AIRCRAFT ACCIDENT AND

INVESTIGATION

AMTE 419
INTRODUCTION
DEFINITIONS
FINDINGS, CAUSES AND
RECOMMENDATIONS
INDEPENDENT INVESTIGATORS
UNITED STATES INVESTIGATIONS
INTERNATIONAL INVESTIGATIONS
FIELD INVESTIGATIONS
WRECKAGE DISTRIBUTION
ACCIDENT PHOTOGRAPHY
ACCIDENT DIAGRAMS
FIRE INVESTIGATIONS
STRUCTURAL INVESTIGATION
TIRES AND RUNWAY ACCIDENTS
MID-AIR COLLISION
AIRCRAFT RECORDERS
AIRCRAFT RECORDERS
OPERATION AND MAINTENANCE
AIRFIELD, AIR TRAFFIC AND
WEATHER
WITNESSES
AIRCRAFT ACCIDENT REPORT
INVESTIGATION MANAGEMENT
PRELIM
DEFINITIONS
 DEFINITIONS

AIRCRAFT ACCIDENT – involving some degree of damage or injury associated

with the operation of the aircraft.

ACCIDENT(ICAO) - An occurrence associated with the operation of the aircraft

which takes place between the time any person boards the aircraft with the
intention of flight until such time as all such person have disembarked
 DEFINITIONS
A. A person is fatally or seriously injured as a result of:

- Being in the aircraft

- Direct contact with any part of the aircraft including the parts which have become detached
from the aircraft
- Direct exposure to jet blast

Except when the injuries are:

- From natural causes

- Self-inflicted or inflicted by other persons
- When the injuries are to stowaways hiding outside the areas normally available to the
passengers or crew

B. The aircraft is missing or is completely inaccessible.

 DEFINITIONS
SERIOUS INJURY(ICAO) - An injury which is sustained by a person in an accident and
which:

- Requires hospitalization for more than 48 hours, commencing within 7 days from
the date of injury was received.
- Results in a fracture of any bone (except simple fractures of fingers, toes, or nose).
- Involves lacerations which cause severe hemorrhage, nerve, muscle and tendon
damage.
- Injury to any internal organ
- Involves second or third degree burns, or any burns affecting 5 percent of the body
surface.
- Involves verify exposure to infectious substances or injurious radiation.
 DEFINITIONS

SUBSTANTIAL DAMAGE – define as damage or

failure which adversely affects the structural strength,
performance, or flight characteristics of the aircraft,
and which normally require major repair or
replacement of the affected component.
 DEFINITIONS

Not considered as substantial damage:

Engine failure or damage limited to an engine if only one
engine fails or is damaged, bent fairings or cowling, dented
skin, small punctured holes in the skin or fabric, ground
damage to rotor or propeller blades, damage to landing
gear, wheels, tires, flaps, engine accessories, brakes or
wingtips.
PURPOSE OF INVESTIGATION
 PURPOSE OF
INVESTIGATION

The sole purpose of the investigation of an accident or

incident are as follows:
- Shall be for prevention of accident or incident.
- It shall not be proposed of such investigation to
apportion blame or liability.
 PURPOSE OF
INVESTIGATION

An Investigation shall include. . .

- The gathering, recording, and analysis of all available information

on the accident or incident.
- If appropriate, the issuance of safety recommendation.
- If possible, the determination of causes.
- In the case of an accident, the completion of the final report.
 PURPOSE OF
INVESTIGATION

Required information included in the notice

- In the case if an accident, the identifying abbreviation “ACCID” of,
in the case of a serious incident, the identifying abbreviation
“INCID”.
- The manufacturer, model, nationality, and registration marks, and
serial number of the aircraft.
- The name of the owner, operator and hirer of the aircraft.
 PURPOSE OF
INVESTIGATION

Required information included in the notice (cont. . . .)

- The name of the pilot – in – command of the aircraft and the nationality of the
crew and passengers.
- The date and local time or Coordinated Universal
- Time (UTC) of the accident or serious incident.
- The last point of departure and the next point of intended landing of the
aircraft.
- The position of the aircraft with reference to some easily defined geographical
point and the latitude and longitude.
 PURPOSE OF
INVESTIGATION

Required information included in the notice (cont. . . .)

- The number of crew members and passengers on board the aircraft at the
time of the accident or serious incident.
- In case of an accident, the number of crew members, passengers, or other
persons respectively killed or seriously injured as a result of the accident.
- A description of the accident or serious incident and the extent of damage to
the aircraft so far as is known.
 PURPOSE OF
INVESTIGATION

Required information included in the notice (cont. . . .)

- The physical characteristics of the area in which the accident or serious

incident occurred and the indication of access difficulties or special
requirements to reach the site.
- The identification of the person sending the notice and where the accident or
serious incident occurred outside Republic of the Philippines, the means by
which the investigator – in – charge and the accident investigation authority of
the State of Occurrence (the state in whose territory an accident or incident
occurs.
FINDINGS, CAUSES AND
RECOMMENDATIONS
 FINDINGS, CAUSES AND
RECOMMENDATIONS

FINDINGS – All significant conditions and events, casual or non-casual, found in

the investigation(defined by International Society of Air Safety Investigators, ISASI).
Conclusion of the investigative body. They are based on the weight of evidence,
the investigators professional knowledge and their best judgment (defined by
United States Air Force).
 FINDINGS, CAUSES AND
RECOMMENDATIONS

- Development of findings is a very handy way to account for

the investigator’s conclusions about the accident.
- It must be listed chronologically, the findings must be
sequence of events which is the easiest way to describe
the accident.
 FINDINGS, CAUSES AND
RECOMMENDATIONS

CAUSE(ICAO) – defined as an action, omissions, events,

conditions, or combination thereof, which led to the accident
or incident.
Are those findings which singly or in combination with other
causes, resulted in the damage or injury that occurred. A
cause is a deficiency, the correction, elimination or avoidance
of which would likely have prevented or mitigated the mishap
damage or significant injuries (Defined by US Air Force).
 FINDINGS, CAUSES AND
RECOMMENDATIONS

Two types of Causes as defined by ICAO

Descriptive Causes (What Happened) - The sequence of
conditions and events which, singly or in combination, led to the
accident; listed in chronological order.
Explanatory Causes (Why the accident happened) - The
predisposing events and conditions which explains why the
descriptive causes existed or occurred. Explanatory causes usually
form the basis for safety recommendations.
 FINDINGS, CAUSES AND
RECOMMENDATIONS

Other existing causes according to the National Transportation

and Safety Board (NTSB)
Probable Cause – it is a description of the accident event along
with its cause and effect relationship.
Primary Cause – that event after which the accident become
inevitable.
Aggravated Cause – it didn’t cause the accident, but they made
the result worse.
 FINDINGS, CAUSES AND
RECOMMENDATIONS

Several General Conclusions about the process of cause

determination.
There is no such thing as a single cause aircraft accident. All accidents
results in multiple cause.
All causes should be identified and listed chronologically. Listing them any
other way implies some sort of priority ranking; which is impossible.
Arguments about whether a particular finding is or is not a cause are
generally a waste of time. It doesn’t make that much of a difference. If it
has any usual causal elements in it, identify it as a cause.
 FINDINGS, CAUSES AND
RECOMMENDATIONS

RECOMMENDATIONS – It is the most important aspect of the

investigation. After all, the purpose of investigating the accident in the first
place is to do something to prevent the accident from happening again and
correct the deficiencies identified in the process
PARTICIPATION IN INVESTIGATION

The STATE OF REGISTRY, the STATE OF THE OPERATOR, the STATE

OF DESIGN, and the STATE OF MANUFACTURER are entitled to
APPOINT an accredited REPRESENTATIVE to participate in the
INVESTIGATION.
When neither the STATE OF REGISTRY, nor the STATE OF OPERATOR,
appoints an accredited representative, the STATE conducting the
investigation should invite the operator to PARTICIPATE as well as
EXPERTS to attend the investigation.
 THE KEY PLAYERS

When an aircraft accident occurs, a number of organizations may have

some authority or responsibility.
A. INTERNATIONAL CIVIL AVIATION ORGANIZATION(ICAO)
B. INVESTIGATOR – IN – CHARGE (IIC)
- The person or group charged with conducting the investigation.
C. NATIONAL TRANSPORTATION SAFETY BOARD (NTSB)
- This is an independent board charged with investigating all civil aircraft in
the United States.
 THE KEY PLAYERS

D. FEDERAL AVIATION ADMINISTRATION (FAA)

- The government agency responsible for aviation safety in the United States; not investigation.

E. LOCAL LAW ENFORCEMENT

- Those who govern with jurisdiction on any matters involving accident.

F. LOCAL FIRE DEPARTMENT

- Those govern with jurisdiction over fire involvement.

G. CORONERS AND MEDICAL EXAMINERS

- Those who govern with complete authority over any human remains found in the area of his
jurisdiction.
 THE KEY PLAYERS

H. MILITARY

- Those who has complete jurisdiction over accidents involving military installation.

I. INSURANCE CARRIERS

- The agency carrying the hull insurance on the civil aircraft becomes the owner of the wreckage
after the hull loss is paid.

J. PROPERTY OWNER

- the property owner retains all his rights if the aircraft crashed in his private property.

K. AIRCRAFT OWNER/OPERATORS
 THE KEY PLAYERS

L. OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA)

- Those who has complete jurisdiction over accidents involving the injury or fatality in workplace
related situations (Ex. Airplane collides with vehicle; driver injured).

M. ENVIRONMENTAL PROTECTION ADMINISTRATION (EPA)

- They have the jurisdiction with accidents resulting on damage to the environment
 INDEPENDENT INVESTIGATORS

Those organizations not affiliated with a government agency.

A. AIRFRAME, ENGINE AND COMPONENT MANUFACTURERS

- These organizations have a strong interest in the quality and performance of their products.

B. AIRCRAFT OPERATORS

C. UNIONS

D. INSURANCE COMPANIES

E. CONSULTANTS
ACCIDENTS AND INCIDENTS
ACCIDENTS AND INCIDENTS

Some NTSB definitions used in measuring aviation safety in

commercial passenger transportation are as follows:
ACCIDENT
- an occurrence associated with the operation of an aircraft that takes
place between the time any person boards the aircraft with the intention
of flight and the time all such persons have disembarked, and in which
any person (occupant or no occupant) suffers a fatal or serious injury or
the aircraft receives substantial damage.
ACCIDENTS AND INCIDENTS

INJURY
Serious injury - any injury that requires hospitalization for
more than 48 hours, results in a bone fracture, or involves
internal organ or burns.

Fatal Injury - any injury that results in death within 30 days of

the accident.
ACCIDENTS AND INCIDENTS

DAMAGE
Substantial damage - damage or failure that
adversely affects the structural strength, performance,
or flight characteristics of the aircraft and that would
normally require major repair or replacement of the
affected component.
ACCIDENTS AND INCIDENTS

DAMAGE
Substantial damage - damage or failure that
adversely affects the structural strength, performance,
or flight characteristics of the aircraft and that would
normally require major repair or replacement of the
affected component.
TYPES OF ACCIDENT
 TYPES OF ACCIDENT

Major accident
an accident in which a Part of an aircraft was
destroyed, or there were multiple fatalities, or
there was 1 fatality and a Part was substantially
damaged.
 TYPES OF ACCIDENT

Serious accident
an accident in which there’s 1 fatality without
substantial damage to any Part of an aircraft, or
there was at least 1 serious injury and the
aircraft was substantially damaged.
CODE OF FEDERAL REGULATION
 CODE OF FEDERAL
REGULATION

The codification of the general and permanent

rules published in the Federal Register by the
departments and agencies of the Federal
Government.
 CODE OF FEDERAL
REGULATION

OPERATING REQUIREMENTS:
DOMESTIC, FLAG, AND SUPPLEMENTAL OPERATIONS
Prescribes the operating requirements for air operations of
aeroplanes that have a passenger seating configuration of
more than 30 seats, excluding any required crew member
seat, or a payload capacity of more than 3410 kg, carried out
by the holder of an Airline Air Operator Certificate issued
under Part 119 of the Rules.
 CODE OF FEDERAL
REGULATION

INCIDENT
- an occurrence other than an accident associated
with the operation of an aircraft that affects or could
affect the safety operations.
LEVELS OF INVESTIGATION
 LEVELS OF INVESTIGATION

Considering the number of aircraft accidents occurring in the

United States, the NTSB cannot investigate all of them with
equal intensity. Here is a list of the investigative levels
generally available:
1. Major Investigation
2. Major Field Investigation
3. Field Investigation
4. Limited Investigation
 LEVELS OF INVESTIGATION

Major Investigation
This involves the headquarters “GO” Team and is generally reserved for air
carrier accidents and some mid-air collisions. The “GO” team consists of
one of the Board members, a senior IIC, a public affairs officer and
perhaps a dozen specialists in various investigation areas.
These specialists become the Group Chairmen of the groups organized in
the field investigation. The “GO” team travels by commercial air and
expects to be en route to the scene within two hours.
 LEVELS OF INVESTIGATION

Major Field Investigation

This is usually headed by an IIC from the
headquarters using technical assistance from
the headquarters and the Regional Office.
 LEVELS OF INVESTIGATION

3. Field Investigation - Usually a single IIC from

the Regional Office.
4. Limited Investigation - These are
“fender-bender” type accidents wherein the
operator submits the report and the NTSB reviews
it.
 ACCIDENTS AND INCIDENTS

The NTSB goes on to list the following

occurrences as reportable incidents:
1. Flight control system malfunction or failure.
 ACCIDENTS AND INCIDENTS

2. Inability of any required flight crewmember to

perform normal flight duties as a result of injury or
illness.
 ACCIDENTS AND INCIDENTS

3. Failure of structural components of a turbine

engine excluding compressor and turbine blades
and vanes.
 ACCIDENTS AND INCIDENTS

4. In-flight fire.
5. Aircraft collide in flight.
6. Damage to property, other than the aircraft,
estimated to exceed $25,000 for repair (including
materials and labor) or fair market value in the
event of total loss, whichever is less.
 ACCIDENTS AND INCIDENTS

7. For large multi-engined aircraft (more than 12,500

pounds maximum takeoff weight):
a. In-flight failure of electrical systems which requires
the sustained use of an emergency bus powered by
a back-up source such as a battery, auxiliary power
unit, or air-driven generator to retain flight control or
essential instruments.
 ACCIDENTS AND INCIDENTS

b. In-flight failure of hydraulic systems that results in sustained

reliance on the sole remaining hydraulic or mechanical system
for movement of flight control surfaces.
c. Sustained loss of the power or thrust produced by two or
more engines.
d. An evacuation of an aircraft in which an emergency egress
system is utilized.