Civil aviation serves as a vital catalyst for sustainable socio-economic development across States. While it boasts an impressive safety record, continuous and focused efforts are crucial to further enhancing aviation safety and effectively managing the growing volumes of air traffic. These initiatives have to address all aspects of aviation, including operational safety, safety oversight, safety management, and the independent investigation of aircraft accidents and serious incidents.
Importance of investigation authorities
Investigation authorities play a vital and distinctive role in aviation safety due to their independence and authority. They conduct comprehensive, international investigations, leveraging all pertinent evidence to ensure thorough analysis and understanding.
Each investigation team includes representatives, advisers, and experts from all concerned States and organizations. This collaborative approach helps determine the root causes of aircraft accidents and serious incidents, allowing the aviation community to learn from past failures and “near misses” to prevent future occurrences.
Challenges in serious incident investigation
Serious incidents occur more frequently than accidents. According to Annex 13 of ICAO, they require an independent investigation by the Accident Investigation Authority (AIA), typically of the State of occurrence. Challenges can hinder a States’ ability to meet their international obligations for serious incident investigations. Recent analyses reveal that 45% of States in the ICAO European and North Atlantic Office’s accreditation area (the “ICAO Paris Office”) have not established the necessary policies, processes and procedures for effective serious incident investigations.
In December 2022, the European Region Aviation System Planning Group (EASPG), managed by the ICAO Paris Office, urged EUR/NAT States to enhance their processes for investigating serious incidents. The EASPG highlighted the need for detailed and customized policies, processes and procedures to fit the specific aviation systems in place.
ICAO Paris Office initiatives
To address these challenges, the ICAO Paris Office adopts a collaborative, State-centric, risk-based, and result-oriented approach. The objective is to understand each State’s evolving situation and priority needs, and effectively address them while exploring synergies and avoiding duplication of efforts.
Within the ICAO Paris Office’s accreditation area—covering 56 States across Europe, Central Asia, North Africa, and the North Atlantic—several regional organizations support States in fulfilling their obligations under Annex 13 to the Chicago Convention. These include the Air Accident and Incident Investigation Group of Experts (ACC) of the European Civil Aviation Conference (ECAC), the European Network of Civil Aviation Safety Investigation Authorities (ENCASIA), and the Interstate Aviation Committee (IAC). The ICAO Paris Office continues to partner with these organizations and invite leading investigation authorities, as well as relevant international and regional entities, to help share information and experiences in support of regional activities.
Webinar on serious incident investigation
On 11 June 2024, the ICAO Paris Office, in collaboration with France’s Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) and the United Kingdom’s Air Accidents Investigation Branch (AAIB), organized a webinar to address various aspects of the serious incident investigation process. This event gathered 176 participants from 32 States across the EUR/NAT area and included contributions from the International Air Transport Association (IATA).
Guidance for AIAs
The European Civil Aviation Conference (ECAC) and the European Network of Civil Aviation Safety Investigation Authorities (ENCASIA) have collaborated to develop guidance to support the European Accident Investigation Authorities (AIAs) in identifying serious incidents and determining the need for investigations. This guidance consolidates insights from a workshop organized by the Air Accident and Incident Investigation Group of Experts (ACC), exploring the topic from various perspectives. Its goal is to foster consistency in addressing serious incidents while maintaining the autonomy of AIAs in their decision-making processes.
Defining serious incidents
ICAO defines a serious incident as “an incident involving circumstances indicating that there was a high probability of an accident.” The distinction between an accident and a serious incident lies solely in the outcome. According to international standards, the State of Occurrence must initiate an investigation for serious incidents involving aircraft with a maximum mass over 2,250 kg. Investigations are also recommended for lighter aircraft.
Investigation process
Conducting effective, independent, timely, and thorough investigations of serious incidents significantly benefits aviation safety. An appropriate, effective and consistent approach to classifying occurrences based on risk is crucial. The process typically involves four steps, starting with classifying the occurrence and assessing the probability of an accident, as outlined in Annex 13 to the Chicago Convention.
Resource considerations
Various factors can influence the decision to investigate a serious incident, even when not mandated. The classification of an occurrence (as an accident, serious incident, or incident) and subsequent risk assessment should remain unaffected by resource considerations. However, once classified, resource factors may need to be considered in determining the AIA’s response. Given their finite resources, AIAs often face difficult choices about where to focus efforts for maximum safety improvements.
Collaboration for improvement
When an investigation is warranted, the AIA should define the scope and procedures, considering the consequences of the incident and the lessons to be learned for enhancing aviation safety. Though accidents and serious incidents are investigated using similar methodologies, incident investigations typically benefit from a more favorable context, often leading to impactful safety lessons and recommendations.
Serious incidents may involve complex factors requiring comprehensive examination due to the interplay of multiple variables affecting aviation safety. In such cases, AIAs should collaborate with relevant experts and organizations to gather diverse insights, ensuring a thorough understanding and effective safety recommendations.
Conclusion
High-quality investigations of aircraft serious incidents are imperative, relying on adequate resources and expertise. To meet their investigation responsibilities in accordance with the Chicago Convention and its Annexes, States may consider agreements with existing Regional Accident and Incident Investigation Organizations (RAIOs) or other cooperative mechanisms. This collaboration can facilitate resource sharing and enhance overall effectiveness.
The ICAO Paris Office will continue to work with its partners to support States in establishing and implementing systems to help ensure effective, independent, timely, and thorough investigations of aircraft accidents and serious incidents, in compliance with ICAO provisions.
The article was written by:
- Nicolas Rallo, Regional Director of the ICAO European and North Atlantic Office (EUR/NAT)
- Crispin Orr, Air Accidents Investigation Branch of UK
- Jérôme Bauer, Bureau d’enquêtes et d’analyses pour la sécurité de l’aviation civile (BEA) of France
- Hatem Oueslati, Regional Officer, Aerodromes, and Gounds Aids, ICAO European and North Atlantic Office (EUR/NAT)
