ICAO DOC 6920 PDF

The sole objective of the technical investigation is to reveal the causes and circumstances of aviation accidents, incidents or irregularities and to initiate the necessary technical measures and make recommendations in order to prevent similar cases in the future. It is not the purpose of this activity to apportion blame or liability. Act CXL of on the general rules of administrative authority procedure and service when Kbvt. The Transportation Safety Bureau of Hungary shall investigate aviation accidents and serious aviation incidents.

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International Civil Aviation Organization. Landover Company, P. Aviaizdat, 48, 1. Airplan Flight Equipment Ltd. Oxford Book and Stationery Co. Avex Air Training Pty Ltd. Monthly supplements announce new publications and audio-visual training aids, amendments, supplements, reprints, etc. These amendments are available free upon request. IV 1. IV 3. IV IV 4. Iv 4. IV 4. IV 5. Page No. The Manual should enable them t o adhere t o a uniform system and organization of i n v e s t i g a t i o n which i s known and understood i n t e r n a t i o n a l l y.

XI Manual of A i r c r a f t Accident Investigation of a i r s a f e t y , it i s most important t h a t adequate and relevant measures a r e taken expedi- t i o u s l y t o prevent a recurrence a r i s i n g from a similar cause.

An equally important purpose i s t o determine t h e f a c t s , conditions and circumstances pertaining t o t h e s u r v i v a l o r non- survival, of the occupants, and the crashworthiness of t h e a i r c r a f t. Pievertheless, i t is unavoidable t h a t acts o r ommissions, by i n d i v i d u a l persons o r organi- zations, a r e sometimes c l e a r l y revealed and i n such instances i t is t h e duty of t h e inquiry t o say so. I n doing t h i s he must seek o u t , record and analyse the f a c t s , draw conclusions and, where appropriate, make recommendations.

The basic cause of an accident and the remedial a c t i o n necessary t o ensure t h a t i t w i l l not recur does not always emerge from t h e physical f a c t s of t h e case. The inquiry should not cease i f o r when i t is established an e r r o r has been made: the inquiry should endeavour t o e s t a b l i s h why the e r r o r occurred. Poor design, i n d i f f e r e n t human engineering , inadequate o r improper operational procedures could w e l l have confused o r m i s l e d t h e person.

Experience has shown t h a t t h e majority of a i r c r a f t accidents have been caused o r compounded by human e r r o r , o f t e n by circumstances which were conducive t o human e r r o r ; t h i s a p p l i e s t o design, manufacture, t e s t i n g , main- tenance, inspection and operational procedures both ground and a i r.

Some a i r c r a f t accidents have r e s u l t e d from organizational d e f e c t s o r weak- nesses i n management; f o r example, an operator may have prescribed o r condoned procedures not commensurate with s a f e operating conditions i n p r a c t i c e. It may t h e r e f o r e be necessary t o inquire c l o s e l y i n t o o t h e r organizations o r agencies not immediately or d i r e c t l y concerned with t h e circumstances of the accident but where a c t i o n , o r lack of i t , may have permitted o r even caused t h e accident t o happen.

This approach w i l l o f t e n r e s u l t i n some degree of speculation and prolonged exploration but i t may be t h e only course open t o t h e investigator. Surviving passengers o r eyewitnesses should inform l o c a l c i v i l o r m i l i t a r y personnel who snoul? For c e r t a i n accidents the S t a t e of Occurrence may a l s o wish t o forward a Notification message t o other S t a t e s which may be requested t o provide important information immediately f o r example, the S t a t e whose A i r T r a f f i c Services had the a i r c r a f t under c o n t r o l p r i o r t o the accident.

Clear i n s t r u c t i o n s regarding the preparation and dispatch of Votificatioii riessages s h o u l d be r e a d i l y a v a i l a b l e t o investigators. I f necessary t o the S t a t e of Registry. Generally the Aeronautical Fixed Telecommunication Network X-Prrr w i l l be used f o r t h i s purpose: f i c a t i o n of the correspondent may a l s o be used but aormally o f f e r less guarantee f o r safeguarding the c o n f i d e n t i a l nature of communications.

Part I. Note 2 : Since the S t a t e of Registry always has the r i g h t t o be represented at the i n v e s t i - gation, it may supply the information r e f e r r e d t o above on its own i n i t i a t i v e i n the case of any delay i n the transmission of t h e Notification. Should the S t a t e of Registry consider i t unnecessary t o be represented at t h e 2.

Should the S t a t e of Manufacture consider i t unnecessary t o be represented a t the- It I n any c a s e , i t is the duty of the St. Part The standard of t h e i n v e s t i g a t o r assigned t o an accident inquiry determines t h e thoroughness and c l a s s of r e s u l t s obtained more than i n any o t h e r f i e l d of aeronautics and the longer a well-qualified member serves, the more expert he becomes.

Wherever possible, t h e r e f o r e , a t least one experienced i n v e s t i g a t o r should be assigned t o each inquiry so t h a t a continuing thread of experience may maintain the standards of accident i n v e s t i g a t i o n and reporting. It may, ix :! Advance consideration should a l s o be given t o such i t e m s as inoculations, passport requirements, t r a v e l f a c i l i t i e s , etc. Investigators who work amongst wreckage are advised t o b e regularly inoculated with anti-tetanus serum.

It should be f u l l y Accidents are apt t o occur anywhere; a t a i r p o r t s , on mountains, i n swamps, i n deeply wooded areas, i n d e s e r t s , etc. It is important therefore t h a t the investigator should be physically f i t and a c t i v e and t h a t the s e l e c t i o n of h i s working gear i s carried out with considerable care, bearing i n mind the t e r r a i n i n which he might have t o work.

Clothes should be comfortable and afford protection against any conditions o r elements t h a t may be encountered. It i s advisable t o have t h i s type of equipment readily available a t a l l t i m e s so t h a t i f an accident occurs i n an area where s p e c i a l equipment i s required, there w i l l be no delay i n procuring i t.

Additional dry clothing may be required especially i f t h e scene of the accident is some distance removed from,the operations headquarters. Probably t h e most e s s e n t i a l i t e m s of personal clothing f o r d i f f i c u l t country a r e good footwear, a windproof and waterproof jacket and trousers and s u i t a b l e headgear. It i s not easy t o prescribe the kind of footwear but the investigator should be in possession of s u i t a b l e boots which are water- proof, a t least t o above t h e ankles.

Climbing boots a r e e s s e n t i a l in' a p a r t i c u l a r l y mountainous t e r r i t o r y but it is worthwhile remembering t h a t although n a i l studded s o l e s a r e considered t o be good when climbing on grass and snow they can be dangerous on hard rocks.

On the other hand, rubber or composition s o l e s can be a disadvantage i f climbing on fresh snow, i c e o r w e t ground, whereas they give good r e s u l t s on clean dry rock. It has been found from experience t h a t a "paratroop" type of boot with a heavy moulded s o l e gives good service as general-purpose footwear i n d i f f i c u l t t e r r a i n ; "desert" boots have been found s u i t a b l e i n dry broken ground. Climbing boots and such l i k e footwear should have been "broken-in" before use otherwise considerable discomfort and hindrance of movement may r e s u l t.

Sunburn cream, anti-glare spectacles and i n s e c t repellent should a l s o be provided. Communication f a c i l i t i e s are especially important i n such circumstances. Investigators should a l s o be experienced i n the use of equipment most The i n v e s t i g a t o r ' s equipment should be s u f f i c i e n t t o enable wreckage exami- nation, the plotting of impact points and wreckage p a t t e r n , p a r t s i d e n t i f i c a t i o n and the recording of observations.

This may possibly be h i r e d and can be of Portable t a p e recorder. However, care must be taken not t o r e l y completely on recorders e s p e c i a l l y portable models which use an enclosed cassette, otherwise a mishap, similar t o a non-rotating f i l m i n a camera c a s s e t t e , may r e s u l t i n wasted effO r t and l o s s of va luab l e evidence.

Although i t should not be taken f o r granted, c i v i l and military organizations may be able t o provide a d d i t i o n a l manpower and f a c i l i t i e s. When a v a i l a b l e , h e l i c o p t e r s , transport, heavy l i f t i n g and moving gear, mine d e t e c t o r s , geiger counters, and radio equipment may be provided by these sources. It is important t h a t plans e x i s t whereby heavy moving gear and recovery equipment such a s cranes, bulldozers or l i f t i n g h e l i c o p t e r s may be made r e a d i l y available.

It may a l s o be necessary t o obtain the services of profes- s i o n a l surveyors p a r t i c u l a r l y when an extensive wreckage p l o t is required. Standing instructions should be i n existence t o ensure t h a t i n the event of an a i r c r a f t accident, a l l tape recordings and a i r t r a f f i c c o n t r o l documents deemed t o be associated with the f l i g h t are secured and placed i n safe-keeping u n t i l f u r t h e r i n s t r u c t i o n s a r e received from the investigator.

Arrangements may be entered i n t o with f u e l companies t o obtain automatically f u e l samples from stocks, o r t h e r e f u e l l i n g point. Arrangements should be pre-planned t o immediately Consideration might be given t o seeking t h e co-operation of l o c a l news media t o withold precise d e t a i l s of the location of an a i r c r a f t accident f o r a limited period i n order t o ensure adequate crowd control measures a r e implemented.

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