CHAPTER NO.

Accident Location: During wreckage investigation, pinpointing the accident site

accurately is key. This involves identifying the point of impact and primary wreckage area.
Using GPS receivers or aerial photographs alongside maps ensures precise location
determination. Consideration of elevation and terrain gradient is important, and in some
cases, a terrain profile from a surveyor may be necessary. Aeronautical charts aid in
understanding the accident's relation to airways facilities and airports, especially for
incidents during approach or take-off.

Using Global Positioning Satellite (GPS) location: Using Global Positioning

Satellite (GPS) technology greatly simplifies accident site tasks. Survey teams no longer
need to return to the site to plot wreckage positions, as GPS receivers allow for immediate
recording. Military grade receivers offer centimeter-level accuracy, while handheld
commercial ones may have a precision of 3-5 meters. It's crucial to ensure consistency across
charts, GPS receivers, and surveyed positions by using the same geodetic survey databases.
During surveying, it's essential to use the same GPS receiver and capture positions
simultaneously to minimize errors. Portable GPS receivers commonly allow waypoint
marking, facilitating data collection without extensive manual input. However, it's advisable
to download waypoints to a computer regularly to avoid memory limitations.

Accident Investigator’s Photography Checklist

This is a checklist for photography that can be used at an aircraft accident site. It lists what
should be photographed at the beginning of an investigation, before the scene is disturbed. As
the investigation progresses, it will be determined, on the basis of the evidence found, if
other photographs need to be taken.

Immediately following the mishap.

• Fire fighting (Video)

• Rescue activities (Video)
• Radar and ATC (Recordings)
• Weather (forecast and actual conditions)

Once the investigation begins.

1. Aerial view of the site (Video)

2. The site ground view from each cardinal compass position
3. The site from the direction the aircraft was traveling at impact
4. Ground scars
5. Damage to trees and foliage
6. Skid marks
7. Photo inventory of major wreckage components
8. Flight control surfaces and actuators
9. Landing gear and other hydraulic components
10. Cockpit switch positions
11. Fire/heat damage and discoloration
12. Human remains, injuries, blood/tissue smears on wreckage
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13. Extra items or items adjacent to items not accounted for
14. Close-ups of fracture surfaces
15. Close-ups of improperly installed components
16. Close-ups of any other items you suspect may have contributed to the
mishap 17. Private property damage
18. Steps in removing, opening or cutting apart components
19. Any other photos deemed necessary

CHAPTER NO.3

Organizational investigations aim to uncover how systemic issues within an

organization contribute to accidents. These issues, such as management systems and
corporate culture, may not directly cause accidents but increase the likelihood of them
occurring. By identifying these latent conditions, corrective actions can be taken to prevent
future accidents.

THE REASON MODEL AND THE ORGANIZATIONAL INVESTIGATION:

The Reason Model illustrates how accidents stem from a combination of factors, including
human errors and latent unsafe conditions within organizations. While frontline personnel
may commit unsafe acts, organizational factors and management decisions can create latent
failure conditions. These latent conditions, often stemming from decisions made by decision-
makers and regulators, may remain dormant until system defenses are breached. Safety
management efforts aim to identify and mitigate these latent unsafe conditions system-wide.
Fallible decisions by line management, such as inadequate procedures or neglect of hazards,
can set the stage for errors or violations. Ultimately, effective safety management requires
addressing systemic issues rather than focusing solely on individual behaviors.

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 THE SIX “M” MODEL FOR ORGANIZATIONAL INVESTIGATION

The Six "M" Model for Organizational Investigation helps uncover how management
decisions affect operations, maintenance, and support activities before an accident occurs. It
highlights the critical factors influenced by management decisions and their
interrelationships, essential for understanding systemic issues leading to accidents or
inadequate defenses.

➢ Formulation of the Mission:

The Mission, or the aircraft's purpose, is influenced by three factors: the Man (personnel),
the Machine (equipment), and the Medium (environment). Organizational investigation
focuses on how the organization affects these factors.

a) The Man: This includes personnel involved in aircraft operations, maintenance, and
oversight. Organizational policies regarding employment, scheduling, supervision, and
procedures are examined to understand their impact on individual actions. For example,
inadequate rest policies may contribute to crew fatigue.

b) The Machine: This encompasses aircraft and supporting equipment. Organizational

decisions regarding equipment procurement, maintenance, and training are investigated. For
instance, using inadequate equipment due to procurement issues reflects organizational
influence.

c) The Medium: This refers to environmental conditions during operations, such as weather
and lighting. Organizational actions (or lack thereof) to mitigate risks associated with these
conditions are scrutinized.

Inter-relationships between these factors are crucial, including:

a) The Man-Machine interface: Consideration of how individuals interact with equipment.

For instance, if equipment is not suitable for all personnel due to design limitations, the
organization should address this.

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 b) The Man-Medium interface: Examination of how individuals cope with environmental
conditions. If the organization fails to address risks associated with the environment during
activities like maintenance, they may contribute to accidents.

c) The Machine-Medium interface: Assessment of equipment's compatibility with

environmental conditions. For instance, operating an aircraft on a runway shorter than
required due to organizational oversight reflects significant organizational contribution.

➢ Management:
Management oversees all aspects of the organization, from senior officials to frontline
supervisors. They establish policies and standards that shape the corporate culture, which can
influence behavior and decision-making at all levels. Investigating management's role
involves examining how their decisions and actions contribute to systemic factors that may
lead to accidents.

Management plays a crucial role in ensuring safety within organizations. Here are some key
points to consider:
1. Procedures: Organizations establish procedures to maintain safety during operations and
maintenance. Investigators need to evaluate these procedures for any potential safety issues.
For instance:

• Different state requirements can create conflicting procedures for aircraft transitioning.
• Organizational procedures on compliance and personnel may affect safety, like
managing crew rest periods.
• Over time, organizations changing manufacturer procedures can introduce safety
risks.

2. Standardization: Ensuring consistency in procedures across the organization is vital but can
be challenging without a centralized reference library.

3. Information Transfer: Careful management is necessary when transferring critical

information from manuals to operational checklists or work cards to prevent errors,
especially during emergencies.

➢ Funding:
"Funding" refers to resource adequacy. Sufficient resources prioritize safety, but scarcity
may normalize risks over time as organizations stretch resources, accepting them as
standard procedures.

1. Manpower Availability: Ensuring there are enough qualified personnel to meet operational
needs, as shortages may lead to safety compromises.

2. Manpower Quality: Evaluating the experience levels of personnel relative to their roles, as
imbalances can affect work quality and safety.

3. Parts Acquisition: Examining how organizations obtain necessary parts, especially when
resources are limited, to avoid compromising safety through alternative methods.

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 ▪ Information about rescue operations.
▪ Names and addresses of other witnesses.
▪ Witness's signature on the statement and any sketches.

Final Notes:

▪ Record the date, place, and investigator's name and role on the statement.
▪ Use a map to indicate each witness's location during the accident and reference their
statements accordingly.

➢ Aircraft Investigation Authorities (NOTES)

Aircraft investigations are typically conducted by various organizations and authorities to
determine the causes of accidents or incidents involving aircraft. Some of the key
organizations involved in aircraft investigations include:

National Transportation Safety Board (NTSB): In the United States, the NTSB is the
primary agency responsible for investigating civil aviation accidents and incidents. They
conduct thorough investigations to establish the probable cause of accidents.

Federal Aviation Administration (FAA): The FAA may also be involved in investigations,
particularly when issues related to aircraft maintenance, regulations, or air traffic control are
relevant.

Aircraft Manufacturers: Aircraft manufacturers like Boeing and Airbus may conduct their
investigations if an incident involves their aircraft. They aim to identify any design or
manufacturing issues.

Airline Companies: Airlines often conduct their investigations into incidents involving their
aircraft. These investigations focus on operational aspects and safety procedures.

International Civil Aviation Organization (ICAO): On a global scale, ICAO plays a role
in setting international standards and guidelines for aviation safety and investigating incidents
involving international flights.

Military Authorities: For military aircraft accidents or incidents, the respective military
branch's investigation agency is responsible for conducting inquiries.

Independent Experts: In some cases, independent experts or consultants may be hired by

involved parties to provide additional expertise and conduct parallel investigations.

➢ NTSB Aircraft Investigation Process

NTSB investigation process includes following major steps;

Notification: The NTSB is alerted to an aircraft accident or incident, and a "Go Team" is
assembled. This team typically includes investigators, specialists, and other relevant experts.

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On-Site Investigation: The Go Team travels to the accident site. They secure the scene,
collect evidence, and document the accident site, wreckage, and any perishable evidence.
They interview witnesses, air traffic controllers, and those involved in the incident.

Wreckage and Records Examination: The NTSB thoroughly examines the aircraft
wreckage, engines, components, and maintenance records. They may also recover the flight
data recorder (FDR) and cockpit voice recorder (CVR) for analysis.

Laboratory Analysis: The FDR and CVR data are analyzed at the NTSB's laboratory.
Aircraft components and materials may also undergo detailed analysis to identify any
structural failures, malfunctions, or defects.

Human Performance Analysis: Investigators assess the roles of the flight crew, air traffic
controllers, and other personnel involved, looking at factors like pilot performance, fatigue,
training, and decision-making.

Meteorological Analysis: Weather conditions at the time of the accident are examined to
determine if weather played a role in the incident.

Aircraft Systems and Operations Analysis: NTSB investigators evaluate the aircraft's
systems, procedures, and maintenance to identify any issues that contributed to the accident.

Report Development: After a thorough investigation, the NTSB develops a final report that
includes findings of fact, analysis, conclusions, probable cause, and safety recommendations.
The report is then reviewed and approved by the NTSB board.

Public Release: The final report is made publicly available on the NTSB's website and is
widely disseminated to stakeholders in the aviation industry.

➢ Eye Witness Interviews in Aviation Occurrence Investigations

Introduction: This article outlines best practices for aviation occurrence investigations,
focusing on the importance and procedure of conducting eye witness interviews.

Investigation Approach:

1. Unbiased Approach: Focus on understanding what happened rather than confirming

assumptions.
2. Just Culture: Emphasize learning lessons over assigning blame.

Evidence Gathering and Examination: The process of gathering and examining evidence
in investigations is crucial for maintaining objectivity and thoroughness. Here are key
practices:

▪ Gather and sort all evidence before starting the examination.

▪ Categorize the evidence to help with later steps.
▪ Use a systematic approach and don’t draw conclusions until all evidence is reviewed.
▪ Don’t change evidence to fit conclusions; consider all evidence, even if it contradicts.

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▪ Take lots of photos to keep details of the scene, especially of gauges and switches.
▪ Make simple sketches of the scene early on, which are helpful before computer models
are ready.

Interview Techniques:

▪ Conduct interviews promptly to capture accurate recollections before memories fade.

▪ Value all witness statements equally, regardless of the witness's aviation experience.
▪ Prefer oral interviews over written statements for detail and accuracy.
▪ Recording interviews (with consent) is preferable to note-taking, especially with multiple
witnesses.
▪ Prefer individual interviews to group sessions to prevent influence and encourage
openness.
▪ Minimize interruptions during interviews to maintain continuity and capture crucial
details.
▪ Ensure interviewees feel comfortable to encourage additional contact if they recall more
information later.

Conclusions and Recommendations:

▪ Focus conclusions on factors directly related to the event; address unrelated hazards
separately.
▪ Develop recommendations tied to specific factors, aiming to prevent similar events.
▪ Avoid punitive measures in recommendations to foster cooperation and learning.
▪ Provide short, medium, and long-term solutions, ensuring specificity and practicality.

This structured approach ensures thorough investigation and effective prevention of future
aviation incidents.

➢ Mid Air Collision:

Definition: A Mid-Air Collision (MAC) is an accident where two aircraft come into contact
with each other while both are in flight.

Effects: It is commonly assumed that any MAC would cause the loss of both aircraft and all
people on board. In some cases, MACs have been non-fatal, but typically result in total loss.
Ground fatalities can also occur following a MAC.

Why Midair collision happens: Midair collisions often result from a combination of factors
rather than a single cause. These factors can be categorized into different barriers that, when
unsuccessful, contribute to the collision:

▪ Technical reasons: Failures in equipment or systems.

▪ Human error: Mistakes in judgment, decision-making, or response.
▪ Impracticability: Situations where constraints like time or resources prevent proper
action.
▪ Lack of coverage: Insufficient equipment or procedures to detect and prevent collisions.

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Sometimes, conflicts at a tactical level (lower operational level) can bypass strategic conflict
management efforts, further increasing the risk of collision. This complex interplay of factors
underscores why midair collisions typically involve multiple causes rather than a singular
reason.

Contributory Factors:

1. Traffic conditions
2. ATCO (Air Traffic Controller) performance
3. Flight crew training and corporate culture
4. ATC (Air Traffic Control) systems
5. Aircraft equipment
6. Navigation infrastructure
7. Flight plan processing
8. Airspace configuration
9. Weather conditions

Solutions:

1. Improve positive Safety Culture.

2. Enhance aircraft systems, e.g., ACAS (Airborne Collision Avoidance System).
3. Upgrade ATC systems and procedures.
4. Improve communications systems and procedures, such as CPDLC (Controller-Pilot
Datalink Communication).

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