1、DOC 9756-ANI965 Amendment No. 1 3019103 Transmittal Note MANUAL OF AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION Part I - Organization and Planning First Edition - 2000 Amendment No. 1 1. to incorporate Amendment No. 1. 2. Replace pages 1-4-5 to 1-4-30 in Appendix 2 to Chapter 4 with the attached new
2、 pages dated 3019103 Record the entry of this amendment on page (ii). States are encouraged to update contact information contained in the Manual of Aircru8 Accident and Incident Investigation, Part I - Organization and Planning (Doc 9756), Chapter 4, Appendix 2, by writing to: International Civil A
3、viation Organization Accident Investigation and Prevention Section 999 University Street Montral, Quebec H3C 5H7 Canada E-mail: apalovicao.int Fax: +I (514) 954-8166 Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking
4、 permitted without license from IHS-,-,-Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,- Published in separate English, Arabic. French, Russian and Spanish edirions by the In
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6、urrency of the couny in which the order is placed. Credit card orders (American Express, MasterCard and Visa) are accepted at ICAO Headquarters. hremrional Civil Aviation Organization. Attention: Document Sales Unit 999 University Sweet, Montreal. Quebec. Canada H3C 5H7 Telephone: (514) 954-8022 Tel
7、ex: 05-24513: Facsimile: (514) 9544769 Sitatex: YULADYA: E-mail: sales-uniticao.int Egypr. ICAO Regional Director. Middle East Office, Egyprian Civil Aviation Complex, Cairo Airport Road. Heliopolis. Cairo I1776 Telephone: (20 2) 267-4840: Facsimile: (20 2) 267-4843: Sitatex: CAICAYA France. Directe
8、ur regional de IOACI, Bureau Europe et Atlanrique Nod, 3 bis, villa tmile-Bergewt. 92522 Neuilly-sur-Seine (Cedex) Telephone: (33 I) 46 41 85 85: Telecopieur: (33 1) 46 41 85 00; Sitatex: PAREUYA India. Oxford Book and Starioncry Co Scindia House, New Delhi ll0M)I or 17 Park Sweet. Calcutta 700016 T
9、elephone: (91 II) 331-5896 Facsimile: (91 II) 332-2639 Japan. Japan Civil Aviation Promotion Foundation, 15-12. I-chome. Toranomon, Minato-Ku. Tokyo Telephone: (81 3) 3503-2686 Facsimile: (81 3) 3503-2689 Kenya. ICAO Regional Director. Eastem and Southern African Office, United Nations Accommodation
10、. P.O. Box 46294, Nairobi Telephone: (254-2) 622-395; Facsimile: (254 2) 226-706 Sitatex: NEOCAYA Mexico. Director Regional de la OACI. Oficina Noneamerica. Cenuoamkrica y Caribe, Masaryk No. 29-3er. piso. Col. Chapultepec Morales. MCxico, D.F., 11.570 Telefono: (52 5) 250-321 I: Facsimile: (52 5) 2
11、03-2757: Sitarex: MEXCAYA Peru. Director Regional de la OACI. Oficina Sudamerica. Apanado 4127. Lima 100 Telefono: (51 14) 302260 Facsimile: (51 14) 640393: Sitatex: LIMCAYA Russian Federation. Aviaizdar, 48, 1. Franko Sueet. Moscow 121351 Telephone: (7 095) 417-0405; Facsimile: (7 095) 417-0254 Sen
12、egal. Directeur regional de IOACI. Bureau Afrique occidentale et cenuale, Boite postale 2356. Dakar Telephone: (221) 8-23-54-52; TklCcopieur: (221) 8-23-69-26: Siutcx: DKRCAYA Sourh Africa. Avex Air Training (Pry) Ltd Private Bag X102, Halfway House, 1685. Republic of South Africa Telephone: (27-1 I
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14、nd. ICAO Regional Director. Asia and Pacific Office, P.O. Box 11, Samyaek Ladprao, Bangkok 10901 Telephone: (66 2) 537-8189: Facsimile: (66 2) 537-8199: Sitatex: BKKCAYA Unired Kingdom. Westward Documedia. 37 Windsor Street. Cheltenham. Glos GL52 2DG Telephone: (44 1242) 235-151: Facsimile: (44 1242
15、) 584-139 5100 Catalogue of ICAO Publications and Audio-visual Training Aids training aids currently available. Issued annually, the Catalogue lists all publications and audio-visual Monthly supplements announce new publications and audio-visual training aids, amendments, supplements, reprints, etc.
16、 Available free from the Document Sales Unit, ICAO i Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Doc 9756 AN1965 Manual of Aircraft Accident and Incident Investigation Pa
17、rt I Organization and Planning Approved by the Secretary General and published under his authority First Edition - 2000 International Civil Aviation Organization Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking per
18、mitted without license from IHS-,-,-AMENDMENTS The issue of amendments is announced regularly in the ICAO Journal and in the monthly Supplement to the Catalogue of ICAO Publicarions and Audio-visual Training Aids, which holders of this publication should consult. The space below is provided to keep
19、a record of such amendments. RECORD OF AMENDMENTS AND CORRIGENDA I AMENDMENTS I Date Date No. of issue entered Entered by I CORRIGENDA I of issue entered Entered . Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking p
20、ermitted without license from IHS-,-,-FOREWORD The purpose of this manual is to encourage the uniform contained in Annex 13 and to provide infomation and guid- application of the Standards and Recommended Practices ance to States on the procedures, practices and techniques that can be used in aircra
21、ft accident investigations. Since accident investigations vary in complexity, a document of this kind cannot cover all eventualities. The more common techniques and processes, however, have been included. Although this manual will be of use to experienced and inexperienced investigators alii, it is
22、not a substitute for investigation training and experience. This manual will be issued in four separate parts as follows: Part I - Organization and Planning; Pan ll- Procedures and Checklists; Part Ill - Investigation; Part N - Reporting. Because this manual deals with both accident and incident inv
23、estigations and. for reasons of brevity, the terms “accidents” and ”accident investigation”, as used herein, apply equally to “incidents” and “incident investigation”. The following ICAO documents provide additional information and guidance material on related subjects: - Annex 13 - Aircraft Acciden
24、t and Incident Investigation; - Accidenrhcidenr Reporting Manual (ADREP Manual) (Doc 9156); - Accident Prevenrion Manual (Doc 9422); - Manual of Civil Aviation Medicine (Doc 8984); - Human Facrors Training Manual (Doc 9683); - Human Facrors Digest No. 7 - Invesrigarion of Human Facrors in Accidenrs
25、and Incidents (Ci. 240). will be amended periodically as new investigation This manual, which supersedes Doc 6920 in its entirety, techniques are developed and new information becomes available. inclusion in subsequent editions of this manual. This Readers are invited to submit material for possible
26、 material should be addressed to: The Secretary General International Civil Aviation Organization Montrkal. Quebec 999 University Street Canada H3C SUI I-(iii) Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permi
27、tted without license from IHS-,-,-TABLE OF CONTENTS page Chapter 1 . The objective of an aircraft accident investigation 1-1-1 Chapter 2 The accident investigation authority . 1-2-1 2.1 Structure 1-2-1 2.2 Legislation 1-2-1 2.3 Funding 1-2-2 2.4 Personnel . 1-22 2.5 Equipment 1-2-3 Appendix to Chapt
28、er 2 - Investigation field kit 1-2-5 Chapter 3 . Planning the investigation . 1-3-1 3.2 The investigation management system 1-3-1 3.1 Accident investigation management 1-3-1 3.3 Liaison with other authorities . 1-3-2 3.4 Cooperation with the media 1-3-3 3.5 Securing of records . recordings. samples
29、. . 1-3-3 3.6 Removal of disabled aircraft 1-3-3 Chapter 4 . Notification of accidents and incidents . 1-4-1 page 4.1 General . i41 4.2 Notification within a State . i41 4.3 Responsibilities of the State of Occurrence 1-41 4.4 Format and content of the notification 142 4.5 Dispatch of the notificati
30、on to other Stam I42 4.6 Receipt of the notification . 1-42 4.7 Responsibility of the State receiving the notification 1-42 Appendix 1 to Chapter 4 - Example of a nouficatlon 144 Appendix 2 to Chapter 4 - Addresses of investigation authorities 1-45 Chapter 5 . Actions at the accident site 1-5-1 5.1
31、Initial actions 1-5-1 5.2 Rescue operations 1-5-1 5.3 Security 1-5-2 5.4 Safety at the accident site 1-5-2 5.5 Environmental and natural hazards . 1-5-6 5.6 Wreckage in water 1-5-8 5.7 Planning for specialist examinations .I. 5.11 Appendix to Chapter 5 - Personal protective equipment against biologi
32、cal hazards . 1-5-15 Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Chapter 1 THE OBJECTIVE OF AN AIRCRAFT ACCIDENT INVESTIGATION 1.1 Annex 13 defines the sole objective of
33、an aircraft accidents and incidents. It also states that it is not the accident or incident investigation as the prevention of future purpose of an investigation to apportion blame or liability. Any judicial or administrative proceedings to appottion blame or liability should be separate from any in
34、vestigation conducted under the provisions of AMex 13. Thus, the emphasis of an aircraft accident or incident investigation is on remedial actions. 1.2 An aircraft accident provides evidence of hazards or deficiencies within the aviation system. A well- conducted investigation should therefore ident
35、ify all immediate and underlying systemic causes of an accident avoiding the hazards or eliminating the deficiencies. The and recommend appropriate safety actions aimed at investigation may also reveal other hazards or deficiencies causes of the accident. Thus, a properly conducted accident within t
36、he aviation system not directly connected with the investigation is an impomnt method of accident prevention. conditions and circumstances pertaining to the survival or 1.3 An investigation should also determine the facts, non-survival of the occupants of the aircraft. Recommen- dations for improvem
37、ents to the crashworthiness of the aircraft are aimed at preventing or minimizing injuries to aircraft occupants in future accidents. 1.4 The Final Report, which is produced at the completion of an investigation, constitutes the official conclusions and record of the accident. Copyright Internationa
38、l Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Chapter 2 THE ACCIDENT INVESTIGATION AUTHORITY 2.1 STRUCTURE on International Civil Aviation, it is incumbent on the State 2.1.1 In conformity with
39、Article 26 of the Convention in which an aircraft accident occurs to institute an inquiry into the circumstances of the accident. This obligation can only be met when appropriate legislation on aircraft accident investigation is in place. Such legislation must establish an accident investigation aut
40、hority (or commission, board or other body) for the investigation of aircraft accidents. strictly objective and totally impartial and must also be 2.1.2 The accident investigation authority must be perceived to be so. It should be established in such a way that it can withstand political or other in
41、terference or pressure. Many States have achieved this objective by setting up their accident investigation authority as an independent statutory body or by establishing an accident investigation organization that is .separate from the civil aviation administration. In these States, the accident inv
42、estigation authority reports direct to Congress. Parliament or a ministerial level of government (see Figure 1-2-1). 2.1.3 In many States it may not be practical to establish a permanent accident investigation authority. These States generally appoint a separate accident investigation commission for
43、 each major accident to be investigated, the members of which are often seconded from the civil aviation administration. It is essential that such a commission report direct to a ministerial level of government so that the endings and safety recommendations of the investigation are not diluted durin
44、g passage through regular adminis- trative channels. 2.1.4 Seconded experts are responsible to the This is not an ideal arrangement, however, since seconded investigator-inxharge for the duration of an investigation. personnel may fear retribution when they return to their normal duties should the c
45、ivil aviation administration react unfavourably to the findings in the Final Report of the investigation. States should take steps to alleviate any possibility of retribution. to determine the causes of an accident and to make safety 2.1.5 The accident investigation authority is required recommendat
46、ions. However, responsibility for the im- plementation of safety recommendations should rest with the civil aviation administration. This division of responsi- bility is appropriate since the civil aviation administration has overall responsibility for the regulatory framework of aviation and its de
47、velopment 2.1.6 ICAO encourages States to foster regional aviation safety groups. Regional arrangements may include aircraft accident investigation matters, such as the delegation of investigations or parts thereof or enlisting the mutual assistance and cooperation of States in an investigation. 2.2
48、 LEGISLATION 2.2.1 Appropriate legislation that defines the rights and responsibilities of the aircraft accident investigation authority is required. The accident investigation authority should, through legislation, have immediate and unresttic- ted access to all relevant evidence without requiring
49、prior consent from judicial bodies or other authorities. Accident investigators should be aware that aircraft accidents may be subject not only to technical investigation but also to some form of judicial inquiry. However, accident investigation procedures should not be constrained by judicial processes, and national legislation and regulations should specify the procedures to be followed in order to keep
