2201

• Accident Investigation


  A systematic process whereby all of the possible causes of an adverse event are evaluated and eliminated until the remaining causes are identified as applicable to that investigation
• Investigation of accidents


  1. Collection of data

  2. Analysis of data

  3. Presentation of findings
• Collection of data


  The initial phase of investigation where it focuses on defining and obtaining data relevant to the accident
• Primary sources of data


  • Flight plans
  • Air traffic services radar data
  • Navigation and topographical charts

  
• Types of data to be collected

  • Accident particulars
  • Meteorological particulars
  • Technical particulars
  • Human factors particulars
• Collection of meteorological particulars


  Forecast and local weather conditions may have significant importance on the flight conditions and aircraft performance
• Collection of technical particulars


  Site along with maintenance and manufacturing records, onboard data collection devices and laboratory analysis of aircraft components
• Collection of human factors particulars


  Actions and conditions the flight crew were experiencing, sometimes the most difficult in fatal accidents
• Analysis of data


  Conducted in parallel with data collection, initiates additional questions that require further data collection, simulation and consultation
• Presentation of findings


  Accidents reports must provide the format that ICAO Annex 13 given, often the investigation and presentation of information from incidents can be more useful and provides greater safety benefits than accident investigations
• Wreckage investigation


  The location of the accident site must be determined and recorded
• Determining location of accident site

  1. Use of global positioning satellite (GPS) receiver and aeronautical charts or aerial photographs

  2. Plotting bearings and distances from known positions on a large-scale map

  3. Using aerial photography of the accident site in conjunction with a suitable map
• Accident investigation photography


  An important element of the investigation process, allows the investigator to preserve perishable evidence
• Photography equipment


  • Camera
  • Disposable camera
  • Point and shoot camera
  • Single lens reflex camera
  • Video camcorder
• Camera


  • Durable and reliable, enough features to fulfil the photography needs, controls conveniently located and easy to operate while using gloves
• Disposable camera


  • Simply to use, many have built in electronic flash, the camera is turned in to the processing laboratory and is not returned to the user
• Point and shoot camera


  • More versatile than disposable camera, usually fully automatic, many have zoom lenses and some have macro capability
• Single lens reflex camera


  • A mirror between the camera's lens and the film or light sensor directs the light coming through the lens to a focusing screen that is used by the photographer to compose and focus the photograph
• Video camcorder


  • Extremely useful to investigators, modern ones are light and compact, and the video digital medium can be edited on a computer using simple to use software
• Accessories useful to accident investigators

  • Lenses
  • Flash
  • Filters
  • Camera supports
  • Camera/remote release
  • Notebook
  • Film and electronic media
• Examination of impact marks and debris


  The marks of first impact of the aircraft with the ground should be found, from these and the distribution of the wreckage, it can usually be determined which part of the aircraft struck the ground first, ground scars used in conjunction with height of broken trees or brush will assist in establishing the angle and attitude in which the aircraft struck the ground
• Accident Investigator's photography checklist

  • Firefighting (Video)
  • Rescue activities (Video)
  • Radar and ATC (Recordings)
  • Weather (forecast and actual conditions)
• Wreckage plotting methods

  • Grid
  • Polar
  • Single - Polar
  • Two - polar
  • Straight line
• Operation investigation


  Concerned with the investigation and reporting of the facts relating to the history of the flight and to the activity of the flight crew before, during, and after the flight in which the accident occurred
• Major areas involved in the operations investigation


  • Crew history
  • Crew Qualifications/Proficiency
  • Crew Flight, Duty and Rest Period
  • Task Management, Crew Resource Management (CRM)
  • Human - Machine Interfaces
  • Personal Equipment
  • Flight Planning
  • Weight and Balance
  • Maps, Charts and Navigational Databases
  • Operating Guidance
  • Witness Interviews
  • Final Flight Path Determination
  • Sequence of Flight
• Crew history


  A study of the facts pertaining to the crew forms an important part of both the operations and human factors investigation
• Crew Qualifications/Proficiency


  Investigators should determine the individual crew members level of qualifications to determine whether the flights were conducted in accordance the crew's experience or training
• Crew Flight, Duty and Rest Period


  State regulations on the length of crew flight and duty period to commencing flight activities
• Task Management, Crew Resource Management (CRM)


  It is not enough to evaluate crew actions during an emergency situation with regard to the single emergency action performed or required
• Human - Machine Interfaces


  Effective design principles are brought to bear when designing the aircraft crew stations, controls are designed to be accessible when necessary and instruments and warning lights placed for effective visibility
• Personal Equipment


  All equipment provided or taken by the crew for use in performance of their duties needs evaluation for effectiveness and appropriateness
• Flight Planning


  Prepared and filled with air traffic control agencies, this will provide the investigator with certain specific data which require detailed examination
• Weight and Balance


  A weight and balance sheet based on the planned flight and weather conditions may have been prepared
• Maps, Charts and Navigational Databases


  May be necessary to establish what maps and charts were provided for navigational purposes and to examine their adequacy and accuracy in relation to the navigational effort involved in the flight

  
• Operating Guidance


  The basic source of information concerning aircraft performance is the Flight Manual; detailed research into the records of the appropriate airworthiness authority and the aircraft manufacturer may be necessary
• Witness Interviews


  The investigator should bear in mind that in some States it may be the responsibility of the police to interview witnesses during an investigation of an accident, it normally concerns itself with interviewing "eye witnesses", main task for investigator of collecting evidence
• Final Flight Path Determination


  The last stage of the flight, i.e. the accident phase, necessitates close coordination between many groups of the investigation but it is the primary concern of the Operations investigation
• Sequence of Flight


  Enumeration of the above information should bring to light the items of importance in the Operations investigation in relation to the other areas of accident investigation
• Aircraft Performance Group


  Normally will be responsible for gathering factual information and performing analyses related to the aircraft performance and to aircraft handling qualities
• Performance investigation


  Relates to determining and analyzing the path and attitude of the aircraft as it traveled through the air, or on the surface, prior to impact, the Performance Group may also be responsible to evaluate the aircraft's motion following impact until the aircraft finally came to rest