Aircraft Accident

Investigation
Introduction

AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY,

Saturday, 18 May 2024 PPT 1.1
ZARIA
 Investigation
Course Overview
q Curriculum Basis
- International Civil Aviation Organization (ICAO)
Circular 298
- International Society of Air Safety Investigators
(ISASI)
- Aircraft Accident Investigation 2nd Edition, Wood &
Sweginnis
q Instructional Outline

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.2
 Investigation
Course Overview (Cont’d)

- Investigation Background and Accident Causation

Theory
- ICAO Annex 13 / NTSB Application
- Investigation Techniques
- Special Subjects
q Methodology
q Case Study

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.3
 Course objectives
q What you should know at the end
q Understand the elements in accident and incident
investigations, how they interrelate and some means to
control them
q Be familiar with the issues facing investigators and
managers; and some practical solutions to dealing with
problems

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.4
 Course objectives
(Cont’d)
q Understand the processes for preparation of the Final
Report; as well as identifying, proposing and
implementing required safety actions

q Understand and the roles and responsibilities for

accident prevention (and fundamentals of safety
management systems (SMS))

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.5
 Elements of an
investigation
q Pre-event preparation

q International requirements (ICAO Annex 13 and EU

Directives)

q National legislation, regulations and procedures

Accident/incident notification
q Accident site

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.6
 Elements of an
investigation (Cont’d)
q Investigator/team dispatch
q Initial on-scene activities and site safety Organization of
the investigation Wreckage/accident site management
Investigation progress meetings
q Dissemination of factual information, including urgent
safety actions
q Closeout of the accident site

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.7
 Elements of an
investigation (Cont’d)

q Off-site investigation activities

q Gathering, custody and protection of evidence Witness
interviewing
q Off-site testing
q Investigative reports Research
q Simulations
q Analysis and Final Report

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.8
 Elements of an
investigation (Cont’d)

q Analysis of evidence
q Draft Final Report
q Consultations with interested parties Safety
recommendations
q Dissemination of Final Report ( + Safety Recs) Follow-
up of implementation of safety recs ?

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.9
Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.10
 Working with
parties involved

qUnderstand strategies for working with the interested

parties involved
q Regulator (civil aviation authority) Airline
q Aircraft manufacturer
q Accredited representatives and their advisers Labor
unions
q Emergency services Coroner, police Pathologists
q Scientific support News media
q Families (family associations)

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.11
 Accident investigation
management
q The IIC must have the experience to direct the
investigation in a manner to ensure resources
(investigators and funds) are used to extract the
maximum benefit to the safety of aviation Do not
squander on irrelevant lines of inquiry

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.12
 Accident investigation
management (Cont’d)
q The relevant lines of inquiry should be terminated as
soon as they have achieved the level beyond which
further expenditure of resources will be uneconomical in
terms of enhancing safety

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.13
 Principles involved
q A major accident is always a major political event
q Never surprise anyone (your boss, your agency, your
transport minister, the civil aviation authority, accredited
representatives, families of the victims, the airline
involved, a recipient of safety recommendations, etc.)

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.14
 Principles involved
(Cont’d)
q Transparency (must not only be transparent, but must
be seen and perceived to be transparent by the public)
q Tremendous differences in “outside pressure” when
investigating a major aircraft accident as compared to an
incident

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.15
 Principles involved
(Cont’d)
q Good investigations are based on common sense, good
judgment and teamwork

q The above is supplemented by investigator training,

knowledge and experience

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.16
 Principles involved
(Cont’d)
qDo not wait for “luck” or rely on “luck” - however, never
refuse “luck”

q Efficiency does not mean “jump to conclusions” or “wrap

up in a haste”

q What you look for is what you find ! What you find is
what you fix !

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.17
 Fundamental principles
q Honesty and truth

q Sharing data and information Transparency

q Personal ambitions versus the good of the investigation
team/accident investigation authority

q Logic versus personal ambitions Logic versus personal

attacks

q Listen carefully and listen for the message, not the

delivery

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.18
 Fundamental principles
What makes a good investigator?
What makes a good investigation?

• How many of theses traits can we instill in you in a

four days course?
• How many of these traits can you work on after the
course?
• How can you ensure your investigation is a good
one?

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.19
 Investigation
Integrity

• Integrity is a concept of consistency of actions,

values, methods, measures, principles,
expectations, and outcomes

• Applies to the individual as well as the instructor or

organization

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.20
 Investigation &
Prevention Process
q Preparation Beforehand
- Investigators
Preparation
- Organization
• Deployment
• Conduct Field Investigation
Investigation
• Perform Analysis
• Determine Conclusions
• Write & Validate Report
• Issue Recommendations Prevention
• Corrective Action Applied
• Review Adequacy of Actions
Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.21
 Essential steps for
a successful investigation
q An effective organization
q Control of actions
q Group dynamics
q All options opened – till eliminated
q All the facts needed
q Reports – timely, accurate, complete

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.22
 First - develop an
Accident Response Plan

AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY,

Saturday, 18 May 2024 PPT 1.23
ZARIA
 The “Plan”
vStart at the top vAppointing the
vClear objectives coordinator
vQualified people vEstablishing the
vEnough people response center -
command post
vWho starts the plan
vWho launches
vWho gets notified
vWhere is the
vWho handles the equipment
media/families

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA 24

 More on the “Plan”

q Establishing the contacts with DGAC

q Practicing the plan – regularly!
q Keeping it current – contacts
q Distributing the plan
q Networking with other operators
q Practice again!

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.25
 Important first actions
v Wreckage security
v Minimum disturbance of wreckage
v Early photos/video of site
v Notify appropriate agencies
v Impound records – aircraft/personnel
v Aircraft manifest

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.26
 When you arrive – before the
organization meeting

q Stay focused – distractions

q Who’s in charge at the site – security
q Photo/video/notes
q Request preservation of the perishable data
q Recorders

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.27
 What to take with you

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.28
 Investigator’s
Pre-Packed “Go Kit”
q Tape Measure (12’ & 100’) q Notebook / Scratch Pad
q Magnifying Glass q Engineering Pad
q Rulers q Pencils & Pens
q Compass q Felt Tip pens
q First Aid Kit q Rubber Bands
q Whistle q Stapler
q Tools (Appropriate) q Tags & Labels
q String q Surgical Gloves / Masks
q Small Magnet q Exposure Suit (1)
q Chalk & Eraser q Towelettes
q Water Container & Cup q Plotter Knapsack
q Cellophane Tape q Paper clips
q Duct Tape q Zip-Lock & Static-Safe plastic
Saturday, 18 May 2024 Bags
AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA 29
 Investigator’s
“Go Bag”

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.30
 Bags

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.31
 Witness Equipment

Taping

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.32
 Survival Gear

Whistle

First aid

Bug spray
Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.33
 Collecting evidence

Telescoping mirror
Plastic zip bags tags

5x - 10x magnifier Markers

Several small plastic bottles
Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.34
 Other items

Measuring tape

GPS

Alcohol wipes + clean rags

Strong string Red Book Batteries

Saturday, 18 May 2024 AMS NIGERIAN COLLEGE OF AVIATION TECHNOLOGY, ZARIA PPT 1.35