Operator Responsibilities in Reporting and Investigation
In the United Arab Emirates (UAE), it is the responsibility of the Air Accident Investigation Sector (AAIS) of the GCAA to investigate civil aircraft Accidents and serious incidents that occur in the territory of the UAE. AAIS will assign an Accredited Representative to investigations of Accidents or serious incidents involving A6-registered aircraft that occur in other States.
Depending on the circumstances, the investigations may involve several entities, including the operator, aircraft manufacturer, engine manufacturer, ATC or airport authority. Such investigations are carried out in line with the Standards and Recommended Practices (SARPS) of Annex 13 to the Convention on International Civil Aviation (Chicago Convention)- Aircraft Accident and Incident Investigation that is promulgated by the International Civil Aviation Organization (ICAO).
ICAO is a UN specialized agency, created in 1944 on the signing of the Chicago Convention. ICAO works with the 191 Contracting States and global aviation organizations to develop the SARPs, which States reference when developing their legally enforceable national civil aviation regulations.
Operators should be aware of the scope of an Annex 13 investigation, and focus on their responsibilities and obligations in support of such an investigation. The first priority of an Operator in the immediate aftermath of an Accident is to assist the emergency services by providing details of dangerous goods on board the aircraft. Later, as the investigation commences, the input of the Operator is important, particularly in providing aircraft and crew records, and operational and technical documentation.
In some investigations, information provided by the Operator on previous incidents may be requested. The
operator knows, better than any other participant in the investigation, how the aircraft was actually operated and maintained.
Each Operator should have procedures in place across appropriate departments to ensure that relevant
documents and records can be secured as soon as possible following an Accident, and then be made
available to the investigation, on request.
Flight Data Recorders
The Operator’s Emergency Response Plan (ERP) should include provision for the possible impounding of the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), on request of the AAIS. No attempt should be made by the Operator to download data from either recorder, unless requested by the AAIS. Quick Access Recorders (QAR) are used for the purpose of the Operator’s Flight Operations Quality Assurance (FOQA) program and/or Flight Data Monitoring (FDM) program. The QAR is not designed to be crash survivable. In comparison to the FDR, the QAR will not survive high G loads, exposure to high temperature fire, or immersion in water. If the QAR does survive and the data is available, or can be retrieved, it is useful and may assist the investigation by providing more flight data.
Annex 13, Section 5.16 states: “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.”
Accredited Representatives and Advisers
ICAO Annex 13 provides for participation of Accredited Representatives in investigations; Section 5.18 states: “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.” Since Accident investigations are conducted at the State level, the representatives of entities other than States are
involved in the capacity of Advisers to the Accredited Representatives.
The Accredited Representatives are the representatives of the States which are carrying out the investigation. There should be an understanding by the Adviser proposed by the Operator, the manufacturer, or design organization, that he/she is functioning as an Adviser to the Accredited Representative of either the State of the Operator, Registration, Manufacture or Design, respectively.
Annex 13, Chapter 1, defines an Adviser as “A person appointed by a State, on the basis of his or her qualifications, for the purpose of assisting its accredited representative in an investigation. Annex 13, Section 5.24.1 states: “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”.
Annex 13, Section 5.19, provides for the participation of Adviser(s): “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.”
The distinction between the State representative and the representative of the Operator during an investigation is one of, an “Accredited Representative” of the State, versus an Operator proposed “Adviser” to the Accredited Representative of the State of Registry, or to the State of the Operator.
In addition, Section 5.19 recommends: “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”.
Advisor Proposed by the Operator
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The Adviser proposed by the Operator to an Accident investigation should be familiar with the SARPS of Annex 13, and the contents of the ICAO Manual of Aircraft Accident and Incident Investigation (Doc 9756). The Adviser is normally the Operator Safety Manager or a senior member of the staff of the Safety Office. He/she will have completed an appropriate aircraft Accident investigation course. It is also desirable that he/she undergoes annual bio-hazard training and receives the relevant vaccinations. In the event that the Accident site is declared a biological hazard area, verification of completion of this training, and receipt of the vaccinations, will be required before access to the Accident site is granted. Only those investigators whose presence is essential will be allowed to enter the site. |
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The Adviser nominated by the Operator shall be aware that Annex 13 investigations are distinctly separate from the judicial process and do not assign blame or liability as described in Annex 13 Section 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.” It is crucial that participants in an investigation do not feel constrained either in terms of providing information, or participating fully in the investigation process.
Rights of the Adviser
On his/her appointment, the Adviser is granted certain rights as specified in Section 5.25 of Annex 13: The
Adviser is entitled to participate in all aspects of the investigation, under the control of the investigator-inchange, in particular to:
a) visit the scene of the accident;
b) examine the wreckage;
c) obtain witness information and suggest areas of questioning;
d) have full access to all relevant evidence as soon as possible;
e) receive copies of all pertinent documents;
f) participate in read-outs of recorded media;
g) participate in off-scene investigative activities such as component examinations, technical briefings, tests
and simulations;
h) participate in investigation progress meetings including deliberations related to analysis, findings, causes and safety recommendations; and
i) make submissions in respect of the various elements of the investigation.
These rights are conferred on the Adviser with the proviso that all information obtained by, or made available to the Adviser, is treated as being confidential, and not to be discussed with anyone outside the investigation team.
Provision of information by the Operator
The Adviser proposed by the Operator should have sufficient authority in his/her organization to be able to obtain, and provide to the State Accredited Representative, any required records or documentation. In the event of an Accident or Serious Incident, the Operator must be able to comply with Section 4.10 of Annex 13 which states: “Upon receipt of the notification, the State of the Operator, the State of Design and the
State of Manufacture shall, upon request, provide the State of Registry with any relevant information available to them regarding the flight crew and the aircraft involved in the Accident or Serious Incident.” This section applies where the State of the Operator and the State of Registry are different. The requested information will be provided by the Operator to the Accredited Representative of the Semi-annual publication on Air Accident Investigation from UAE General Civil Aviation Authority 25 State of the Operator for onward transmission to the State of Registry.
For an Operator, the most safety critical information that must be provided rapidly following an Accident are the details of dangerous goods onboard the aircraft. This requirement is contained in Annex 13, Section 4.11: “Upon receipt of the notification, the State of the Operator shall, with a minimum of delay and by the most suitable and quickest means available, provide the State of Registry with details of dangerous goods on board the aircraft”.
This requirement should form part of the Operator’s ERP and will help to ensure the immediate safety of emergency response personnel and Accident investigators, when the investigation commences.
Release of Investigation Information Some information gathered for the investigation is not released to the public unless it is appropriate to make it available. This is covered in Annex 13, Section 5.12:
“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:
a) all statements taken from persons by the investigation authorities in the course of their investigation;
b) all communications between persons having been involved in the operation of the aircraft;
c) medical or private information regarding persons involved in the Accident or incident;
d) cockpit voice recordings and transcripts from such recordings;
e) recordings and transcriptions of recordings from air traffic control units;
f) cockpit airborne image recordings and any part or transcripts from such recordings; and
g) opinions expressed in the analysis of information, including flight recorder information.
This information is not included in the final report unless the information is pertinent to the analysis of the Accident.
The requirements of Section 5.12 must be strictly observed by all parties to the investigation.
Information regarding the investigation will be provided by the GCAA, firstly to the families of the victims, and later to the public. This will be accomplished through the Family Assistance process implemented as part of the Operators ERP in the immediate aftermath of the Accident. Other requirements of the Family Assistance process, such as facilitating a visit to the Accident location by relatives of the victims, and the return of victims personal belongings, will be subject to arrangement with the AAIS Investigator In Charge (IIC).
Confidentiality of Identities of Involved Personnel The names of people involved in an Accident or Serious Incident will not be released by the AAIS. This is a requirement of Annex 13, Section 5.12.2: “The names of the persons involved in the Accident or incident shall not be disclosed to the public by the Accident investigation authority.” The final investigation report issued by the AAIS refers only to the positions of those involved in the event, such as captain, first officer (co-pilot), maintenance engineer, dispatcher, ramp agent, air traffic controller, etc. Names are never included in AAIS reports. The Adviser selected by the Operator should be familiar with the constraints that apply to information obtained by the investigation, and he/she should make these limitations known to the senior management of the Operator. Advance planning by the Operator in this area will prevent potential embarrassment for the Operator, and the investigation agency, in the event of an Accident or Serious Incident.
At the beginning of an investigation, the AAIS Investigator in Charge (IIC) will provide guidance on the dissemination of information relevant to the investigation to people or entities outside the investigation. To help ensure that the investigation proceeds smoothly, each participant is expected to observe the guidelines.
Organizational Information
There are many entities, external to the Operator, which affect the operation of an aircraft such as ATC and airports. There are also organizations that are sub-contracted to provide services to the Operator. The modern airline relies heavily on sub-contracting some operational and technical aspects of their business to reduce costs and improve efficiency. There are several Accidents on record where unsafe acts, or omissions, by a sub-contracted organization, or lack of adequate oversight of a subcontracted organization by an operator, contributed to an Accident or Serious Incident. Responsibility for safety cannot be sub-contracted by the Operator to a service provider. Ultimately, responsibility for the safety of operations rests with the Operator. Section 5.17 of Annex 13 deals with the provision of organizational information. It states: “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.” If the organization referred to was subcontracted by the Operator, it is possible that information such as audit results and records of past incidents could be required by the investigation. The Operator must provide such information, if it is requested.
Reporting of an Accident or Missing or Inaccessible Aircraft
The definition of an aircraft Accident is:
An occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place Semi-annual publication on Air Accident Investigation from UAE General Civil Aviation Authority 26
between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down in which:
a) 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; or
b) 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); or
c) the aircraft is missing or is completely inaccessible.
Events as defined above will be reported immediately to the AAIS Duty Investigator. Reporting of Serious Incidents A serious incident is defined by ICAO as: “An incident involving circumstances indicating that there was a high probability of an Accident and associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down.”
Annex 13, Attachment C, contains a list of typical examples of incidents that are likely to be classified as
Serious Incidents. The list is not exhaustive and only serves as guidance to the definition of Serious Incident. It is expected that the reporter will use their good judgment, knowledge and experience to report appropriate safety events. If a safety event occurs, and there is a doubt as to whether the event can be classified as a Serious Incident, the event should be reported to the DI anyway.
Operators should bear in mind that operational issues such as long flight delays, or diversions due to operational reasons, or the aircraft returns to the stand due to a sick passenger, etc., do not constitute Serious Incidents. This type of operational event should not be reported to the AAIS Duty Investigator (DI).
Some Examples of Serious Incidents For guidance, Annex 13, Attachment C, provides examples of safety events that can be classified as Serious Incidents:
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, on a taxiway or unassigned runway.
Take-offs from a closed or engaged runway, from a taxiway or unassigned runway.
Landings or attempted landings on a closed or engaged runway, on a taxiway or unassigned 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, including uncontained turbine engine failures, 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.
Runway incursions classified with severity A. The Manual on the Prevention of Runway Incursions (Doc 9870) contains information on the severity classifications.
Take-off or landing incidents. Incidents such as undershooting, 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.
The Operator is required to report an Accident or Serious Incident, that occurs outside the UAE, to the investigation authority of the State of Occurrence, as well as to the AAIS DI.
General UAE Incident Occurrence Overview by AAIS
AAIS monitors the overall safety event reporting situation for A6-registered aircraft by continuous examination of incidents reported through the GCAA Reporting of Safety Incidents (ROSI) system. This allows AAIS to identify safety issues that, while not coming under the classification of Serious Incidents or Accidents, can be examined as the subjects of AAIS safety cases, upon which safety improvement recommendations can be based.
