NOTIFICATION - Kementerian Perhubunganknkt.dephub.go.id/knkt/ntsc_aviation/Investigator Area/1 Peraturan dan... · Committee, NTSC) is no blame, no liability, independent, multimoda

NOTIFICATION GUIDELINES

2nd Edition

2017

KOMITE NASIONAL KESELAMATAN TRANSPORTASI

NOTIFICATION AND ACCIDENT DATA REPORTING GUIDELINES

Notification and Accident Data Reporting Guidelines

2nd Edition – 2017




Published in separate Bahasa Indonesia and English by:

Komite Nasional Keselamatan Transportasi

Jalan Medan Merdeka Timur No. 5

Jakarta – Indonesia

www.knkt.dephub.go.id/knkt

http://www.kemhubri.dephub.go.id/knkt



RECORD OF REVISION

Revision No. Date of Revision Affected Pages Remarks/Purpose of Revisions

Original 9 September 2014 All First Edition

1 10 May 2015

Section 1.2.2

Section 2.12

Appendix A and B

In according with the current and latest

revision of CASR 830 21 January 2015

2 14 September 2015 Foreword Person in charge changed

0 4 September 2017 All

2nd Edition:

Change of KNKT Logo

Revision to several chapters to refer ICAO

Annex 13 amendment 15 and CASR 830

Note:

Each amended page of KNKT guideline shall show the appropriate amendment number and date. A vertical black

line on the right margin adjacent to the item that has been changed will indicate all changes. However, in any

circumstances, the vertical black line is not necessary when the amendment is more than 50 percent of total

pages, therefore new edition will be issued.



FOREWORD

Komite Nasional Keselamatan Transportasi, KNKT (National Transportation Safety

Committee, NTSC) is no blame, no liability, independent, multimoda safety investigation body

within the Republic of Indonesia responsible directly to the President of the Republic of

Indonesia.

KNKT has the main duty of conducts objective and independent transport safety investigation

(investigation) for four modes of transportation which are; aviation, railway, road and marine

transportation. KNKT investigation is intended to prevent similar occurrence in the future

without implying blame or liability.

KNKT investigation in aviation is to conduct objective and independent investigation of civil

aircraft accident and serious incident under the provision of International Civil Aviation

Organization (ICAO) Annex 13 and the Indonesian laws and regulations.

This guideline contains policies and procedures related to the responsibilities and functions

of the KNKT and its personnel during the conduct of investigations and reporting of civil

aircraft accidents and incidents.

The purposes of this guideline is as the fundamental principles in governing the investigation

in a standardized basis to ensure that Aviation investigations are conducted in accordance

with the correct application of Standard and Recommended Practices (SARP) for the

provisions of ICAO Annex 13 as well as the Indonesian laws and regulations.

Because of this guideline deals with both accident and serious incident investigations and,

for reasons of brevity, the term “accident”, as used herein, applies equally to “serious

incident”. Throughout this guideline, the use of the male gender should be understood to

include male and female persons.

This guideline will be amended periodically as new investigation techniques are developed

and new information becomes available. Readers are invited to submit material for possible

inclusion in subsequent editions of this guideline. This material should be addressed to:

Komite Nasional Keselamatan Transportasi; Gedung Kementerian Perhubungan lantai 3,

Jalan Medan Merdeka Timur Nomor 5, Jakarta – INDONESIA 10110 or email to

[email protected].

Jakarta, 4 September 2017

Dr. Ir. Soerjanto Tjahjono

Chairman

mailto:[email protected]

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This document is uncontrolled if printed, please verify that it is the latest copy, see online version



TABLE OF CONTENTS

TABLE OF CONTENTS ....................................................................................................... i

TABLE OF FIGURES .......................................................................................................... ii

GLOSSARY ....................................................................................................................... iii

LIST OF ACRONYMS ........................................................................................................ vi

1 INTRODUCTION ....................................................................................................... 1-1

1.1 General ........................................................................................................... 1-1

1.2 Regulation References ................................................................................... 1-2

1.2.1 Indonesia Law number 1 of 2009 ....................................................... 1-2

1.2.2 Government Decree number 62 of 2013 ............................................ 1-2

1.2.3 Civil Aviation Safety Regulation Part 830 ........................................... 1-4

1.3 KNKT Notification Policy ................................................................................. 1-5

1.4 Duty Officer .................................................................................................... 1-6

2 STAGES OF NOTIFICATION PROCESS .................................................................. 2-1

2.1 Stage 1 – Receive and Assess Occurrence Information ................................. 2-1

2.2 Stage 2 – Classifying the Occurrence ............................................................. 2-2

2.3 Stage 4 – Forward the Notification .................................................................. 2-3

3 RECEIVING NOTIFICATION FROM OTHER STATE ................................................ 3-1

4 ACCIDENT INCIDENT DATA REPORT (ADREP) .................................................... 4-1

4.1 KNKT Database .............................................................................................. 4-1

4.1.1 "Microsoft Excel" Database ................................................................ 4-1

4.1.2 "ECCAIRS" Database ........................................................................ 4-1

4.2 Notification ...................................................................................................... 4-2

4.3 Preliminary Report .......................................................................................... 4-3

4.4 Accident Data Report ...................................................................................... 4-5

5 APPENDICES............................................................................................................ 5-1

5.1 Mandatory Occurrence Report ........................................................................ 5-1

5.2 KNKT Notification Form .................................................................................. 5-3

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TABLE OF FIGURES

Figure 1: Process of Occurrence Report Received ......................................................... 2-2

Figure 2: Process of Notification from Other State .......................................................... 3-1

Figure 3: Data Input into ECCAIRS Notification file ......................................................... 4-3

Figure 4: Data Input into ECCAIRS Preliminary Report file ............................................. 4-4

Figure 5: Data Input into ECCAIRS Accident Data Report file ......................................... 4-6

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GLOSSARY

When the following terms are used in this guideline, they have the following meanings:

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 as a result of:

1) being in the aircraft, or

2) direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or

3) direct exposure to jet blast,

except when the injuries are from natural causes, self-inflicted or inflicted by other

persons, or when the injuries are to stowaways hiding outside the areas normally

available to the passengers and crew; or

b) The aircraft sustains damage or structural failure which:

1) adversely affects the structural strength, performance or flight characteristics of the aircraft, and

2) would normally require major repair or replacement of the affected component,

except for engine failure or damage, when the damage is limited to a single engine,

(including its cowlings or accessories), to propellers, wing tips, antennas, probes,

vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the

aircraft skin (such as small dents or puncture holes), or for minor damages to main

rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird

strike (including holes in the radome); or

c) the aircraft is missing or is completely inaccessible.

Note 1 – For statistical uniformity only, an injury resulting in death within thirty days of

the date of the accident is classified as fatal injury

Note 2 – An aircraft is considered to be missing when the official search has been

terminated and the wreckage has not been located

Note 3 – Guidance for the determination of aircraft damage can be found in KNKT

Investigation Guideline.

Accredited representative: A person designated by a State, on the basis of his or her

qualifications, for the purpose of participating in an investigation conducted by another

State. Where the State has established an accident investigation authority, the

designated accredited representative would normally be from that authority.

Adviser: A person appointed by a State, on the basis of his or her qualifications, for the

purpose of assisting its accredited representative in an investigation.

Aircraft: Any machine that can derive support in the atmosphere from the reactions of the air

other than the reactions of the air against the earth’s surface.

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Directorate General of Civil Aviation: The Indonesia governmental entity that are directly

responsible for the regulation of all aspects of civil air transport, technical (i.e. air

navigation and aviation safety) and economic (i.e. the commercial aspects of air

transport).

Incident: An occurrence, other than an accident, associated with the operation of an aircraft

which affects or could affect the safety of operation.

Investigation: A process conducted for the purpose of accident prevention which includes

the gathering and analysis of information, the drawing of conclusions, including the

determination of causes and/or contributing factors and, when appropriate, the making

of safety recommendations.

Investigator: A person on the basis of his or her qualification and competency to conduct

transportation safety investigation. In this guideline, investigator is KNKT

investigator unless otherwise specified

Investigator-in-Charge: A person charged, on the basis of his or her qualifications, with the

responsibility for the organization, conduct and control of an investigation.

Maximum mass: Maximum certificated take-off mass.

Operator: A person, organization or enterprise engaged in or offering to engage in an

aircraft operation.

Preliminary Report: The communication used for the prompt dissemination of data obtained

during the early stages of the investigation.

Safety recommendation: A proposal of an accident investigation authority based on

information derived from an investigation, made with the intention of preventing

accidents or incidents and which in no case has the purpose of creating a presumption

of blame or liability for an accident or incident. In addition to safety recommendations

arising from accident and incident investigations, safety recommendations may result

from diverse sources, including safety studies.

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.

Note 1 – The difference between an accident and a serious incident lies only in the

result.

Note 2 – Examples of serious incidents can be found in the Investigation Guideline.

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

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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.

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.

Note – In the case of the registration of aircraft of an international operating agency

on other than a national basis, the States constituting the agency are jointly

and severally bound to assume the obligations which, under the Chicago

Convention, attach to a State of Registry. See, in this regard, the Council

Resolution of 14 December 1967 on Nationality and Registration of Aircraft

Operated by International Operating Agencies which can be found in Policy

and Guidance Material on the Economic Regulation of International Air

Transport (Doc 9587).

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LIST OF ACRONYMS

The following abbreviations are used throughout this guideline:

ACCID : Accident

ADREP : Accident/incident Data Reporting System

ATA : Air Transport Association

BASARNAS : Badan SAR Nasional / National Search and Rescue Agency

CASR : Civil Aviation Safety Regulation

Cir. : Circular

DGCA : Directorate General of Civil Aviation

Doc. : Document

DVI : Disaster Victim Identification

ECCAIRS : European Coordination Centre for Accident and Incident Reporting

System

ICAO : International Civil Aviation Organization

IIC : Investigator-in-charge

INCID : Incident

KNKT : Komite Nasional Keselamatan Transportasi /

National Transportation Safety Committee (NTSC)

LT : Local Time

NOK : Next of Kin

SARPs : Standards and Recommended Practices

SEM : Scanning Electron Microscope

UTC : Universal Time Coordinate

WIB : Waktu Indonesia Barat / Western Indonesia Standard Time

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1 INTRODUCTION

1.1 General

Komite Nasional Keselamatan Transportasi (KNKT) is accident investigation

authority of Indonesia assigned by the President of Republic Indonesia as stipulated

in Presidential Decree number 2 of 2012. KNKT is an agency in Indonesia

responsible to fulfill the requirement of Annex 13 “Aircraft Accident and Incident

Investigation” of the Chicago Convention on International Civil Aviation and its

amendments.

This Guideline establishes procedures for receiving the notification from government

agencies, aviation industries, aviation society or any person observing any aviation

incident within Indonesia territories and forwarding the notification to related parties,

including ICAO when appropriate.

This Guideline also provided procedure to response the notification submitted by

other State about an accident or serious incident that occurred outside of Indonesia

involving Indonesian Registered, Operated, Designed, or Manufactured aircraft.

The Notification Guidelines contained herein are in conformity with international

standards and best practices. This guideline was developed using the SARPs and

guidance material promulgated by ICAO, as well as materials and best practices.

The Investigation Guidelines are referring to the following ICAO documents as

follows:

a. Annex 13, Aircraft Accident and Incident Investigation;

b. Manual of Aircraft Accident and Incident Investigation (Doc. 9756);

c. Manual on Accident and Incident Investigation Policies and Procedures (Doc.

9962);

d. Accident Incident Reporting Manual, ADREP Manual (Doc. 9156);

e. Safety Management Manual (Doc. 9859);

f. Training Guidelines for Aircraft Accident Investigators (Cir. 298).

The purposes of this guideline are:

a. To establish a standardized basis and the fundamental principles governing the

notification process conducts by KNKT.

b. To ensure that KNKT notification process are conducted in accordance with the

provisions of ICAO Annex 13 and Indonesian laws and regulations.

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1.2 Regulation References

1.2.1 Indonesia Law number 1 of 2009

Pasal 321

(1) Personel penerbangan yang

mengetahui terjadinya

penyimpangan atau

ketidaksesuaian prosedur

penerbangan, atau tidak

berfungsinya peralatan dan fasilitas

penerbangan wajib melaporkan

kepada Menteri.


melaporkan kejadian sebagaimana

dimaksud pada ayat (1) diberi

perlindungan sesuai dengan

ketentuan yang berlaku.


melanggar ketentuan sebagaimana

dimaksud pada ayat (1) dikenakan

sanksi administratif berupa:

a. peringatan;

b. pembekuan lisensi atau sertifikat

kompetensi; dan/atau

c. pencabutan lisensi atau sertifikat

kompetensi.

Article 321

(1) Any aviation personnel in knowledge

of occurrence of deviation or

discrepancy in aviation procedure, or

malfunction of any aviation

equipment and facility shall be

obligated to report it to the Minister.

(2) The aviation personnel reporting any

occurrence as meant in item (1) shall

be given adequate protection

according to valid regulations.

(3) Any aviation personnel violating the

provision as meant in item (1) shall

be imposed with administrative

sanction(s) in the form of:

a. warning

b. freezing of certificate or license;

and/or

c. revocation of certificate or

license.

1.2.2 Government Decree number 62 of 2013

Pasal 22

Setiap kecelakaan Pesawat Udara dan

Kejadian Serius Pesawat Udara

sebagaimana dimaksud dalam Pasal 16

wajib diberitahukan kepada Komite

Nasional Keselamatan Transportasi

oleh:

a. badan usaha angkutan udara;

b. penyedia jasa penerbangan; atau

c. kementerian yang

menyelenggarakan urusan

pemerintahan di bidang transportasi

Article 22

Every aircraft accident and serious

incident as stated in the article 16 shall

be notified to the KNKT by:

a. Air operator;

b. Aviation service provider; or

c. Ministry of Transportation.

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Pasal 23

Komite Nasional Keselamatan

Transportasi wajib segera meneruskan

pemberitahuan kecelakaan Pesawat

Udara atau Kejadian Serius

sebagaimana dimaksud dalam Pasal 22

kepada:

a. negara tempat pesawat terdaftar;

b. negara operator;

c. negara tempat perancang pesawat;

d. negara industri pesawat atau

komponen; dan

e. International Civil Aviation

Organization apabila berat pesawat

melebihi 2.250 Kg (dua ribu dua

ratus lima puluh kilogram).

Article 23

KNKT shall forward the notification of

aircraft accident and serious incident as

stated in the article 22 in timely manner

to:

a. State of Registration;

b. State of Operator;

c. State of Design;

d. State of Manufacturer; and

e. International Civil Aviation

Organization when involving an

aircraft with weight of more than

2.250 Kg.

Pasal 24

(1) Pemberitahuan Kecelakaan

Transportasi sebagaimana

dimaksud dalam Pasal 20, Pasal

21, dan Pasal 22 disampaikan

segera dengan cara lisan atau

tertulis.

(2) Pemberitahuan Kecelakaan

Transportasi paling sedikit memuat:

a. Lokasi kejadian;

b. Waktu kejadian;

c. Akibat kecelakaan;

d. Jumlah korban jiwa dan/atau

luka-luka; dan

e. Prasarana dan sarana

transportasi yang mengalami

kecelakaan.

Article 24

(1) Notification of aircraft accident or

serious incident as stated in the

article 20, 21 and 22 can be

submitted in verbal or written.

(2) Notification of transportation

accident shall contain minimum of:

a. Place of occurrence;

b. Time of occurrence;

c. Other effect (collateral);

d. number of fatality or injury; and

e. damage to the transportation

vehicle or facility.

Pasal 25

Ketentuan lebih lanjut mengenai tata

cara dan prosedur pemberitahuan diatur

dengan Peraturan Ketua Komite

Nasional Keselamatan Transportasi.

Article 25

Detail procedure of the notification will

be described in the KNKT regulation.

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1.2.3 Civil Aviation Safety Regulation Part 830

830.6 Mandatory Occurrence Report

a. Indonesian operators or foreign operators shall immediately, with the minimum

delay and by the most suitable and quickest means available, shall report to the

Komite Nasional Keselamatan Transportasi (KNKT) when an aircraft accident or

serious incident occurs within Indonesia territory.

b. The operators involved in the accident or serious incident shall submit written

occurrence report to KNKT within 24 hours after the accident or serious incident

occurred, contains information collected in accordance with appendix A in this

Part.

830.7 Voluntary Occurrence Report

a. Any person who has knowledge of any accident or incident should report as a

voluntary report to the Director General or KNKT or nearest transportation

authority office or any government official offices as soon as is reasonably

practicable and by any means.

b. Any government official who received a voluntary occurrence report shall

forward it to the Director General and the KNKT as soon as is reasonably by a

practicable means.

c. A voluntary occurrence report as stated in point (a) and (b) above, shall be non

punitive and afford protection to the sources of the information.

830.8 Occurrence Report Format

a. The immediate Mandatory and Voluntary Occurrence Report shall contain

available information related to the occurrence.

b. The written Mandatory Occurrence Report shall be in plain language and

contain as much of information available as possible, but its dispatch as

requires on Subpart 830.6 shall not be delayed due to the lack of complete

information.

c. The form of written Mandatory Occurrence Report is available on Appendix A in

this Part.

830.9 Determination of Occurrence Classification

a. All report of occurrence shall be reviewed to determine the final classification by

KNKT.

b. If the result of review indicated that the occurrence classified as incident, KNKT

shall forward the report to Director General.

830.10 Notification

a. The KNKT shall forward a notification of an accident or serious incident occurs

within Indonesia territory as soon as practicable, to:

1) the State of Registry;

2) the State of the Operator;

3) the State of Design;

4) the State of Manufacture; and

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5) the ICAO

b. If a serious incident involving Indonesian registered or operated aircraft and the

State of Occurrence is not aware, KNKT shall forward a notification of such an

incident to the State of Design, the State of Manufacture and the State of

Occurrence.

c. Upon receipt of the notification of accident or serious incident involving

Indonesian registered, operated, designed and manufactured aircraft, KNKT

shall, as soon as possible:

1) provides the State conducting investigation with any relevant information

available to them regarding the aircraft and flight crew involved in the

accident or serious incident and details of dangerous goods on board the

aircraft.

2) inform the State conducting investigation whether it intends to appoint an

accredited representative and if such an accredited representative is

appointed, the name and contact details; as well as the expected date of

arrival if the accredited representative will travel to the State of Occurrence

or State conducting investigation.

d. In accordance with Subpart 830.10 c, Indonesian aircraft operator, organization

responsible for the type design or final assembly as soon as possible, shall

provide KNKT with any relevant information available regarding the aircraft and

flight crew involved in the accident or serious incident and details of dangerous

goods on board the aircraft as practicable.

1.3 KNKT Notification Policy

Based on Indonesia regulation, there are two types of occurrence information of an

accident or incident that maybe received by KNKT. The mandatory occurrence

report which reported by operator and voluntary report which reported by any

person. KNKT may also receive notification from other State for an accident or

incident involving Indonesia registered, operated or manufactured and Indonesia

citizen become the victims. KNKT shall able to receive notification at any time.

The KNKT maintain 24-hour call center to receive occurrence report of accidents.

Duty Officer will handle the 24-hour call center. Duty Officer will be scheduled

weekly basis. The Duty Officer will equip with a prepaid mobile telephone. There will

be a backup to the Duty Officer in case he cannot perform his duty during his duty

period.

During office time, the information will received via KNKT Office telephone, facsimile

and/or email address. The KNKT operational office hour normally is Monday to

Friday between 0730 and 1600 local time (Waktu Indonesia Barat - WIB, Western

Indonesia Standard Time). Telephone and facsimile are available in the KNKT office

KNKT will ensure that up-to-date contact and address information for reporting of

accidents and serious incidents to KNKT is available to relevant organizations and

personnel within Indonesia and to other States through ICAO by use of the ICAO

website. The 24-hour contact information for KNKT also will be published on the

KNKT internet web site for the benefit of the international aviation community.

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The following contact details for the purpose of notification:

Phone (line) +62 21 3847601

Facsimile +62 21 3517606

24-hour Call Contact +62 81212655155

Website www.knkt.dephub.go.id/knkt

e-mail [email protected]

1.4 Duty Officer

The Chairman issued six monthly duty officer rosters. The duty period for Duty

Officer is weekly basis that is started on Monday at 10.00 WIB and transfer to

subsequent Duty Officer on the following Monday.

Change over Duty Officers is scheduled on Monday, at 10.00 WIB in the KNKT

office, unless mutually agreed by both duty officers.

The Duty Officer shall be ready to receive report of accident or incident or other

transportation occurrence report. The Duty Officer provided with dedicated mobile

phone on number +6281212655155 and shall not be turn off during his duty period.

Respond in an appropriate manner to the range of information received can be

expected. As such, it is inappropriate for the Duty Officer to perform the duties on

the public places such as mosque/church, theater, restaurant, shopping center or

other public area. Rather, Duty Officer should operate from home, minimal

disturbance or avoid busy public area to ensure that he can respond in an effective

and timely manner.

The Duty Officer job descriptions are:

a. to keep the mobile phone standby in operation during his duty.

b. to receive and verify the occurrence report and seek for further detail

information.

c. to forward the occurrence report to Chairman and/or Head of Aviation Accident

Investigation Sub Committee.

d. forward the information to the IIC and investigation team that are assigned by

Chairman and/or Head of Aviation Accident Investigation Sub Committee.

----

http://www.knkt.dephub.go.id/knkt

mailto:[email protected]

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2 STAGES OF NOTIFICATION PROCESS

2.1 Stage 1 – Receive and Assess Occurrence Information

After received the initial information, the Duty Officer shall reconfirm the occurrence

report to other possible sources. After the occurrence has been confirmed, the Duty

Officer shall seek detail information as much as possible, if available.

In the case accident or serious incident involving Indonesia registered, operated,

designed, or manufactured aircraft occurred in a non-Contracting State, or outside

the territory of any State, or if the State of Occurrence was not aware to the

particular occurrence, then Duty Officer shall notify the Chairman and Head of

Aviation Investigation Sub Committee.

The information may include the following:

a. Reporter detail such as his/her name, position, contact number or email

address;

b. Aircraft detail such as 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 (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/or latitude and longitude;

h. Number of crew and passengers; number of person on board, number of injured

occupant and level of injury;

i. Brief of the occurrence and the extent of damage to the aircraft, so far as is

known;

j. Physical characteristics of the accident or serious incident area, as well as an

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

k. Presence and description of any explosives, radioactive materials, or other

dangerous goods carried on board the aircraft;

l. Presence of any government agency or authority at the occurrence site.

To be able to get more detail information required, the Duty Officer may contact the

aircraft operator and/or nearest authorities to the accident site such as airports

authority, local police or search & rescue agency. During this process, the duty

officer shall advise reporter and/or parties that he may get back to them if require

further information.

The Duty Officer should remind the involved operator to send a written mandatory

occurrence report in according to CASR Part 830. The Mandatory Occurrence

Report Form can be found at CASR Part 830.

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Not to

Investigate

Input into

KNKT

Database

investigate

Receive Information or

Occurrence Report

List of DIPs

Classifying the

Occurrence

Forward the

Notification

Serious Incident

or Accident

Incident

List of

AccReps

Forward To

DGCA

Figure 1: Process of Occurrence Report Received

2.2 Stage 2 – Classifying the Occurrence

Based to the legislation, KNKT is responsible to conduct investigation for accident

and serious incident of civil aircraft within the territory of the Republic of Indonesia or

Indonesian registered aircraft involved on an accident while the State of Occurrence

does not intend to conduct investigation.

The decision to investigate of an incident shall be made by the Chairman or the

Head of Aviation Accident Investigation Sub Committee when under his opinion an

investigation is necessary to be conducted.

The more information available will allow the Chairman or the Head of Aviation

Accident Investigation Sub Committee to make decision about whether to

investigate at all and, if so, what resources are required

After detail information available, the Duty Officer shall forward to the Chairman

and/or the Head of Aviation Accident Investigation Sub Committee including the

propose classification of the occurrence.

The Chairman and/or Head of Aviation Accident Sub Committee shall determine the

occurrence classification. If the occurrence is determined as incident, the Duty Officer

will forward the case to the DGCA for further action.

The CASR Part 830 stated that KNKT has final authorization to classify the

occurrence as accident, serious incident or incident. If the Chairman or the Head of

Aviation Accident Investigation Sub Committee decide to investigate, the

investigation team member shall be assembled. The Duty Officer shall contact the

assigned team members at the soonest possible time to enable them to prepare for

the earliest possible departure to the accident site. Adequate briefing shall be

provided to the investigation team member so that they able to prepare of the

investigation and protective equipment suitable for the location and accident site.

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2.3 Stage 4 – Forward the Notification

The Duty Officer will prepare the draft of notification and submit to the Head of

Aviation Accident Sub Committee for approval. When it has been approved, the Duty

Officer will send the notification of an accident, with a minimum of delay and by the

most suitable and quickest means available.

Note – Telephone, facsimile or e-mail will in most cases constitute “the most

suitable and quickest means available”. More than one means of

communication may be appropriate.

The notification shall be in plain English and contain as much as information contain

in Appendix 5.2 is readily available, but its dispatch shall not be delayed due to the

lack of complete information.

The notification shall be sent 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 ICAO, when the aircraft involved is of a maximum mass of over 2,250 kg or

is a turbojet-powered aeroplane.

In the case any accident or serious incident involving Indonesia interest occurred in

a non-Contracting State, or outside the territory of any State, or if the State of

occurrence was not aware to this particular occurrence, then Duty Officer will take

the necessary steps to notify the appropriate authorities of these States, and ICAO

when the aircraft involve has maximum mass over 2,250 kg, in accordance with the

ICAO Annex 13.

The Investigator or Duty Officer also sends the information to the State which has a

special interest by virtue of fatalities or serious injuries to its citizens. The State is

entitled to appoint an Expert.

Normally, after forward the initial notification to Direct Involved Parties (DIPs), they

will response and inform KNKT about their Accredited Representative. Some of

them will join KNKT on-site investigation, and some will not join on-site investigation

or also known as "non-travelling Accredited Representative".

If neither the State of Registry nor State of the Operator appoints an Accredited

Representative, the investigator or Duty Officer may send the invitation to the

operator to participate in the investigation. Similarly, when the State of Design

and/or the State of Manufacturer not appoint an Accredited Representative, the

investigator or Duty Office may send the invitation to the organization responsible to

the type design and/or final assembly of the aircraft to participate in the

investigation.

The investigator or Duty Officer may also send the inquiry to the relevant State

regarding the detail of personnel and schedule of arrival in order to forward the

information to Ministry of Foreign Affair for the purpose of entry permit.

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3 RECEIVING NOTIFICATION FROM OTHER STATE

The KNKT shall response the notification submitted by other State about an

accident or serious incident that occurred outside of Indonesia involving Indonesia

registered, operated, designed, or manufactured aircraft.

The Duty Officer shall report to the Chairman or the Head of Aviation Accident

Investigation Sub Committee to make a decision the KNKT intention to participate

in the investigation as Accredited Representative.

The Duty Officer will notify State conducting the investigation whether Indonesia will

participate or not in the investigation. If Indonesia intend to participate in the

investigation, the Duty Officer shall notify to the State conducting the investigation

about the Accredited Representative name and contact detail (email and mobile

phone number) including the intention to travel or not.

If the Accredited Representative requires support form Adviser, the Accredited

Representative shall contact to relevant organization requesting appointment of

Adviser.

If the Accredited Representative and Adviser intend to travel, the Accredited

Representative shall provide the details about the travel and other arrangements to

the State conducting the investigation. The information of Accredited Representative

should not exceed than two days after notification received.

Chairman or Head of

Aviation Accident

Investigation Sub

Committee DecisionInput into

KNKT

Database

Join the Other

State

investigation

Receive Notification

from Other State

Accredited

Representative

will travel to

join the

investigation

Detail

information &

travel date

Provide

information to

the State

conducting

investigationNo

Yes

Submit the

Accredited

Representative

Name and

detail

2 days

5 days

Figure 2: Process of Notification from Other State

The Duty Officer shall solicit further information and coordinate with other Indonesia

government agencies such as Ministry of Foreign Affair, Ministry of Transportation,

Search and Rescue Agency, Indonesia Police and relevant organizations

KNKT may appoint an Accredited Representative and adviser to participate in the

investigation. Upon receipt of the notification from the State conducted Investigation,

the KNKT shall, as soon as possible, provide any relevant information available to

them regarding the detail of aircraft, flight crew and dangerous good on board

involved in the accident or serious incident.

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The Duty officer will notify and coordinate with other Indonesia government agencies

such as Ministry of Foreign Affair, Ministry of Transportation, Indonesia Police

(Disaster Victim Identification – DVI), National Search and Rescue Agency

(BASARNAS) and relevant organizations

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4 ACCIDENT INCIDENT DATA REPORT (ADREP)

4.1 KNKT Database

All occurrences reported to or investigated by KNKT are recorded in KNKT database

system by the Duty Officer or investigator. There are two type of database: Microsoft

Excel Database and ECCAIRS Database.

4.1.1 "Microsoft Excel" Database

Aviation Accident Investigation Sub Committee manages an occurrence database

using “Microsoft Excel” application. The “Microsoft Excel” database file secure save

in the KNKT server and can be accessed by Duty Officer with his log password.

The “Microsoft Excel” database design to simply transfer basic information received

and easy to view by other KNKT official with his/her log password.

4.1.2 "ECCAIRS" Database

For all ICAO requirement occurrences, KNKT will transfer all information into the

ECCAIRS (European Coordination Centre for Accident and Incident Reporting

System) Database. The KNKT uses ECCAIRS since May 2009 and the ECCAIRS

database is secure save in the KNKT server and can be accessed by Duty Officer

and/or investigator with his log password.

The KNKT policy requires the filing of an Accident/Incident Data Report (ADREP) to

ICAO in accordance with Annex 13 Chapter 7. KNKT utilized the European

Coordination Center for Accident and Incident Reporting System (ECCAIRS) for

filing ADREP data.

The KNKT provides ICAO with the following ADREP reports:

a. Accident Data Report for accident of aircraft maximum mass of over 2,250 kg;

b. Incident Data Report for serious incidents of aircraft maximum mass of over

5,700 kg.

The main principles to entry and coding occurrence data into ECCAIRS are:

a. Fill the "Headline" column as much detail

The headline column will described the occurrence detail in one sentences. The

accepted pattern is as follows:

"INITIAL [Accident/Serious Incident] KNKT.YY.MM.Seq.04 [Registration]:

[Category] - [Location] - [Date]"

example:

"INITIAL Accident KNKT17.02.06.04 PK-XYZ: Runway Excursion - Soekarno

Hatta Airport (WIII) Jakarta, Indonesia - 12 February 2017"

"INITIAL Serious Incident KNKT17.03.07.04 PK-YZX: Abnormal Runway

Contact - Wamena Airport (WAJW) Papua, Indonesia - 20 March 2017"

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b. Read the definitions

The duty Officer or data entry officer should read the definitions during entry

and coding data into ECCAIRS database.

Even most experienced users read the definitions when in doubt. If definitions

are not applied properly, data points are present, but values are incorrect or

misleading and may leading to incorrect conclusions

c. Do not invent

The duty officer or data entry officer should only code facts that have at hand

regarding to the occurrence. All data coding has been established or reported.

d. Be specific

The duty officer or data entry officer should specific as possible, without

speculating on details, during coding any data.

The less specific information coded, may derived bias to the reader.

Example: The nose landing gear did not extend

Use: “Nose/tail landing gear related event (ATA Code:3220)” Not : “Landing gear related event (ATA Code:3200)”

e. Enter causal factors not consequences

Causes and causal factors are more essential for analysis in order to find out

deficiencies which led to an occurrence and determine needed actions for

accident prevention.

f. Event must be in time sequence

a. In chronological (time) order,

b. Frequently used in analysis,

c. Precursors, consequences.

g. Complete background data

a. Administrative: filing data, reporting organization, report status

b. When: date, time

c. Where: state, location, airport, runway

d. Who involved: aircraft, operator, operation type

e. Severity: injury level, damage

f. Description: headline, narrative

4.2 Notification

The Duty Officer will fill data into ECCAIRS with minimum data fields such:

a. Headline: described the occurrence detail in one sentences

b. Narrative: brief of the occurrence and the extent of damage to the aircraft

c. Nationality: brief of detail nationality of the flight crew, other crew and passenger

d. Site Access: brief of characteristics of the occurrence area, as well as an

indication of access difficulties or special requirements to reach the site

e. Events: information about the sequence and chronological of the event

f. Aircraft information: information about the aircraft type, registration and other

detail.

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g. History of Flight: information about the last Point of departure and point of

intended landing of the aircraft.

h. Injuries: information about number of fatality or injuries of person on board.

i. Flight Crew: information about the flight crew license, rating and experience.

j. Management: information about information source, data input name, status

and type of occurrence.

Figure 3: Data Input into ECCAIRS Notification file

4.3 Preliminary Report

The IIC or investigator will fill the preliminary report data into ECCAIRS in sequence

with Preliminary Report (word format). If available, the data shall be filled in:

a. Headline: described the occurrence detail in one sentences.

b. Narrative: brief of the occurrence and the extent of damage to the aircraft.

c. Nationality: brief of detail nationality of the flight crew, other crew and passenger.


indication of access difficulties or special requirements to reach the site.

e. Events: information about the sequence and chronological of the event.

f. Weather: Information about the weather.

g. Aircraft information: information about the aircraft type, registration and other

detail.

h. History of Flight: information about the last Point of departure and point of


i. Injuries: information about number of fatality or injuries of person on board.

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j. Fire: the information about fire before or after the occurrence, and information

about the dangerous goods involved.

k. Survival: information regarding the survival aspect of the occurrence.

l. Wreckage/Impact: information regarding wreckage and impact.

m. Flight Crew: information about the flight crew license, rating and experience.

n. Aerodrome and Runway: information about aerodrome and runway of the

occurrence.

o. Management: information about information source, data input name, status and

type of occurrence.

Figure 4: Data Input into ECCAIRS Preliminary Report file

The Duty officer will send the Preliminary of an accident in word format and ECAIRS

format (e4f file), within 30 day after the date of occurrence, 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. The operator or organization involve;

f. Any State that provided relevant information, significant facilities or experts; and

g. The International Civil Aviation Organization (ICAO) when the accident involving

aircraft with maximum mass over 2,250 kg.

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4.4 Accident Data Report

When the investigation has been completed and the Final Report approved by the

Head of Aviation Accident Investigation Sub Committee, an Accident Data Report is

to be compiled by the IIC or investigator. The Accident Data Report provides

accurate and complete information, including factors (causes) and safety

recommendations.

The data shall be filled in:

a. Headline: described the occurrence detail in one sentences

b. Narrative: brief of the occurrence and the extent of damage to the aircraft

c. Nationality: brief of detail nationality of the flight crew, other crew and passenger


indication of access difficulties or special requirements to reach the site

e. Events: information about the sequence and chronological of the event

f. Safety Recommendation

g. Weather: Information about the weather

h. Aircraft information: information about the aircraft type, registration and other

detail.

i. History of Flight: information about the last Point of departure and point of


j. Injuries: information about number of fatality or injuries of person on board.

k. Aircraft Recording

l. Fire: the information about fire before or after the occurrence, and information

about the dangerous goods involved

m. Survival: information regarding the survival aspect of the occurrence

n. Air Traffic Services

o. Wreckage/Impact: information regarding wreckage and impact

p. Flight Crew: information about the flight crew license, rating and experience.

q. Aerodrome and Runway: information about aerodrome and runway of the

occurrence

r. Management: information about information source, data input name, status

and type of occurrence.

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Figure 5: Data Input into ECCAIRS Accident Data Report file

The Duty officer will send the Final Report in word format and ADREP in ECAIRS

format (e4f file), within 12 months after the date of occurrence, to

a. The State that instituted the investigation;

b. The State of Registry;

c. The State of the Operator;

d. The State of Design;

e. The State of Manufacture;

f. Any State that participated in the investigation;

g. Any State having suffered fatalities or serious injuries to its citizens;

h. Any State that provided relevant information, significant facilities or experts;

i. ICAO if the accident involving an aircraft of a maximum mass of over 5,700 kg;

j. Operator and organization involve;

k. The families of the victims of the accident when requested.

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If after the investigation Final Report has been reported, new and significant

evidence becomes available that may affect to the contributing factor, KNKT shall

reopen the investigation. However, when KNKT did not institute the investigation,

KNKT shall first obtain the consent of the State which instituted the investigation.

When the investigation reopen, the KNKT investigation process applied as

practicable including publish a revised Final Report, if necessary.

For this circumstance, if an investigation is considered to reopen, the information

previously reported should be corrected by a new report.

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5 APPENDICES

5.1 Mandatory Occurrence Report

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5.2 KNKT Notification Form

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