6-1 ACCIDENT / INCIDENT INVESTIGATION COORDINATION.
- Delegated Aircraft accident/incident investigation to one of Standard Directorates (SDs):
The primary responsible of aircraft accident / incident investigation is AAIU. In some cases, AAIU may delegate the investigation to one of SDs. The delegation should be as per the following procedure:
- AAIU shall use Investigation Delegation Form (Form No.31-7, appendix 2). The form is to be properly filled out and signed by Director AAIU; the delegated side should be indicated in the form (i.e. FSD).
- After receiving the form, the Directorate should start the investigation immediately. If any significant findings appeared during the investigation, AAIU should be informed.
- The Directorate shall investigate aircraft accident/incident to the extent necessary to:
- Establish the facts, conditions, and circumstances of the occurrence.
- Identity safety issues surrounding the accident and submit meaningful safety recommendations.
- Submit a factual report to AAIU from which the AAIU may make a determination of probable cause.
- After completing the investigation, the Directorate should complete the Investigation Delegation Form which should be signed by the SDs Director(s). Date of investigation report completion should be indicated. The completed form and the investigation report are to be submitted to AAIU as soon as possible.
- Delegated Investigation to Airport Ground Operations:
In case of ground accident / incident that an aircraft is involved in, AAIU may delegate the investigation to either FSD or Airport Ground Operations as the nature of the occurrence requires.
If delegated to the Airport Ground Operations, the procedure prescribed in point (a) in this paragraph is to be followed; in this case Director Airport will be copied.
- The following situations require extensive investigation:
- Fatal or serious injuries are involved.
- Notification information indicates possible aircraft structural failure, design or manufacturing defects, an airworthiness deficiency, or violation to JCARs.
- Aircraft in-flight fire is involved.
6-2 AAIU COMMITTEE OF INVESTIGATION INCLUDING ONE OR MORE MEMBERS FROM SDs.
The committee of investigation which includes one or more members from Standard Directorates SDs requires the following coordination procedures:
- The investigation will be under the control and direction of the AAIU IIC.
- SDs shall at all times have a coordinator designated as its principal representative until the investigation is completed. The designation of a person conveys the authority to procure and utilize the services of all needed SDs personnel, facilities, and records. Through this principal representative, AAIU will make available to SDs documents, reports, and other evidence from the investigation and any tentative recommendations, so that SDs may immediately take the necessary corrective actions.
- Safety Directorates personnel assigned to a group shall work under the direction of the group chairperson and remain with the group until that phase of the investigation has been completed or he/she/they is/are released by the AAIU IIC.
6-3 DIRECTOR AAIU PRIMARY ACTION.
Upon aircraft accident/incident, Director AAIU should do the following:
- Verify that Aircraft Accident / Incident Preliminary Notice Form (Form No. 31-2, appendix 2) Notice, has been sent by ATC facility. If the information has not been sent, obtain the information, relay it to the nearest ATC facility, and confirm that they transmit the information.
- Immediately after notification, Director AAIU shall conduct a meeting with his staff and will decide wither to delegate the investigation or to conduct it by AAIU depending on the nature of the accident / incident and any expected causal factors.
- AAIU IIC should send (on writing) to the Aircraft Operator requesting:
- Flight Data Recorder & Cockpit Voice Recorder custody. Form 31-13 (appendix 2) should be filled and sent by AAIU IIC to operator as early as possible.
- All necessary information and documents such as a copy of the load sheet and any information of onboard Dangerous Goods if available. AAIU IIC may request the information from JCAA / Air Transport Directora
- Ensure that the operator of the aircraft involved in the accident / incident make a preservation, in the extent possible, to any aircraft wreckage, cargo and mail aboard the aircraft, and all records, including all recording mediums of flight, maintenance, and voice recorders, pertaining to the operation and maintenance of the aircraft and to the airmen until AAIU takes custody or release is granted.
- If any Advisor from the Operator, Manufacturer or any other side is needed in the investigation, Director AAIU shall send a request letter to the DGCAA asking for the needed expert. In this case, the DGCAA may use the authorization discharged to him by article 141 in Jordan Civil Aviation Law No. 50 of 1985 to bring the required person/s.
- If any of FSD Inspectors or any Advisor from any Airport Department, Meteorology, ATC. . . etc. is required in the investigation, Director AAIU shall send a proposed committee to DGCAA including the name of the needed person/s.
- If the investigation is going to be conducted by AAIU, Director AAIU will nominate the appropriate investigation team and he may nominate himself or any of the team members as IIC depending on the nature of the accident / incident and the expected causal factors.
- AAIU IIC will immediately send an investigator to the accident scene, if possible, or request for scene custody by calling Civil Aviation Security who, in his turn, will call the appropriate Law Enforcement Agency.
- AAIU IIC will open a file for the accident / incident and give a number which will be a Record Number and will stay inherently. The way of numbering is explained in this manual chapter 8 (Accident Investigation Records).
- The Investigator/s should carry the investigation kit which should be completed by the involved investigator/s, any missing or extra items are to be requested.
- AAIU may contact any Geographical Center and / or Meteorological Office asking about the scene geography and weather condition and forecast. Depending on the information supplied by the above center/s, the Investigator/s shall carry the proper safety wear and equipment.
- The transport vehicle (heavy 4 wheel drive) is to be prepared well. The vehicle should be technically checked covering the engine, heat exchanger water, battery, main and spare wheels, wheel change kit, extra water container, wipers’ water container, engine oil, fuel level and extra fuel container... etc.
- The Investigator/s should carry the appropriate communication means (Walkie-Talkie, Cellular Phone….etc.)
6-4 ON SCENE ACTIONS.
The following actions are to be taken by the Investigator/s upon arriving to the accident scene, the actions are to be taken into priority bases, and the Investigator/s will judge the situation. The following are recommended actions as priority, AAIU Investigator will:
- Arrange for security at the accident scene. Determine if hazardous materials are on the aircraft and request special assistance, if necessary. On request, Civil Aviation Security or the local Law Enforcement Agency will provide assistance in establishing and maintaining appropriate security at crash scenes.
- Ensure that All Search and Rescue drills are conducted as per the specified manual and are not adversely affecting the evidences.
- Ensure that the emergency locator transmitter has been deactivated (remove batteries, antennae, etc.). This action is necessary to preclude its continued operation, or reactivation during aircraft wreckage removal.
- Determine if crew incapacitation was a factor for fatal accidents. Promptly contact the involved body for obtaining the services of an aviation medical examiner. The local coroner should be contacted to ensure that the flight crew bodies have not and will not be embalmed until an aviation medical examiner is consulted. Also, expeditious medical examination of passengers and involved aviation personnel by a physician is required.
- If the Investigator found that Aerial Photographing is necessary, he may tell AAIU IIC, who in his turn will contact any facility that can provide such services. For this purpose, it is recommended to contact Roya1 Jordanian Air force requesting a Helicopter for such service. Director AAIU will send a petition to FSD requesting a Special Flight Permit, FSD will immediately issue this certificate and send it to Director AAIU. In case of rejection of any requested service, AAIU IIC may call Director AAIU who, in his turn, will take actions to facilitate this service.
- If part or all of the aircraft wreckage is/are in water, wreckage plotting techniques and procedures are to be conducted as per the technical manuals. If any assistance is required, the procedures indicated by point (e) in this paragraph are to be followed as applicable to the specialists in the field of diving and under water searching.
- All parts, components are to be packed and packaged properly to prevent the damage to the evidence.
- AAIU IIC should establish the status of or accomplish the following:
- Rescue operations (who, where, when).
- Wreckage security. Treat accident scene like a crime scene.
- Site safety.
- Notification procedures.
- Emergency locator transmitter should be deactivated.
- Flight data and cockpit voice recorder, if installed, should be located and secured.
- Perishable evidence. This must be documented quickly or preserved.
- Victim identification. Contact Law Enforcement officers.
- Autopsy and toxicology studies. Contact the concerned air surgeon office.
- News releases.
- Photographic documentation should occur before wreckage is moved.
- Wreckage recovery and movement. Delay until perishable evidence and photographic documentation are completed.
- Names, Addresses, and telephone numbers of witnesses are obtained from law enforcement officers and any other sources.
- If required the Pathologist should be called, and all Pathology procedures are to be conducted at the specified area as indicated in the specified manuals (Disaster Management Manual, or Airport Emergency Plan and Emergency Management Manual).
6-5 ACCIDENT SCENE ACCESSES.
It is appropriate to review the regulations under which inspectors may demand immediate access to the accident scene when conducting inspections for AAIU or FSD. If the Investigator / Inspector has difficulty in gaining access to inspect and photograph the accident scene due to objection by the Law Enforcement Party Officers, remind them that aircraft accident and incident investigations are a Governmental matter and that no other authority has any legal or right to hide the wreckage or refuse access to it for as long as access is required.
AAIU Inspectors as well as FSD Inspectors involved in these matters will be covered by their credentials, which allow their access to any site and any materials. Other officials such as Consultants, Advisors assistants to team members, will be granted temporary passes.
government has custody of the wreckage by law and that custody will be released upon completion of the investigation by completing Aircraft Wreckage Release Form (Form No. 31-12, appendix 2).
AAIU Investigators permanent credential cards (Form No. 31-14) Temporary passes (Form No. 31-15)
Jordan Civil Aviation Law of 1985 (articles 141,142 and 144) , require any person having custody of an aircraft, or other property involved in an aircraft accident, to permit accredited AAIU investigators to have access to the aircraft and / or the accident scene and conduct all inspections necessary for a proper investigation. FSD personnel investigating an accident under delegation from AAIU are accredited AAIU investigators while operating pursuant to the delegation and are, therefore, entitled to demand access under the above law articles.
If confronted with a person who resists granting access, the investigator should first inform that person of the above law articles and regulations. If access is still not granted the investigator should immediately notify AAIU IIC who, in his turn, will take the legality procedures and will consult the Legal Advisor if required.
6-6 ORGANIZATION AND CONDUCT OF THE FIELD INVESTIGATION.
- Organization. Before or after the accident scene familiarization visit, AAIU IIC should hold an organizational meeting. The organizational meeting for most accidents may be an informal conversation involving AAIU IIC and one or more of the following:
- AAIU participants;
- FSD participants or aircraft Operator;
- Owner or Manufacturer representatives.
The purpose of the meeting is to define briefly the AAIU’s responsibility procedures and objectives investigation participants are also apprised of what is expected of them.
- Investigation. After completing the organizational meeting and ensuring the documentation and / or preservation of perishable evidence, e.g., human factors data, fuel samples, pressurized systems, and transient witnesses, AAIU IIC shall expedite the on-scene investigation. Photographs of the accident scene are a good place to start.
- Documentation. Further documentation by notes, measurements, etc, is necessary to be completed. The most thorough photographic coverage, suggested documentation subjects include:
- Wreckage distribution using the most suitable wreckage plotting techniques and forms (e.g. ICAO Doc. 6920-AN/855, ICAO Doc. 9756-AN/965 Part I & IV or any other specialized handbooks).
- Human Bodies distribution
- External flight control positions, e.g., rudder, elevators, ailerons, flaps, slats, spoilers, stabilizers, and tabs.
- Cockpit flight control indications.
- Cockpit instrument readings.
- Abnormalities in cabin and cockpit areas.
- Investigation Suggestions. During the investigation certain evidence will require more detailed examination. The knowledgeable, experienced investigator is continually evaluating evidence as a possible causal factor. The following suggestions may stimulate the investigator’s analyses.
- Missing extremities; wing or horizontal stabilizer tips, vertical stabilizer tip, propeller, or rotor tips.
- Missing flight control surfaces; rudder, elevators, ailerons, flaps, stabilizers, spoilers, slats, tabs, etc.
- Missing structure.
- Pre-impact versus post-crash fire evidence.
- Metal fatigue versus instantaneous breaks.
- In flight versus impact breaks.
- Positive versus negative wing or stabilizer separation.
- Overloading or out-of-center-of-gravity evidence.
- Evidence of aircraft attitude at impact.
- Controlled versus uncontrolled attitude at impact.
- Engine power at impact.
- Systems operation before impact.
- Flight control problems.
- Evidence of an explosion.
- Cockpit documentation.
- Evidence of impact before final contact with terrain; trees, wires, buildings, terrain, poles, obstructions.
- Aircraft performance.
- Meteorological conditions.
6-7 Investigation tools.
The following are the tools that are to be available as recommended by IGAO Doc. 9756-AN965, Part I. The listed items are considered the minimum, if required; Director AAIU should provide the non-listed items to be available at the time. If special accident conditions require special tools, AAIU IIC will request for them and they should be provided immediately:
- Large scale maps of the area of the accident.
- A good magnetic compass.
- A steel measuring tape at least 20 meters long.
- Circular slide rule, protractor and dividers.
- Grease pencils or indelible marking crayons.
- Writing material, note books and labels.
- Suitable tool kit.
- Model aircraft.
- A strong multipurpose knife.
- A coil of nylon rope about 20 to 30 meters 1ong (usefu1in difficult territory).
- Pocket lens and small mirrors.
- Heavy twine or cord.
- Flag markers.
- Heavy gloves and protective overhauls.
- Accurate wrists watch with sweep second hand.
- A waterproof electric torch with spare batteries and filament.
- Photographic equipment and video camera.
- Small first aid kit
- Crimping ‘tools and lead seals for marking, sealing and locking components and pieces of wreckage.
- COPIES of relevant accident investigation documentation (Regulations, accident report forms, and Manual of aircraft accident investigation, etc.).
- Walkie-talkie radio equipment with spare batteries (or Mobile ).
- Portable tape recorder.
- The following items can usually be supplied by the operator at his base nearest the scene of the accident :
- Canvas sheets and bags.
- Containers for oil and fuel samples.
- First aid kit.
- Quantities of ropes.
6-8 INVESTIGATOR’S SAFETY.
Safe investigative practices and common sense safety precautions are of vital importance, but are often overlooked during an investigation. Each investigation participant must consider several items including the following:
- Calm and competent behavior to preclude frantic or ill-advised action is a necessity.
- Suitable gear for the climate and terrain is needed upon arrival.
- Wearing gloves when handling wreckage is mandatory.
- Helmet (Hard hats) should be worn when working inside or under wreckage
- At high elevations, portable oxygen and other emergency equipment should be available.
- Unexpected weather or equipment failures may isolate the investigation team in remote areas; therefore, provisions for first aid, shelter, food, water, and fuel should be made before the need arises.
- Reliable communications between the investigation headquarters and the various activity scenes should be maintained by telephone, walkie-talkie, or long-range radio equipment.
- The following potentially hazardous items or situations may be encountered:
- Sharp, jagged pieces of metal. Wreckage may shift.
- Fuel and other flammable agents. Toxic agents may be present with a fire.
- Ignition sources; hot metal, battery (may also explode), ignition wires, electrical wires, grass or wood fire, or any explosive agent. Tires may explode.
- Hazardous materials from the aircraft or at the scene.
- Still-loaded aircraft systems, including; fuel and oil, pneumatic, hydraulic, electrical, and oxygen. Remember that controls may move.
- On frozen water, ice may give under wreckage.
- Possibility of snakes.
- Lacerations from wreckage; where human remains are present will require a hepatitis injection.
- Use industrial rubber gloves and caution to avoid cuts, scrapes, or scratches when working on wreckage where human debris (blood, fluids, and tissue) are present.
6-9 THOROUGH DATA COLLECTION SOURCES.
After all the required investigations and data collection from the various sources (i.e. the accident scene, witness interview.. etc.) and depending on the accident scene investigation results which may guide the investigator to a number of probable causes, every investigator should conduct his assignment as his specialty dictates in completing the other investigation sources. The following is a list of recommended data sources which should be considered as a minimum, every investigator should use his / her experience in judging where, when and how to collect his / her data:
- In case Of Domestic Accident / Incident:
- The Operator’s Maintenance Department:
- Technical Log Sheets.
- Aircraft logbook.
- Engine Log Book.
- Components’ Traceability.
- Records of the aircraft operator including worksheets and maintenance routine task cards.
- The various shops’ records.
- Weight and Balance sheets.
- Service Bulletins, Telex to Operators, Engineering Advisory Work Order, Engineering Order, Airworthiness Directives and any other related documents.
- Maintenance Personnel files; qualifications, certificates, training, position, job description and any of their duty time within one week before the accident / incident.
- The Operator’s Operations Department:
- Scheduling of the crewmember (if the operator is an air carrier).
- Duty time of the crewmember.
- Crewmember’s Personnel files; Qualifications, training, experience, last simulator check, proficiency check, medical certificates... etc.
- Flight plans.
- The Operator’s Traffic / Passengers Services Department:
- Load Sheets.
- Luggage weights files.
- Flight Safety Directorate:
- The involved aircraft file.
- Spot, Ramp, En-route and Loading / Unloading Inspection files.
- Personnel Licensing files.
- Repair Station Audits file.
- Facility Inspection files.
- Any related inspection files concerning the involved aircraft or crew.
- Air Traffic Control:
- At controller duty time schedules.
- At controller Personnel file.
- ATC voice recorders.
- Radar screen video tapes.
- Related Airport Directorates.
- Meteorological Office: Any related weather reports.
- Notice to Airmen (NOTAM) Office: Any related NOTAMs.
- Other data can be collected from other sources:
AAIU IIC should direct the investigators to other data collection sources depending on his own experience and information.
- b. In case of International Accidents occurring in :
The above data may be collected by contacting the Aviation Authority of the aircraft Operator and Registry States . In this case, Standard and Recommended Practices in Annex 13 pertain the subject shall be complied with.
6-10 THOROUGH INVESTIGATION AND ANALYSIS.
Every investigator should use his / her own experience while investigating and he / she should employ this experience in analyzing the collected data. All analysis is to be put on reports and the AAIU IIC is responsible to point out the probable cause/s. The following are references and guidelines for the investigators that may be followed depending on the investigation:
- For Aircraft Power plant, Airframe, Structure and Avionics Investigation:
- The investigator should always refer to the relevant manuals (Aircraft Maintenance Manual, Engine Maintenance Manual, Engine Overhaul Manual, Troubleshooting Manual, Aircraft Wiring Manual, Component Maintenance Manual, Maintenance Planning Data Manual, Aircraft Loading / Unloading Manual, Aircraft Weight and Balance Manual, Structure Repair Manual...etc.).
- All the collected parts and components are to be inspected thoroughly by using the feasible equipment and techniques in order to evaluate the damage or malfunction, the type and cause of damage is to be identified depending on the inspection.
Many technical manuals and publications (ICAO, FAA... etc.) are to be consulted for determining the nature of failure and the cause.
The mechanical part may be inspected by any suitable means and equipment in order to identify the type of damage; if under a normal stress, shear stress, twist, fatigue, thermal fatigue or intergranual defects due to poor chemical composition or manufacturing defects.
The investigator/s should be familiar with the testing techniques; he/they may use Non Destructive Test; X-Ray, Ultrasonic, Eddy Current, Borescope or Florescent Penetrant.
If any consultation is required from any specialist, AAIU IIC should request from Director AAIU to contact that specialist. The following are recommended specialists in the field of Metallurgy science:
- Scientific Association.
- Jordanian Governmental and Private Universities.
- Royal Jordanian Air Force.
- Royal Jordanian Army.
The investigator may use the Operators’ laboratories and equipment. In case of component investigation, any of the Operator’s test benches may be used, if not feasible due to any reason, the investigator may use or may send the involved component for testing to any specialist facilities inside or outside the Kingdome.
- The data extracted from the aircraft Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) is to be analyzed in order to find the aircraft systems performance prior to the accident. FDR and CVR specialists should accurately supply the investigator with all the readings.
- Aircraft Operations Investigation:
- The investigator should refer to all relevant manuals (Aircraft Flight Manual, Aircraft Operations Manual, Jeppesen Charts... etc.). The Investigator may depend on his / her experience and should consult any specialized hand books or publications (ICAO, FAA…etc.) for analyzing the data.
- All collected data should enable the investigator to establish the aircraft flight path prior to the accident. The operations investigator should strongly depend on the wreckage plots, measurements and any photographs taken in the accident scene.
- FDR and CVR specialist should supply the investigator with all requested readings.
- Meteorology Investigation:
The Meteorology expert should be able to analyze the data in order to evaluate the weather condition. He may consult any of the specialized hand books or publication.
- AIR Traffic Control Investigation
The ATC expert should be able to analyze all the data in order to assist the Operations Investigator in finding the aircraft flight path prior to the accident. He / She should be able to analyze the CVR and the radar voice recorder. He / She should always refer to the relevant manuals and he / she may refer to any of the specialized hand books or publication.
- FDR and CYR Investigation:
The specialist of aircraft FDR should have the ability to read any of the FDR readings and plots and compile them, similarly, the CVR specialist should have the ability to hear and compile any voice in the CVR and write a full transcript. They should, upon request, sit with the investigators and explain any relevant information.
- Other Investigations:
The other investigations (Human Factors, Witness Statement, Evacuation, Search and Rescue, and Fire fighting…etc.) are to be conducted by AAIU Investigators who should be trained for such investigations; any consultations may be taken from the specialist persons or organizations.
All the above investigation and analyses are to be put in reports by every nominated investigator and submitted to AAIU IIC who will study and evaluate them and request fix corrections or more investigations if required. Pointing out the probable cause/s is the responsibility of AAIU IIC.
6-11 REGISTRATION CERTIFICATES.
When an aircraft is destroyed or damaged to the extent that repair is unlikely, the owner or the owner’s agent is required to request cancellation of the registration certificate. AAIU will request from FSD to conduct all the legality matters relevant to the cancellation.
6-12 DESIGN DEFICIENCIES.
If, during an accident investigation, it is ascertained that a deficiency may exist in the design of an aircraft, AAIU IIC shall take immediate action and send a Prompt Action Request Form (Form No.31-6, appendix 2) to FSD to conduct the necessary action.
6-13 RELEASE OF AIRCRAFT WRECKAGE / FDR & CYR.
- Aircraft wreckage.
Upon completion of Investigation, AAIU will release wreckage-using Wreckage Release Form (Form No.31-12, appendix 2).
- FDR & CVR.
AAIU will release FDR & CVR when AAIU complete the data collection and be sure that these data can be used by operator for operator’s internal use. (Form 3l-13, appendix 2).
The form is to be signed by Director AAIU and submitted to the aircraft operator who, in his turns, responsible to remove the wreckage.
6-14 PASSENGER´S & WITNESS’S STATEMENTS.
At time of accident requiring interviews with witnesses, AAIU investigator may use Witness Statement Form (Form No. 31-4 or 31-8, appendix 2).
- Written Statements.
Written statements are to be taken from any witness who may help in investigation. Always witnesses are reminded that this investigation will help in preventing similar accidents. The information is to be registered in Form 31-4 or 31-8.
- Oral Statements.
When a witness refuses to give written information, he / she may verbally give information. Recorder may be used.
6-15 PROCEDURES COVERING THE INVESTIGATION OF INTERNATIONAL ACCIDENT / INCIDENT INVOLVING JORDANIAN REGISTERED OR OPERATOR AIRCRAFT OR JORDANIAN FATALITIES AND/OR SERIOUS INJURIES.
CAO Annex 13 paragraph 5.18 entitles the State of Registry and State of Operator to participate in the investigation by their appointed accredited representative.
DGCAA shall decide whether to send an accredited representative/s and an advisor/s or not, depending on the nature of the accident / incident.
NOTE: As recommended by ICAO Annex 13 , Chapter 5.19.1, when neither the State of Registry, nor the State of 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.
All the investigation techniques, procedures and requirements of Domestic Accidents are applicable and could be completely or partially applied depending on the conditions.
6-16 ACCIDENT OF JORDANIAN REGISTERED OR OPERATOR AIRCRAFT IN NON-CONTRACTING STATE OR IN INTERNATIONAL AREAS.
JCAA may conduct the investigation by its AAIU or delegate it to any foreign organization depending on conditions and judgment. If JCAA / AAIU is going to conduct the investigation, all the investigation techniques, procedures and requirements are applicable and may be either completely or partially applied.