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Investigation - Final Report

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Article Information
Category: Safety Management Safety Management
Content source: ICAO About ICAO
Content control: EUROCONTROL About EUROCONTROL

Description

In accordance with International Civil Aviation Organisation (ICAO) Standards and Recommended Practices (SARPS) provided in Annex 13, when a State accident investigation body conducts an investigation to an aircraft accident/serious incident, the progress and result of the investigation is to be published, including any safety recommendation(s), via the release of a Preliminary Report and a Final Report. The purpose of the preliminary report is to communicate promptly the data obtained during the early stages of the investigation. The Preliminary and the Final reports, along with any safety recommendations are sent to the relevant parties to the investigation, States and organisations. Requirements and guidance regarding the notification of accidents are provided in Annex 13.

In practice, not all State Investigation Agencies automatically issue Preliminary Reports but many do issue Interim Reports if significant matters, which it is judged deserve prompt disclosure, come to light during a major investigation.

Format of the Final Report

The recommended format presented below has been extracted from Annex 13, Appendix to Chapter 6. Additional guidance for completing each section of the Final Report can be found in ICAO Doc 6920 - Manual of Aircraft Accident Investigation.

One notable area where the recommended format is widely ignored, even by otherwise reputable agencies, is that 'Personnel Information' is rarely given for any directly involved person except flight crew even when their actions have been found to have had much more bearing on the outcome of the event investigated than those of the flight crew.

Title

The Final Report begins with a title comprising: Name of the operator; manufacturer, model, nationality and registration marks of the aircraft; place and date of the accident or incident.

Synopsis

Following the title is a synopsis describing briefly all relevant information regarding:

  • Notification of accident to national and foreign authorities;
  • Identification of the accident investigation authority and accredited representation: organization of the investigation;
  • Authority releasing the report and date of publication;
  • A brief resume of the circumstances leading to the accident.

Body

The body of the Final Report comprises the following main headings:

Factual information

History of the flight. A brief narrative giving the following information: Flight number, type of operation, last point of departure, time of departure (local time or UTC), point of intended landing.

  • Flight preparation, description of the flight and events leading to the accident, including reconstruction of the significant portion of the flight path, if appropriate.
  • Location (latitude, longitude, elevation), time of the accident (local time or UTC whether day or night).

Injuries to persons

Completion of the following (in numbers):

Annex 13 Injury chart.jpg

Damage to aircraft

Brief statement of the damage sustained by aircraft in the accident (destroyed, substantially damaged, slightly damaged, no damage).

Other damage

Brief description of damage sustained by objects other than the aircraft.

Personnel information

a) Pertinent information concerning each of the flight crew members including: age, validity of licences, ratings, mandatory checks, flying experience (total and on type) and relevant information on duty time.

b) Brief statement of qualifications and experience of other crew members.

c) Pertinent information regarding other personnel, such as air traffic services, maintenance. etc., when relevant.

Aircraft information

a) Brief statement on airworthiness and maintenance of the aircraft (indication of deficiencies known prior to and during the flight to be included if having any bearing on the accident).

b) Brief statement on performance, if relevant, and whether the mass and centre of gravity were within the prescribed limits during the phase of operation related to the accident. (If not and if of any bearing on the accident give details.)

c) Type of fuel used.

Meteorological information

a) Brief statement on the meteorological conditions appropriate to the circumstances including both forecast and actual conditions, and the availability of meteorological information to the crew.

b) Natural light conditions at the time of the accident (sunlight, moonlight, twilight, etc.). Aids to navigation. Pertinent information on navigation aids available, including landing aids such as ILS, MLS, NDB, PAR. VOR, visual ground aids, etc., and their effectiveness at the time.

Communications

Pertinent information on aeronautical mobile and fixed service communications and their effectiveness. Aerodrome information. Pertinent information associated with the aerodrome, its facilities and condition, or with the take-off or landing area if other than an aerodrome.

Flight recorders

Location of the flight recorder installations in the aircraft, their condition on recovery and pertinent data available therefrom.

Wreckage and impact information

General information on the site of the accident and the distribution pattern of the wreckage; detected material failures or component malfunctions. Details concerning the location and state of the different pieces of the wreckage are not normally required unless it is necessary to indicate a break-up of the aircraft prior to impact. Diagrams, charts and photographs may be included in this section or attached in the Appendices.

Medical and pathological information

Brief description of the results of the investigation undertaken and pertinent data available therefrom.

Note.- Medical information related to flight crew licences should be included in Personnel information.

Fire

If fire occurred, information on the nature of the occurrence, and of the fire fighting equipment used and its effectiveness.

Survival aspects

Brief description of search, evacuation and rescue, location of crew and passengers in relation to injuries sustained, failure of structures such as seats and seat-belt attachments.

Tests and research

Brief statements regarding the results of tests and research.

Organisational and management information

Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator. the air traffic services, airway. aerodrome and weather service agencies: and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices. and regulatory framework.

Additional information

Relevant information not already included in History of the Flight to Organisational and Management Information above.

Useful or effective investigation techniques

When useful or effective investigation techniques have been used during the investigation, briefly indicate the reason for using these techniques and refer here to the main features as well as describing the results under the appropriate sub-headings from History of the Flight to Additional Information.

Analysis

Analyse, as appropriate, only the information documented in section “Factual information” and which is relevant to the determination of conclusions and causes.

Conclusions

List the findings and causes established in the investigation. The list of causes should include both the immediate and the deeper systemic causes.

Safety Recommendations

As appropriate, briefly state any recommendations made for the purpose of accident prevention and any resultant corrective action.

Appendices

Include, as appropriate, any other pertinent information considered necessary for the understanding of the report.


Further Reading

ICAO

  • Annex 13 - Aircraft accident and incident investigation;
  • ICAO Doc 6920 - Manual of Aircraft Accident Investigation;


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