1、Doc 9756 AN1965 Manual of Aircraft Accident and Incident Invest gat ion Part IV Report i ng Approved by the Secretary General and published under his authority First Edition - 2003 International Civil Aviation Organization Copyright International Civil Aviation Organization Provided by IHS under lic
2、ense with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Piihlished iri separate Etiglisli, Arabic, Chitiese. Fretich, Russian arid Spariish editions DJ. the Ititertiatiotial Civil Aviation Orgatikatioti. All correspotidetice, escept orders and suDscriptioris,
3、 should De addressed to the Secretary Gerieral. Orders should be sent to one of the following addresses. together with the appropriate remittance (by bank draft, cheque or money order) in U S dollxs or the currency of the country in which the order IS placed. Crqdit card orders (Amencan Express, Mas
4、terCard and Visa) are accepted at ICAO Headquarters. .t hiternmiorid Civil Aliarion Orgnnizniion. Attention: Document Sales Unit 999 University Street. Montreal, Quebec, Canada H3C 5H7 Tclcphonc: +I (5 14) 954-8022; Facsimile: +I (514) 954-6769; Sitatex: YULADYA; E-mail: salesicao.int Telephone: +20
5、 (2) 267-4840; Facsimile: +20 (2) 267-4843; Sitatex: CAICAYA Tlphone: +33 (i) 46 41 85 85; Fax: +33 (i) 46 41 85 00; Sitatex: PAREUYA Telephone: +91 (i I) 331-5896; Facsimile: +91 (il) 332-2639 Telephone: +81 (3) 3503-2686; Facsimile: +81 (3) 3503-2689 Telephone: +254 (2) 622-395; Facsimile: +254 (2
6、) 226-706; Sitatex: NBOCAYA Masaryk No. 29-3er. piso, Col. Chapultepec Morales, Mxico, D.F., I1570 Telfono: +52 (55) 52 50 32 11: Facsimile: +52 (55) 52 03 27 57; Sitatex: MEXCAYA Nigeria. Landover Company, P.O. Box 3 165, Ikeja, Lagos Telephone: +234 (i) 4979780; Facsimile: +234 (i) 4979788; Sitate
7、x: LOSLORK . Peru. Director Regional de la OACI, Oficina Sudamrica, Apartado 4127, Lima 100 Telfono: +51 (i) 302260; Facsimile: +51 (i) 640393; Sitatex: LIMCAYA Russian Federarion. Aviaizdat, 48, I. Franko Street, Moscow 121351 Telephone: +7 (095) 417-0405; Facsimile: +7 (095) 417-0254 Senegal. Dire
8、cteur rgional de IOACI, Bureau Afrique occidentale et centrale, Bote postale 2356, Dakar Tlphone: +221 8-23-54-52; Fax: +221 8-23-69-26; Sitatex: DKRCAYA Slovakia. Air Traffic Services of the Slovak Republic, Letov prevdzkov sluzby Slovenskej Republiky, State Enterprise, Lctisko M.R. Stefnika, 823 0
9、7 Bratislava 21, Slovak Republic Telephone: +421 (7) 4857 1 I1 I; Facsimile: +421 (7) 4857 2105 Telephone: +27 (I i) 315-0003/4; Facsimile: +27 (i 1) 805-3649; E-mail: Planta Tercera, Despacho 3. 1 I, 28027 Madrid Telfono: +34 (91) 321-3 148; Facsimile: +34 (91) 321-3157; Correo-e: sscc.ventasoacia
10、ena.es Telephone: +66 (2) 537-81 89; Facsimile: +66 (2) 537-8 199; Sitatex: BKKCAYA Telephone: +44 161 499 0023; Facsimile: +44 161 499 0298; E-mail: ; World Wide Web: http:/ Egypt. ICAO Regional Director, Middle East Office. Egyptian Civil Aviation Complex. Cairo Airport Road, Heliopolis, Cairo 1 1
11、776 Frcirice. Directeur rgional de IOACI, Bureau Europe et Atlantique Nord, 3 bis, villa mile-Bergerat, 92522 Neuilly-siir-Seine (Cedex) India. Oxford Book and Stationery Co Scindia House, New Delhi 110001 or 17 Park Street, Calcutta 700016 Japan. Japan Civil Aviation Promotion Foundation. 15- 12. I
12、-chome, Toranomon, Minato-Ku, Tokyo Kenya. ICAO Regional Director, Eastern and Southern African Office, United Nations Accommodation, P.O. Box 46294, Nairobi Mexico. Director Regional de la OACI, Oficina Norteamrica, Centroamrica y Caribe Sourh Africa. Avex Air Training (Pty) Ltd., Private Bag Xl02,
13、 Halfway House, 1685. Johannesburg, Republic of South Africa Spain. A.E.N.A. - Aeropuertos Espafioles y Navegacin Area, Calle Juan Ignacio Luca de Tena, 14, Thailand. ICAO Regional Director, Asia and Pacific Office, P.O. Box 1 I, Samyaek Ladprao, Bangkok 10901 United Kii7gdorn. Airplan Flight Equipm
14、ent Ltd. (AFE), la Ringway Trading Estate, Shadowmoss Road, Manchester M22 5LH 2/03 Catalogue of ICAO Publications and Audio-visual Training Aids Issued annually, the Catalogue lists all publications and audio-visual training aids currently available. Monthly supplements announce new publications an
15、d audio-visual training aids, amendments, supplements, reprints, etc. Available free from the Document Sales Unit, ICAO. Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Doc 9
16、756 AN/965 Manual of Aircraft Accident and Incident Investigation Part IV Report i ng Approved by the Secretary General and published under his authority First Edition - 2003 International Civil Aviation Organization Copyright International Civil Aviation Organization Provided by IHS under license w
17、ith ICAONot for ResaleNo reproduction or networking permitted 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 Publications and Audio-visual Training Aids, which holders of this publicati
18、on should consult. The space below is provided to keep a record of such amendments. RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS Entered entered CORRIGENDA Entered of issue entered IV-(ii) Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo r
19、eproduction or networking permitted without license from IHS-,-,-FOREWORD The purpose of this manua is to encourage the uniform application of the Standards and Recommended Practices contained in Annex 13 and to provide information and guidance to States on the procedures, practices and techniques t
20、hat can be used in aircraft 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 i
21、nvestigators alike, it is not a substitute for investigation training and experience. This manual will be issued in four separate parts as follows: Part1 - Organization and Planning; Part II - Procedures and Checklists; Part IIi - Investigation; and Part IV - Reporting. Because this manual deals wit
22、h both accident and incident investigations and, for reasons of brevity, the terms “accidents” and “accident investigation”, as used herein, apply equally to “incidents” and “incident investigation”. The following ICA0 documents provL additional information and guidance material on related subjects:
23、 - Annex 13 - Aircraff Accident and Incident - Accidenflncident Reporting (ADREP) Manual - Accident Prevention Manual (Doc 9422); - Manual of Civil Aviation Medicine (Doc 8984); - Human Factors Training Manual (Doc 9683); - Human Factors Digest No. 7 - Investigation of Human Factors in Accidents and
24、 Incidents (Circular 240). Investigation; (Doc 9156); This manual, which supersedes Doc 6920 in its entirety, will be amended periodically as new investigation techniques are developed and new information becomes available. Readers are invited to submit material for possible inclusion in subsequent
25、editions of this manual. This material should be addressed to: The Secretary General International Civil Aviation Organization 999 University Street Montral, Quebec Canada H3C 5H7 IV-(iii) Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo rep
26、roduction or networking permitted without license from IHS-,-,-TABLE OF CONTENTS Page Page Chapter 1 . The Final Report . IV-1-1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 General The group reports . Format and content of the Final Report Consultation on the draft Final Report Release and distribution of the F
27、inal Report Final Reports to be included in the ICAO Aircraft Accident Digest Exchange of Final Reports between States ICAO address IV-1-1 IV-1-1 IV- 1-2 IV-1-2 IV-1-3 IV-1-3 IV- 1-3 IV-1-4 Appendix 1 to Chapter 1 . Format and content of the Final Report . IV-1-5 Appendix 2 to Chapter 1 . Report wri
28、ting conventions IV-1-17 Appendix 3 to Chapter 1 . Symbols and abbreviations IV-1-20 Appendix 4 to Chapter 1 . Aviation Appendix 5 to Chapter 1 . Commonly terminology . iv-1 -24 used findings IV-1-27 Chapter 2 . The Accidenncident Data Reporting (ADREP) System . IV-2-1 2.1 Reports IV-2-1 2.2 ADREP i
29、nformation available to States IV-2-1 2.4 Preliminary Report 2.5 Accident Data Report 2.6 Incident Data Report 2.7 Constraints on Incident Data Reports . . IV-2-3 2.3 Data validity . IV-2-2 (ADREP Form P) . IV-2-2 (ADREP Form D) . IV-2-2 (ADREP Form D) . IV-2-2 IV-(v) Copyright International Civil A
30、viation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Chapter 1 THE FINAL REPORT 1.1 GENERAL 1.1.1 The Final Report of an aircraft accident investigation is the foundation for initiating the safety actions which
31、 are necessary to prevent further accidents from similar causes. Therefore, the Final Report on an accident must establish in detail what happened, how it happened and why it happened. The findings and the causes of the Final Report should lead to safety recommendations so that appropriate preventiv
32、e measures can be taken. 1.1.2 The Final Report should provide: - a record of all the relevant facts (including any conflicting evidence); - an analysis of the relevant facts; - conclusions in the form of findings and causes; and - safety recommendations. The findings and the causes of a Final Repor
33、t should point clearly to the safety issues that need to be addressed. 1.1.3 The Final Report is usually the report of the investigator-in-charge or the accident investigation authority. The report should cover in detail all relevant aspects of the investigation. When the investigation of an acciden
34、t is organized by establishing specialized groups, each group chairperson should submit a written report to the investigator-in-charge together with all supporting documentation and data covering the facts and findings established. The Final Report will be drafted based, to a large extent, on the re
35、ports of the various groups. The investigator-in-charge is responsible for ensuring that the Final Report is written in a consistent and uniform style. 1.1.4 The investigation of a general aviation accident seldom requires organization into groups. Such investigations are usually carried out by one
36、or two investigators. As in the case of a major investigation, the responsibility for the completeness and quality of the Final Report rests with the investigator-in-charge and the accident investigation authority. 1.2 THE GROUP REPORTS in consultation with the group members, the group chairperson i
37、s responsible for scrutinizing the evidence gathered in relation to the tasks assigned to the group, and for drafting a group report, which presents all the facts relevant to the activities of the group. Also, the group chairperson should draft an analysis of the facts which the group has establishe
38、d, draft the findings of the groups investigation and make proposals for safety recommen- dations. A group report should be presented in the following format: Introduction This section gives brief identification details of the accident and lists the names, titles and affiliations of the group member
39、s. Matters of organization, such as the forming of sub-groups to handle specific tasks within the terms of reference of the group, should be explained. For example, in the case of the Operations Group, sub-groups such as a Witness Group and a Performance Group are sometimes formed. The terms of refe
40、rence for the group and sub- groups and brief details of the time and location of investigation activities should also be recorded in this section. Investigation The facts, conditions and circumstances established by the group should be presented under appropriate headings describing the areas inves
41、tigated. For example, in the case IV-I-1 Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-IV-1-2 Manual of Aircraft Accident and Incident Investigation of the Operations Group
42、, headings would include crew histones, flight planning, dispatch, and aircraft mass and balance. All the relevant facts, whether or not considered significant to the findings of the group, must be included. Relevant documentation should be attached to the group report. Analysis The analysis discuss
43、es the significance of the facts stated in the previous section of the goup report and presents the groups analysis of those facts as they pertain to the terms of reference of the group. This information should be presented in a logical way that leads to and supports the findings. Conclusions The co
44、nclusions section of the group report should contain the substantiated findings of the groups investigation. An indication of the findings of the group which are considered to be factors in the accident will assist the investigator-in- charge in the drafting of the Final Report. The group report sho
45、uld include information on any safety issues established, safety actions already taken, and proposals for safety recommendations. 1.3 FORMAT AND CONTENT OF THE FINAL REPORT 1.3.1 An investigation into an aircraft accident is not complete until all the relevant facts revealed by the investigation, th
46、e analysis of the facts, the conclusions and the safety recommendations have been recorded in the Final Report. The Final Report should be structured logically and written in clear and concise language. The report should explain what happened, how it happened, and why the accident happened, and it s
47、hould address the safety issues involved. A standardized format of the Final Report assists in the production of a complete and reliable record of the investigation of the accident. 1.3.2 In a major investigation, the investigator-in- charge receives the group reports and is responsible for the deve
48、lopment and the drafting of the Final Report. The Final Report should be a comprehensive report of the whole investigation. The factual information collected during the investigation should form the basis for the analysis section of the report, which leads to and supports the establishment of the fi
49、ndings, causes and safety recommendations. The standardized format for the Final Report, which is contained in the Appendix to Annex 13, provides a well- structured record of the investigation. The Final Report contains five parts: introduction (Title and Synopsis), Factual Information, Analysis, Conclusions (Findings and Causes) and Safety Recommendat
