaciones Air Accident and Incident Investigation Board
Instituto de Aeronáutica Civil de Cuba Alpha Building
Calle 23, No. 64 Vedado Block A – 1st floor
Ciudad de la Habana 4 Pindarou 27 Street
Cuba 10600 1060 Nicosia
Tel.: (53) 7 838-1115 Cyprus
(53) 7 838-1120 / 1132 (24 hours) Tel.: (357) 404166/3/4/5
E-mail: dsa@iacc.avianet.cu / (357) 9935 6060 / 9963-3500 / 9933-5492 (mobile)
pedro.colmenero@iacc.avianet.cu E-mail: aaiib@mcw.gov.cy
pm@iacc.avianet.cu (24 hours) corphanos@mcw.gov.cy
Fax: (53) 7 838-4575 SITA: NICTOYA
(53) 7 834-4553 (24 hours) AFTN: LCNCYAYX
SITA: HAVSACU Cable: 6055CIVAIR CY
AFTN: MULHYLYX
Telex: 511737 A CIV CU

CZECH REPUBLIC DEMOCRATIC PEOPLE’S REPUBLIC OF KOREA


Air Accidents Investigation Institute Director General
Director General Administration of Civil Aviation
Beranových 130 Sunan District
199 01 Prague 9 Pyongyang
Czech Republic Democratic People’s Republic of Korea
Tel.: (420) 225 115 426 Tel.: (850) 2 381 8108
(420) 724 300 800 (24 hours) Fax: (850 2) 381 4625
E-mail: INFO@uzpln.cz SITA: FNJEDJS
Fax: (420) 225 115 430 AFTN: ZKKKYAYX
Website: http://www.uzpln.cz Telex: 5471 JS KP
Cable: CIVILAIR Pyongyang

DEMOCRATIC REPUBLIC OF THE CONGO DENMARK


Direction de l’Aéronautique Civile Accident Investigation Board
Ministère des Transports et Communications Langebjergvaenget 21
Building Ontara, boulevard du 30 juin DK-4000 Roskilde
B.P. 3304 Denmark
6
Kinshasa/Gombe Tel.: (45) 38 71 10 66 (24 hours)
République démocratique du Congo E-mail: aaib@hcl.dk
Tel.: (243) 24 21710 Fax: (45) 38 71 92 31
Cable: CIVILAIR KINSHASA Website: http://www.aib.dk

DJIBOUTI DOMINICAN REPUBLIC


Direction de l’Aviation Civile et de la Météorologie Comisión Investigadora de Accidentes de Aviación
B.P. (204) 250 Junta de Aviación Civil
Djibouti Calle José Joaquín Pérez no. 104, Gazcue
République de Djibouti Santo Domingo
Tel.: (253) 340169 / 341647 República Dominicana
Fax: (253) 355975 Tel.: (1) 809 689-4167
AFTN: HFFFYAYX E-mail: ciaa.jac@gmail.com
Telex: 5871 PRESIDEN DJ Fax: (1) 809 221-8616
AFTN: MDCDYFYX
Cable: DIRACIV-SANTO DOMINGO

EASTERN CARIBBEAN STATES ECUADOR


Directorate of Civil Aviation of Eastern Caribbean States Junta Investigadora de Accidentes
P.O. Box 1130 Dirección General de Aviación Civil
Factory Road Seguridad de Vuelo
St. John’s Av. Colón E5-56 y Rábida
Antigua Quito
Tel.: (1) 809 462-0907 Ecuador
E-mail: oecs.dca@candw.ag Tel.: (593) 2-223-8981
Fax: (1) 809 462-4145 (593) 2-330-1497 (24 hours)
AFTN: TAPAYAYX (593) 9-350-5927 (Mobile)
Telex: 2089 CIVILAV AK E-mail: jaime_salazar@dgac.gov.ec
Website: http://www.oecs.org/DCA_WEBsite/ Fax: (593) 2-223-8981
contacting_the_dca.htm (593) 2-330-1534 (24 hours)
AFS: SEQUZXSM
Telex: 22710 DACUIO ED

EGYPT EL SALVADOR
Central Department of Aircraft Accident Investigation Autoridad de Aviación Civil
and Prevention Boulevard del Ejercito Nacional KM 9 1/2
Civil Aviation Authority Aeropuerto de Ilopango
Ministry of Transport and Communications San Salvador
P.O. Box 52, Cairo Airport Road El Salvador
Cairo Tel.: (503) 2295-0265 / (503) 2295-0406 / (503) 2295-
Egypt 0433 ext. 128
Tel.: (20) 2 634 9068 / (20) 2 666 850 (503) 7729-7690 (mobile 24 hours)
E-mail: egoca@idsc.gov.eg E-mail: accidentes_incidentes@aac.gob.sv
Fax: (20) 2 247 0351 Fax: (503) 2296-6349 / (503) 2295-0406
SITA: CAIXYYF AFTN: MSSSYAYX / MSSSYOYX
AFTN: HECAYAYX Cable: AEROCIVIL San Salvador
Cable: TYARAN-CAIRO

EQUATORIAL GUINEA ERITREA


Ministerio de Transportes y Comunicaciones Director General
Dirección General de Transportes y Aviación Civil Civil Aviation Authority
Calle Arallia, N˚ 22 Sematat Avenue Street No. 172
Malabo (Bioko-Norte) P.O. Box 252
República de Guinea Ecuatorial Asmara
Tel.: (240) 9 3231 / (240) 9 2062 Eritrea
Fax: (240) 9 3313 Tel. (291) 1 124335 (Director General)
AFTN: FGSL YD YX (291) 1 127250 (Air Navigation Division)
7
Telex: GE913101 PUBMBO PBX: (291) 1 123090 / 127222
Cable: DIRAVIACIVIL MALABO E-mail: asmcaya@sita.gmsmail.com
Fax: (291) 1 124334
SITA: ASMCAYA
AFTN: HHAAYAYX

ESTONIA ETHIOPIA
Ministry of Economic Affairs and Communications Civil Aviation Authority
Emergency Management Department P.O. Box 978
Harju 11 Addis Ababa
Tallinn 15072 Ethiopia
Estonia Tel.: (251) 1 610277 / 180359
Tel.: (372) 625-6313 E-mail: civilaviation@telecom.net.et
E-mail: aib@mkm.ee Fax: (251) 1 612533
Fax: (372) 631-3660 SITA: ADDYAYF
AFTN: ULTTYAYX AFTN: HAABYAYX
Telex: 21162 CIV AIR ET
Cable: CIVILAIR Addis Ababa

FIJI FINLAND
Civil Aviation Authority of Fiji Accident Investigation Board
Private Mail Bag Sörnäisten rantatie 33 C
Nap 0354 FIN-00580 Helsinki
Nadi Airport Finland
Fiji Tel.: (358) 9 1606 7643
Tel.: (679) 672 1555 E-mail: onnettomuustutkinta@om.fi
(679) 999 5201 (after hours) Fax: (358) 9 1606 7811
E-mail: info@caaf.org.fj / ce@caaf.org.fj AFTN: EFHKYAYX
Fax: (679) 672 1500 Telex: 12-1247 AVIA SF
Website: http://www.caafi.org.fj Website: http://www.onnettomuustutkinta.fi

FRANCE GABON
Bureau d’Enquêtes et d’Analyses pour la Secrétariat Général à l’Aviation Civile et Commerciale
Sécurité de l’Aviation civile B.P. 2.212
Bâtiment 153 Libreville
Aéroport du Bourget Gabon
93350 Le Bourget Tel.: (241) 76 38 95 / (241) 73 08 28
France Fax: (241) 73 08 25
Tel.: (33) 1 49 92 72 00 AFTN: FOOVYAYX
(33) 1 48 35 86 54 (Emergency 24 hours) Telex: 5352 GO
E-mail: permanence@bea-fr.org Cable: AVIACIVIL Libreville
Fax: (33) 1 49 92 72 03
AFTN: LFPSYLYX
Telex: 203591 F
Website: http://www.bea-fr.org

GAMBIA GEORGIA
Gambia Civil Aviation Authority Head of Air Transport Department
Banjul International Airport Ministry of Transport
Yundum, P.O. Box 285 28 Rustaveli Avenue
Banjul 380008 — Tbilisi
Gambia Georgia
Tel.: (220) 472831, 82167 / 71 Tel.: (995) 32 93 30 92
Fax: (220) 472190 Fax: (995) 32 98 96 30
AFTN: GBYDYAYX SITA: TBSDMSU
Telex: 2295 MINWOCOM GV AFTN: UGGUDD
Cable: CIVILAIR BJL
8
GERMANY GHANA
Federal Bureau of Aircraft Accidents Investigation The Director General
Hermann-Blenk-Str. 16 Ghana Civil Aviation Authority
38108 Braunschweig Private Mail Bag
Germany Kotoka International Airport
Tel.: (49) 531 3548 0 Accra
E-mail: box@bfu-web.de Ghana
Fax: (49) 531 3548 246 Tel.: (233) 21 776171
Telex: 952749 ACCID D E-mail: dg.gcaa@ighmail.com
Website: http://www.bfu-web.de Fax: (233) 21 773293
SITA: ACCATYA
AFTN: DGAAYAYX
Telex: 94 2336 GHACAA GH
Cable: AIRCIVIL ACCRA

GREECE GUATEMALA
Hellenic Republic Dirección General de Aeronáutica Civil
Ministry of Transport and Communication Aeropuerto Internacional ―La Aurora‖
Air Accident Investigation and Zona 13
Aviation Safety Board Guatemala, Centro América
Ex. American Base Tel.: (502) 2 331 0311 / 9484
Building 221 Fax: (502) 2 331 4840
Helliniko AFTN: MGGTYAYZ
167 01 Athens Telex: 3120 ACIVIL GU
Greece Cable: DAEROCIVIL Guatemala
Tel.: (30) 210 960 8090
(30) 6973-430405 / 430406 (24 hour)
E-mail: monada@aaiasb.gr
Fax: (30) 210 961-7137

GUINEA GUINEA-BISSAU
Ministère de l’Équipement Direction Générale de l’Aviation Civile
Direction Nationale de l’Aviation Civile C.P. 77
B.P. 95 Bissau
Conakry Guinée-Bissau
République de Guinée Tel.: (245) 21 30 03 / 21 39 61
Tel.: (224) 45 34 57 / 45 19 28 AFTN: GGOVYAYX
Fax: (224) 41 35 77 Cable: AEROCIVIL Bissau
AFTN: GUCYYAYX
Telex: 22349 MITRANS
Cable: AVIACIVIL CONAKRY

GUYANA HAITI
Civil Aviation Authority Office National de l’Aviation civile
82 Premniranjan Place Aéroport International de Port-au-Prince
Prashad Nagar B.P. 1346
Georgetown Port-au-Prince
Guyana Haiti
Tel.: (592) (592) 225-6822 Tel.: (509) 46 052
E-mail: director-general@gcaa-gy.org Fax: (509) 46 0998
Fax: (592) 225-6800 AFTN: MTEGYAYX
AFTN: SYGCYAYX Telex: CIVILAV ITT 2030465

HONDURAS HONG KONG1


Junta de Prevencion e Investigación de Accidentes Civil Aviation Department
e Incidentes Aereos Queensway Government Offices, 46th Floor
9
Dirección General de Aeronáutica Civil 66 Queensway
Apartado Postal 30145 Hong Kong
Tegucigalpa, M.D.C. China
Honduras Tel.: (852) 2867 4332
Tel.: (504) 234-2507 (COCESNA – 24 hours) (852) 2910-6821 (24 hours)
(504) 233-4489 (COFAH – 24 hours) E-mail: aid@cad.gov.hk
Tel./Fax: (504) 233-3683 (DGAC) Fax: (852) 2810-0093
AFTN: MHTGYTYX (852) 2910-1177 (24 hours)
Website: www.dgachn.org AFTN: VHHHYAYX
Website: www.cad.gov.hk

HUNGARY ICELAND
Transportation Safety Bureau (TSB) Aircraft Accident Investigation Board
P. O. B. 62 Hus FBSR
H-1675 Budapest Flugvallarvegi
Hungary 101 Reykjavik
Tel.: (36) 1 294 5529 Iceland
(36) 1 296 9504 Tel.: (354) 511 1666 (0800 – 1600 hrs)
(36) 30 931-0832 (mobile) (354) 660 0336 (24 hour)
Fax: (36) 1 296 9520 E-mail: rnf@rnf.is
AFTN: LHBPYLYX Fax: (354) 511 1667
AFTN: BICAYAY
Website: http://www.rnf.is

INDIA INDONESIA
AIRCRAFT ACCIDENT INVESTIGATION National Transportation Safety Committee
BUREAU Gedung Karya, 7th Floor
MINISTRY OF CIVIL AVIATION Ministry of Transport
Phone numbers +911124610843, 24610848 Merdeka Barat No. 8
Jakarta 10110
Fax number +9111 24693963 Indonesia
e-mail opsctrl@aai.aero Tel.: (62) 21 351 7606
(62) 21 381 1308 ext. 1497
E-mail: knkt@dephub.go.id
Fax: (62) 21 351 7606
AFTN: WIIXYAYX
Telex: 49482 CIVAIR IA
Cable: CIVILAIR JAKARTA
Website: www.dephub.go.id/knkt

. IRAN (ISLAMIC REPUBLIC OF) IRAQ


Ministry of Roads and Transportation Directorate of Flight Safety
Civil Aviation Organization General Establishment of Civil Aviation
Mehrabad International Airport P.O. Box 23006
P.O. Box 13445-1798 Baghdad International Airport
Tehran Baghdad
Islamic Republic of Iran Iraq
Tel.: (98) 21 6602-5230 / 6602-5238 / 4465-9349 Tel.: (964) 1 8863999 (ext. 28278)
E-mail: Info@cao.ir Fax: (964) 1 8880178
Fax: (98) 21 4465-9348 SITA: SDAYAYD
AFS: OIIIYAYX AFTN: ORBSYDYX
Telex: 213889 EPDIR Telex: 212500 YIA IK
Cable: CIVILAIR, TEHRAN Cable: SDA
Website: http://www.cao.ir

IRELAND ISRAEL
Air Accident Investigation Unit (AAIU) Ministry of Transport
10
Department of Transport Chief Investigator
44 Kildare Street P.O. Box 120
Dublin 2 Ben Gurion International Airport 70100
Ireland Israel
Tel.: (353) 1 604 1293 Tel.: (972) 3-975-1380
E-mail: aaiu@transport.ie (972) 50-621-2329 (24 hours mobile)
Fax: (353) 1 604 1514 E-mail: razchik@mot.gov.il
AFTN: EIDWYAYX Fax: (972) 3-760-4442
Website: http://www.aaiu.ie AFTN: LLADYAYX
Telex: 381000 CAATS IL
Cable: MEMTEUFA-BENGURION AIRPORT-ISRAEL

ITALY JAMAICA
Agenzia nazionale per la sicurezza del volo Civil Aviation Authority
Via A. Benigni, 53 4 Winchester Road
00156 Rome Kingston 5
Italy Jamaica
Tel.: 39 068 207 8219 / 39 068 207 8200 Tel.: (876) 960-3965 / (876) 920-2280
Fax: 39 068 273 672 E-mail: jcivav@toj.com
Fax: (876) 920-0194
AFTN: MKJKYAYX
Cable: CIVAV JA

JAPAN JORDAN
Director-General Civil Aviation Authority
Secretariat of the Aircraft and Railway Accidents Aircraft Accident Investigation Unit (AIU)
Investigation Commission P.O. Box 39257
Ministry of Land, Infrastructure and Transport Amman 11104
2-1-2, Kasumigaseki, Chiyoda-ku Jordan
Tokyo 100-8918 Tel.: (962) 6 445 2027 / (962) 6 489 2282
Japan (962) 6 445 1140
Tel.: (81) 3 5253 8813 E-mail: investigation@jcaa.gov.jo
E-mail: ARAIC@mlit.go.jp Fax: (962) 6 445 1141
Fax: (81) 3 5253 1677 SITA: AMMXYA
AFTN: RJTDYAYA AFTN: OJAMYAYX
Cable: KOKUKYOKU-TOKYO Telex: 21325 CIVAIR JO
Website: http://www.motnet.go.jp/araic/index.html Website: http://www.jcaa.gov.jo/
air_accident_investigation.asp

KAZAKHSTAN KENYA
Ministry of Transport and Communications The Chief Inspector of Accidents
Civil Aviation Committee Directorate of Civil Aviation
47, Kabanbai batyr Avenue P.O. Box 30163
010000 Astana Nairobi
Kazakhstan Kenya
Tel.: (7) 7172-242605 (0900 – 1830) Tel.: (254) 2 822950 (ext. 238)
Fax: (7) 7172-243165 Fax: (254) 2 822195
AFTN: UACDYAYD AFTN: HKNCYAYD
Telex: KE 25239 DCA HQ
Cable: DIRECTAIR

KIRIBATI KUWAIT
The Director of Civil Aviation Directorate General of Civil Aviation
Ministry of Information, Communications and Transport P.O. Box 17 SAFAT
P.O. Box 277 Kuwait 13001
Bikenibeu, Tarawa Kuwait
Kiribati Tel.: (965) 2 476-5815
11
Tel.: (686) 28092 / 26003 (965) 2 476-2755
Fax: (686) 28280 / 26193 Fax: (965) 2 476-5796
AFTN: NQTAYF SITA: KWIASYA/KWIDDYA/KWIAPYA
Telex: KI77022 AFTN: OKAAYAYX
Cable: MINCOM TARAWA Cable: CIVAIR KUWAIT

KYRGYZSTAN LAO PEOPLE’S DEMOCRATIC REPUBLIC


Interstate Aviation Committee Department of Civil Aviation
22/2/1 Bolshaya Ordynka Str. Wattay International Airport
119017 Moscow P.O. Box 119
Russia Vientiane Capital
Tel.: (7) 495 953-1244 Lao People’s Democratic Republic
Fax: (7) 495 953-3508 / 1600 Tel.: (856) 21 512161 / 512163
E-mail: mak@mak.ru E-mail: laodca@laotel.com
Website: www.mak.ru Fax: (856) 21 520237 / 512044
AFTN: VLAOYAYX
Cable: AVIACIVIL Vientiane

LATVIA LEBANON
Transport Accident and Incident Investigation Bureau Directorate General of Civil Aviation
Brivibas Street 58, Room 209 Beirut International Airport
LV-1011 Riga Khalde
Latvia Lebanon
Tel.: (371) 6728 8140 Tel.: (961) 1 628195 / 6 / 7
E-mail: taiib@taiib.gov.lv (961) 3 032443
Fax: (371) 67 283 339 E-mail: dgca@beirutairport.gov.lb
AFTN: UMRUYAYX Fax: (961) 1 629010
Telex: 161100 PTB SJ 1237 AVTO AFTN: OLDDYAYX
SITA: BEYXYYF
Telex: LE20314 DGACLN LE
Cable: CIVILAIR, BEIRUT

LESOTHO LIBERIA
Directorate Civil Aviation Directorate of Civil Aviation
P.O. Box 629 Ministry of Transport
Maseru 100 P.O. Box 9041-1000
Lesotho Monrovia 10
Tel.: (266) 312499 Liberia
Fax: (266) 310188 Tel.: (231) 22 66 91
AFTN: FXMMYAYX Fax: (231) 22 75 15
Telex: 4321 LO AFTN: GLRBYAYX
Cable: CIVILR Telex: 44384 MINTRANS

LIBYAN ARAB JAMAHIRIYA LITHUANIA


Civil Aviation and Meteorology Higher Institute Ministry of Transport
P.O. Box 84116 Chief Investigator of Aircraft
Tripoli Accidents and Incidents
Libyan Arab Jamahiriya Gedimino Av. 17
Tel.: (218) 21 3615994 / 3330256 LT-01505 Vilnius
Fax: (218) 21 3615995 Lithuania
SITA: TIPYAXS-TIPTOYA Tel.: (370) 5 239 3907
AFTN: HLLTYAYX E-mail: transp@transp.lt
Telex: 20353 CALLY Fax: (370) 5 212 4335
Cable: SIRECTAIR TRIPOLI BYA

LUXEMBOURG MADAGASCAR
Ministère des Transports Ministère des Transports et de la Météorologie
12
Direction de l’Aviation Civile Direction de l’Aviation Civile
19-21, Boulevard Royal B.P. 921 Anosy
Boîte postale 590 Antananarivo 101
L-2938 Luxembourg Madagascar
Tel.: (352) 478-4413 / 14 Tel.: (261) 20 22 35689
Fax: (352) 467-7790 (261) 20 22 28418
AFTN: ELLXYAYX (261) 20 22 44757
Telex: 1465 CIVAIR LU Fax: (261) 20 22 30444
Cable: CIVILAIR-LUX AFTN: FMMDYAYX

MALAWI MALAYSIA
Director of Civil Aviation Chief Inspector of Air Accidents
Private Bag 322, Capital City Ministry of Transport
Lilongwe 3 Department of Civil Aviation
Malawi Level 1 – 4, Podium Block
Tel.: (265) 780 577 27, Persiaran Perdana, Precinct 4
E-mail: aviation@malawi.net Federal Government Administrative Centre
Fax: (265) 784 986 62618 Putrajaya
AFTN: FWHQYAYX Malaysia
Telex: 44736 AVIATION MI Tel.: (60) 3-8871-4000
Cable: AVIATION-LILONGWE Fax: (60) 3-8871-4069
AFTN: WMKKYAYX
Telex: PENAWA MA 30128
Cable: CIVIL KUALA LUMPUR

MALDIVES MALI
Civil Aviation Department Direction Nationale de l’Aéronautique Civile
Ministry of Transport and Civil Aviation Ministère des Travaux Publics et des Transports
2nd Floor, Huravee Building B.P. 227
Ameer Ahmed Magu Bamako
Malé 20-05 Mali
Maldives Tel.: (223) 22 55 24
Tel.: (960) 324 986 / 324 983 Fax: (223) 22 61 77
E-mail: civav@transcom.gov.mv AFTN: GABVYAXY
Fax: (960) 323 039 Cable: AVIACIVIL Bamako
AFTN: VRMMYAYX
Telex: 66034 CIVAV MF

MALTA MARSHALL ISLANDS


Department of Civil Aviation Directorate of Civil Aviation
Luqa Airport P.O. Box 1114
Luqa Cmr 02 Majuro 96960
Malta Marshall Islands
Tel.: (356) 222 936 / (356) 249 170 Tel.: (692) 247 3889
Fax: (356) 239 278 Fax: (692) 247 7615 / 3888
AFTN: LMMLYAYX
Telex: 1654 CAMLT MW
Cable: CIVILAIR MALTA

MAURITANIA MAURITIUS
Ministère de l’Équipement et des Transports Department of Civil Aviation
Direction de l’Aviation civile S.S.R. International Airport
Boîte Postale 91 Plaine Magnien
Nouakchott Mauritius
Mauritanie Tel.: (230) 603-2000
Tel.: (222) 253 337 / (222) 535 78 E-mail: civil-aviation@mail.gov.mu
Fax: (222) 535 78 Fax: (230) 637-3164
13
SITA: NKCYAYX SITA: MRUXTYF
AFTN: GQNVYAMR AFTN: FIMPYAYX
Cable: MINITRANSPORTS Nouakchott Telex: 4896 DCAMAU

MEXICO MICRONESIA (FEDERATED STATES OF)


Dirección General de Aeronáutica Civil Division of Civil Aviation Administration
Secretaría de Comunicaciones y Transportes Department of Transportation, Communications and
Providencia No. 807 — 6˚ piso Infrastructure
Colonia del Valle P.O. Box PS-2
Codigo Postal 03100 Palikir, Pohnpei, FM 96941
México, D.F. Federated States of Micronesia
Mexico Tel.: (691) 320 2865
Tel.: (52) 55 5 523 33 77 E-mail: transfsm@mail.fm
Fax: (52) 55 5 523 72 07 Fax: (691) 320 5853
AFTN: MMMXYAYX AFTN: PTPNYAYX
Telex: 1764154 ACIAME Telex: 729-6807

MONACO MONGOLIA
Service de l’Aviation Civile Air Accident Investigation Bureau Mongolia
Héliport de Monaco Ministry of Road, Transportation, Construction
MC-98000 Monaco and Urban Development of Mongolia
La Principauté de Monaco Chinggis Khaan International Airport
Tel.: (377) 98 98 87 11 (office hours) Ulaanbaatar 34
(33 6) 07 93 28 38 (out-of-office hours) Mongolia
Fax: (377) 98 98 87 08 Tel.: (976) 11 282095
AFTN: LNMCYAYX E-mail: aaib@aaib.gov.mn
Telex: 469525 MONAVI Fax: (976) 11 379974
AFTN: ZMUBYAYX

MOROCCO MOZAMBIQUE
Bureau d’enquêtes et d’analyses des accidents National Civil Aviation Administration
d’aviation civile P.O. Box 227
Avenue Maâ El Aynaine Maputo
B.P. 1073 Mozambique
Agdal, RP Rabat Tel.: (258) 1 465416
Maroc Fax: (258) 1 465415
Tel.: (212) 5 37 67 94 41 / 42 AFTN: FQHQYAYX
(212) 6 60 18 18 70 (24 hours) Telex: 6-175 SEAC MO
Fax: (212) 5 37 77 30 74 Cable: AERONAUTICA-MAPUTO
AFTN: GMMRYAYA
MYANMAR NAMIBIA
Department of Civil Aviation Directorate of Aircraft Accident Investigation
Headquarters Building Ministry of Works, Transport and Communication
Yangon International Airport Private Bag 13341
P.O. Box 11021 Mingaladon 6719 Bell Street, Snyman Circle
Yangon Windhoek
Myanmar Namibia
Tel.: (95) 1 665 637 / 635 996 Tel.: (264) 61 208 8411 / 05 / 10
Fax: (95) 1 665 124 / 6078 (264) 81 242 9279 (mobile)
AFTN: VYYYYAYX Fax: (264) 61 238 884
Telex: 21228 CIVAIR BM AFTN: FYHQYAYX

NAURU NEPAL
Director of Civil Aviation Director General of Civil Aviation
Civil Aviation Authority Civil Aviation Authority
Government Office Babar Mahal
Yaren District Kathmandu
14
Nauru, Central Pacific Nepal
Tel.: (674) 444 3113 Tel.: (977) 1-262387 / 262518
Fax: (674) 444 3117 E-mail: cnsatm@mos.com.np
AFTN: ANAUYAYX Fax: (977) 1-262516
Telex: 33081 AFTN: VNKTYAYX
Cable: GOVNAURU Telex: 2553 DCA NP
Cable: AIRCIVIL

NETHERLANDS ANTILLES1 NETHERLANDS


Directorate of Civil Aviation Dutch Safety Board
Seru Mahuma Z/N P.O. Box 95404
Curaçao 2509 CK The Hague
Netherlands Antilles Netherlands
Tel.: (599) 9 839-3319 Tel.: (31) 70 333 70 00
(599) 9 839-3518 (24 hours) (31) 800 6353 688 / (31) 70 333 7072 (24 hours)
E-mail: civilair@gov.an E-mail: aviation@safetyboard.nl
Fax: (599) 9 868-9924 Fax: (31) 70 333 70 77
AFTN: TNCCYAYX AFTN: EHGVYLYS
Telex: 1102 DCA NA Website: www.safetyboard.nl
Cable: CIVILAIR-CURAÇAO

NEW ZEALAND NICARAGUA


The Chief Executive Officer Dirección General de Aeronáutica Civil
Transport Accident Investigation Commission Ministerio de Transporte y la Construcción
11 Cigna House KM 11½ Carretera Norte
40 Mercer Street Managua
P.O. Box 10-323 Nicaragua
Wellington 6143 Tel.: (505) 2 276-8580
New Zealand E-mail: dg@inac.gob.ni / eoaci@inac.gob.ni
Tel.: (64) 4-473-0199 (24 hours) Fax: (505) 2 276-8588
(64) 4-473-3112 AFTN: MNMGYAYX
E-mail: inquiries@taic.org.nz Telex: 1308 AEROCIVIL
Fax: (64) 4-499-1510
AFTN: NZHOYAYX
Cable: CIVAIR NZ
Website: http://www.taic.org.nz

NIGER NIGERIA
Direction de l’Aviation Civile Accident Investigation Bureau
Ministère des Transports Nnamdi Azikiwe Airport
B.P. 727 P.M.B. 7009 Area 1
Niamey Abuja
Niger Nigeria
Tel.: (227) 72 32 66 / 67 Tel.: (234) 9 8100420
Fax: (227) 74 17 56 (234) 9 8100421
SITA: DRRVSITX (234) 9 8100422
AFTN: DRRVYAYX (234) 9 8033174991
Telex: MINTRANS 5249 NI E-mail: aiblos@infoweb.abs.net
Cable: AVIACIVILE Niamey Fax: (234) 9523 2113 / 1603
AFTN: DNLLYAYX
Telex: 26567 FCAA NG
SITA: LOSXSYF

NORWAY OMAN
Accident Investigation Board Norway Directorate General of Civil Aviation and Meteorology
P. O. Box 213 Seeb International Airport
N-2001 Lillestrøm P.O. Box 1, Postal Code 111
15
Norway Muscat
Tel.: (47) 63 89 63 00 Oman
(47) 63 89 63 20 (24H) Tel.: (968) 519 210 / 519 315
E-mail: post@aibn.no E-mail: dgen@dgcam.com
Fax: (47) 63 89 63 01 Fax: (968) 510 122
AFTN: ENCAYAYX AFTN: OOMSYAYX
Cable: 71032 ENFB N Telex: 5418 DGCAOMAN ON
Website: http://www.aibn.no Cable: CIVAIR MUSCAT

PAKISTAN
Headquarters, Civil Aviation Authority PALAU
Terminal-1, JIAP Ministry of Commerce and Trade
Karachi-75200 P.O. Box 1471
Pakistan Koror
Tel.: (92) 21 924 8720 Palau 96940
E-mail: dgcaa@caapakistan.com.pk Tel.: (680) 488 1116 / 587 2111
Fax: (92) 21 924 8722 E-mail: mincat@palaunet.com
Telex: 29534 DGCAA PK Fax: (680) 587 3521 / 2222
SITA: KHIAPXX to DG HQCAA
AFTN: OPHQYAYX
PANAMA PAPUA NEW GUINEA
Jefatura de la Unidad de Prevención e Investigación de Chairman Accident Investigation Commission – PNG
Accidentes Paulus Dowa
Autoridad Aeronáutica Civil P.O. Box 1265
Panama 0816-03073 Mt Hargen, Western Highlands
Panama Papua New Guinea
Tel.: (507) 501-9134 Tel.: (675) 542-2833 (24 hrs)
E-mail: eperez@aeronautica.gob.pa (675) 688-4156 (mobile)
Fax: (507) 501-9317 Fax: (675) 542-2861
AFTN: MPTOYAYX AFTN: AYPYYAYX
Telex: 2057CIVILAV PA Telex: 22203 NE
Website: www.aeronautica.gob.pa

PARAGUAY PERU
Centro de Investigación y Prevención Dirección General de Aeronáutica Civil
de Accidentes Aeronáuticos Ministerio de Transportes y Comunicaciones
Dirección Nacional de Aeronáutica Civil Avenida 28 de Julio #800
Aeropuerto Internacional ―Silvio Pettirossi‖ Lima-1
Luque Peru
Paraguay Tel.: (511) 433 7800 / 433 3166
Tel.: (595) 21 645-599 Fax: (511) 433 2808
(595) 21 646-114 (24 hrs) AFTN: SPLIYAYD-SPLIYAYX
E-mail: cipaa@dinac.gov.py Telex: 25511 PE DIGECOM
Fax: (595) 21 645-599 Website: http://www.mtc.gob.pe
AFTN: SGASIPAX
Web: www.dinac.gov.py

PHILIPPINES POLAND
Civil Aviation Authority of the Philippines Ministry of Transport
Ninoy Aquino Avenue corner MIA Road State Commission of Aircraft Accident Investigation
Pasay City 1301 Metro Manila (SCAAI)
Philippines 4/6 Chalubinskiego
Tel.: (63) 2 879-9110 / 2 / 3 (OPCEN) 00-928 Warsaw
E-mail: orcc_caap@yahoo.com.ph Poland
Fax: (63) 2 834-0143 / 831-6215 Tel.: (48) 22 630-11-31
AFTN: RPLLYAYX (48) 22 630-11-42
(48) 500 233 233 (24 hours - event notification)
16
E-mail: pkbwl@mt.gov.pl
Fax: (48) 22 630-11-43
SITA: WAWGILO

PORTUGAL QATAR
Gabinete de Prevençao e Investigação Department of Civil Aviation and Meteorology
de Acidentes com Aeronaves (GPIAA) P.O. Box 3000
Praça Duque de Saldanha, n.˚ 31, 4˚ Doha
1050-094 Lisboa Qatar
Portugal Tel.: (974) 426262
Tel.: (351) 91 519-2963 (24 hours) Fax: (974) 429070
(351) 21 273-9230 (general) AFTN: OTBDYAYX
(351) 21273-9250 (director) Telex: 4306 CIVAIR DH
E-mail: geral@gpiaa.gov.pt Cable: CIVILAIR DOHA
Fax: (351) 21 273-9260
AFTN: LPPTYLYX
Website: www.gpiaa.gov.pt

REPUBLIC OF KOREA REPUBLIC OF MOLDOVA


Aviation and Railway Accident Investigation Board State Administration of Civil Aviation
Ministry of Construction and Transportation Investigation Bureau
281, Gonghang-Dong Airport
Gangseo-gu, Seoul MD 2026 Chisinau
Republic of Korea 157-815 Republic of Moldova
Tel.: (82) 2 6096-1017 Tel.: (373) 2 524064 / 525766
(82) 2 6096-1030 (24 hours) (373) (0) 799 91 307 / 793 00 351 (mobile)
E-mail: byeonsc@moct.go.kr E-mail: chiriliuc@caa.md
Fax: (82) 2 6096-1031 info@caamd
AFTN: RKSLYLYX Fax: (373) 2 529118 / 529190
Website: http://www.araib.go.kr AFTN: LUKKYGYX

ROMANIA RUSSIAN FEDERATION


Ministry of Transport Federal Aviation Authorities of Russia
Direction of Air Transport Investigation State Oversight Flight Safety Department
38 Dinicu Golescu Blvd., Sector 1 37 Leningradsky Prospect
010873 Bucharest 125167 Moscow
Romania Russian Federation
Tel.: (40) 21 319-6185 Tel.: (7) 095 155-5784
(40) 750 032-401 Fax: (7) 095 155-5535
E-mail: mircea.ciuca@mt.ro SITA: MOWYASU
Fax: (40) 21 312-4791 AFTN: UUUFYLY
(40) 750 032-493 Interstate Aviation Committee
SITA: BUHYARO Air Transport Accident Investigation Commission
AFTN: LRBBYAYA Building 22/2/1
Telex: 11181 AIRBUHR Bolshaya Ordynka Street
109017 Moscow
Russian Federation
Tel.: (7) 095 951-1686
Fax: (7) 095 953-1145
AFTN: UUUUZXDD

RWANDA SAINT-PIERRE ET MIQUELON1


Direction de l’Aéronautique Service de l’Aviation Civile
B.P. 898 Blvd de Port-en-Bessin
Kigali B.P. 4265 Saint-Pierre
Rwanda 97500 Saint-Pierre et Miquelon
Tel.: (250) 75971 Telex: 914439 DDE SPM
17
Fax: (250) 72971 AFTN: LFVPYAYX
AFTN: HRYRYAYX Cable: AVIACIVIL Saint-Pierre
Cable: DIRAVIAMET Kigali

SAMOA SAN MARINO


Ministry of Transport: Civil Aviation, Marine and Ministry of Communications and Transport
Shipping Via A. di Suberchio
P.O. Box 1607 47898 Cailungo
Apia San Marino
Samoa Tel.: (378) 549 992 345
Tel.: (685) 23 290 / 2
E-mail: sectport@samoa.net
Fax: (685) 20 048
AFTN: NSFAYD
Telex: 21 MALO SX
Cable: MALO APIA

SAO TOME AND PRINCIPE SAUDI ARABIA


Direction de l’Aviation Civile Safety Department
C.P. 97 General Authority of Civil Aviation
Sao Tomé P.O. Box 887
Sao Tomé-et-Principe Jeddah 21421
Tel.: (239 2) 241450 (INAC Administration) Saudi Arabia
(239 2) 225860 (Head of Investigation Commission) Tel.: (966) 2 640-685-5515 / 5491
(239 9) 903178 (Mobile) Fax: (966) 2 685-5507
Fax: (239 2) 225118 AFTN: OEJDYAYX
AFTN: FPSTYA Telex: 601093 CIV AIR SJ
Telex: 245 DAC ST Cable: CIVIL AIR JEDDAH
Cable: AERONAUTICA São Tomé

SENEGAL SERBIA
Direction de l’Aviation Civile Civil Aviation Directorate
B.P. 8184 Aircraft Accidents Investigations Department
Aéroport de Dakar-Yoff Omladinskih brigada 1
Sénégal 11070 Beograd
Tel.: (221) 20 04 03 Serbia
Fax: (221) 20 39 67 Tel.: (381 11) 313-2516
AFTN: GOO YAYX (381 64) 803-3509
Telex: 51206 SG (381 11) 228-6415 (24 hours)
Cable: AVIACIVIL SENEGAL E-mail: sdobrosavljevic@cad.gov.rs
Fax.: (381 11) 311-7518 / 7579
AFTN: LYBNYLYX
Website: www.cad.gov.rs

SEYCHELLES SIERRA LEONE


Directorate of Civil Aviation Director of Civil Aviation
P.O. Box 181 Victoria Ministry of Transport and Communications
Mahé Ministerial Office Block
Seychelles George Street
Tel.: (248) 373 001 / 373 533 Freetown
E-mail: dcaadmin@seychelles.net Sierra Leone
Fax: (248) 384 009 Tel.: (232) 22 22106 / 26191
AFTN: FSIAYNYX Fax: (232) 22 228 488
Telex: 2239 DCA SZ AFTN: GFLLYA
Cable: DIRECTAIR SEYCHELLES Telex: SE3574
Cable: AIRCIVIL Freetown

18
SINGAPORE SLOVAKIA
Air Accident Investigation Bureau of Singapore Civil Aviation Administration
Changi Airport Post Office M.R. Stefanik Airport
P.O. Box 1005 823 05 Bratislava
Singapore 918155 Slovakia
Tel.: (65) 6541-2796 / 3042 Tel.: (421) 918 382 059 / 060 / 061 (mobile numbers)
(65) 9826 2359 (Mobile) E-mail: vysetrovanie@caa.sk
Fax: (65) 6542 2394 Fax: (421) 2 3303 4077
AFTN: WSSSYAYX SITA: BTSTOYA
Telex: RS 21231 AVIATEL AFTN: LZIBYIYX, or LZIBYIYP
Cable: AIRCIVIL Telex: 92264 MDSR SK
Website: http://www.mot.gov.sg

SLOVENIA SOLOMON ISLANDS


Ministry of Transport Civil Aviation Division
Aircraft Accident and Incident Investigation Division Ministry of Culture, Tourism and Aviation
Langusova 4 P.O. Box G20
SI-1535 Ljubljana Honiara
Slovenia Solomon Islands
Tel.: (386) 1 478-8155 Tel.: (677) 36561 / 3
E-mail: mzp.splni@gov.si Fax: (677) 36775
Fax: (386) 1 478-8189 AFTN: AGGHYAYX
AFTN: LJLAYAYX Telex: 66470 HQ
Website: http://www.mzp.gov.si/ Cable: CIVILAIR Honiara

SOMALIA SOUTH AFRICA


Somali Civil Aviation Authority Civil Aviation Authority
Flight Safety Division Accidents Investigations Department
P.O. Box 1737 Private Bag X 73
Mogadishu Halfway House 1685
Somalia South Africa
Tel.: (252) 1 20203 Tel.: (27) 11 545 1000/1050
AFTN: HCMMYAYX E-mail: mail@caa.co.za
Telex: 3033 MINTRAS Fax: (27) 11 545 1466
Cable: CIVAIR Mogadishu Website: http://www.caa.co.za

SPAIN SRI LANKA


Comisión de Investigación de Accidentes Civil Aviation Authority
e Incidentes de Aviación Civil Supreme Building
Ministerio de Fomento No. 64, Galle Road
C\Fruela, 6 — 1ª planta Colombo 03
28011 Madrid Sri Lanka
Spain Tel.: (94) 11 233-3447
Tel.: (34) 91 597 89 60 E-mail: sldgca@caa.lk
E-mail: ciaiac@fomento.es Fax: (94) 11 242-4540
Fax: (34) 91 463 55 35 AFTN: VCCCYAYX
AFTN: LEACYAYX Cable: AIRCIVIL Colombo
Telex: 27702 CIAIR E Website: http://www.caa.lk
Website: http://www.ciaiac.es

SUDAN SURINAME
Air Accident Investigation Central Directorate Permanent Secretary
Civil Aviation Authority Ministry of Transport, Communications and Tourism
P.O. Box 430 Prins Hendrikstraat 26-28
Khartoum Paramaribo
Sudan Suriname
Tel.: (249) 15 577-5152 Tel.: (597) 420 100 / 420 422
19
(249) 91 291-9213 (mobile) E-mail: tctdir@sr.not
E-mail: info@caa.gov.sd Fax: (597) 420 425 / 420 100
Fax: (249) 15 577-5150 AFTN: SMPBYAYX
AFTN: HSSSYAYG Telex: 148 CIVPBM SN
Telex: 22650 DGACA ASD Cable: CIVILAIR

SWAZILAND SWEDEN
Ministry of Public Works and Transport Accident Investigation Board
Directorate of Civil Aviation P.O. Box 12538
Swazi Bank Building S-102 29 Stockholm
P.O. Box 58 Sweden
Mbabane 4100 Tel.: (46) 8 5088-6200
Swaziland E-mail info@havkom.se
Tel.: (268) 48683 Fax: (46) 8 5088-6290
E-mail: dca@iafica.sz Website: http://www.havkom.se
Fax: (268) 48682
AFTN: EDMBYQ
Telex: 2104 WD

SWITZERLAND SYRIAN ARAB REPUBLIC


Bureau d’enquêtes sur les accidents d’aviation Directorate General of Civil Aviation
Aéropôle 1 Route de Morens P.O. Box 6257
CH-1530 Payerne Damascus
Switzerland Syrian Arab Republic
Tel.: (41) 26 662-3300 Tel.: (963) 11 3331306
(41) 333 333-333 (24-hour — ask for AAIB) Fax: (963) 11 2232201
E-mail: info@bfu.admin.ch AFTN: OSDIYAYX
Fax: (41) 26 662-3301 Telex: 411928 CIVAIR SY
Website: http://www.bfu.admin.ch

TAJIKISTAN THAILAND
Aircompany ―Tajik Air‖ Aircraft Accident Investigation Committee
734006 Dushanbe Flight Standards Bureau
Titova Str. 32/1 Department of Civil Aviation
Tajikistan 71 Ngarmduplee, Rama IV Road
Tel.: (7) 3772 212247 Bangkok 10120
Fax: (7) 3772 510041 / 218685 Thailand
SITA: DYUWW7J Tel.: (66) 2 287 3198
AFTN: UTDDTJKW (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 TOGO


OF MACEDONIA Direction de l’Aviation Civile
Aircraft Accident Investigation Commission B.P. 2699
Luj Paster 23-1/3 Lomé
1000 Skopje Togo
The former Yugoslav Republic of Macedonia Tel.: (228) 263 740
Tel.: (389) 2 3148-408 / 415 (RCC, 24 hours) (228) 265 574
(389) 70 344-899 (RCC, 24 hours) Fax: (228) 260 860
Fax: (389) 2 3148-263 (RCC, 24 hours) AFTN: DXXXYAYX
SITA: SKPAPYF; SKPOCYF (RCC)
AFTN: LWSKYSYX (RCC)

TONGA TRINIDAD AND TOBAGO


20
Ministry of Civil Aviation Quality Assurance and Accident Investigation
P.O. Box 845 South Airport Terminal Building
Queen Salote Road Golden Grove Road
Nuku’alofa Piarco
Tonga Trinidad and Tobago
Tel.: (676) 24 144 Tel.: (1) (868) 669 4251
(676) 24 045
Fax: (676) 24 145
AFTN: NFTNYAYX
Telex: 66269 PRIMO TS
Cable: CIVILAIR TONGA

TUNISIA TURKEY
Ministère du Transport Directorate General of Civil Aviation
Direction Générale de l’Aviation Civile Ministry of Transport
BP 179 – 2035 Tunis CEDEX Bosna Hersek Cad., ( 90.Sok) No: 5
Tunisie 06510 Emek
Tel.: (216) 71 806-522 Ankara
(216) 71 848 000 ext. 34657 (after business hours) Turkey
Fax: (216) 71 806-469 Tel.: (90) 312 212 4635
(216) 71 752-022 / 753-327 (after business hours) Fax: (90) 312 212 4684
SITA: TUNXYXH / TUNOAXH SITA: ANKYXYA
AFS: DTTVYAYX AFTN: LTAAYAYX
Cable: CIVILAIR TUNIS Telex: 44659 CAD TR

TURKMENISTAN TURKS AND CAICOS ISLANDS1


Department of Transport and Communications Department of Civil Aviation
National Civil Aviation Administration Grand Turk
Chary Nurymov Street, 3a Turks and Caicos Islands
744000 Ashgabad Tel.: (1) 649 946 2138
Turkmenistan Fax: (1) 649 946 1185
Tel.: (993) 12 35 10 52 / 511804
Fax: (993) 12 35 44 02
SITA: ASBTCT5
AFTN: UTAUYAYX
Telex: 228 118 AKHAL RU

UGANDA UKRAINE
The Managing Director Independent Aircraft Accident Investigation Department
Civil Aviation Authority State Aviation Administration
P.O. Box 5536 Prospect Peremogy 14
Kampala 01135 Kyiv
Uganda Ukraine
Tel.: (256) 414-352-000 / 312-352-000 Tel.: (380) 44 461-5551 (24 hours)
(256) 414-320-905 / 892 (24 hours) E-mail: safety@avia.gov.ua
E-mail: aviation@caa.co.ug Tel./Fax: (380) 44 486-4271
Fax: (256) 414-321-401 AFTN: UKKAPLXX
AFTN: HUENYAYX
Cable: 61508 CAA UGA
Website: www.caa.co.ug

UNITED KINGDOM
UNITED ARAB EMIRATES Air Accidents Investigation Branch
General Civil Aviation Authority Department of Transport
P.O. Box 6558 Farnborough House
Abu Dhabi Berkshire Copse Road
United Arab Emirates Aldershot
21
Tel.: (971) 2 444 7666 Hants
E-mail: atmuae@emirates.net.ae GU11 2HH
Fax: (971) 2 499 1599 / 405 4485 United Kingdom
AFTN: OMAEYAYX Tel.: (44) 1252 510300
(44) 1252 512299 (accident line)
E-mail: investigations@aaib.gov.uk
Fax: (44) 1252 376999
AFTN: EGGCYLYX
Telex: 858119 ACCINV G
Website: http://www.aaib.gov.uk

UNITED REPUBLIC OF TANZANIA UNITED STATES


The Chief Inspector of Accidents National Transportation Safety Board
Ministry of Communications and Transport 490 L’Enfant Plaza East, SW
Accident Investigation Branch Washington, DC 20594
P.O. Box 2819 United States
Dar es Salaam Tel.: (1) 202-314-6290 (24 hours)
United Republic of Tanzania E-mail: communicationscenter@ntsb.gov
Tel.: (255) 22 2115079 Fax: (1) 202-314-6293
(255) 22 2115080 AFTN: KRWAYAYL
E-mail: tcaa@tcaa.go.tz Cable: TRANSAFETY Washington, DC
Fax: (255) 22 2118905 Website: http://www.ntsb.gov
AFTN: HTDQYAYA
Telex: 41120 DIRECTAIR
Website: http://www.aviationauthority.org

URUGUAY UZBEKISTAN
Oficina de Investigación y Prevencion de Accidentes e State Inspection of the Republic of Uzbekistan for Flight
Incidentes Safety Oversight (Gosavianadzor)
de Aviación 73B Nukus Street
Av. Wilson Ferreira Aldunate 5519 - Aeropuerto Tashkent 100015
Internacional de Carrasco, Canelones Uzbekistan
Uruguay Tel.: (998) 71 120-0060 254-3571
Tel.: (598) 2 601-4851 E-mail: caa@uzcaa.uz / investigation@uzcaa.uz
(598) 2 604-0408 INT. 5172 Fax: (998) 71 254-1482 / 120-0065
(598) 9961-1290 (24 hours) SITA: TASDDHY, TASCAHY
E-mail: ciada@adinet.com.uy AFTN: UTTAYAYX, UTTAYAYR
Fax: (598) 2 601-4851 Telex: 116169 POLET
AFTN: SUMUCAR UY 2228
Telex: DINACIA UY23412
Cable: AEROCIVIL — MONTEVIDEO
Website: www.dinacia.gub.uy

VENEZUELA
VANUATU Direccion de la Junta Investigadora de Accidentes
Director of Civil Aviation de Aviacion Civil
Pacific Building Av. Francisco Miranda
Private Mail Bag 068 Torre MINFRA, Piso 20
Port-Vila Chacao, Caracas 1060
Vanuatu Venezuela
Tel.: (678) 22819 Tel.: (58) 0212 201-5410 / 5491
Fax: (678) 23783 (58) 0426 517-8259 (Emergency accident/incident
SITA: VLICBYA reporting)
AFTN: NVVVYAYX E-mail: Jiaave@infraestructura.gob.ve /
Telex: 1040 VANGOV Jiaave@gmail.com
Fax: (58) 0212 201-5545
AFTN: SVCCLALX
22
Telex: 24626 MTCAC VC
Cable: DIGETRAERO-CARACAS
Website: www.infraestructura.gob.ve

VIET NAM YEMEN


Director General Civil Aviation and Meteorology Authority
Civil Aviation Administration Civil Aviation Sector
Gia Lam Airport P.O. Box 7251
Hanoi Sana’a
Viet Nam Yemen
Tel.: (84) 4 827-3384 Tel.: (967) 1 337166
(84) 4 827-1992 (24 hours) E-mail: CIVILAVIATION@Y.NET.YE
(84) 9128-19130 (mobile) Fax: (967) 1 326811
E-mail: hmtan@caa.gov.vn AFTN: OYSNYAYX
Fax: (84) 4 827 1913 Cable: CIVILAIR
(84) 4 873-2291 (24 hours)
SITA: HANCFVN
AFTN: VVVVYAYX
Telex: 412242 BGTVT VT

ZAMBIA ZIMBABWE
The Director Civil Aviation Authority
Department of Civil Aviation Karigamombe Centre, 16th Floor
P.O. Box 50137 Samora Machael Ave.
Ridgeway Private Bag 7716
Lusaka Causeway Harare
Zambia Zimbabwe
Tel.: (260) 1 253 149 Tel.: (263) 4 756 418 / 9
E-mail: dca@zamnet.zm (263) 4 765 751
Fax: (260) 1 251 841 E-mail: gtm@africaonline.co.sw
AFTN: FLHQYFDYQX Fax: (263) 4 756 748
Telex: 42280 ZA SITA: HREXTYF
Cable: AVIATION LUSAKA AFTN: FVHAYZYX
Telex: 4738 ZW

23
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.
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

1
GOVERNMENT OF INDIA
MINISTRY OF CIVIL AVIATION
AIRCRAFT ACCIDENT INVESTIGATION BUREAU

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

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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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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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 a k e a s s i s t a n c e
o f e x p e r t s o r e x p e r t g r o u p s as required, to cover various functional areas of the
investigation. Normally, offi ce rs of AA IB 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. 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.
 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.
APPENDIX G1
Part IV. Reporting
Chapter 1. The Final Report IV-1-5

Appendix 1 to Chapter 1
FORMAT AND CONTENT OF THE FINAL REPORT

To enable the Final Report to be presented in a convenient in this report are addressed to the regulatory authorities of
and uniform manner, a standardized format is contained in the State having responsibility for the matters with which
the Appendix to Annex 13. Detailed guidance on the recommendation is concerned. It is for those authorities
completing each section of the Final Report is provided to decide what action is taken.”
below.
The introduction should contain a reference to the time of
day used in the report, and the differential between local
INTRODUCTION (Title and Synopsis) time and Co-ordinated Universal Time (UTC).

The title of the Final Report should contain the following A table of contents, a list of abbreviations used in the report
information: name of the operator; manufacturer, model, and a list of appendices will enhance the readability of the
nationality and registration marks of the aircraft; and place report.
and date of the accident.

The introduction should contain brief information on the


notification of the accident to national and foreign 1. FACTUAL INFORMATION
authorities, the identification of the accident investigation
authority conducting the investigation, the accredited This part of the Final Report is descriptive in character and
representation from other States and brief information on should be a comprehensive record of the facts and
the organization of the investigation. The authority circumstances established in the investigation. When the
releasing the report, as well as the date of release, should investigation was conducted by groups, the report should
also be given. comprise a consolidation of the relevant information from
the group reports. Supporting documents, such as
The introduction should contain a synopsis which briefly photographs, diagrams, relevant parts of flight recorder
describes the accident. It should provide an overview of the readouts and technical reports, should be included or
accident flight, a statement of why the accident happened appended to the report. However, only those documents, or
and a brief summary of the injuries and damage. The portions thereof, which are required to support the facts,
synopsis could be described as an executive summary of analysis and conclusions should be appended to the Final
the Final Report and should usually not exceed one page in Report.
length.
The collection of Human Factors information is an integral
The title page, or the inside cover, may contain a statement part of the investigation. Thus, the Human Factors infor-
on the accident prevention objective of the investigation mation should be integrated into the appropriate areas of
and the Final Report. It may also be stated that it is not the the factual part of the report, rather than being placed under
purpose of the investigation and the Final Report to a separate heading. Human Factors information should be
apportion blame or liability. For example, the following presented in a language that is consistent with the
text may be considered: “In accordance with Annex 13 to presentation of the other factual information.
the Convention on International Civil Aviation, it is not the
purpose of aircraft accident investigation to apportion The factual information part of the Final Report should
blame or liability. The sole objective of the investigation contain a description of all the events and circumstances
and the Final Report is the prevention of accidents and directly related to the occurrence. The sequence should
incidents.” begin as far back in time as is necessary to include the
significant events which preceded the accident. This part
The introduction may also contain a statement regarding also contains all factual information, i.e. information
the responsibility for implementing the safety recommen- resulting from direct verification, which is essential for the
dations. For example, the following text may be development of the analysis, conclusions and safety
considered: “Unless otherwise indicated, recommendations recommendations. The significance of the facts should not

1
APPENDIX G1

IV-1-6 Manual of Aircraft Accident and Incident Investigation

be explained in the factual information part. Such — the latitude and longitude, as well as a geographical
discussions should be presented in the analysis part. reference to a well-known location (such as 75 km
south of XYZ);

1.1 History of the flight — the elevation of the accident site;

1.1.1 The history of the flight describes the significant — time of the occurrence in local time (and UTC if the
events which preceded the accident, in chronological order flight crossed time zones); and
when this is practicable. The information is usually
obtained from sources such as flight records, flight data — whether it was day, dawn, dusk or night.
recorders, cockpit voice recorders, air traffic services
records and recordings, and witness accounts. The
information should be correlated to local time, or UTC if
1.2 Injuries to persons
the flight involved more than one time zone. The
information presented in this section of the report should be
1.2.1 Table 1-1 should be completed in numbers.
based on established facts. Usually the flight number, the
type of operator and operation, the crew briefing and flight
1.2.2 Fatal injuries include all deaths determined to be
planning, the departure point and time of departure, and the
a direct result of injuries sustained in the accident. Serious
point of intended landing will be given, followed by a
injury is defined in Chapter 1 of Annex 13. For statistical
description of the events leading to the accident, including
purposes, ICAO classifies a fatal injury as an injury which
navigational details and relevant radio communications. It
results in death within thirty days of the accident. The
is important to give a description of the flight and the
heading “Others” in the table refers to persons outside the
pertinent events as they occurred, including a
aircraft who were injured in the accident. When the
reconstruction of the significant portion of the flight path,
accident involves a collision between two aircraft, a
if appropriate. Evidence which facilitated the reconstruction
separate table should be used for each aircraft.
of the sequence of events, such as witness accounts, cockpit
voice recorder and air traffic services transcripts, should be
1.2.3 Also, the nationalities of the passengers and the
mentioned.
crew should be listed by stating the number of fatalities and
serious injuries for each nationality.
1.1.2 In the history of the flight section, the objective
is to enable the reader to understand how the accident
happened but to avoid any analysis of why the accident
occurred. 1.3 Damage to aircraft

1.1.3 With regard to the location of the occurrence, 1.3.1 This section should contain a brief statement of
include: the 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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(destroyed, substantially damaged, slightly damaged, or no 1.6 Aircraft information


damage). A detailed description of damage to relevant
aircraft components and systems should be included in 1.6.1 When relevant to the accident, provide a brief
Section 1.12 — Wreckage and impact information. statement of the airworthiness and maintenance of the
aircraft including the following information:

1.4 Other damage — General information: Aircraft manufacturer and


model, serial number and year of manufacture;
1.4.1 Make a brief statement of damage sustained by nationality and registration marks, validity of the
objects other than the aircraft, such as buildings, vehicles, Certificate of Registration; name of the owner and
navigation facilities, aerodrome structures and installations, the operator; and validity of the Certificate of
and any significant damage to the environment. Airworthiness;

— Aircraft history: Total flying hours since


manufacture, since overhaul, and since last periodic
1.5 Personnel information
inspection. Include relevant information on
maintenance log and maintenance documentation,
1.5.1 Provide a brief description of the qualifications,
compliance (or otherwise) with airworthiness
experience and history for each flight crew member (pilot,
directives, manufacturer service bulletins and
co-pilot and flight engineer) including age, gender, type and
aircraft modification status;
validity of licences and ratings; flying experience (total
hours), types flown and hours on the type; hours flown in — Helicopters: Main rotor and tail rotor types and
the last 24 hours, 7 days and 90 days prior to the accident; serial numbers. When relevant, include total time,
results of recent training and mandatory and periodic time since overhaul, time since inspection, and
checks; experience on route and aerodrome involved in the certificated time and cycle limits for relevant
accident; relevant information on duty time and rest periods components;
in the 48 hours prior to the accident; significant medical
history and medical checks. Also, state the position — Engines and propellers: Engine manufacturer and
occupied by each flight crew member and identify who was model, position on the aircraft and engine or engine
flying the aircraft. module serial numbers; engine overhaul period if
an engine failure occurred; and total hours, hours
1.5.2 When relevant to the accident, give a brief since overhaul and hours since last inspection, for
statement of the duties and responsibilities of the cabin each engine. If relevant, provide the same
crew, as well as their qualifications, experience and information for the propellers;
training. For example, these details would be relevant if the
accident involved an evacuation of the aircraft. — Fuel: Type of fuel used and type of fuel authorized.
Also, state the amount of fuel on board and how it
1.5.3 When relevant to the accident, include a brief was determined, its specific gravity and its
statement of the validity of licences and ratings, the distribution in the fuel tanks;
qualifications and experience of air traffic services
— Accessories: In respect of any component which
personnel, including age, gender, position manned, total
failed, give details of the manufacturer, type,
experience (in years), and details of experience specific to
model, part and serial number, certificated time and
the position manned. Details of training and pertinent
cycle limits, and operating time since manufacture
checks should be included, as well as duty times and rest
and since overhaul;
periods in the 48 hours prior to the occurrence.
— Defects: List any technical defects in the aircraft,
1.5.4 When relevant to the accident, information on engine or accessories which were discovered during
maintenance personnel and other personnel involved should the investigation or recorded in the appropriate log
include qualifications, experience, time on duty, shift work and not cleared. Indicate whether the defects were
rosters, workload and the time of the day. recurring and whether the flight was permissible
under the aircraft master minimum equipment list.
1.5.5 Use sub-headings, as appropriate, to organize If there were no defects, make a statement to that
the information in this section. effect; and

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— Aircraft load: The maximum certificated take-off — A general view of the weather situation (synoptic
mass and landing mass, actual take-off mass, and weather);
mass at the time of the occurrence should be given.
Also, state the certificated limits for the centre of — Weather radar recordings, satellite photos, low-level
gravity of the aircraft, and the centre of gravity at wind shear alert system (LLWSAS) data, and other
take-off and at the time of the occurrence. Include recorded meteorological information; and
a description of the operator’s loading control
system, the load distribution and its security, and — Natural light conditions at the time of the accident,
how the details of the aircraft mass and centre of such as day (sunlight or overcast), twilight (dawn or
gravity were established. dusk; when relevant, the time of sunrise or sunset at
the applicable altitude should be included), night
1.6.2 Describe any aircraft part or system which had (dark or moonlight) and when relevant, the position
a bearing on the accident. Similarly, describe operational of the sun relative to the direction of the flight.
procedures, performance limitations and other aircraft
related circumstances which played a role in the accident. 1.7.2 The amount of meteorological information to be
The objective is to enable the reader to fully understand included in this section depends on the significance of the
how the accident happened. meteorological factors in the occurrence. A detailed
description of the forecast and weather observations is
appropriate for a weather-related occurrence whereas a
1.6.3 The availability, serviceability and use of
brief summary of the weather is appropriate when the
transponder, airborne collision avoidance system (ACAS)
weather was not a factor.
and traffic alert and collision avoidance system (TCAS),
ground proximity warning system (GPWS) and terrain
awareness warning system (TAWS), should be stated. The
1.8 Aids to navigation
relevant systems should be discussed in detail for near-
collisions, mid-air collisions, approach and landing
1.8.1 Include relevant information on navigation and
accidents and controlled flight into terrain accidents.
landing aids available, such as global navigation satellite
system (GNSS), non-directional radio beacon (NDB), very
high frequency omnidirectional radio range (VOR),
1.7 Meteorological information
distance measuring equipment (DME), instrument landing
system (ILS), and visual ground aids, as well as their
1.7.1 Provide a brief statement on the relevant
serviceability at the time of the accident.
meteorological conditions, including the forecast and actual
weather, together with an appreciation of the weather in
1.8.2 When relevant, include pertinent information on
retrospect. When relevant to the occurrence, the following
equipment on board the aircraft, such as autoflight system,
information should be included:
flight management system (FMS), global positioning
system (GPS), and inertial navigation system (INS),
— Describe when, where and how the pilot obtained
including their serviceability. Relevant maps, charts,
weather information;
approach plates and radar recordings should also be
discussed and included in, or attached to, the report.
— Weather forecast: Route and aerodrome forecasts
available to the pilot, and details of any weather
briefing obtained by the pilot prior to departure or 1.9 Communications
received en route;
1.9.1 Describe the communication facilities available
— Weather observations at the time and place of the to the flight crew and their effectiveness. Describe the
occurrence including precipitation, ceiling, communications with the air traffic services and other
visibility, runway visual range, wind speed and communications relevant to the flight, including reference
direction, temperature and dewpoint; to communication logs and transcripts of recordings. When
essential to the analysis and understanding of the
— Actual weather on the route of the flight, including occurrence, pertinent extracts from the transcripts of air
weather observations, SIGMETs, pilot reports and traffic services communications recordings should be
witness accounts; included in this section or attached to the report.

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1.10 Aerodrome information could not be extracted, describe the reasons for the
malfunction or loss of data. Include techniques used to
1.10.1 When the occurrence took place during take- extract data and any problems encountered. If the recorders
off or landing, include information concerning the operated properly, a short statement to this effect should be
aerodrome and its facilities. When relevant, include the made and the pertinent data presented.
following information:
1.11.3 In this section, provide information recorded
— Name of aerodrome, location indicator, reference by the flight recorders. Because of the length of a flight
point (latitude/longitude) and elevation; data recording read-out report, include here or in an
appendix to the Final Report only those parts of the read-
— Runway identification, runway markings, runway out reports which are pertinent to the analysis and findings.
length and slope, length of overrun, and
obstructions; 1.11.4 Transcripts from the cockpit voice recordings
should be included in the Final Report or its appendices
— Runway conditions, such as pavement texture and only when essential to the analysis and understanding of
grooving, rubber deposits, presence of water, slush, the occurrence. Parts of the recordings not essential to the
snow, ice, friction coefficient and braking action; analysis shall not be disclosed. Chapter 5 of Annex 13
contains provisions pertinent to transcribed voice
— Lighting, such as runway, taxiway and stopway recordings and should be taken into account when it is
lighting; and visual aids, such as visual approach considered necessary to include such transcripts in the Final
slope indicator system (VASIS) and precision Report or its appendices.
approach path indicator (PAPI);
1.11.5 If the aircraft was not required to be equipped
— Runway inspection programmes and inspections with flight recorders, a statement along the following lines
carried out; and may be used: “The aircraft was not equipped with a flight
data recorder or a cockpit voice recorder. Neither recorder
— Bird and wildlife programmes. was required by the relevant aviation regulations.”

1.10.2 If the aircraft was taking off from, or landing


on, an area other than an aerodrome, relevant information 1.12 Wreckage and impact information
on the take-off or landing area should be given.
1.12.1 Provide a general description of the site of the
1.10.3 This section should be divided into departure accident and the distribution pattern of the wreckage,
aerodrome information and destination aerodrome including the final portion of the flight path, the impact
information, if both aerodromes were pertinent to the path, the impact sequence and the location of impact
occurrence. impressions on the ground, trees, buildings and other
objects. The impact heading, aircraft attitude (pitch, roll
and yaw) and aircraft configuration at impact should be
1.11 Flight recorders given. When relevant, the terrain surrounding the site of the
accident should be described. Relevant wreckage dis-
1.11.1 Provide the particulars for each flight recorder, tribution diagrams, charts and photographs should be
such as manufacturer, model, number of parameters included in this section or appended to the report. The
recorded, recording medium and duration of the recording. location and the state of the major parts of the wreckage
The recorders would include flight data recorders (FDR), should be presented. In case of an in-flight break up of the
cockpit voice recorders (CVR), quick access recorders, aircraft, a detailed description of the wreckage distribution
engine parameter recorders, video recorders, non-volatile should be provided.
memory chips in aircraft systems, and other on-board or
ground-based recorders. 1.12.2 In major accident investigations, it might be
necessary to present the examination of the wreckage and
1.11.2 Describe the condition of the recorders on the technical investigations under appropriate sub-headings
recovery, in particular their exposure to fire and impact in this section, such as structures, power plants,
forces. If the flight recorder(s) could not be recovered, the instruments, flight controls and systems. The descriptions
reasons should be explained. If data was not recorded or under each sub-heading should embrace the significant

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facts determined by the group which was responsible for should be taken that such information is disclosed in the
the detailed investigation. Under appropriate sub-headings Final Report only when pertinent to the analysis and
also include the relevant results of special technical conclusions of the accident.
investigations, examinations and laboratory tests, and the
significance of the results obtained (see also Section 1.16 1.13.5 If the medical examinations indicate that the
— Tests and research). When relevant, the technical performance of flight crew members was not degraded, a
laboratory and test reports should be appended to the Final sentence along the following lines may be used: “There
Report. was no evidence that physiological factors or incapacitation
affected the performance of flight crew members.”
1.12.3 It is important to include all pertinent material
failures and component malfunctions, and to indicate
whether they occurred prior to or at impact. It is essential 1.14 Fire
that failed or malfunctioning components which are
deemed to be significant to the accident be described. A 1.14.1 If a fire or an explosion occurred, give a brief
detailed description of all wreckage components is not description of whether the fire started in flight or after
necessary; describe only components considered to be ground impact. For in-flight fires, describe the effectiveness
relevant or which required examination and analysis. The of the aircraft fire warning systems and the aircraft fire
inclusion of drawings of components and photographs of extinguishing systems. The determination of the origin of a
specific failures will enhance the Final Report. Such fire, source of ignition, fuel source, duration, severity and
drawings and photographs could be presented together with effects on the aircraft structure and the occupants usually
the appropriate text or as an appendix. requires an analysis of the facts and indications, and should
therefore be dealt with in the analysis part of the Final
Report. This section should describe the factual information
1.13 Medical and pathological information which was established in the investigation related to the fire
and which should then be discussed and analysed in the
1.13.1 Describe the results of the medical and analysis part.
pathological investigations of the flight crew. Medical
information related to flight crew licences should be 1.14.2 For fires on the ground, describe the
included under Section 1.5 — Personnel information. propagation and the extent of the fire damage. The response
When relevant to the accident, the medical investigation time of the rescue fire service, access to the accident site by
may also concern the cabin crew members, passengers and the rescue fire service vehicles, the type of fire fighting
ground personnel. equipment used, the type of extinguishing agent and the
amount that was used and its effectiveness should also be
1.13.2 The results of the pathological and described.
toxicological examinations concerning injuries, detection of
disease and factors which impaired human performance, 1.14.3 The effect of the fire on the evacuation and
such as carbon monoxide, oxygen deficiency, alcohol and survivability of the occupants should be described in
other drugs, should be stated. If alcohol and drugs are Section 1.15 — Survival aspects.
detected, their effects on human performance as determined
by medical experts should be presented in this section. 1.14.4 If there was no fire, a sentence along the
following lines may be used: “There was no evidence of
1.13.3 Describe the pathological evidence of fire in flight or after the impact.”
significance to the survival investigation such as the
relationship of injuries and pathological evidence to the
deceleration forces, aircraft attitude at impact, seat design 1.15 Survival aspects
and attachments, seat belts (see also Section 1.15 —
Survival aspects), break-up of the aircraft structure, smoke 1.15.1 Give a brief description of the search and
inhalation, decompression and any evidence of preparation rescue activities. When applicable, include information
for an emergency situation, such as forced landing, ditching regarding the serviceability and effectiveness of the
and unlawful interference. emergency locator transmitters.

1.13.4 Given the provisions of Annex 13, Chapter 5 1.15.2 The location of crew members and passengers
with regard to medical and private records, particular care in relation to injuries sustained should be stated. The failure

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of structures, such as seats, seat belts and overhead bins — operator;


should be described. Also, the use and effectiveness of
safety equipment should be reported. Aspects pertinent to — maintenance organizations;
the crashworthiness of the aircraft should be addressed, as
well as occupant survivability in relation to impact forces — air traffic services;
and fire.
— aerodrome administration;
1.15.3 If an evacuation was conducted, a description
of the following information is usually included: — meteorological services;

— first notification of an accident to the emergency — aircraft manufacturer;


services and the response time;
— certification and licensing authority; and
— emergency lighting in the aircraft (installation,
activation, functioning and failures); — regulatory authority.

— communications; 1.17.2 When deficiencies in the organizational


structure and functions had a bearing on the accident, the
— passenger behaviour and carry-on baggage; information could include, but need not be limited to, the
following factors:
— emergency exits (types of exits and their use);
— safety culture;
— evacuation slides (types of slides, activation and
their use); — resources and financial viability;

— injuries sustained in the evacuation; and — management policies and practices;

— post-evacuation events. — internal and external communications; and

— certification, safety oversight and regulatory


1.16 Tests and research framework.

1.16.1 Describe the results of any tests and research 1.17.3 When relevant, provide pertinent information
undertaken in connection with the investigation. Flight concerning the operator, such as type and date of issuance
tests, simulator tests and computer modelling of aircraft of the air operator certificate, types of operations
performance are examples of the type of information that authorized, types and number of aircraft authorized for use,
should be included in this section. Relevant details of and authorized areas of operation and routes. Also, include
research that is used to support the analysis should also be information concerning any deficiencies found in the
included. operator’s company operations manual and other operator
documentation, when the deficiencies had a bearing on the
1.16.2 The results of examinations of aircraft and accident.
engine parts may alternatively be included in Sections 1.6
— Aircraft information, 1.12 — Wreckage and impact
information or 1.16. 1.18 Additional information

1.18.1 Give relevant information and facts, not


1.17 Organizational and management information already included in Sections 1.1 to 1.17, which are essential
to the development of the analysis and conclusions parts of
1.17.1 When relevant to the accident, provide the Final Report.
pertinent information on any organization and its manage-
ment whose activities may have directly or indirectly Note.— Ensure that the factual information part of the
influenced the operation of the aircraft. The organizations Final Report contains all the technical data which is
to be addressed in this section could include: essential to the analysis and conclusions parts of the report.

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1.19 Useful or effective investigation techniques groups in a major investigation) will contribute to the
analysis part of the report, the development of an outline
1.19.1 When useful or effective investigation and sub-headings for the analysis part will ensure that the
techniques have been used during the investigation, briefly investigators know their drafting assignments. Such an
describe the main features of these techniques and their outline will also indicate to the investigators how the sub-
pertinence to future investigations. However, the data and headings will come together in forming the analysis part of
the results obtained as they relate to the accident, should be the Final Report. An example of such an outline is provided
included under the appropriate Sections 1.1 to 1.18. The in Table 1-2.
full report on the use of these techniques may be included
as an appendix to the Final Report.

3. CONCLUSIONS
2. ANALYSIS
This part should list the findings and the causes established
2.1 In the analysis part of the Final Report, the in the investigation. The conclusions are drawn from the
significance of the relevant facts and circumstances which analysis. However, it is essential to maintain the same
were presented in the factual information part should be degree of certainty in a conclusion as was established in the
discussed and analysed in order to determine which events analysis. For example, if the discussion in the analysis
contributed to the accident. There might be a necessity to indicates that an event or circumstance was likely, then the
repeat the description of some of the evidence already finding should contain the same qualifier (likely).
presented in the factual information part, however, the
analysis should not be a restatement of the facts. Also, no
new facts should be introduced in the analysis part. The 3.1 Findings
purpose of the analysis is to provide a logical link between
the factual information and the conclusions that provide the 3.1.1 The findings are statements of all significant
answer to why the accident occurred. conditions, events or circumstances in the accident
sequence. The findings are significant steps in the accident
2.2 The analysis part should contain an evaluation of sequence, but they are not always causal or indicate
the evidence presented in the factual information part and deficiencies. Some findings point out the conditions that
should discuss the circumstances and events that existed or pre-existed the accident sequence, but they are usually
may have existed. The reasoning must be logical and may essential to the understanding of the occurrence. The
lead to the formulation of hypotheses which are then findings should be listed in a logical sequence, usually in a
discussed and tested against the evidence. Any hypothesis chronological order.
which is not supported by the evidence should be
eliminated; it is then important to clearly state the reasons 3.1.2 All findings must be supported by and directly
why a particular hypothesis was rejected. When a related to the factual information and the analysis. No new
hypothesis is not based on fact but is an expression of factual information should be introduced in the findings.
opinion, this should be clearly indicated. As well, the
justification for sustaining the validity of a hypothesis 3.1.3 It is customary to report on certain conditions in
should be stated and reference should be made to the every investigation, such as the validity of licences, the
supporting evidence. Contradictory evidence must be dealt training and experience of the flight crew members, the
with openly and effectively. Cause-related conditions and airworthiness and maintenance of the aircraft, the loading
events should be identified and discussed. The discussion of the aircraft, and whether there was a pre-impact failure.
in the analysis should support the findings and the The following findings are typical of what is usually
immediate and systemic causes of the accident. included:

2.3 Also, discuss and analyse any issue that came to — The flight crew members were licensed and
light during the investigation which was identified as a qualified for the flight in accordance with existing
safety deficiency, although such issue may not have regulations;
contributed to the accident.
— The maintenance records indicated that the aircraft
2.4 Because the Final Report is often drafted as the was equipped and maintained in accordance with
investigation progresses and several investigators (all the existing 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 the
occupants are killed or injured. Based on these few facts, the investigator-in-charge can identify many of the areas to
be investigated and analysed. At an early stage of the investigation, the investigator-in-charge is able to allocate
drafting 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 qualifications


2.2.2 Operational procedures
2.2.3 Weather
2.2.4 Air traffic control
2.2.5 Communications
2.2.6 Aids to navigation
2.2.7 Aerodrome

2.3 Aircraft

2.3.1 Aircraft maintenance


2.3.2 Aircraft performance
2.3.3 Mass and balance
2.3.4 Aircraft instrumentation
2.3.5 Aircraft systems

2.4 Human Factors

2.4.1 Psychological and physiological factors affecting the personnel involved

2.5 Survivability

2.5.1 Rescue fire service response


2.5.2 Analysis of injuries and fatalities
2.5.3 Survival aspects

The tentative sub-headings in the analysis part may require adjustments as the investigation progresses, but the list
identifies the major areas that should be covered in the analysis. The list is a good starting point as it indicates to the
investigators 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 were 3.2.3 Some States list the causes, usually sequentially
within the prescribed limits; and as they occurred, without attempting to prioritize the
causes. Other States would prioritize the causes by using
— There was no evidence of airframe failure or system terms such as primary causes and contributing causes.
malfunction prior to the accident.
3.2.4 When certain of a cause, a definite statement
should be used; if reasonably sure of a cause, a qualifying
3.1.4 Significant events and factors that were
word such as “probable” or “likely” should be used. The
investigated in detail, but eliminated in the analysis, should
causes statement is usually a reiteration of statements made
also be stated in the findings. For example, findings such as
at or near the end of the analysis and in the findings. For
“flight crew fatigue was not a factor in the accident” and
example, if the analysis and the findings state that a cause-
“there was no malfunction of the elevator control system”
related event or circumstance was “probable”, then the
should be considered when a comprehensive investigation
causes statement should contain the same qualifier
was made into these aspects. Areas of ambiguity should be
(probable).
identified and stated, for example, “the investigation was
unable to establish whether the pilot-in-command or the co- 3.2.5 When there is insufficient evidence to establish
pilot was the pilot flying the aircraft at the time of the why an accident occurred, there should be no hesitation in
accident”. stating that the causes remain undetermined. In many
instances, the most likely scenario could be stated provided
3.1.5 Some States present the causes of the accident that a qualifier, such as “likely” or “probable” is included.
separately from the findings under their own heading. However, a list of possible causes should not be given.
Other States indicate in the list of findings which of the
findings were causes of the accident, for example by adding 3.2.6 The causes should be formulated in a way
after such a finding “(causal factor)” or “(contributory which, as much as practicable, minimizes the implication of
factor)”. blame or liability. Nevertheless, the accident investigation
authority should not refrain from reporting a cause merely
because blame or liability might be inferred from the
3.1.6 Examples of frequently used findings in
statement of that cause. An example of a formulation of the
accident reports are listed in Appendix 5 to Chapter 1.
causes is given in Table 1-3.

3.2 Causes
4. SAFETY RECOMMENDATIONS
3.2.1 Causes are those events which alone, or in
4.1 In accordance with Annex 13, the sole objective
combination with others, resulted in injuries or damage. A
of the investigation of an accident shall be the prevention
cause is an act, omission, condition or circumstance which
of accidents and incidents. Therefore, the determination of
if eliminated or avoided would have prevented the
appropriate safety recommendations is of utmost
occurrence or would have mitigated the resulting injuries or
importance. The safety recommendations are actions which
damage.
should prevent other accidents from similar causes or
reduce the consequences of such accidents. In order to
3.2.2 The determination of causes should be based on ensure that appropriate action is taken, each safety
a thorough, impartial and objective analysis of all the recommendation should include a specific addressee. This
available evidence. Any condition, act or circumstance that is usually the appropriate authority of the State which has
was a causal factor in the accident should be clearly responsibility for the matters with which the safety
identified. Seen together, the causes should present a recommendation is concerned.
picture of all the reasons why the accident occurred. The list
of causes should include both the immediate causes and the 4.2 Annex 13 requires that at any stage of the
deeper or systemic causes. No new information should be investigation of an accident, the accident investigation
introduced in the causes. The causes should be presented in authority of the State conducting the investigation shall
a logical order, usually chronological order, bearing in recommend to the appropriate authorities, including those
mind that it is essential that all the causes be presented. The in other States, any preventive action that is considered
causes should be formulated with preventive action in mind necessary to be taken promptly to enhance aviation safety.
and linked to appropriate safety recommendations. 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 and • the known and uncorrected lack of runway drainage;
correct poor runway drainage;

• the failure of the air traffic controllers to inform • lack of communication between the ATC and the
the flight crew that there was standing water on the flight crew regarding the degenerated runway
runway; condition;

• the flight crew’s mismanagement of the aircraft’s • the aircraft crossing the threshold 16 knots above
airspeed; and Vref; and

• the flight crew’s mismanagement of thrust • the late application of reverse thrust.
reversers.

Note. — The causal statement to the left implicates three groups of persons -— the flight crew, the airport
management 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 required
for safe operation. Such a functional statement logically leads to corrective or preventive measures that should be
recommended to prevent future accidents.

investigation may be presented in the safety for the authorities responsible for the matters in question to
recommendations part of the Final Report. Also, the determine how to accomplish the objective of the
preventive actions taken in response to the interim recommendation. This is particularly important if all the
recommendations should be presented, as well as any other salient facts are not available and additional examination,
preventive actions taken by the appropriate authorities and research and testing appears necessary. In addition, the
the industry, such as changed operating procedures by the accident investigation authority may lack the detailed
aircraft operator and the issuance of service bulletins by the information and experience required to evaluate the
manufacturer. Some States present the interim safety financial, operational and policy impacts on the addressee
recommendations and describe the preventive actions taken of specific and detailed recommendations.
in the factual information part, Section 1.18, in lieu of
including this information in the safety recommendations 4.4 During aircraft accident investigations, safety
part. Publishing the preventive actions taken in the Final issues are often identified which did not contribute to the
Report has significant accident prevention value for those accident but which, nevertheless, are safety deficiencies.
involved in similar operations. These safety deficiencies should be addressed in the Final
Report. Some States include safety recommendations not
4.3 A safety recommendation should describe the related to the causes of the accident in the safety
safety problem and provide justification for safety actions. recommendations part of the Final Report. Other States
An example of a recommendation is given in Table 1-4. have adopted means other than the Final Report to notify
Attention should be focussed on the problem rather than the the appropriate authorities of safety deficiencies that are not
suggested solution. Consideration should be given to related to the accident, although the actions taken are
whether a safety recommendation should prescribe a usually described in the Final Report.
specific solution to a problem or whether the
recommendation should be flexible enough to allow the 4.5 In summary, the safety recommendations should
addressee latitude in determining how the objective of the include a convincing presentation of the safety problem with
recommendation can be achieved. A safety recommen- the attendant safety risks deriving from it, as well as a
dation should identify what actions to take, but leave scope recommended course of action for the responsible authority

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IV-1-16 Manual of Aircraft Accident and Incident Investigation

to take in order to eliminate the unsafe condition. The safety appearance and should show only the information required
recommendations should identify what action is required, but for understanding the report. The appendices should be
should leave considerable scope for the implementing numbered and listed in the table of contents. The following
authority to determine how the problem will be resolved. is a list of appendices commonly found in a Final Report:

— communications transcripts;
APPENDICES — flight data recorder readouts;
— flight plan and loadsheet;
The appendices should include, as appropriate, any — technical investigation reports;
pertinent information considered necessary to understand — pertinent pages from manuals and handbooks;
the report, such as a glossary, supporting technical reports, — pertinent maintenance records;
accident site diagrams, photographs and flight recorder — maps and diagrams; and
data. Graphics and diagrams should have a professional — 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 in
Annex 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 latitude
in determining how to achieve the objective of the recommendation. It should be left to ICAO to determine how
the work is to be undertaken, e.g. working group, consultant or panel. A general statement, such as “international
requirements” could also be used, thus leaving it to ICAO to determine whether Standards, Recommended
Practices and/or guidance material would be appropriate to meet the objective of the recommendation. Based on
the foregoing reasoning, the following formulation of the safety recommendation would be preferable:

“The (accident investigation authority) recommends that ICAO re-examine the international requirements in
Annex 14 regarding the marking of runway centrelines in relation to co-located threshold markings and turn-
around areas.”

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APPENDIX 'H'

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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:

 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.

He/ She may be permitted to carry out the above functions.

(B. S. Rai)
DDG
(*) Delete whichever is not applicable