L13 Accidents and Incidents

Accidents and Incidents

Introduction

  • Understanding and practicing safety procedures is crucial for survival during accidents or incidents.
  • Learning from past incidents and accidents reduces the likelihood of similar events.
  • ICAO Annex 13 focuses on preventing accidents and incidents, not assigning blame.
  • The lesson covers accidents, incidents, serious incidents, and occurrences.
  • It also discusses mandatory reporting obligations and systems for collecting confidential information and publishing lessons learned.
  • "In aviation we seek to fill the bucket of experience before we empty the bucket of luck."

International Standards and Recommended Practices

  • ICAO Annex 13 covers Aircraft Accident and Incident Investigation.
  • The tenth edition was published in July 2010.

Accidents and Incidents

  • Reporting and investigating aircraft accidents are governed by State law, but most States follow ICAO recommendations.
  • According to ICAO, an aircraft accident is an occurrence between boarding and disembarking that leads to:
    • Fatality.
    • Serious injury.
    • Missing aircraft.
    • Aircraft damage affecting structural strength, performance or flight characteristics and requiring major repair or component replacement.
  • An incident is defined as an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.
  • Example: Aircraft veered off the runway with structural damage but no injuries.

Serious Incidents

  • Pilots often read accident reports, especially those involving familiar aircraft or airfields.
  • Organizations investigating civil aviation accidents also investigate serious incidents.
  • A serious incident is an incident indicating that an accident nearly occurred.
  • ICAO Annex 13: "The difference between an accident and a serious incident lies only in the result".
  • Reports of serious incidents can be as valuable as accident reports.
  • Competent authorities may publish compilations of incident and serious incident reports.
  • These reports may include narratives from engineers and air traffic control officers.

Examples of Serious Incidents

  • Examples of serious incidents include:
    • Near collisions requiring avoidance maneuvers.
    • Aircraft structural failures or engine disintegrations (excluding those classified as accidents).
    • Multiple malfunctions of aircraft systems seriously affecting operation.
    • Flight crew incapacitation in flight.
    • Controlled flight into terrain only marginally avoided.
    • Aborted take-offs on a closed, engaged, or unassigned runway/taxiway.
    • Take-offs from a closed, engaged, or unassigned runway/taxiway.
    • Landings or attempted landings on a closed, engaged, or unassigned runway/taxiway.
    • Gross failures to achieve predicted performance during take-off or initial climb.
    • Fires and smoke in passenger/cargo compartments or engine fires, even if extinguished.
    • Events requiring emergency oxygen use by flight crew.
    • Fuel quantity requiring emergency declaration by the pilot.
    • Runway incursions with narrowly avoided collisions.
    • Take-off or landing incidents like undershooting, overrunning, or running off the runway.
    • System failures, weather, or operations outside the approved flight envelope causing control difficulties.
    • Failures of more than one system in a mandatory redundancy system.

Accident Investigations

  • Most States have an organization dedicated to investigating civil aviation accidents.
  • Details are notified in the State's AIP.
  • Accident investigation results are published.
  • Reports do not identify individuals and are usually accurate and unbiased.
  • Accident reports are freely accessible and contain valuable safety lessons.
  • Learn from the mistakes of others.
  • Responsibility for reporting an accident rests with the Pilot-In-Command (PIC) or the aircraft operator.

Mandatory Occurrence Reporting (MOR)

  • Notifying and investigating accidents has benefits for aviation safety.
  • Estimated at least 30 incidents for every accident.
  • EU regulations define an incident as "an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation."
  • Better information on incidents can help prevent accidents and improve aviation safety.
  • European legislation requires the pilot-in-command to report incidents (mandatory reporting).
  • Reportable occurrences are those posing a significant risk to aviation safety, including occurrences related to the operation of aircraft such as:
    • collision-related occurrences;
    • take-off and landing-related occurrences;
    • fuel-related occurrences;
    • in-flight occurrences;
    • communication-related occurrences;
    • occurrences related to injury, emergencies and other critical situations;
    • crew incapacitation and other crew-related occurrences;
    • meteorological conditions or security-related occurrences.
  • An occurrence means any safety-related event which endangers or could endanger an aircraft, its occupants or any other person.
  • EASA member states must establish a Mandatory Occurrence Reporting (MOR) system.
  • The pilot-in-command must report an occurrence within 72 hours of becoming aware of it, unless exceptional circumstances prevent this.
  • Personal details in occurrence reports are not recorded in national or EASA databases.
  • Publicly available information does not identify specific aircraft, operators, or individuals.

Definitions of General Aviation 'Occurrences' Which Require Reporting

  • Air Operations
    • (1) Unintentional loss of control.
    • (2) Landing outside of intended landing area.
    • (3) Inability or failure to achieve required aircraft performance in normal conditions during take-off, climb or landing.
    • (4) Runway incursion.
    • (5) Runway excursion.
    • (6) Any flight with an aircraft which was not airworthy, or for which flight preparation was not completed.
    • (7) Unintended flight into IMC (Instrument Meteorological Conditions) conditions by an aircraft not IFR (Instrument Flight Rules) certified, or a pilot not qualified for IFR.
    • (8) Unintentional release of cargo.
  • Technical Occurrences
    • (1) Abnormal severe vibration (for example: aileron or elevator 'flutter', or of propeller).
    • (2) Any flight control not functioning correctly or disconnected.
    • (3) A failure or substantial deterioration of the aircraft structure.
    • (4) A loss of any part of the aircraft structure or installation in flight.
    • (5) A failure of an engine, rotor, propeller, fuel system or other essential system.
    • (6) Leakage of any fluid which resulted in a fire hazard or possible hazardous contamination of aircraft structure, systems or equipment, or risk to occupants.
  • Interaction with Air Navigation Services and Air Traffic Management
    • (1) Interaction with air navigation services (for example: incorrect services provided, conflicting communications or deviation from clearance) which has or could have endangered the aircraft, its occupants or any other person.
    • (2) Airspace infringement.
  • Emergencies and Other Critical Conditions
    • (1) Any occurrence leading to an emergency call.
    • (2) Fire, explosion, smoke, toxic gases or toxic fumes in the aircraft.
    • (3) Incapacitation of the pilot leading to inability to perform any duty.
  • External Environment and Meteorology
    • (1) A collision on the ground or in the air, with another aircraft, terrain or obstacle.
    • (2) A near collision, on the ground or in the air, with another aircraft, terrain or obstacle, requiring an emergency avoidance manoeuvre to avoid a collision.
    • (3) Wildlife strike including bird strike which resulted in damage to the aircraft or loss or malfunction of any essential service.
    • (4) Interference with the aircraft by firearms, fireworks, kites, lasers, Remotely Piloted Aircraft Systems, model aircraft or by similar means.
    • (5) A lightning strike resulting in damage to, or loss of functions of, the aircraft.
    • (6) Severe turbulence encounter which resulted in injury to aircraft occupants or the need for a post-flight turbulence damage check of the aircraft.
    • (7) Icing including carburettor icing which has, or could have, endangered the aircraft, its occupants or any other person.

Reporting Occurrences

  • Reports are required from pilots, maintenance personnel, air navigation services, and aerodromes/ground services.
  • Occurrence reports are treated confidentially to encourage reporting and protect identities.
  • Published information identifies hazards, and reports from EASA states are collated and analyzed.
  • Many organizations have voluntary reporting schemes.
  • Voluntary schemes can lead to effective safety campaigns and measurable improvements.

Safety Information Bulletins

  • EASA publishes Safety Information Bulletins on its website.
  • These tend to be aircraft type-specific airworthiness directives or safety information for commercial air transport (CAT) operators.

General Aviation Safety Publications

  • Numerous sources of aviation safety publications and information are available.
  • These include association websites, magazines, newsletters, and safety promotional material.
  • Thanks to the internet, most information is available for free.
  • Pilots who read safety publications are likely to be more knowledgeable and safer.
  • The most avid readers of safety publications are often the most qualified and experienced pilots.

ICAO Annex 13 Formal Definitions

  • Accident: An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which:
    • a person is fatally or seriously injured as a result of:
      • being in the aircraft;
      • direct contact with any part of the aircraft, including parts which have become detached from the aircraft; or
      • direct exposure to jet blast.
    • the aircraft sustains damage or structural failure which:
      • adversely affects the structural strength, performance or flight characteristics of the aircraft; and
      • would normally require major repair or replacement of the affected component.
    • the aircraft is missing or is completely inaccessible.
  • Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.

ICAO Annex 13 Formal Definitions continued

  • Serious incident:
    • An incident involving circumstances indicating that there was a high probability of an accident and associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down.
  • Serious injury: An injury which is sustained by a person in an accident and which:
    • a) requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received;
    • b) results in a fracture of any bone (except simple fractures of fingers, toes or nose);
    • c) involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage;
    • d) involves injury to any internal organ;
    • e) involves second or third degree burns, or any burns affecting more than 5 percent of the body surface; or
    • f) involves verified exposure to infectious substances or injurious radiation.