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Session 2
ICAO International Framework
SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014
2
ICAO International Framework
� ICAO Secretariat
� Annex 13
� Which State shall investigate
� Objective of investigation
� Notification of Accident / Serious Incident
� Definitions of Accident and Serious Incident
ICAO Secretariat
� Air Navigation Bureau
� Air Transport Bureau
� Legal Affairs and External Relations Bureau
� Bureau of Administration and Services
� Technical Co-operation Bureau
3
Air Navigation Bureau
Monitoring & Oversight
Safety & AN Oversight Audit
Oversight Support
Safety
Accident Investigation
Aviation Medicine
Operation Safety
Cargo Safety
Implementation Planning & Support
Air Navigation
Integrated Planning
Airport Operations &
Interoperability
Airspace Management & Optimisation
Implementation Planning & Support
Key Functions of ICAO
� To secure international co-operation in air transport safety, security and reliability
� To achieve the highest possible degree of uniformity in regulations, standards, procedures and organisation
� To produce guidance material on a range of aviation subjects
� To provide technical assistance to States
5
ICAO Standards and
Recommended Practices (SARPs)
� To achieve the highest possible degree of
uniformity in regulations, standards, procedures
and organisation -
� ICAO develops internationally agreed SARPs
� Safety standards are minimum requirements
� State shall translate SARPs into national
legislation, policies or procedures
� State needs to file a difference with ICAO if it
deviates from or cannot comply with any
Standard6
SARPs in Annexes to the Convention on International Civil Aviation
� Annex 1 - Personnel Licensing
� Annex 2 - Rules of the Air
� Annex 3 - Meteorological Service
� Annex 4 - Aeronautical Charts
� Annex 5 - Units of Measurement to be used
� Annex 6 - Operation of Aircraft
� Annex 7 - Aircraft Nationality and Registration Marks
� Annex 8 - Airworthiness of Aircraft
� Annex 9 – Facilitation
� Annex 10 - Aeronautical Telecommunications
Annexes
� Annex 11 - Air Traffic Control Service
� Annex 12 - Search and Rescue
� Annex 13 - Accident and Incident Investigation
� Annex 14 - Aerodromes
� Annex 15 - Aeronautical Information Services
� Annex 16 - Environmental Protection
� Annex 17 - Aviation Security
� Annex 18 - Safe Transport of Dangerous Goods by Air
� Annex 19 – Safety Management
Investigation-related Activities of ICAO
� Development and updating of investigation
related documents and guidance material, e.g.:
� Annex 13
� Manuals
� Information (Circulars/Electronic Bulletins)
� Maintaining accident/incident database and
providing related inquiry service to States
� Organising AIG Divisional Meeting and other
investigation related meetings
9
Article 26 of the Convention
… the State in which the accident occurs will
institute an inquiry into the circumstances of the
accident, in accordance, … with the procedure
which may be recommended by the ICAO [in
Annex 13]
10
Annex 13
11
Annex 13
� First Edition in 1951
� Title change in 1994 to include incident
investigation
� Latest edition - 10th Edition, July 2010
� Latest amendment - Amendment 14
� Applicable 14 November 2013
12
Annex 13
� Chapter 1 - Definitions
� Chapter 2 - Applicability
� Chapter 3 - General
� Chapter 4 - Notification
� Chapter 5 - Investigation
� Chapter 6 - Final Report
� Chapter 7 - ADREP Reporting
� Chapter 8 - Accident Prevention Measures
� Appendix - Format of the Final Report
13
Annex 13 Requirements
� Objective of investigation
� ICAO definitions
� Notification of occurrences
� Removal of damaged aircraft
� Occurrences requiring investigation
� Appointment of investigator-in-charge, accredited
representatives and advisers
� Entitlement of foreign accredited representatives and
advisers
14
Annex 13 Requirements (Cont’d)
� Investigation report format
� Dissemination of draft reports to parties concerned
for comments
� Dissemination and public release of final reports
� Issuance of safety recommendations
� Rights and obligations of participants
� Re-opening of investigation
� Protection of information gathered
15
Attachments to Annex 13
� A - Rights and obligations of the State of the Operator in respect of accidents and incidents involving leased, chartered or interchanged aircraft
� B - Notification and reporting checklist
� C - List of examples of serious incidents
� D - Guidelines for flight recorder read-out and analysis
� E - Legal guidance for the protection of information from safety data collection and processing systems
� F - Guidance for the determination of aircraft damage16
Recent Changes to Annex 13
� Inclusion of unmanned aircraft in definition of accident
� Mandatory for States to investigate serious incidents
� Emphasis on “contributing factor” over “cause” to avoid being seen as apportioning blame and liability
� Definition of “contributing factors” was added
� Mandatory for State to implement a voluntary incident reporting system which shall be non-punitive and afford protection to the sources of the information
� Guidance for the determination of aircraft damage in Attachment F
� Transferring the Attachment on Framework for the State Safety Programme (SSP) to Annex 19
17
Recent Changes (Cont’d)
� Additional examples of possible serious incident in Attachment C:
� Collisions not classified as accidents
� Fire and/or smoke in the cockpit
� Fuel quantity level or distribution situations requiring the declaration of an emergency by the pilot, such as insufficient fuel, fuel exhaustion, fuel starvation, or inability to use all usable fuel on board
� The unintentional or, as an emergency measure, the intentional release of a slung load or any other load carried external to the aircraft
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Recent Changes (Cont’d)
Many provisions in Chapter 8 (Accident Prevention Measures) were transferred to Annex 19. Chapter 8 now consists of:
�Standard 8.1 (previously 8.4) – A State shall establish and maintain an accident and incident database to facilitate the effective analysis of information on actual or potential safety deficiencies and to determine preventive actions required.
�Recommendation 8.2 (new) – State authorities responsible for the implementation of the SSP should have access to the accident and incident database to support their safety responsibilities.
�Recommendation 8.3 (previously 8.3) – In addition to safety recommendations arising from accident and incident investigations, safety recommendations may result from diverse sources, including safety studies. If safety recommendations are addressed to an organization in another State, they should also be transmitted to that State’s investigation authority.
19
Proposed amendments
� ICAO State Letter 2013/55 dated 19 July 2013 [Ref.
AN 6/12-13/55] proposed a new standard:
Standard 3.2 - States shall establish an accident investigation authority that is independent from State aviation authorities and other entities that could interfere with the conduct or objectivity of an investigation”
20
Proposed amendments (Cont’d)
� ICAO State Letter 2014/47 dated 7 July 2014 [Ref. AN 8/1-14/47] proposed changing a note
after 5.4.3 to a new recommendation:
Recommendation 5.4.4 — A State should ensure
cooperation between its accident investigation authority and
judicial authorities so that an investigation is not impeded
by administrative or judicial investigations or proceedings.
Note.— Cooperation may be achieved by legislation, protocols, agreements or other arrangements, and may cover the following subjects: access to the site of the accident; preservation of and access to evidence; initial and on-going debriefings of the status of each process; exchange of information; appropriate use of safety information; and resolution of conflicts.
21
Proposed amendments (Cont’d)
� ICAO State Letter 2014/47 proposed also upgrading
Recommendation 8.3 to a standard:
Standard 8.3 – In addition to safety recommendations arising
from accident and incident investigations, safety
recommendations may result from diverse sources,
including safety studies. If safety recommendations are
addressed to an organization in another State, they shall
also be transmitted to that State’s accident investigation
authority
22
Military Aviation
� Annex 13 does not apply to investigation of purely
military aviation occurrences
� An accident or incident may involve both civil and
military aircraft, e.g. midair collision or airmiss
� Such occurrence could arise because of the
military aircraft’s:
� Operating in civil airspace
� Operating at joint civil/military airports
Annex 13 - Significance
� Annex 13 spells out SARPs governing
investigation protocol at the international level:
� States’ responsibilities / obligations
� Responsibility for conducting investigation
� Types of occurrences requiring investigation
� Independence of investigation
� Responsibility on confidentiality
� States participation rights / entitlement
� Duty of State conducting investigation vis-à-vis ICAO
� Format of investigation report
� Release of report
� Timeliness of report
Guidance materials
� Annex 13 does not really spells out the “how-to-do” to meet the SARPs.
� Guidance materials available for the “how-to-do”.
ICAO Guidance Materials on “How”
� Manual of Aircraft Accident and Incident Investigation (Doc 9756)� Part I – Organisation and Planning
� Part II – Procedures and Checklists
� Part III – Investigation
� Part IV – Reporting
� Manual on Accident and Incident Investigation Policies and Procedures (Doc 9962)
� Accident Prevention Manual (Doc 9422)
� Manual on Regional Accident and Incident Investigation Organisation (Doc 9946)
� ICAO Policy on Assistance to Aircraft Accident Victims and their Families (Doc 9998)
ICAO Guidance Materials on “How”
� Safety Management Manual (Doc 9859)
� Human Factors Training Manual (Doc 9683)
� Technical Instructions for the Safe Transport of Dangerous Goods by Air (Doc 9284)
� Emergency response Guidance for Aircraft Accident involving Dangerous Goods (Doc 9481)
� Hazards at Aircraft Accident Sites (Circular No. 315)
� Guidance on Assistance to Aircraft Accident Victims and Their families (Circular No. 285)
� Training Guidelines for Aircraft Accident Investigators (Circular No. 298)
Which State Shall Investigate
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State of Registry
State of the Operator
State that instituted
investigation
State conducting
investigation
States involved
State of Occurrence
State of Manufacture
(Component)
State of Manufacture
(Engine)
State of Manufacture
(Aircraft)
State that provided information,
facilities and experts
“State of Victim”having suffered fatalities or
serious injuries to its citizens
� Standard 5.1 – The State of Occurrence shall
institute an investigation into the circumstances of
the accident and be responsible for the conduct of
the investigation, but it may delegate …”
30
Investigation of Accident is
Mandatory
Investigation of Serious Incident is Mandatory
� Standard 5.1.2 – The State of Occurrence shall
institute an investigation into the circumstances of
a serious incident when the aircraft is of maximum
mass of over 2 250 kg. Such a State may
delegate …”
31
� Recommendation 5.2 – If the non-Contracting
State does not investigate, the State of Registry
or, failing that, the State of the Operator, the State
of Design or the State of Manufacture should
investigate.
32
Accident /Serious Incident in
Non-Contracting State
� Standard 5.3 – State of Registry shall investigate.
However, it may delegate …
33
Accident /Serious Incident outside the Territory of any State
(e.g. International Waters)
Objective of Investigation
34
Objective of Annex 13 Investigation
� Standard 3.1 –
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.
El único objetivo de la investigación de accidentes o incidentes será la prevención de futuros accidentes e incidentes.
El propósito de esta actividad no es determinar la culpa o la responsabilidad.”
Independence of Annex 13 Investigation
� Standard 5.4:
The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of this Annex.”
Las autoridades encargadas de la investigación de accidentes gozarán de independencia para realizar la investigación y de autoridad absoluta al llevarla a cabo, en forma consecuente con lo dispuesto en este Anexo.
Separation from Judicial or Administrative Proceedings
� Standard 5.4.1 –
Any investigation conducted in accordance with the provisions of this Annex shall be separate from any judicial or administrative proceedings to apportion blame or liability.
Toda investigación que se realice de conformidad con las disposiciones del presente Anexo será independiente de todo procedimiento judicial o administrativo para determinar la culpa o la responsabilidad.
Notification of Accident / Serious Incident
(State-to-State / State-to-ICAO)
38
Notification of Accident / Serious Incident
� Standard 4.1 – State of Occurrence shall notify:
� State of Registry
� State of the Operator
� State of Design
� State of Manufacture
� ICAO (if aircraft > 2 250 kg or if turbojet-powered
aeroplane)
39
Notification of Accident / Serious Incident
� Standard 4.1 – If State of Occurrence is not aware of a serious incident (e.g. aircraft has landed elsewhere) � State of Registry (or State of the Operator, as appropriate) shall notify:
� State of Occurrence
� State of Design
� State of Manufacture
40
On Receipt of Notification
� Recommendation 4.5 – State of Registry, State of the Operator, State of Design and State of Manufacture should acknowledge receipt of the notification.
� Standard 4.6 – These States shall provide State of Occurrence with information regarding:
� Aircraft and flight crew
� Accredited representative and travel details
� Standard 4.7 – State of the Operator shall provide State of Occurrence with details of dangerous goods on board the aircraft.
41
Accident / Serious Incident in Non-Contracting State or Outside
the Territory of any State
� Standard 4.8 – State of Registry shall notify:
� State of the Operator
� State of Design
� State of Manufacture
� ICAO (if aircraft > 2 250 kg or if turbojet-powered
aeroplane)
42
On Receipt of Notification
� Recommendation 4.9 – State of the Operator, State of Design and State of Manufacture should acknowledge receipt of the notification.
� Standard 4.10 – These States shall provide State of Registry with information regarding:
� Aircraft and flight crew
� Accredited representative and travel details
� Standard 4.11 – State of the Operator shall provide State of Registry with details of dangerous goods on board the aircraft.
43
a) Identifying abbreviation ACCID for accident or INCID for serious incident
b) Manufacturer, model, nationality and registration marks, and serial number of the aircraft
c) Name of the owner, operator and hirer, if any, of the aircraft
d) Qualification of the pilot-in-command, and nationality of crew and pax
e) Date and time of the accident/serious incident
f) Departure airport, and intended destination
g) Position of the aircraft (latitude and longitude, reference to some point)
Information to be included in the State of Occurrence’s notification
h) Fatalities and injuries � On board – Total number of crew and pax� On board – Killed� On board – Seriously injured� Others – Killed� Others – Seriously injured
i) Description of accident or serious incident, and extent of damage to aircraft
j) Indication as to what extent the investigation will be carried out or delegated
k) Characteristic of occurrence site, access difficulties or special requirements to reach site
l) Name/contact of sender, investigation authority and investigator-in-charge
m) Description of dangerous goods on board
� Standard 4.2 – The notification shall contain as
much of the information as is readily available,
but its dispatch shall not be delayed due to the
lack of complete information..
Definitions
47
Definitions
� Accident
� Serious Incident
� Serious injury
48
Accident
� An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have
disembarked, in which:
� A person is fatally or seriously injured
� the aircraft sustains damage or structural failure
� the aircraft is missing or is completely inaccessible
49
Accident (cont’d)
� a person is fatally or seriously injured as a result
of:
� being in the aircraft, or
� direct contact with any part of the aircraft, including
parts which have become detached from the aircraft,
or
� 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;
50
Accident (cont’d)
� the aircraft sustains damage or structural failure
which:� adversely affects the structural strength, performance
or flight characteristics of the aircraft, and
� 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);
51
Serious Injury is one which
(a) requires hospitalisation for more than 48 hours,
commencing within 7 days from the date the injury was
received
(b) results in a fracture of any bone (except simple fractures of
fingers, toes, or nose)
(c) involves lacerations which cause severe haemorrhage,
nerve, muscle or tendon damage
(d) involves injury to any internal organ
(e) involves second or third degree burns, or any burns
affecting more than 5% of the body surface
(f) involves verified exposure to infectious substances or
injurious radiation
Serious Incident
� An incident involving circumstances indicating
that there was a high probability of an accident,
e.g.:
(a) Near collision requiring avoidance maneuver
(b) CFIT marginally avoided
(c) Runway overrun/undershoot, runway excursion
(d) Aborted take-offs on a closed or engaged runway
(e) Landings or attempted landings on a closed or
engaged runway
(f) Flight crew incapacitation in flight, etc.
53
Attachment F - Guidance for the determination of aircraft damage
� Engine separation from aircraft is an accident
� Structural damage that affects pressurisation is considered as an accident
� Emergency evacuation are not counted as an accident unless someone receives serious injuries or the aircraft has otherwise sustained significant damage.
54
Not considered an accident:
�Loss of engine cowls with no damage to the aircraft
�Compressor, turbine blade and engine internal components ejected through engine tail pipe
�Missing flap, slat and other lift augmenting devices, winglets, etc.
�Collapsed or missing radome with no substantial damage to other structures or systems
�Retraction of a landing gear leg, or wheels-up landing resulting in skin abrasion which can be despatched after minor repair or patching up
�Substantial removal of components for inspection following an occurrence is not an accident unless significant damage is found.
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Determination of aircraft damage (cont’d)
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- End -
Session 2
ICAO International Framework
SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014
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