session 2 - icao international...

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Session 2

ICAO International Framework

SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014

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� 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

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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

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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

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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]

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Annex 13

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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

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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

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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

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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

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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

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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.

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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”

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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.

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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

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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)


(Engine)


(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 …”

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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 …”

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� 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.

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Accident /Serious Incident in

Non-Contracting State

� Standard 5.3 – State of Registry shall investigate.

However, it may delegate …

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Accident /Serious Incident outside the Territory of any State

(e.g. International Waters)

Objective of Investigation

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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)

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� 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)

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� 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


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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.

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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


� ICAO (if aircraft > 2 250 kg or if turbojet-powered

aeroplane)

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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.

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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

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Definitions

� Accident

� Serious Incident

� Serious injury

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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

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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;

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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);

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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.

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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.

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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


SEMINAR ON AIRCRAFT ACCIDENT INCIDENT INVESTIGATION11-15 AUGUST 2014

session 2 - icao international...

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