Embed Size (px)
Citation preview
© Entry Point North AB
ACCIDENT / INCIDENT INVESTIGATION
TABLE OF CONTENTS
FOREWORD
CHAPTER 1. Definitions
CHAPTER 2. Applicability
CHAPTER 3. General ● Objective of the investigation
● State safety programme
● Protection of evidence, custody and removal of aircraft
● Responsibility of the State of Occurrence
● Release from custody
TABLE OF CONTENTS
CHAPTER 4. Notification Responsibility of
● the State of Occurrence
● the State of Registry,
● the State of the Operator,
● the State of Design and
● the State of Manufacture
TABLE OF CONTENTS
CHAPTER 5. Investigation ● Responsibility for instituting and conducting the investigation
● Organization and conduct of the investigation
● Participation in the investigation
● Participation of other States
● Entitlement of accredited representatives
● Participation of States having suffered fatalities or serious injuries to its citizens
TABLE OF CONTENTS
CHAPTER 6. Final Report ● Responsibility of any State
● Responsibility of the State conducting the investigation
● Consultation
● Recipient States
● Release of the Final Report
● Safety recommendations
● Responsibility of a State receiving or issuing safety recommendations
● Action on safety recommendations
TABLE OF CONTENTS
CHAPTER 7. ADREP Reporting
CHAPTER 8. Accident Prevention Measures ● ATTACHMENT A. Rights and obligations of the State of the Operator in respect of accidents and
incidents involving leased, chartered or interchanged aircraft
● ATTACHMENT B. Notification and reporting checklist
● ATTACHMENT C. List of examples of serious incidents
● ATTACHMENT D. Guidelines for flight recorder read-out and analysis
● ATTACHMENT E. Legal guidance for the protection of information from safety data collection and
processing systems
● ATTACHMENT F. Framework for the State safety programme (SSP)
● ATTACHMENT G. Guidance for the determination of aircraft damage
DEFINITIONS
Accident.
● An occurrence associated with the operation of an aircraft which, in the case of a
manned aircraft, takes place between the time any person boards the aircraft with
the intention of flight until such time as all such persons have disembarked, or in
the case of an unmanned aircraft, takes place between the time the aircraft is
ready to move with the purpose of flight until such time as it comes to rest at the
end of the flight and the primary propulsion system is shut down, in which:
● a) a person is fatally or seriously injured
● b) the aircraft sustains damage
● c) the aircraft is missing or is completely inaccessible
DEFINITIONS
Serious injury.
● An injury which is sustained by a person in an accident and which:
● a) requires hospitalization for more than 48 hours, commencing within
seven days from the date the injury was received; or
● b) results in a fracture of any bone (except simple fractures of fingers, toes
or nose); or
● c) involves lacerations which cause severe hemorrhage, nerve, muscle or
tendon damage; or
● d) involves injury to any internal organ; or
● e) involves second or third degree burns, or any burns affecting more than
5 per cent of the body surface; or
● f) involves verified exposure to infectious substances or injurious radiation.
DEFINITIONS
Serious incident.
● An incident involving circumstances indicating that there was a high
probability of an accident and associated with the operation of an
aircraft which, in the case of a manned aircraft, takes place between the
time any person boards the aircraft with the intention of flight until
such time as all such persons have disembarked, or in the case of an
unmanned aircraft, takes place between the time the aircraft is ready to
move with the purpose of flight until such time as it comes to rest at the
end of the flight and the primary propulsion system is shut down.
DEFINITIONS
● State of Design. The State having jurisdiction over the organization
responsible for the type design.
● State of Manufacture. The State having jurisdiction over the organization
responsible for the final assembly of the aircraft.
● State of Occurrence. The State in the territory of which an accident or
incident occurs.
● State of the Operator. The State in which the operator’s principal place of
business is located or, if there is no such place of business, the operator’s
permanent residence.
● State of Registry. The State on whose register the aircraft is entered.
What is an investigation?
● Why do we conduct accident investigations? ● What is the main purpose?
GENERAL
● The sole objective of the investigation of an accident or incident shall be the
prevention of accidents and incidents.
● It is not the purpose of this activity to apportion blame or liability.
Investigation phases
Fact finding
Analazys Report writing
Recommendations Conclusions
Investigation
Elements within an investigation
● What happened?
● Who was involved?
● Where did it happened?
● When did it happened?
● Describe Chain of event
● Why did it happened? ● Establish
● main cause
● contributing factors
● root causes
Elements within an investigation
● The investigation should also include an examination of post-
occurrence human-survival factors (e.g. crashworthiness, search
and rescue, emergency response) to the extent that they
contributed to or reduced the severity of the occurrence.
Criteria for an investigation
● Realistic
● Non blame
● Consequent
The goal of an investigation is to determine.......
Who
What
When
Where
How
Why
Who was involved?
● Determine who was involved in the accident/incident. ● Who has vital information about the accident
● Include all, not just own personell
● Don´t forget wittnesses
When did it happened?
● All relevant dates and point of time ● might go far back in time
● describe time and dates in chronological order
JAS 39 ”U 59” 2007-04-19
Occurence reports
Where did it happened?
● Describe where the accident/incident occured. ● Location
● Airspace
● Facility
● Position
Why did it happened?
Base on: Who
What
When
Where
How
You might be able to establish why the accident/incident occured
Put all information/facts together
How did it happened?
● Describe chain of events in a chronological order ● All Contributing factors
● Who did what an why
● What was the outcome of each event
Definitions
Accident: ● A sequence of logical and chronological related events that result in harm or
danger for life, equipment and or environment.
Causes: ● Parts in accident/incident scenario that influence or create undesired results.
● Main cause
● Contributing factors
● Root causes
Definitions
Main cause:
● The direct cause of the accident/incident
Contributing factors:
● An event that together with other events increse the risk of an
accident/incident.
● Does not create an accident /incident by it self
Root causes:
● Underlying causes ● Without root causes the accident would never had occured
Causes
Depending on what to investigate the
main cause, contributing factors and
root causes may differ.
Example
An employee breaks his leg when he slips on the floor because of spilled coffe wich made the floor slippery
What was the causes that broke the leg?
Causes Event
Main cause Employee slips
Contributing factors There was coffe on the floor The coffe made the floor slippery
Root cause The coffe was not dried up after it was spilled
Example
An employee breaks his leg when he slips on the floor because of spilled coffe wich made the floor slippery
What was the causes that the employee slipped?
Causes Event
Main cause There was coffe on the floor
Contributing factors The coffe made the floor slippey
Root cause The coffe was not dried up after it was spilled
Often an accident/incident is caused by more than one cause.
Mission
Equipment
Human Factors
Management
Economy
Have in mind as investigator......
● An investigation should point out what happened, why it happened and how to prevent it from happening again.
● An investigation should not be judging
● Assume that everybody involved has done their best to avoid the accident, until other is proved.
● Investigate until you find the root cause
● Only use facts
● Don´t assume things
● Behave with integrity
● Suppress personal feelings
Investigation phases
Fact finding
Analazys Report writing
Recommendations Conclusions
Investigation
What is facts?
● refer to a particular situation that exists
● a thing that is known as true
● something that can be proved
Collect facts Involved personnel and witnesess
● Who was involved? ● AFISO ● Pilots ● Ground crew ● Maintenance ● Witnesess
● Education, License, Ratings, Endorsment ● Health ● Attitudes
● Human factor check list
Interview • How did they perceive the situation? • What did they do? • How did they do it? • Why did they do it? • When did they do it? • Where did they do it? • What was the consequences?
Check documentation Ask the involved Ask others
Can you trust a wittness?
Interviewing Introduction
● Your role as an interviewer is to obtain evidence from the witness that is as accurate, complete, and detailed as possible.
● Can be described as a conversation with a specific goal
● Goal is to gather information about a specific event
● Be open minded while interviewing
Interviewing
● Statements should be taken as soon as possible after the accident
● It is always very useful to hear witnesses at the place where they happened to be at the time of the accident.
● It is strongly recommended that discussions with witnesses be in
isolation in order to avoid influencing other witnesses
● Wherever possible witnesses should be encouraged to refrain from discussing their evidence among themselves before it has been taken down.
● No statement should be discarded out of hand.
● It is a sound practice for the investigator to be accompanied by a person who can take down the statement or use a tape recorder to record the statement
Reno Air show
The interview process - Opening
When opening an interview, the investigators should reassure the interviewee
about:
● The purpose of the investigation (not for blame)
● Their roles as investigators in the accident
● The goals of the interview
● The importance of the information the interviewee may provide
● The interviewee‘s rights
● Protection of the statement made by the interviewee
● Use of tape recorder, if the interviewee has no objection
● The interview procedure to be followed
ATS Investigation
Personal Record ● a) full name ● b) contact address and telephone number/s ● c) date of birth ● d) type of air traffic services license/certificate ● e) total length of service ● f) length of continuous service at relevant location ● g) ratings held and date/s obtained ● h) operating position occupied at the time of the occurrence ● i) proficiency check records ● j) medical history (recent illness, last medical examination, investigation of fatigue factor
including an assessment of duty time and rest time within the 28 days preceding the occurrence and particularly within the last week and last 72 hours)
● k) initial and continuation training (including assessments) ● l) use of corrective and/or anti-glare lenses
ATS Investigation
Navigation The navigation facilities may comprise terrestrial components such as NDBs, VOR, DME, ILS,
LORAN, ATS surveillance systems equipment and space-based GNSS and its augmentation.
● location (geographic co-ordinates)
● identification signal
● power output and supply
● emergency equipment - warning system(s) recording of malfunction
● equipment calibration and radiation pattern
● operating and maintenance schedules, and their notification (AIP, NOTAMs)
● normal level of performance
● interference(s)
● past complaints, interruptions and failures (crew, operation, etc.)
● statements from relevant personnel including other aircrew who used these aids
ATS Investigation
Aerodrome Facilities
● characteristics of the runway(s) in use
● characteristics of the movement areas
● surrounding terrain, obstructions and meteorology characteristics
● aerodrome diagrams
● lighting and guidance signage
● electronic surface movement detection systems
● standard, contingency and emergency operating procedures
● visual and electronic navigation aids
● communications networks
● environmental conditions
● facility status register
ATS Investigation
Communications Facilities, Procedures and Phraseology
certain specific data should be provided with each transcript and a uniform
presentation should be adopted:
● each succeeding page may contain at least the following columns; ● i) time indications
● ii) sending stations
● iii) receiving stations
● iv) material which was read-out without difficulty
● v) doubtful or unintelligible material
● vi) remarks of the person(s) responsible for the transcript.
ATS Investigation
Standard Operating Procedures and Practices ● National legislation ● ICAO Annexes ● ICAO Procedures for Air Navigation Services ● air traffic services manuals and instruction circulars ● workstation/sector handbooks and/or instructions ● copies of any pertinent letters of agreement ● map/chart of area of responsibility ● co-ordination requirements with other units ● aeronautical information publications ● applicable aircraft proximity standard/s ● NOTAMs ● flight progress preparation, processing and displays ● level change and non-standard flight levels procedures ● communications, navigation and surveillance procedures
• Up to date • Readable • Understandable • Spread • Used
ATS Investigation
ATS Duties and Functions
● duties and functions
● area of responsibility
● air traffic management responsibilities
● co-ordination responsibilities
ATC Investigation
Work Practices and Staffing
● applicable regulations and standard operating procedures were satisfactory
● differences existed between workload and human resources
● effective use was made of all known and relevant information
Dependent upon the nature of the occurrence, some or all of the following
items may be relevant:
● prescribed work practices
● actual and required staffing requirements
● licensing and staffing qualifications/requirements
● ratings qualifications/requirements
● initial and continuation training
AERODROME INVESTIGATION
Runway in use
● dimensions (length and width) of runways, stopways, clearways, runway
strips, runway end safety areas (RESA), deceleration areas and shoulders
● location of threshold at the time of the accident ● this should address the intentional use of less than full runway available
● is the position visible from the tower (blind spots)?
● runway markings: including center line, side stripe, and touchdown zone
markings.
● runway designation, threshold, fixed distance, and taxi-holding position
markings.
AERODROME INVESTIGATION
Runway in use
● runway signs including hold-position signs, ILS critical area signs, distance
remaining signs and destination signs as appropriate.
● Lighting ● approach (type, dimensions, color, intensity)
● VASIs, PAPIs and PLASI (check alignment)
● runway edge, threshold, and end (color, intensity) and number and locations of inoperative
fixtures.
● runway center line and acute-angle taxi center line (color, intensity and number and locations
of inoperative fixtures.)
● runway touchdown zone, distance remaining marker illumination and locations, land-hold
short lighting
● Runway environment and background lighting contrast including lighting distractions such as
laser lights or special events
AERODROME INVESTIGATION
Runway in use
● runway surface condition–describe levels, textures and dimensions of
contaminants ● Surface type
● current condition (dry, wet, ice, snow, slush, etc)
● excessive rubber buildup
● presence of debris (potential for foreign object damage (FOD))
● evaluate the frequency and adequacy of runway sweeping schedules
● texture and coefficient of friction measurement, conduct pavement texture measurements and
coefficient of friction evaluations in accordance with ICAO Airport Services Manual, Part 2, as
appropriate, utilizing approved continuous friction measuring equipment (CFME).
AERODROME INVESTIGATION
Taxiways ● bearing strength
● dimensional adequacy, shoulders
● markings
● lighting ● taxiway (center line, edge, surface movement guidance and control and aerodrome sign
illumination, etc.)
● obstruction
● obstructions
● current condition ● i) dry, wet, ice, snow, slush, , etc
● ii) presence of debris (potential for foreign object damage (FOD))
● iii) evaluate the frequency and adequacy of runway sweeping schedules.
● layout
● work-in-progress (NOTAM or ATIS applicable)
AERODROME INVESTIGATION
● obstructions, construction hazards and frangibility. ● Describe ditches, holes or depressions within or near safety areas and ascertain the degree
of frangibility of near runway equipment or markings.
● work in progress (NOTAM or ATIS applicable)
● wildlife hazards – history and description of aerodrome program(s) for
reducing incursions with aircraft by wildlife and relevant NOTAMs or ATIS, if
any.
AERODROME INVESTIGATION
Apron or Ramp ● bearing strength ● condition ● markings
● signage ● “red” zones ● FOD areas ● paintovers ● nosewheel stop markings
● lighting (edge, floodlights, etc) ● obstacles ● Jetways ● proximity to active runways ● vehicle operations ● high power areas ● blind spots
AERODROME INVESTIGATION
Ground Icing
● De-Icing and anti-icing methods
● De-icing and anti-icing checks
● De-icing and anti-icing fluids
● Handling of de-icing and anti-icing fluids
● Holdover times
● Updating of holdover time guidelines and de-icing/anti-icing procedures
Recorders
CVFDR CVR Cockpit Voice Recorder FDR Flight Data Recorder CVFDR Combo
Visual recordings
● In some cases, passengers on board or witnesses on the ground have
digital or video cameras or an aircraft may be equipped with a recording
device to capture scenic flights.
● Security cameras on the airport may show info on loading, or on bridges,
tolls, buildings in the vicinity of the accident or on the airport.
● Many of these devices record their data in compressed or proprietary
formats which makes recovery more challenging.
Horrific plane crash Afgahnistan CCTV video of Tupolev
Radar data and ATC transcript
● Radio recordings
● Ambient voice recorder
● Coordination equipment
● Telephones
Transcripts
Photos Films
Audio recordings
Collect facts Fact meeting
● When you have collected all relevant and interesting facts
● Invite all involved to a meeting
● Show all facts
● See if you interpreted facts correctly
● Give the involved an opportunity to comment or clarify
● Insurance that your facts are relevant and correct before you start
analyzing
Collect facts Findings
● Information that is discovered as the result of research
● Things that contributed to the accident
● Things that do not contribute to the accident but can enhance safety if it is
corrected
Analysis of facts
● Check if and how found findings influenced the chain of event ● When
● How
● Consequences
Time line
Accident Event Event Event Event
Broken Barrier
Factor
Primary sequence
Secundary sequence Event Event
● Create a time line in chronological order ● What happened when
● Start with the accident and work back in time
● Should be based on pure facts
● Show that you have considered what others think
Barriers
● Physical barriers ● Physically stops something from happening or prevent consequences
● Functional barriers ● Prevent by some kind of function
● Symbolic barriers ● Action required
● Constitutional barriers ● Builds on knowledge
Errors
Perceptual Errors
Skill-Based Errors
UNSAFE ACTS
Errors
Decision Errors
Exceptional Routine
Violations
Inadequate Supervision
Planned Inappropriate
Operations
Failed to Correct Problem
Supervisory Violations
UNSAFE SUPERVISION
Substandard Conditions of Operators
PRECONDITIONS FOR
UNSAFE ACTS
Substandard Conditions of Operators
PRECONDITIONS FOR
UNSAFE ACTS
Adverse Physiological States
Physical/ Mental
Limitations
Adverse Mental States
Adverse Mental States
Personal Readiness
Interpersonal Resource Mismanagement
Substandard Practices of Operators
Resource Management
Organizational Climate
Organizational Process
ORGANIZATIONAL INFLUENCES
Case study
● No physical check of patient (direct cause)
● Bad routines (contributing factor)
● Problem with monitors (latent factor)
● Handeling occurence reports (latent factor)
● Risk management (latent factor)
● Resources (latent factor)
Case study
Who is responsible?
Problem solved!! Will never happen again!! =
OR?????
Conclusions
All events or circumstances that could have had impact on the accident
or if they were not present should have minimized or prevented the accident
Main cause
Contributing factors
Root cause
Conclusions
● Conclusions, should flow logically from the analysis. The conclusions stated
should be consistent with the analysis and all hazards should be identified
appropriately.
● Important findings may be paraphrases or duplications of the conclusions
drawn in the analysis.
● Investigators must be careful to use the same degrees of certainty in their
conclusions as they have established in their analyses.
THE FINAL REPORT
The Final Report should provide:
● a record of all the relevant facts (including any conflicting evidence);
● an analysis of the relevant facts;
● conclusions in the form of findings and causes; and
● safety recommendations.
Report writing
● ICAO Annex 13 as platform
● Title
● Synopsis
● Body ● Facts
● Analysis
● Conclusion
● Recommendations
● Appendix
Content of the report
● 1. FACTUAL INFORMATION
● 1.1 History of the flight
● 1.2 Injuries to persons
● 1.3 Damage to aircraft
● 1.4 Other damage
● 1.5 Crew members
● 1.6 Aircraft information
● 1.7 Meteorological information
● 1.8 Aids to navigation
● 1.9 Radio communications
● 1.10 Airport data
● 1.11 Flight recorders
● 1.12 Location of incident
● 1.13 Medical information
● 1.14 Fire
● 1.15 Survival aspects
● 1.16 Tests and research
● 1.18 Additional information
2. ANALYSIS 3 STATEMENT 3.1 Findings 3.2 Causes of the incident 4. RECOMMENDATIONS 5. APENDIX
Recommendations
● Prevent that similar events will happen again
● Minimize consequences
● Realistic
● Should be based on a finding (Contributing / Not contributing)
● All causes must not end up in recommendation
● Be aware of how you write recommendations ● Who is resposible for what and how to improve
