COUNCIL DIRECTIVE 9456EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents.pdf

8/14/2019 COUNCIL DIRECTIVE 9456EC of 21 November 1994 establishing the fundamental principles governing the investig

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No L 319/14 Official Journal of the European Communities 12. 12. 94

COUNCIL DIRECTIVE 94/56/ECof 21 November 1994

establishing the fundamental principles governing the investigation of civil aviationaccidents and incidents

THE COUNCIL OF THE EUROPEAN UNION

Having regard to the Treaty establishing the EuropeanCommunity, and in particula r Article 84 2) thereof,Having regard to the proposal from the Commission 1 ),Having regard to the opinion of the Economic and SocialCommittee 2),Acting in accordance with the procedure referred to mArticle 189c of the Treaty 3),Whereas a high general level of safety should bemaintained in civil aviation in Europe and all effortsshould be made to reduce the number of accidents andincidents;Whereas the expeditious holding of technicalinvestigations of civil aviation accidents and incidentsimproves air safety in helping to prevent the occurrenceof such accidents and incidents;Whereas account should be taken of the Convention onInternational Civil Aviation, signed in Chicago on 7December 1994 which provides for implementation ofthe measures necessary to ensure the safe operation ofaircraft; whereas particular account should be taken ofAnnex 13 to this Convention which lays downrecommended international standards and practices foraircraft accident investigation;Whereas, according to the international standards inAnnex 13, the investigation of accidents is to be carriedout under the responsibility of the State. where theaccident occurs;Whereas if, in the case of serious incidents, investigationis not carried out by the State where the incident occurs,such investigation should be conducted by the State ofregistry;

1) OJ No C 257 22. 9. 1993, p. 8, OJ No C 109, 19. 4. 1994,p. 14.2) OJ No C 34, 2. 2. 1994, p. 18.3) Opinion of the European Parliament of 9 March 1994 J

No C 91, 28. 3. 1994, p. 123), Council common position of16 May 1994 OJ No C 172, 24. 6. 1994, p. 46) andDecision of the European Parliament of 26 October 1994OJ No C 323, 21. 11. 1994).

Whereas investigation of serious incidents should becarried out in a similar way to investigation ofaccidents;Whereas the scope of investigations must depend on thelessons which can be drawn from them for theimprovement of safety;Whereas air safety requires investigations to be carriedout in the shortest possible time,Whereas investigators should be able to accomplish theirtasks unhindered;Whereas the Member States must, in compliance with thelegislation in force as regards the powers of theauthorities responsible for the judicial inquiry and, whereappropriate, in close collaboration with those authorities,ensure that those responsible for the technical inquiry areallowed to carry out their tasks in the best possibleconditions;Whereas investigation of accidents and incidents whichhave occurred in civil aviation should be carried out byor under the control of an independent body or entity inorder to avoid any conflict of interest and any possibleinvolvement in the causes of the occurrences being

i n ~ e s t i g a t e d

Whereas the body or entity should be suitably equippedand its tasks could include prevention activities;Whereas Member States should take measures to ensuremutual assistance, if required, m carrying outinvestigations;Whereas a Member State must be able to delegate thetask of carrying out an investigation to another MemberState;Whereas it is important for accident prevention to makepublic the findings of accident investigations in theshortest time possible;Whereas the particular nature of incidents should betaken into account when circulating the findings ofinvestigations into them;Whereas the safety recommendations resulting from anaccident or incident investigation should be duly takeninto account by the Member States;


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12. 12. 94 Official Journal of the European Communities No L 319/15Whereas the sole aim of the technical investigation is todraw lessons which could prevent future accidents andincidents and whereas therefore the analysis of theoccurrence, the conclusions and the safetyrecommendations are not designed to apportion blame orliability,

HAS ADOPTED THIS DIRECTIVE:

ArticleObjective

The purpose of this Directive is to improve air safety byfacilitating the expeditious holding of investigations, thesole objective of which is the prevention of futureaccidents and incidents.

Article 2Scope

1. This Directive shall apply to investigations into civilaviation accidents and incidents which have occurred inthe territory of the Community taking into account theinternational obligations of the ember States.

2. This Directive shall also apply outside the territory ofthe Community to:i) investigations into accidents involving aircraftregistered in a ember State, when suchinvestigations are not carried out by another State; .ii) investigations into serious incidents involving aircraftregistered in a Member State or operated by anundertaking established in a ember State, whensuch investigations are not carried out by anotherState.

Article 3Definitions

For the purposes of this Directive:a) accident means an occurrence associated with the

operation of an aircraft which takes place betweenthe time any person boards the aircraft with theintention of flight until such time as all such personshave disembarked, in which:1. a person is fatally or seriously injured as a resultof:

being in the aircraft, ordirect contact with any part of the aircraft,including parts which have become detachedfrom the aircraft, ordirect exposure to jet blast,

except when the injuries are from natural causes,self-inflicted or inflicted by other persons, or whenthe injuries are to stowaways hiding outside theareas normally available to the passengers andcrew; or2. the aircraft sustains damage or structural failurewhich:

adversely affects the structural strength,performance or flight characteristics of theaircraft, andwould normally require major repair orreplacement of the affected component,

except for engine failure or damage, when thedamage is limited to the engine, its cowlings oraccessories; or for damage limited to propellers,wing tips, antennas, tyres, brakes, fairings, smalldents or puncture holes in the aircraft skin;

3. the aircraft Is missing or S completelyinaccessibie;

(b) serious injury mens an injury which is sustained by aperson in an accident and which:1. requires hospitalization for more than 48 hours,commencing within seven days from the date theinjury was received; or2. results in a fracture of any bone (except simplefractures of fingers, toes, or nose); or3. involves lacerations which cause severehaemorrhage, nerve, muscle or tendon damage;

or

4. involves injury to any internal organ; or5. involves second or third degree burns, or anyburns affecting more than 5 of the bodysurface; or6. involves verified exposure to infectious substances

or harmful radiation;

c) fatal injury means an injury which is sustained by aperson in an accident and which results in his/herdeath within 30 days of the date of the accident;


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No L 319/16 Official Journal of the European Communities 12. 12. 94(d) causes means actions, omtsstons, events orconditions, or a combination thereof, which led to theaccident or incident;e) investigation means a process conducted for thepurpose of accident and incident prevention which

includes the gathering and analysis of information,the drawing of conclusions, including thedetermination of cause(s) and, when appropriate, themaking of safety recommendations;f) investigator-in-charge means a person charged, onthe basis of his qualifications, with responsibility forthe organization, conduct and control of aninvestigation;g) flight recorder means any type of recorder installedin the aircraft for the purpose of facilitatingaccident/incident investigations;

(h) undertaking means any natural person, any legalperson, whether profit-making or not, or any officialbody whether having its own legal personality ornot;i) operator means any person, body or undertakingoperating or proposing to operate one or moreaircraft;j) incident means an occurrence, other than anaccident, associated with the operation of an aircraftwhich affects or would affect the safety of

operation;(k) serious incident means an incident involvingcircumstances indicating- that an accident nearlyoccurred (a list of examples of serious incidents canbe found in the Annex);1) safety recommendation means any proposal by theinvestigating body of the State conducting thetechnical investigation, based on information derivedfrom that investigation, made with the intention ofpreventing accidents and incidents.

Article

Obligation to investigate

1 Every accident or serious incident shall be the subjectof an investigation.However, Member States may take measures to enableincidents not covered by the first subparagraph to beinvestigated when the investigating body may expect todraw air safety lessons from it.

2. The extent of investigations and the procedure to befollowed in carrying out such investigations shall bedetermined by the investigating body, taking into account

the principles and the objective of this Directive anddepending on the lessons it expects to draw from theaccident or serious incident for the improvement ofsafety.

3. The investigations referred to in paragraph 1 shall inno case be concerned with apportioning blame orliability.

Article 5Status of investigation

1. Member States shall define, in the framework of theirrespective internal legal systems, a legal status of theinvestigation that will enable the investigators-in-chargeto carry out their task in the most efficient way andwithin the shortest time.2. In accordance wi th the legislation in force in theMember States and, where appropriate, in cooperationwith the authorities responsible for the judicial inquiry,the investigators shall be authorized inter alia to:(a) have free access to the site of the accident or incidentas well as to the aircraft, its contents or itswreckage;(b) ensure an immediate listing of evidence and controlledremoval of debris, or components for examination or

analysis purposes;c) have immediate access to and use of the contents ofthe flight recorders and any other recordings;

(d) have access to the results of examination of thebodies of victims or of tests made on samples takenfrom the bodies of victims;e) have immediate access to the results of examinations

of the people involved in the operation of the aircraftor of tests made on samples taken from suchpeople;

f) examine witnesses;g) have free access to any relevant information orrecords held by the owner, the operator or themanufacturer of the aircraft and by the authoritiesresponsible for civil aviation or airport operation.

Article 6Investigating body or entity

1. Each Member State shall ensure that technicalinvestigations are conducted or supervised by a.permanent civil aviation body or entity. The body orentity concerned shall be functionally independent inparticular of the national aviation authorities responsiblefor airworthiness, certification, flight operation,maintenance, licensing, air traffic control or airport


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12. 12. 94 Official Journal of the European Communities No L 319/17operation and, in general, of any other party whoseinterests could conflict with the task entrusted to theinvestigating body or entity.

2. Notwithstanding paragraph 1, the activities entrustedto this body or entity may be extended to the gatheringand analysis of air safety related data in particular forprevention purposes, in so far as these activities do notaffect its independence and entail no responsibility mregulatory, administrative or standards matters.

3. The body or entity referred to in paragraph 1 shall begiven the means required to carry out its responsibilitiesindependently of the authorities referred to inparagraph 1 and should be able to obtain sufficientresources to do so. Its investigators shall be affordedstatus giving them the necessary guarantees ofindependence. It shall o m p r i ~ e at least one investigatorable to perform the function of investigator-in-charge inthe event of an aircraft accident or serious incident.

4. f necessary, the body or entity may request theassistance of bodies or entities from other Member Statesto supply:a) installations, facilities and equipment for:

the technial investigation of wreckage and aircraftequipment and other objects relevant to theinvestigation,the evaluation of information from flightrecorders, andthe computer storage and evaluation of a raccident data.

b) accident investigation experts to undertake specifictasks but only when an investigation is openedfollowing a major accident.When available, such assistance should, as far as possible,be free of charge.

5. A Member State may delegate the task of carrying outan investigation into an accident or incident to anotherMember State.

Article

Accident report

1. Any investigation into an accident shall be the subjectof a report in a form appropriate to the type and

seriousness of the accident. The report shall state the soleobjective of the investigation as referred to in Article 1and contain, where appropriate safetyrecommendations.

2. The investigating body or entity shall make public thefinal accident report in the shortest possible time, and ifpossible within 12 months of the date of the accident.

Article 8Incident report

1. Any investigation into an incident shall be the subjectof a report in a form appropriate to the type andseriousness of the incident. The report shall, whereappropriate, contain relevant safety recommendations.The report shall protect the anonymity of the personsinvolved in the incident.

2. The incident report shall be circulated to the partieslikely to benefit from its findings with regard to safety.

Article 9Safety recommendations

The reports and the safety recommendations referred toin Articles 7 and 8 shall be communicated to theundertakings or national aviation authorities concernedand copies forwarded to the Commission.

Member States shall take the necessary measures toensure that the safety recommendations made by theinvestigating bodies or entities are duly taken intoconsideration, and where appropriate, acted uponwithout prejudice to Community law.

Article 1

A safety recommendation shall in no case create apresumption of blame or liability for an accident orincident.

Article

Council Directive 80/1266/EEC of 16 December 1980 onfuture cooperation and mutual assistance between theMember StateEj in the field of air accident investigation 1)is hereby repealed.

1) OJ No L 375, 31. 12. 1980, p. 32.


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oL 319/18 Official Journal of the European Communities 12. 12. 94Article 2

1. Member States shall bring into force the lawsregulations and administrative provisions necessary tocomply with this Directive not later than 21 November1994. They shall forthwith inform the Commissionthereof.2. When Member States adopt these provlSlons theyshall contain a reference to this Directive or shall beaccompanied by s uch reference on the occasion of theirofficial publication. The methods of making suchreference shall be laid down by Member States.

Article 3This Directive is addressed to the Member States.

Done at Brussels 21 November 1994.For the CouncilThe President

M. WISSMANN


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12. 12. 94 Official Journal of the European Communities o L 319/19

NNEX

LIST OF EXAMPLES OF SERIOUS INCIDENTS

The incidents listed below are typical examples of serious incidents. The list is not exhaustive and onlyserves as a guide to the definition of serious incident .A near collision requiring an avoidance manoeuvre or when an avoiding manoeuvre would have beenappropriate to avoid a collision or an unsafe situation.Controlled flight into terrain (CFIT) only marginally avoided.An aborted take-off on a closed or engaged runway, or a take-off from such runway with marginalseparation from obstacle(s).A landing or attempted landing on a closed or engaged runway.

Gross failure to achieve predicted performance during take-off or initial climb.ll fires and smoke in the passenger compartment or in cargo compartments, or engine fires, eventhough such fires are extinguished with extinguishing agents.

Any events which required the emergency use of oxygen by the flight crew.Aircraft structural failure or engine disintegration which is not classified as an accident.Multiple malfunctions of one or more aircraft systems that seriously affect the operation of theaircraft.Any case of flight crew incapacitation in flight.Any fuel state which would require the declaration of an emergency by the pilot.Take-off or landing incidents, such as undershooting, overrunning or running off the side of runways.System failures, weather phenomena, operation outside the approved flight envelope or otheroccurrences which could have caused difficulties controlling the aircraft.Failure of more than one system in a redundancy system which is mandatory for flight guidance andnavigation.

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COUNCIL DIRECTIVE 9456EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents.pdf