1/27/12

 

8900.1 CHG 54

Volume 7 Investigations

CHAPTER 1 accident and incident investigation and reporting

Section 2 Incident Investigations and Occurrences

7-31    PROGRAM TRACKING AND REPORTING SUBSYSTEM (PTRS) ACTIVITY CODES.

A.    Operations: 1711/1712/1725.

B.    Maintenance: 3711/3712/3720.

C.    Avionics: 5711/5712/5720.

7-32    GENERAL. This section contains guidance to be used by aviation safety inspectors (ASI) involved with the investigation and reporting of operator incidents. This section supplements Federal Aviation Administration (FAA) Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting.

7-33    DEFINITIONS. Inspectors involved with the investigation of an incident or occurrence should have a clear understanding of the definitions that follow. FAA Order 8020.11 contains the following definition for an incident, which is repeated here only for clarification and convenience. Inspectors should refer to FAA Order 8020.11, chapter 6 to review the investigative and reporting procedures for incident investigations. Inspectors should be aware that Flight Standards Service (AFS) also uses the term “occurrence” to label an event that is investigated.

A.    Incident (PTRS Code 1711/3711/5711 or 1712/3712/5712). An incident is defined as “an occurrence involving one or more aircraft in which a hazard or a potential hazard to safety is involved but not classified as an accident due to the degree of injury and/or extent of damage.” An incident could affect the safety of operations. This definition covers a broad range of events and may include the following:

·    Damage to an aircraft (other than an accident);

·    Runway incursion;

·    Pilot deviations (PD); and

·    Near midair collision (NMAC).

NOTE:  FAA Order 8020.11 identifies an NMAC as an incident. This incident should be investigated by using the procedures in FAA Order 8020.11, chapter 6, section 2. When recording the work activities involved with an NMAC investigation, inspectors should use PTRS code 1720.

B.    Occurrence (PTRS Code 1725/3720/5720). An occurrence is defined as an event that is not readily discernible as an incident. Events, such as a low speed abort or turnbacks, are considered occurrences and must be investigated to determine the impact on safety of operations.

C.    Correlation Between an Occurrence and an Incident. Not all events that are brought to the attention of AFS have an obvious impact on the safety of operations, nor are they readily identifiable as an incident. Until an event can be identified as an incident, it should be regarded as an occurrence. The advantage of labeling an event as an occurrence is that it allows for an investigation of the facts for an accurate identification of the event without generating unnecessary reports.

NOTE:  Safety improvement recommendations may result from either incident or occurrence investigations.

7-34    RESPONSIBILITIES. Managers of Regional Offices (RO) are responsible for investigating incidents occurring within their jurisdiction, except for PDs. Incident investigation responsibility is usually delegated to the local Flight Standards District Office (FSDO). If an incident other than a PD occurs in one regional geographic area, but the aircraft lands in another, the region in which the aircraft first landed is responsible for conducting the investigation. PDs are investigated by the AFS region of occurrence, regardless of where the aircraft lands, except for operations conducted under Title 14 of the Code of Federal Regulations (14 CFR) parts 121, 125, 135 and fractional ownership programs under 14 CFR part 91 subpart K (part 91K), when the certificate‑holding district office (CHDO) conducts the investigation as discussed in paragraph 7‑36B.

7-35    NOTIFICATION. FSDOs normally receive incident notification from either their Regional Operations Center (ROC) or an air traffic facility. If the inspector observes or receives notification of an incident (including NMACs) from a source other than an air traffic facility, and the incident is not known by the air traffic facility, the inspector will immediately notify the nearest AT facility and provide the information that the facility needs to complete its notifications. The inspector may facilitate the notification process in this instance by contacting the ROC.

NOTE:    FAA Form 8020‑11, Incident Report, is no longer used for PDs, and FAA Form 3556, Near Midair Collision Preliminary Report, is no longer used for NMAC reports.

7-36    REPORTS. This paragraph discusses guidelines for the reporting of certain types of incidents. For specific procedures to be followed, inspectors should refer to the current edition of FAA Order 8020.11.

A.    NMAC. An NMAC is classified as an incident involving one or more aircraft in which a hazard or a perceived potential hazard to safety is involved; however, it is not classified as an accident due to the minimal degree of injury or extent of damage.

1)    Reporting. NMACs are reported on FAA Form 8020‑21, Preliminary Near MidAir Collision Report, and should contain the following information:

·     Date, time, and location of the NMAC;

·     Fix or facility nearest the NMAC;

·     The NMAC location in respect to the fix or facility;

·     Aircraft information, such as make, model, and registration number;

·     Type of flight rules during the NMAC;

·     The aircraft altitude during the NMAC; and

·     A brief description of the NMAC, along with comments.

2)    Interviews. In some cases, FAA personnel may meet the aircraft involved in the NMAC for interviews with the flightcrews. When this becomes necessary, the normal order of facilities contacted to send personnel is as follows:

·     Airport traffic control tower (ATCT),

·     Flight Service Station (FSS),

·     Air route traffic control center (ARTCC), and

·     FSDO.

3)    Upgrade of Classification. An NMAC with a fatality is classified as an aircraft accident and will be reported and documented as both an aircraft accident and an NMAC.
4)    Retention. The reporting facility will retain the NMAC investigation package for a period of 30 months, or as described in the current edition of FAA Order 1350.15, Records Organization, Transfer, and Destruction Standards.

B.    PDs. PDs are actions of a pilot that result in a failure to comply with an air traffic control (ATC) clearance and/or instruction (e.g., failure to maintain assigned altitude or course, failure to hold short of active runway during taxi, entering controlled airspace without a clearance, or observed reckless aircraft operations by air traffic). PDs are classified as incidents and investigated by AFS. AFS offices determine if a violation of 14 CFR has occurred and if a subsequent enforcement investigation is appropriate.

1)    Reporting. PDs are reported to AFS through the air traffic quality assurance (ATQA)‑automated program on an electronic FAA Form 8020‑17, Preliminary Pilot Deviation Report, and should contain the following information:

·     Incident report number;

·     Type of deviation: surface or airspace;

·     Date, time, and location of the deviation;

·     Aircraft registration number or flight call sign;

·     Type of flight rules at time of deviation: visual flight rules (VFR) and instrument flight rules (IFR);

·     Aircraft altitude when the deviation was detected; and

·     A brief description of the deviation, with appropriate comments.

2)    Inspector Authorization to Use the ATQA Database. Inspectors must complete the Web‑based ATQA introductory training course, Pilot Deviation Reporting (FAA27100094), found on the electronic Learning Management System (eLMS) employee training site. To access the course, inspectors may have to contact the eLMS Help Desk (405‑954‑4568) and request that the course be added to their learning plan. To obtain a user ID and password to access the site, complete the following steps:
a)    Complete the FAA eLMS training course.
b)    From any Aviation Safety (AVS) computer system, open the ATQA program Web page http://atqa.faa.gov/reportingsystem/logon.jsp.
c)    Click on “Request An Account” from the top right of the screen.
d)    Complete the registration form, click on “Submit,” and select “FSDO Inspector” or “Administrative Staff.”
e)    Look for your registration information via your Lotus Notes account.
f)    Log on to http://atqa.faa.gov/reportingsystem/logon.jsp and change your password as requested. ATQA Helpdesk support is available 24/7 to help users with application issues. Users can also email their questions to 9‑AWA‑ATQA‑Helpdesk@faa.gov or call 800‑404‑1159.
3)    AFS Investigation. CHDOs associated with operations under parts 121 and 135, air operators under part 125, and fractional ownership programs under the operational control of a program manager under part 91K are responsible for the investigation and completion of FAA Form 8020‑18, Investigation of Pilot Deviation Report. This procedure facilitates a proactive approach in determining risk associated with certificated operators by the CHDOs. PDs that are not associated with the certificated operations mentioned above will continue to be investigated by the office with geographical jurisdiction for the event.
a)    ASIs are responsible for determining and verifying that the information contained in FAA Form 8020‑17 is correct and will consider reclassification if the PD is not supported by the results of the investigation using FAA Form 8020‑19, Reclassification of Aviation Incident Report.
b)    Investigating ASIs will utilize the ATQA program automated tool to complete FAA Form 8020‑18 as follows:

1.    Access http://atqa.faa.gov/reportingsystem/logon.jsp and complete the logon.

2.    Under the PD menu, select Investigation of Pilot Deviation Report, FAA Form 8020‑18.

3.    Do not use the “create final” with no preliminary option, as that option generates a new record.

4.    In the search window, enter the report number of the preliminary PD. When the report opens, select the “create final” option from the menu on the right side.

5.    Inspectors must complete all relevant blocks of FAA Form 8020‑18 and place special emphasis on block 18, “Description of Deviation and Comments with Recommendation, if Any.” For all PDs, Form 8020‑18, block 18 must include the following information (include entering the listed section headings):

·    Description of deviation;

·    Causal and/or contributing factors not already addressed in blocks 13 through 16, if any;

·    Recommendations for systemic corrective action to reduce risk of future occurrence; and

·    Comments (if any; if none, state “none”).

c)    ASIs investigating an event involving a PD that has been accepted as a non‑sole‑source report into the Aviation Safety Action Program (ASAP) will request the FAA event review committee (ERC) representative to assist in determining the information specified in subparagraph 7‑36B3)b)4 above; the ERC representative will assist in providing this information.

NOTE:    The submission of a report that has been accepted under the ASAP for an event reported as a PD does not relieve the associated FAA office of the responsibility for completing Form 8020‑18 in the ATQA system. PD investigations and reports are independent of the enforcement investigation responsibilities specified in the current edition of FAA Order 2150.3, FAA Compliance Enforcement Program.

d)    Upon completion of either FAA Form 8020‑18 or FAA Form 8020‑19, the investigating inspector will save the report and select the “Submit Manager Review” button.
4)    Manager Review. Indicates new/changed information. The office manager will be notified via email that a PD report has been submitted for review. Office managers will review each report for completeness and compliance with the note in subparagraph 7‑36B3)c). Once they have completed their review, the office manager will submit the report for RO review by selecting the “Submit Regional Review” button. All changes or corrections to the report should be completed before the report is submitted for RO review.
5)    RO Point of Contact (POC) Review. The RO POCs will receive an email that a PD report has been submitted for RO review. The POC will review the report for completeness. If omissions are identified during the review, the POC will notify the office manager of the discrepancy and will not submit the report to headquarters (HQ). When the corrections have been accomplished, the POC will verify that the report is complete and in compliance with AFS guidance prior to submitting the report to HQ. The POC is responsible for tracking PD report progress and will notify the office manager if a report has exceeded 90 days from the date of initial notification.
6)    Retention. The reporting facility will retain the PD investigation package for 30 months, or as described in FAA Order 1350.15.

C.    Other Incident Reports. Miscellaneous incidents are those other than NMACs or PDs, and may occur on an infrequent basis. Some incidents in this category are as follows:

1)    Forcible Seizure of Aircraft (Hijack). FAA personnel receiving information of a forcible seizure of an aircraft will immediately notify their manager, who in turn will immediately notify the Washington D.C. Operations Center, through the ROC.
2)    Hazardous Materials (hazmat). When a hazmat incident occurs, FAA personnel receiving the report must contact the regional Civil Aviation Security Office and give the appropriate information, including pertinent telephone numbers.
3)    Sonic Boom Complaints. When FAA personnel are notified of a sonic boom complaint, they will refer the matter to the nearest military installation.
4)    Unidentified Flying Object (UFO). If any FAA employee receives a report of a UFO, the individual making the report should be referred to the nearest scientific establishment or institution of higher learning that has expressed interest in such reports. If concern is expressed that life or property might be endangered, refer the individual to the local police department.

7-37    PTRS INPUT. The PTRS will be used to track the work activities of FAA inspectors during the investigations of occurrences and incidents, including NMACs.

A.    Occurrence Investigation (PTRS Code 1725/3720/5720). Indicates new/changed information. Most events that are “called in” to a FSDO can be initially regarded as occurrences. The PTRS offers the FAA supervisor a useful tool to record and track occurrences to a conclusion. Any event that is identified as an occurrence will be assigned to an inspector. The inspector will then “open” a new PTRS entry and use activity code 1725/3720/5720, with appropriate comments in section IV. Once a record of the occurrence has been established, it should be left open until the investigation is concluded. The supervisor can use these opened records to balance work activities and to track the progress of the investigation through the Open Items Report.

1)    When an occurrence investigation is concluded and no further action is required, the inspector will close the PTRS record with a “C” in the “Results” field, with the appropriate comments in section IV supporting the conclusion.
Indicates new/changed information. 2)    When an occurrence investigation is concluded and the results indicate that the event is actually an incident, the inspector will close the existing PTRS record with a “C” in the “Results” field, with the appropriate comments in section IV. If further action is required, the inspector should open a new record ID for an incident investigation with activity code 1711/3711/5711 or 1712/3712/5712 in the “Activity” field and activity code 1725/3720/5720 in the “Tracking” field.

NOTE:    The “Triggers” field may be used for this function.

B.    Incident Investigation (PTRS Code 1711/3711/5711 or 1712/3712/5712). If an event is clearly identifiable as an incident, inspectors may enter it into the PTRS directly by either using activity code 1711 for incidents that will require onsite investigations, or activity code 1712 for incidents that will not require onsite investigations.

1)    When an incident investigation is concluded and no further action is required, the inspector will close the PTRS record with a “C” in the “Results” field, with the appropriate comments in section IV supporting the conclusion.
Indicates new/changed information. 2)    When an incident investigation is concluded, and the results indicate that the event is actually an accident, the inspector will close the record with a “C” in the “Results” field, with the appropriate comments in section IV. The inspector will open a new record ID for the accident investigation under activity code 1702/3702/5702 or 1703/3703/5703 in the “Activity” field. Activity code 1711/3711/5711 or 1712/3712/5712 should be placed in the “Tracking” field to show that the accident investigation is the result of an incident.

NOTE:    If the incident results in an enforcement action, the inspector must place the locally generated Enforcement Investigative Report (EIR) number in the EIR field.

7-38    PREREQUISITES AND COORDINATION REQUIREMENTS.

A.    Prerequisites.

·    Knowledge of the regulatory requirements of 14 CFR, and

·    Successful completion of the Airworthiness Inspector Indoctrination course or equivalent.

B.    Coordination. This task requires coordination with Operations and Airworthiness supervisors, the ROC, and the appropriate FSS.

7-39    REFERENCES, FORMS, AND JOB AIDS.

A.    References (current editions):

·    FAA Order 1100.5, FAA Organization—Field,

·    FAA Order 2150.3, Compliance and Enforcement Program,

·    FAA Order 3550.8, Standby and Telephone Availability Policy,

·    FAA Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting,

·    FAA Order 8900.1, Volume 7, Chapter 7, Conduct Violation Investigation,

·    National Transportation Safety Board (NTSB) Title 49 of the Code of Federal Regulations (49 CFR) Part 830,

Indicates new/changed information.

·    Office procedure/policy manual.

B.    Forms:

·    FAA Form 8020‑2, Aircraft/Part Identification and Release Tag,

·    FAA Form 8020‑3, Facility Accident Incident Notification Record,

·    FAA Form 8020‑5, Aircraft Incident Record,

·    FAA Form 8020‑9, Aircraft Accident/Incident Preliminary Notice, and

·    FAA Form 8020‑11, Incident Report.

C.    Job Aids:

·    Personal communication device such as pager, cellular phone, etc.

·    Office accident investigation kit.

·    Sample figures and letters.

·    Special emphasis forms as required by notices (or National Policy).

·    Accident manual.

7-40    FUTURE ACTIVITIES. Conduct a violation investigation, if required.

RESERVED. Paragraphs 7‑41 through 7‑60.