Accident Investigation and Occurrence Reporting

Question 1

What authorities investigate accidents?

Answer 1

• ## permanent national civil aviation safety investigation authority (SIA) of the country the accident/incident occured in

Question 2

Who is in charge in Germany?

Answer 2

BFU Bundesstelle für Flugunfalluntersuchung

Question 3

What are the responsibilities of all the parties involved?

Answer 3

Responsibilities of the State of Occurrence:
- protect the evidence
- to maintain safe custody of the aircraft and its contents
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
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

Question 4

What phases of investigation are there?
In what order are they performed?
What are the key aspects in each?

Answer 4

1. Notificationof Occurrence
2. Setup of the Investigation Team and Involvement of Participators Announcement of the Investigator-in-Charge and Accredited Representative
3. Information and Data GatheringExamination of the Wreckage, Flight Data Collection and Interviews
4. Event ReconstructionWreckage Reconstruction and Simulations
5. Analysisof the Information GatheredExplanationof the Factors Leading to the Occurrence
6. ConclusionsIdentification of the Causes and Contributing Factors Leading to the Occurrence
7. Safety RecommendationsThe Safety Recommendations are the Main Product of Any Safety Investigation
8. Communication of Safety Messages Safety Information Exchange and Lesson Dissemination

Question 5

How are occurence reports handled?

Answer 5

• desciptive and explanatory (bullet points)
• reported to state
• state reports to ICAO
• stored in database ADREP, ECCAIRS (EU)

Question 6

What databases are there?

Answer 6

• STEADES is IATA’s aviation safety database that manages de-identifiedincident reports from participating airlines
• ASRS The Air Safety Reports System by NASA collects voluntarily and de-identified submitted aviation safety incident/situation reports from pilots, controllers and others.
• Bundesstelle für Flugunfalluntersuchung–Occurrence Reports Data Base
• …

Question 7

Who is authorized to investigate flight accidents?

Answer 7

• Investigator in charge

- SIA; permanent national civil aviation safety investing authority (independent from any authority)

Question 8

What are the characteristics of voluntary vs mandatotry reporting?

Answer 8

Mandatory reporting:
- operational personnel is required to report accidents/incident by law
- Reactive- the accident/incident has already happend
- accident to aircraft over 2250kg
- incidents to aircrafts over 5700kg
- investigation by official state representatve
- ECCAIRS database
Voluntary reporting
- no punitive effects just trust of employee in company-> ease and confidentialy of reporting
- Proactive- events have nit yet caused an incident/accident
- issues and hazards which are not mandatory reported and have not yet caused an incident
- independence from State representatives
- integrated into internal company/service providers reporting systems

Question 9

Why is reporting so important?

Answer 9

• helps to identify hazards
• Heinrich theory: 300 unreported occurences-> 30 incident-> 1 accident
• unreported occurences are missing pieces for future mishaps