Flying is generally a safe and fast method of transportation, but accidents always happen whether through human error, mechanical failure, or criminal activity. Over the last two decades, there have been many fatal aircraft accidents per year worldwide. These, and lesser accidents, have to be investigated scientifically in order to gain important lessons about aircraft performance and safety.
The International Civil Aviation Organization (ICAO) requires that a civil aircraft accident be investigated by an independent body belonging to the country where the accident took place. Each country has its own organization taking responsibility for this: in the United States, it is theNational Transportation Safety Board(NTSB); in the United Kingdom, it is the Air Accidents Investigation Branch (AAIB) and in Malaysia it is the Department of Civil Aviation. The purpose of the investigation is to find out why the accident happened and how similar events might be avoided in the future, rather than to apportion blame. The police will be involved in the investigation if sabotage or some other form of criminal activity is suspected, and the military generally looks into accidents involving service aircraft.
My research is about the air disaster investigation procedure for Malaysia on the matter of the procedure step, incident statistic, comparison between the Malaysian investigation procedures with other region.
History for aircraft investigation
The procedures for air accident investigations were first laid down in 1928 by the US National Advisory Committee for Aeronautics. They required air accident investigators to consider the immediate and underlying factors of an accident in order to establish and apportion blame for its occurrence. A credit system was put in place that weighted causal factors according to their overall culpability – for example, an accident could be regarded 70% the result of pilot error and 30% the result of environmental factors.( New Zealand Air Line Pilots’ Association, 2009)
In 1944 the Chicago Convention drafted a set of procedures and processes to govern the burgeoning international civil aviation industry. Included in these procedures were rules concerning the responsibilities of contracting states in the event of an aviation accident on their soil. These standards and recommended practices were developed by the Accident Investigation Division between February 1946 and February 1947, and were later designated as Annex 13 of the convention. The convention allowed states to generate their own rules for accident investigation, so as long as the core practices of Annex 13 were incorporated and investigative practices aligned with ICAO Doc 9620, the Manual of Aircraft Accident Investigation.( New Zealand Air Line Pilots’ Association, 2009)
The primary focus of Annex 13 differed from that of the US National Advisory Committee for Aeronautics in 1928: it was no longer to find fault and apportion blame for an aircraft accident, but to provide a mechanism by which participants in the industry – pilots, aircraft manufacturers and regulatory agencies – could learn from their mistakes.( New Zealand Air Line Pilots’ Association, 2009)
In recent years, progress and development in science and technology have made dramatic contributions to human society. However, these same development have given rise to many new type of dangers, and a massive increase in loses that would have been in conceivable in the past. (Masako Miyagi, 2005)
This trend is by no means an indication of carelessness on the part of the individuals involved: rather, it could be considered an indication that the methods used to implement traditional safety measures in the past have reached a limit of effectiveness. This is because the most basic safety measures taken in the past were limited to reprimands and punishments targeting the person responsible for the accidents, and improvements to mechanical aspects stemming from the result of accident investigations. Such accident investigations placed an emphasis on technical analysis of events in accidents that had already occurred, and for this reason there is no question that they contributed to a sharing of important information regarding the mechanical aspects of these accidents, that this information was put to use in making improvements, and that significant results were archived through this process. (Masako Miyagi, 2005)
Human beings are able to develop and increase their abilities to some extent through education and training. The fact remain, however, that it is extremely difficult to obtain the information on human aspects of accidents that would be required to implement such training, because the people most directly involved may have been killed in the accident, or may be reluctant to come forward for fear of being held responsible. There are definitive limitations to approach described above even if all the relevant information in obtained; namely that when studied are made into accident prevention measures based on accident investigations, the investigations can only begin after the accident has occurred. Furthermore, the improvement measure based on accident investigations will only be of value in preventing the re-occurrence of accidents that are identical to those on which the measures were originally based. (Masako Miyagi, 2005)
Graf below showed that, by years to years, more accident happen because of human carelessness rather than mechanical failure. By times go by the percentage being increasing.
Graft 1.1(Masako Miyagi)
Boeing`s statistical summary
There are several reliable sources of accident data. One of the most easily accessible accident databases is maintained by Boeing, which publishes an annual Statistical Summary of commercial Jet Airplane Accident. Another good sources document is the International Air Transport Association (IATA) Safety Board Record(Jet), also published annually.( Alexander T.Wells and Clarence C.Rodrigues, 2004)
Hull losses were also analyzed according to the phase of flight in which they occurred (Graft 1.2). After the combined approach and lading phases, the next greatest numbers hull-loss accident occurred in the combined phases from landing through initial climb. Cruise, which accounts for about__ of flight time in a 1.5 hour flight, occasioned only 6% of hull-loss accidents.( Alexander T.Wells and Clarence C.Rodrigues, 2005)
The summary also considered primary cause factor for commercial operations hull-loss accidents for the period 1990-1999(Graft1.3). For accidents with known causes, flight crew were considered the primary cause in most 67% over the 10 years periods.( Alexander T.Wells and Clarence C.Rodrigues, 2005)
Graft 1.2 Phase of flight in hull-loss accident, all aircraft, worldwide commercial jet fleet
(Boieng commercial airplanes Group)
Graft 1.3 Primary causes factors (as determined by the investigating authority) in hull-loss accidents, all aircraft, worldwide commercial Jet fleet(1990-1999)(Boeing Commercial Airplanes Group)
Chart below showed about accident categorizes by airplane generation for the period 1990-1999 (Table 1.1). Most accidents occurred on landing, with 157 out of 385 for the 10-years period. Interestingly, most landing accident involved current generation aircraft. (Alexander T.Wells and Clarence C.Rodrigues, 2005)
Type of incident\Generation
|Controlled flight into terrain||5||17||3||11||36|
|Loss of control||8||7||2||12||30|
|Fuel tank explosion||1||1||2|
|off end on landing||7||17||3||22||49|
|Off side on Landing||3||20||3||11||37|
|Off side on takeoff||1||1||3||3||8|
|Runway Incursion vehicle/people||5||1||10||16|
|Ground Crew injury||3||2||2||7|
|Fire on ground||1||2||3||2||8|
|Refused take-off end||3||6||3||2||14|
Table 1.1 Accident categorizes by airplane generation for the period 1990-1999 (Alexander T.Wells and Clarence C.Rodrigues,2005)
-Coffee Maker Explosion
|-Taxied across ditch
(Alexander T.Wells and Clarence C.Rodrigues)
Graft 1.4 Accident categorizes by airplane generation for the period 1990-1999 (Alexander T.Wells and Clarence C.Rodrigues)
|Comet 4, 707/720,DC-8,CV-880/-990,Caravelle|
|727,trident VC-10,BAC 1-11,DC-9,737-100/200,F-28|
|– MD-80,767,757,A310,Bae 146, A300-600, 737-300/-400/-500,F-100,A320/310/321, 747-400,MD-11,A340,MD-90,777,737NG,717|
Table 1.2 Aircraft by generation (Alexander T.Wells and Clarence C.Rodrigues)
Graft 1.5 Accident Categories by airplane generation, all accidents, worldwide commercial jet operations. (1990-1999).(Boeing Commercial Airplanes Group)
1.2 Problem definition
The problem with the current situation is, even thought so many precaution have been make, but air disaster still happen. Is there any way to prevent this disaster to happen? Each country had theirs own investigation team. But after the investigation, still have some aircraft that crash and involve a mass casualty.
This research will study about the limitation of the investigation body if there is an air crash or air disasters occur in or outside of the investigation body region.
1.3 Objectives of research
The main objectives of this thesis are to make a research upon the investigation procedure and type of accident happen in Malaysia and throughout the world. These are several more objectives of the project:
- Compare the investigation procedure between America and Malaysia.
- To understand the concept of how the air disaster investigation procedure.
- To prove that aircraft investigation can reduce air disaster.
- Making a survey about the awareness of the investigation procedures.
- To know the party that involved in board of investigation rules and regulation in Malaysia
1.4 Research scope
This thesis will go through the ICAO annex 13, Aircraft Investigation Procedure Manual and MCAR Part 12 to study the exact procedure of the Aircraft Investigation Procedures.
Chapter 2: Literature Review
The Chicago Convention on International Civil Aviation established the International Civil Aviation Organization (ICAO) as a specialized aviation department within the United Nations. ICAO Annex 13 defines and directs requirements forAircraft Accident and Incident Investigationprocedures. As a result most nations or consortium of nations have some form of air regulating body which subsequently contains an investigation division.
Unfortunately not all agencies are created equally and national differences exist which influencefactual results in accident investigation. Six areas have been presented as a hindrance to proper investigative techniques in a paper by Dr. Horacio A. Larrosa of the International Society of Air Safety Investigators (ISASI)Accident and Incident procedures in Argentina MO4131.
- Expertise and Experience
- Investigative Budgets
- Political and Religious Influence and Beliefs
- Nepotism and Cronyism
- Dedication and Desire
- National Pride or Prejudice
2.2 Internationally Respected Players
2.2.1 National Transportation Safety Board (NTSB)
The National Transportation Safety Board is an independent federal agency charged with determining the probable cause of transportation accidents and promoting transportation safety, and assisting victims of transportation accidents and their families. The NTSB investigates accidents, conducts safety studies, evaluates the effectiveness of other government agencies’ programs for preventing transportation accidents, and reviews the appeals of enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and the U.S. Coast Guard (USCG), as well as the appeals of civil penalty actions taken by the FAA.(NTSB,2002)
To help prevent accidents, the NTSB develops safety recommendations based on our investigations and studies. These are issued to federal, state, and local government agencies and to industry and other organizations in a position to improve transportation safety. Recommendations are the focal point of the NTSB’s efforts to improve the safety of the nation’s transportation system. (NTSB,2002)
To promote transportation safety by
- maintaining our congressionally mandated independence and objectivity;
- conducting objective, precise accident investigations and safety studies;
- performing fair and objective airman and mariner certification appeals; and
- advocating and promoting safety recommendation. And
- to assist victims of transportation accidents and their families.
2.2.2 European Aviation Safety Agency (EASA)
European Aviation Safety Agency has been the cornerstone of the European Union’s aviation safety programs for years; however, accident investigation has been the jurisdiction of each individual member state. In 2009 the EU outlinedthe requirementsto establish a “better and more uniform quality of accident investigations across the EU.” It will establish the rules for accident investigation for all states controlled by a central EU body in the near future. (EASA,2011)
The EASA has become the competent Community Aviation Authority for the safety of aviation underBasic Regulation 1592/2002; thus, it may be the recipient of safety recommendations related to the areas of its responsibilities. Furthermore, ICAO Annex 13 provides that the State of Design and the State of Manufacture shall each be entitled to appoint an accredited representative because of the function that have been attributed to each of those States with respect to the airworthiness of aircraft under Annex 8. Therefore, as the EASA is now in charge of the airworthiness, is shall be represented in Safety investigation in order to fulfil its obligation.(EASA,2011)
Under both, international and community law, all safety recommendations must be taken into full consideration by the entity to which they are addressed. In addition, in the preamble of theBasic Regulation 1592/2002it is stated that the results of the accident investigations should be acted upon by the EASA, as a matter of urgency in particular when, they relate to defective aircraft design or operational matters. ( EASA,2011)
To successfully discharge its responsibilities in this area, the EASA has included in its organ gram an Accident Investigation Section. It is responsible for the follow-up of occurrences where the Safety has been endangered. (EASA,2011)
Its main devoted tasks are:
- To follow the progress of aircraft accidents and incidents investigations,
- To be represented in investigations and collect information related to occurrences,
- To achieve the processing of Safety Recommendations addressed to the Agency,
- To provide progress reports and statistics on the Safety Recommendations processing,
- To maintain a good coordination with European Accident Investigation Bodies,
- To identify safety deficiencies and disseminate related information.
2.2.3 The European Three (E3)
The European Three are combination of the safety bureau in Europe, there are the Air Accidents Investigation Branch ( AAIB) of England, French Air Accident Investigation Bureau ( BEA France) and Aircraft Accident Investigation Bureau (AAIB Switzerland) are recognized as world leaders in several accident investigation areas. Not only do they aid nations of the EU in investigations but also non EU nations that have accidents involving aircraft manufactured in Europe, European registered aircraft, accidents occurring in any nation that was a colony of one of the EU member states and any nations requesting help.
2.2.4 Australian Transport Safety Bureau (ATSB)
Australian Transport Safety Bureau has gained a reputation as Oceana and Asia’s air accident investigating body. They are investigators in most of the small island nations of the South and Central Pacific or whenever requested by other nations. Australia’s development as a nation through the twentieth century was closely linked to the development of the aviation industry. This industry has helped us overcome vast internal distances and geographical isolation from the rest of the world.(ATSB, 2011)
The ATSB is responsible for the independent investigation of accidents and incidents involving civil aircraft in Australia. The ATSB’s primary focus for its investigations is fare-paying passenger operations. However, all accidents and incidents related to flight safety in Australia or involving Australian registered aircraft overseas must be reported to the ATSB. While the ATSB does not investigate all of these, it still needs to be notified so that the data can be recorded for possible future safety research and analysis. (ATSB,2011)
2.2.5 Transportation Safety Board of Canada
The Canadian Transportation Accident Investigation and Safety Board (TSB) has emerged as the leader in South and Central America. Similar to Australia the small population nation that is home to ICAO, works in close coordination with the larger NTSB in the USA However, viewed as an alternative to Washington many Latin American nations work directly with Canada out of desire, security or necessity.(TSB, 2010)
Most nations have the required ICAO investigative agencies but the variations between countries are still very strong. The positive factor for international accident investigation is that many investigators within these nations are willing to call upon each other and aid their work. Working together in the vast majority of air accidents, the public has a good chance of obtaining the truth about accidents within their borders.
Before going through a little further, these are some definition that being use in the investigation for any accident or incident that happen. All definition are taken from ICAO , 2001, Annex 13, MCAR part 12 and NTSB 2002, Aircraft accident Investigation Manual.
2.3.1 Aircraft 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 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.
The aircraft sustains damage or structural failure which is adversely affects the structural strength, performance or flight characteristics of the aircraft, or the aircraft is missing or is completely inaccessible.
2.3.2 Aircraft Incident
An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.
Serious incident – An incident involving circumstances indicating that an accident nearly occurred.
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, when appropriate, the making of safety recommendations.
2.3.4 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.
2.3.5 Chief Inspector
The Chief inspector of Air Accidents and includes any deputy chief inspector;
Aperson appointed as an Inspector of Air Accidents
2.3.7 Field Investigation
An investigation which is not intended to be the subject of a report by an Inspector to the Minister.
2.3.8 Formal Investigation
An investigation which is intended tobe the subject of a report by an Inspector to the Minister.
2.3.9 Serious Injury
An injury which is sustained by a person in a reportable accident and which:
- Requires his stay in hospital for more than forty-eight hours commencing within seven days from the date on which the injury is received
- results in a fracture of any bone except simple fractures of fingers, toes or nose.
- involves lacerations which cause severe nerve, muscle or tendon damage
- involves injury to any internal organ; or involves second or third degree burns or any burns affecting more than five per centum of the surface of the body.
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.
Actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident.
2.3.12 Flight recorder.
Any type of recorder installed in the aircraft for the purpose of complementing accident/incident investigation.
2.3.13 Maximum mass.
Maximum certificated take-off mass.
A person, organization or enterprise engaged in or offering to engage in an aircraft operation
2.3.15 Preliminary Report.
The communication used for the prompt dissemination of data obtained during the early stages of the investigation.
2.3.16 Safety recommendation.
A proposal of the accident investigation authority of the State conducting the investigation, based on information derived from the investigation, made with the intention of preventing accidents or incidents.
2.3.17 State of Design.
The State having jurisdiction over the organization responsible for the type design
2.3.18 State of Manufacture.
The State having jurisdiction over the organization responsible for the final assembly of the aircraft
2.3.19 State of Occurrence.
The State in the territory of which an accident or incident occurs.
2.3.20 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.
2.3.21 State of Registry.
The State on whose register the aircraft is entered.
2.4 Investigation Responsibility for Instituting and Conducting the investigation.( ICAO , 2001)
2.4.1 Accidents or incidents in the territory of a contracting state.
State of Occurrence
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 the whole or any part of the conducting of such investigation to another State by mutual arrangement and consent. In any event the State of Occurrence shall use every means to facilitate the investigation.
Recommendation.— The State of Occurrence should institute an investigation into the circumstances of a serious incident. Such a State may delegate the whole or any part of the conducting of such investigation to another State by mutual arrangement and consent. In any event the State of Occurrence should use every means to facilitate the investigation.
2.4.2 Accidents or incidents in the territory of a non-contracting state.
State of Registry
When the accident or the serious incident has occurred in the territory of a non-Contracting State which does not intend to conduct an investigation in accordance with Annex 13, the State of Registry or, failing that, the State of the Operator, the State of Design or the State of Manufacture should endeavour to institute and conduct an investigation in cooperation with the State of Occurrence but, failing such cooperation, should itself conduct an investigation with such information as is available.
2.4.3 Accidents or incidents outside the territory of any state.
State of Registry
When the location of the accident or the serious incident cannot definitely be established as being in the territory of any State, the State of Registry shall institute and conduct any necessary investigation of the accident or serious incident. However, it may delegate the whole or any part of the investigation to another State by mutual arrangement and consent.
States nearest the scene of an accident in international waters shall provide such assistance as they are able and shall, likewise, respond to requests by the State of Registry.
If the State of Registry is a non-Contracting State which does not intend to conduct an investigation in accordance with Annex 13, the State of the Operator or, failing that, the State of Design or the State of Manufacture should endeavour to institute and conduct an investigation. However, such a State may delegate the whole or any part of the investigation to another State by mutual arrangement and consent.
2.5 Organization and conduct of the investigation.( ICAO , 2001)
2.5.1 Responsibility of the state conducting the investigation.
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. The investigation shall include:
- the gathering, recording and analysis of all available information on that accident or incident;
- if appropriate, the issuance of safety recommendations;
- if possible, the determination of the causes; and
- the completion of the final report.
If possible, the scene of the accident shall be visited, the wreckage examined and statements taken from witnesses.
Recommendation.— Any judicial or administrative proceedings to apportion blame or liability should be separate from any investigation conducted under the provisions of this Annex.
Investigator-in-charge — Designation
The State conducting the investigation shall designate the investigator-in-charge of the investigation and shall initiate the investigation immediately.
Investigator-in-charge — Access and control
The investigator-in-charge shall have unhampered access to the wreckage and all relevant material, including flight recorders and ATS records, and shall have unrestricted control over it to ensure that a detailed examination can be made without delay by authorized personnel participating in the investigation.
Flight recorders — Accidents and incidents
Effective use shall be made of flight recorders in the investigation of an accident or an incident. The State conducting the investigation shall arrange for the read-out of the flight recorders without delay.
In the event that the State conducting the investigation of an accident or an incident does not have adequate facilities to read out the flight recorders, it should use the facilities made available to it by other States, giving consideration to the following:
- the capabilities of the read-out facility;
- the timeliness of the read-out; and
- the location of the read-out facility.
The State conducting the investigation into a fatal accident shall arrange for complete autopsy examination of fatally injured flight crew and, subject to the particular circumstances, of fatally injured passengers and cabin attendants, by a pathologist, preferably experienced in accident investigation. These examinations shall be expeditious and complete.
When appropriate, the State conducting the investigation should arrange for medical examination of the crew, passengers and involved aviation personnel, by a physician, preferably experienced in accident investigation. These examinations should be expeditious.
Coordination — Judicial authorities
The State conducting the investigation shall recognize the need for coordination between the investigator-in-charge and the judicial authorities. Particular attention shall be given to evidence which requires prompt recording and analysis for the investigation to be successful, such as the examination and identification of victims and read-outs of flight recorder recordings.
Informing aviation security authorities
If, in the course of an investigation it becomes known, or it is suspected, that an act of unlawful interference was involved, the investigator-in-charge shall immediately initiate action to ensure that the aviation security authorities of the State(s) concerned are so informed.
Non-disclosure of records
The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations:
- all statements taken from persons by the investigation authorities in the course of their investigation;
- all communications between persons having been involved in the operation of the aircraft;
- medical or private information regarding persons involved in the accident or incident;
- cockpit voice recordings and transcripts from such recordings; and
- opinions expressed in the analysis of information, including flight recorder information
These records shall be included in the final report or its appendices only when pertinent to the analysis of the accident or incident. Parts of the records not relevant to the analysis shall not be disclosed.
Re-opening of investigation
If, after the investigation has been closed, new and significant evidence becomes available, the State which conducted the investigation shall re-open it. However, when the State which conducted the investigation did not institute it, that State shall first obtain the consent of the State which instituted the investigation.
Information — Accidents and incidents
Any State shall, on request from the State conducting the investigation of an accident or an incident, provide that State with all the relevant information available to it.
Any State, the facilities or services of which have been, or would normally have been, used by an aircraft prior to an accident or an incident, and which has information pertinent to the investigation, shall provide such information to the State conducting the investigation.
2.5.3 Responsibility of the state of registry and the state of the operator.
Flight recorders — Accidents and serious incidents
When an aircraft involved in an accident or a serious incident lands in a State other than the State of Occurrence, the State of Registry or the State of the Operator shall, on request from the State conducting the investigation, furnish the latter State with the flight recorder records and, if necessary, the associated flight recorders.
The State of Registry and the State of the Operator, on request from the State conducting the investigation, shall provide pertinent information on any organization whose activities may have directly or indirectly influenced the operation of the aircraft.
2.6 Participation In The Investigation.( ICAO , 2001)
2.6.1 Participation of The State of Registry, The State of The Operator, The State of Design and The State of Manufacture
The State of Registry, the State of the Operator, the State of Design and the State of Manufacture shall each be entitled to appoint an accredited representative to participate in the investigation.
The State of Registry or the State of the Operator shall appoint one or more advisers, proposed by the operator, to assist its accredited representative.
When neither the State of Registry, nor the State of the Operator appoint an accredited representative, the State conducting the investigation should invite the operator to participate, subject to the procedures of the State conducting the investigation.
The State of Design and the State of Manufacture shall be entitled to appoint one or more advisers, proposed by the organizations responsible for the type design and the final assembly of the aircraft, to assist their accredited representatives.
When neither the State of Design nor the State of Manufacture appoint an accredited representative, the State conducting the investigation should invite the organizations responsible for the type design and the final assembly of the aircraft to participate, subject to the procedures of the State conducting the investigation.
When the State conducting an investigation of an accident to an aircraft of a maximum mass of over 2 250 kg specifically requests participation by the State of Registry, the State of the Operator, the State of Design or the State of Manufacture, the State(s) concerned shall each appoint an accredited representative.
2.6.2 Participation of other states.
Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.
Any State that provides an operational base for field investigations or is involved in search and rescue or wreckage recovery operations may also be entitled to appoint an accredited representative to participate in the investigation.
2.6.3 Entitlement of accredited representatives
A State entitled to appoint an accredited representative shall also be entitled to appoint one or more advisers to assist the accredited representative in the investigation.
Advisers assisting accredited representatives shall be permitted, under the accredited representatives’ supervision, to participate in the investigation to the extent necessary to enable the accredited representatives to make their participation effective.
Participation in the investigation shall confer entitlement to participate in all aspects of the investigation, under the control of the investigator-in-change, in particular to:
- visit the scene of the accident;
- examine the wreckage;
- obtain witness information and suggest areas of questioning;
- have full access to all relevant evidence as soon as possible;
- receive copies of all pertinent documents;
- participate in read-outs of recorded media;
- participate in off-scene investigative activities such as component examinations, technical briefings, tests and simulations;
- participate in investigation progress meetings including deliberations related to analysis, findings, causes and safety recommendations; and
- make submissions in respect of the various elements of the investigation.
However, participation of States other than the State of Registry, the State of the Operator, the State of Design and the State of Manufacture may be limited to those matters which entitled such States to participation under 5.23.
Accredited representatives and their advisers:
- shall provide the State conducting the investigation with all relevant information available to them; and
- shall not divulge information on the progress and the findings of the investigation without the express consent of the State conducting the investigation.
2.6.4 Participation of states having suffered fatalities or serious injuries to its citizens.
Rights and entitlement
A State which has a special interest in an accident by virtue of fatalities or serious injuries to its citizens shall, upon making a request to do so, be permitted by the State conducting the investigation to appoint an expert who shall be entitled to:
- visit the scene of the accident;
- have access to the relevant factual information;
- participate in the identification of the victims;
- assist in questioning surviving passengers who are citizens of the expert’s State; and
- receive a copy of the Final Report
2.7 List of examples of serious Incidents(ICAO , 2001)
1. The term “serious incident” is defined in Chapter 1 as follows:
- Serious incident. An incident involving circumstances indicating that an accident nearly occurred.
- The incidents listed are typical examples of incidents that are likely to be serious incidents. The list is not exhaustive and only serves as guidance to the definition of serious incident.
- Near collisions requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when an avoidance action would have been appropriate.
- Controlled flight into terrain only marginally avoided.
- Aborted take-offs on a closed or engaged runway.
- Take-offs from a closed or engaged runway with marginal separation from obstacle(s).
- Landings or attempted landings on a closed or engaged runway.
- Gross failures to achieve predicted performance during take-off or initial climb.
- Fires and smoke in the passenger compartment, in cargo compartments or engine fires, even though such fires were extinguished by the use of extinguishing agents.
- Events requiring the emergency use of oxygen by the flight crew.
- Aircraft structural failures or engine disintegrations not classified as an accident.
- Multiple malfunctions of one or more aircraft systems seriously affecting the operation of the aircraft.
- Flight crew incapacitation in flight.
- Fuel quantity requiring the declaration of an emergency by the pilot.
- Take-off or landing incidents. Incidents such as under-shooting, overrunning or running off the side of runways.
- System failures, weather phenomena, operations outside the approved flight envelope or other occurrences which could have caused difficulties controlling the aircraft.
- Failures of more than one system in a redundancy system mandatory for flight guidance and navigation.
2.8 Right and obligations of the state of the operator in respect of accidents and incidents involving leased, chartered or interchanged aircraft. (ICAO , 2001)
The Standards and Recommended Practices of Annex 13 — Aircraft Accident and Incident Investigation were developed when the State of Registry and the State of the Operator normally were the same. In recent years, however, inter-national aircraft leasing and interchanging arrangements have developed so that in many instances the State of the Operator is different from the State of Registry.
Leasing or interchange arrangements sometimes include the provision of flight crews from the State of Registry. However, more often, flight crews are provided by the State of the Operator and the aircraft operated under national legislation of the State of the Operator. Similarly, a variety of arrangements for airworthiness can emerge from these arrangements.
Airworthiness responsibility may rest, wholly or partly, with the State of the Operator or State of Registry. Sometimes the operator, in conformity with an airworthiness control system specified by the State of Registry, carries out maintenance and keeps records.
In the event of an accident or an incident, it is important that any State which has assumed responsibility for the safety of an aircraft has the right to participate in an investigation, at least in respect of that responsibility. It is also important that the State conducting the investigation should have speedy access to all documents and other information relevant to that investigation.
When the location of an accident or an incident cannot definitely be established as being in the territory of another State, the State of the Operator, after consultation with the State of Registry, should accept full or partial responsibility for the conduct of the investigation.
Chapter 3; Methodology (Draft For next semester progress)
Go through Part 12 of Malaysian Civil Aviation Regulation. Study the procedures of investigation, the person that responsible in the investigation, what body that involve in the investigation. What type of accident that the Department of Civil Aviation (Malaysia) involve? Are there a different between company investigation and DCA investigation? What is the procedure for Military investigation? Is DCA also involved in the investigation or the DCA just involve in civil aircraft only.
Go through the Aircraft Investigation Procedure that being publish by NTSB.
Learn about the procedure, the man in-charge for the investigation. What type of aircraft involve? Each type of aircraft have different approach for start the investigation.
Make a survey at MAS, Airasia or Westar about the awareness in investigation procedure in Malaysia