Investigation Process
Once an occurrence is classified as an accident or serious Incident, an
Investigator-in-Charge or Investigators are appointed by AAIB under Rule 11 of the
Aircraft (Investigation of
Accidents and Incidents) Rules, 2017. Investigator-in-Charge is responsible for conduct
of Investigation into circumstances of the accident or serious
incident.
The Initial Notification of the occurrence is sent to the State of Registry, State of
Operator, State of Manufacturer and State of Design of involved aircraft or other
concerned States in accordance
with Aircraft (Investigation of Accidents and Incidents) Rules, 2017 and ICAO Annex 13.
The Accredited Representatives from the concerned States associate in the Investigation
undertaken by AAIB.
Initial Evidence Collection and Investigation
Immediately on receipt of notification of an occurrence, AAIB deputes one or more Investigators to reach the site and gather evidence.The primary aim for the initial investigation is to gather and preserve perishable evidence, for subsequent analysis, that may be lost over time and not available to the Investigators after a delay. The activities may include:
• Recording and mapping of any signs of impact with terrain or objects in the vicinity.
• Recording wreckage distribution and witness marks.
• Photography and Videography of site and wreckage.
• Basic wreckage examination and retrieval of Flight Recorders or any component perceived to be of value to the Investigators.
• Interview witnesses and obtain their statements.
• Gather recorded data from on-board system equipment, GPS devices, CCTV or any other surveillance devices available at site.
• Gather recordings and data from ATC and Radar Stations and Metrological records.
• Obtain samples from the site.
When an officer from DGCA or any other agency is to carry out Initial Investigation, AAIB seeks report from the said personnel.
Assessment of Investigation Requirements
The Investigation team appointed by AAIB reviews all evidence collected during Initial stages to make assessment about requirement of detailed examination to be carried out on any components or equipment. In case of requirement of any specialised expertise, like type qualified pilot or engineer, Aviation Medicine Specialist, Licensed ATCO etc., Subject Matter Experts (SMEs) of relevant area from Industry are associated in the Investigations.In accordance with ICAO Annex 13, Accredited Representatives from concerned States and their Technical Advisers are consulted during the Investigation for any examination or testing that may be required to be carried out at facilities situated in those States.
AAIB also has Memorandum of Understanding with following agencies for utilization of their Labs or other facilities for Investigation purpose:
1. Hindustan Aeronautics Limited
2. National Aerospace Laboratories
3. National Metallurgical Laboratory
4. Defence Metallurgical Research Laboratory
5. Directorate General of Civil Aviation
Examination and analysis
The evidence and data gathered by AAIB Investigators is subjected to details scrutiny to build a detailed understanding of the circumstances surrounding the occurrence being Investigated and any safety issues that had causal or contributory effect on the occurrence. The extent of data and evidence to be gathered and analysed depends on the severity and complexity of an occurrence and learnings and outcome expected from the Investigation efforts.This may require Investigator to review complex and different set of evidence and seek clarifications from different stakeholders, wherever required. AAIB Investigators may require to have repeated meetings with involved crew or other personnel of operator to discuss the safety issues observed during the Investigations.
Documents and Records gathered from the Operator, Regulator, involved Personnel or other stakeholders are studied and analysed by the Investigators and reviewed in association with SMEs, if required.
The results from the analysis of Flight Recorders Data, examination of any components or other Reports from specialists are studied and may require deliberation with different stakeholders.
Occasionally, the examination and analysis of different set of evidence and data may provide a vague, incomplete and or contradictory picture of the situation. This may prompt collection of more evidence or may also require further interviews with witnesses or other personnel. Such requirements potentially increase the scope of Investigation and adds to the duration of an investigation.
Drafting of Report
After examination and analysis of all available evidence is complete, the investigation team drafts the report to include all factual information, analysis, conclusions and safety recommendations. The format of Investigation Report to be followed is in accordance with ICAO Annex 13.During the drafting of the report it may be necessary to revisit the evidence collection or examination and analysis phases of an investigation. The drafts are reviewed amongst all Investigation Team members and SMEs engaged during Investigation.
Consultation and Review
Once the Draft Report is finalised, it is shared with the State of Registry, State of Operator, State of Manufacturer or State of Design and any other State that rendered assistance during the Investigation. In accordance with Para 6.3 of ICAO Annex 13, comments from concerned States are sought and reviewed to make required amendments in the Draft Report.The Draft Report is reviewed internally and submitted to DG, AAIB for acceptance.
If during consultation or review any issue is identified that may need further deliberation or analysis, the Investigators may be required to gather and analyse additional evidence as may be required to adequately supplement the facts, analysis, conclusions and recommendations of the Draft Report.
Acceptance and Dissemination of Final report
The Final Reports of investigations conducted by AAIB are accepted by Director General, AAIB after a thorough process of consultation and review.The Final Report is made public as deemed fit by Director General, AAIB and published on the AAIB website. The Final Report is shared with DGCA and Regulatory Authorities of concerned State for taking necessary action for implementation of the recommendations contained in the Final Report.
The copy of Final Reports is also shared with the State of Registry, State of Operator, State of Manufacturer or State of Design and any other State that rendered assistance during the Investigation and ICAO in accordance with provision contained in ICAO Annex 13.
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