chapter 168   INVESTIGATE AN ACCIDENT


Section 1  Background

1.  WPMS Activity Codes.

   On-site: 1702

   Other: 1703

3.  Objective.  The objective of this task is to perform an accident investigation according to national and district office standards. Successful completion of this task results in a factual report submitted to the National Transportation Safety Board (NTSB) that establishes the facts, conditions, and circumstances surrounding the accident. Completion of this task may also result in an enforcement action or the counseling of an airman.

5.  General.

A.  Definitions.

(1)  An "aircraft accident" is 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 and all persons have disembarked and in which any person suffers death or serious injury or in which the aircraft receives substantial damage.

(2)  "Serious injury" means any injury which:

(a)  Requires hospitalization for more than 48 hours, commencing within seven days from the date an injury was received

(b)  Results in a fracture of any bone (except simple fractures of fingers, toes, or nose)

(c)  Causes severe hemorrhages, nerve, muscle, or tendon damage

(d)  Involves any internal organ

(e)  Involves second- or third- degree burns, or any burns affecting more than five percent of the body surface.

(3)  "Substantial damage " means damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component.

(a)  Exceptions: engine failure, damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, damage to landing gear, wheels, brakes, tires, flaps, engine accessories, or wingtips are not considered "substantial damage" for the purpose of this task.

(b)  Field inspectors are urged to fully consider all aspects of the exceptions in paragraph (a) above before making a final "substantial damage" determination that would classify the occurrence as an accident. An airworthiness inspector may be needed to make a "substantial damage" determination.

(4)  "Public use aircraft" means any aircraft used exclusively in the service of any government or of any political subdivisions thereof including the government of any state, territory, or possession of the United States, or the District of Columbia, but not including any government-owned aircraft engaged in carrying persons or property for commerical purposes.

B.  Incidents.  Incidents involving aircraft damage will be investigated using the same procedures, as appropriate, as an accident investigation. Procedures for all other incidents are contained in Related Task #167, Investigate an Incident.

7.  Types of Aircraft Accidents/Incidents.

a.  FAA Participation in Military Accident Investigations.

(1)  Section 702 of the Federal Aviation Act of 1958 provides for participation in military accident investigations by the Administrator when a function of the FAA is involved. Military procedures for implementing Section 702 are set forth in a consolidated Armed Forces Regulations/DOT Order designated as AFR 127-11.

(2)  The military commander in charge of the investigation determines the FAA's involvement and includes this in the notification to the FAA. Despite an initial negative determination, the senior member of an investigating board or the director of a military safety center may later make a determination of FAA involve­ment and advise the FAA.

(3)  A function of the FAA will be considered to be involved when an FAA employee or designee, an FAA facility, procedure, directive, or publication, an FAA certificated civilian airman, or an FAA certificated joint use airport possibly are associated with an acci­dent. The FAA may have an interest when the aircraft and/or equipment is common to both civil and military aviation or when there are environmental factors of common interest.

(4)  In a military aircraft accident (mishap) in which a mutual interest exists but no FAA function is or may be involved, the FAA may request to participate in the investigation. Requests for participation shall be forwarded to the appropriate military safety center following coordination with the Accident Investigation Division, AAI-100.

(5)  In the case of accidents involving solely military aircraft and in which a function of the Adminis­trator is or may be involved, the military authorities shall provide for participation in the investigation by the Administrator.

B.  Agricultural Aircraft Accidents.  The IIC should use extreme caution when arriving at an acci­dent site which has involved an agricultural aircraft. The site may be contaminated with "economic poisons" or chemicals which could be hazardous to the investigators or anyone who may come in contact with the substance. Therefore, protective clothing is a must when investigating an agricultural accident. If there is any question as to what type of substance was on board the aircraft at the time of the accident, the IIC should make every attempt to identify the substance and determine that there is no risk before allowing anyone on the site. This information may be obtained from the operator, the State Poison Control Center, or the National Poison Control Center. Once the chemical or "economic poison" has been identified, the IIC may obtain information on precautions, cleanup procedures, symptoms, decontamination procedures, etc., by calling the National Pesticide Telecommunications Network at 1- 800-858-7378.

C.  Foreign Accidents.  FAA responsibilities remain unchanged when U.S. registered or U.S. manufactured aircraft are involved in an accident or incident in foreign territories. The degree of participation in the investigation, however, is subject to ICAO Annex 13,l current U.S. State Department policy, and any special agreements that may apply in certain countries. Foreign accidents are investigated in accordance with Order 8020.11.

D.  Ultralight Vehicle Accidents.  The NTSB is no longer investigating this category of accident. The responsibility to determine if the operation is in compliance with the FAR is still with the FAA and is delegated to an inspector assigned by the district office manager. Most of the time it is very difficult to determine compliance with the FAR without going to the site. The initial telephone notification should have sufficient information for the IIC to determine if an on-site investigation is required. If the accident involves fatalities, conflict with other aircraft, operating over a congested area, buzzing before crash, two-place ultralight, etc., should be a clue to the IIC that violations of the FAR could have occurred and an on-site investigation should be accomplished to document the areas of noncompliance. FAA Form 8020-9, Aircraft Accident Preliminary Notice, is NOT to be used for ultralight vehicle accident notification.

E.  Public Use Aircraft.  An IIC may assist in the conduct of the accident investigation of public use aircraft in those instances where written agreements have been made to conduct such investigations. Investigations on a selective basis are made upon request when the interests of the FAA are involved. It should be noted that the FAA is not normally funded to investigate public aircraft accidents. NTSB Form 6120.4, Factual Report Aviation Accident, may be used as the format for the investigation, but all references to the NTSB must be removed from the form. Copies of the report are NOT distributed to the NTSB or within the FAA to AVN- 120. NTSB Form 6120.19A shall not be prepared. Any recommendations that may result from the investigation will be processed in accordance with Order 8020.11.

9.  Pre-accident Plan.  A pre-accident plan should be developed by the Flight Standards District Office (FSDO) and should be tailored for each office's specific requirements (e.g., geographic location, climate, staffing, resources, etc.) The success of an accident investigation often depends on how well the pre-accident plan is carried out. A pre-accident plan is viable only if it is kept current and rehearsed.

A.  Functions and Responsibilities.  The pre-accident plan for a NTSB conducted investigation and a NTSB delegated investigation are much the same and should consider the following functions and responsibilities:

(1)  Readiness of investigators (e.g., training, capability, qualifications, availability, etc.)

(2)  Assignment of investigator-in-charge

(3)  Personnel notification (e.g., owner, operator, manufacturers, participants, local authorities, etc.)

(4)  Travel coordination

(5)  NTSB/FAA coordination

(6)  Wreckage security

(7)  Preservation of human factors evidence

(8)  Preservation of aircraft and airman records

(9)  Investigator equipment (e.g., clothing, report/accident forms, funds, tools, first aid kit, etc.)

(10)  Psychological preparation

(11)  Physiological preparation

(12)  Expeditious departure to accident site

(13)  Wreckage recovery

(14)  News media contacts

(15)  Office standby policy

(16)  Investigator credentials

(17)  Status of Cockpit Voice Recorder (CVR), Flight Data Recorder (FDR), and ELT

(18)  Public or foreign aircraft accidents

B.  List of Telephone Numbers.  The following is a sample list of possible telephone numbers that should be on hand in district offices having aircraft accident investigation responsibilities.

(1)  FAA Personnel, Office/Home

(a)  Local Office Personnel

(b)  Regional Communications Center (RCC)

(c)  Washington Headquarters Communications Control Center (WCC)

(d)  Regional Flight Standards

(e)  Air Traffic (Center, Approach, Tower)

(f)  Flight Service Station (FSS)

(g)  Air Carrier

(h)  General Aviation

(i)  Aviation Standards

(j)  Engineering and Manufacturing

(k)  Flight Inspection

(l)  Regional Flight Surgeon

(m)  Civil Aeromedical Institute (CAMI)

(n)  FAA Technical Center

(o)  Regional Counsel

(p)  Airway Facilities

(q)  Airports

(r)  Airman Records

(s)  Aircraft Records

(t)  Public Affairs


(u)  Aviation Security

(v)  Maintenance Analysis Center

(2)  Non-FAA Personnel/Organizations

(a)  National Transportation Safety Board (NTSB)

(b)  Manufacturer Representatives

(c)  Operators

(d)  Aviation Medical Examiners (AME)

(e)  Airport Managers/Owners

(f)  Insurance Agencies

(g)  State Aeronautics Commissions

(h)  News Media

(i)  Consultants

(j)  Law Enforcement

(k)  Civil Air Patrol

(l)  Military Facilities

(m)  Drug Enforcement Administration

(n)  Alcohol, Tobacco and Firearms Administration

(o)  Customs

(p)  Federal Bureau of Investigation

(q)  Internal Revenue Service (IRS)

(r)  Motels

(s)  Airlines

(t)  State and Federal Poison Control Centers

(u)  GSA motorpool

(v)  Aircraft repair stations

C.  Identification Badges.  Each office should establish a means of identifying investigation participants (e.g., coroner, security, etc.) at the accident site. A recommended method would be to use plastic, clip-on badges which are numbered and controlled with a sign-out log to identify those who are authorized to be within the confines of the accident site.


11.  Post-Notification Activities.  The actual accident notification procedures will not be discussed here; they are thoroughly described in Order 8020.11 and in current GENOT's which contain special emphasis notification procedures.

a.  Delegated Investigation.  If the NTSB field office delegates the investigation to the FAA, certain steps have to be taken immediately to initiate the investigation. When the situation permits the IIC to immediately depart for the site, these steps should be taken by somebody in the district office, preferably by the office coordinator. The facilities of the Regional Communications Center (RCC) are very effective in establishing the necessary contacts and coordination with:

(1)  Law enforcement or airport authorities (Wreckage and site security. Deactivation of ELT, CVR, and FDR. Rescue operations in accordance with Part 830 of the NTSB rules. Accessibility of the accident site, environmental conditions, and arrangements for local travel to the site when appropriate.)

(2)  Coroner or nearest AME. (Arrangements for autopsies and toxicological tests. The local coroner should be contacted to assure that the flight crew's bodies have not and shall not be embalmed until the regional flight surgeon has been consulted.)

(3)  Manufacturer, operator, or owner. (Request specific assistance, documents, or data when preliminary indications justify such requests.)

(4)  FSS, ATC, and tower facilities (Preliminary information on flight plan, pilot's intent, radio communications, progress of the flight, etc.)

(5)  Weather information from the National Weather Service, FAA facilities, or certified observers.

B.  Organizing the Investigation.  Organizing the investigation is a dynamic process which begins with the initial notification and continues throughout the investigation. Before or following the accident site familiarization visit, the IIC should hold an organizational meeting. The organizational meeting for delegated aviation accidents may be nothing more than an informal conversation involving two or more of the following: FAA IIC and FAA participants, or representatives of the operator, owner, or manufacturer. The purpose for the organizational meeting is to define briefly the investigation responsibilities, procedures, and objectives, and the participants in the investigation are apprised of what is expected of them as a party to the investigation. The office or unit supervisor will usually determine which inspectors from each required specialty will participate in the investigation.

C.  NTSB Conducted Investigation.  The IIC receiving notification should proceed with the above steps as requested by the NTSB (e.g., wreckage security, etc.)

D.  Office Coordination.  The appointed office coordinator should give local authorities the name of the IIC and his or her expected time of arrival. Before departing, the IIC should designate an initial contact point where messages can be sent during the transient status. NOTE: Some G-cars are equipped with a mobile phone or FM transceiver which may be used for this purpose. For an off-airport accident, if the mobile phone is not available, the law enforcement agency (Sheriff, State Highway Patrol, or Police Chief) in whose jurisdiction the accident occurred can be used as the point of contact; for an accident occurring on an airport, the airport manager's have their own investigating and reporting responsibilities and should be contacted. By the time the IIC arrives, a considerable amount of essential information, including written reports that should be reviewed for possible inclusion in the accident report, may be available. Furthermore, when special arrangements have to be made to reach a remote accident site it may be the sheriff's office that will play a leading role. The more difficult the conditions at an accident site, the more essential and mutually beneficial the cooperation between local officials and the IIC becomes.

E.  Response to an Accident.  Time, location, weather, transportation, and type of accident may dictate whether the IIC will proceed immediately to the site or wait until weather or proper coordination has been completed.

F.  Investigation Equipment.  The diversity of aircraft accidents makes it difficult to have all the necessary equipment available. Certain items commonly used in every investigation should be kept in readiness. Proper clothing should be the first consideration; good serviceable clothing capable of withstanding rough usage is recommended (e.g., coveralls, parka, rainwear, hardhat, etc). Selection should be based on the climate likely to be encountered. Heavy duty, waterproof footwear is a must. Each office must develop their own requirements. Accidents occurring in remote areas require special consideration for shelter, food, and water. Since the investigator's kit has to be carried, it is recommended that it not be overloaded with unnecessary or duplicate items. Keep in mind that many improvisations can be made in the field. Also, most participants in the investigation (law enforcement, aircraft and engine manufacturer representatives, etc.) may bring certain types of equipment. For example, most fire departments or rescue squads have specialized saws, jack, and pumps that can be used. The following items are commonly used by the investigator in most investigations:

(1)  Photographic equipment (e.g., film, flashbulbs, camera, lenses, extra batteries, etc.)

(2)  Mini-camcorder (extra tape cassettes)

(3)  Magnetic compass

(4)  Flashlight, spare batteries, and bulbs

(5)  Gloves (e.g., leather, rubber, heavy duty, etc., with latex or surgical gloves worn inside)

(6)  Hand tools (e.g., screwdrivers, pliers, adjustable wrench, spark plug wrench, etc.)

(7)  Magnifying glass (10X or stronger)

(8)  Marking pens and grease pencils

(9)  Tape measure, 50-foot or longer

(10)  Knife

(11)  Note pad, clipboard, and paper

(12)  Accident report forms

(13)  Other related forms (e.g., wreckage release, autopsy authorization, etc.)

(14)  Parts tags with string or wire

(15)  Plastic bags

(16)  First aid kit, snake bite kit, and sunscreen

(17)  Accident investigation statutes

(18)  Toxicology mailing kit

(19)  Nylon cord

(20)  Map (Grid, county, road)

(21)  Investigator's checklist

(22)  Containers for fuel, oil, and hydraulic samples

(23)  Government credit cards

(24)  Small protractor

(25)  Insect repellent

(26)  Paint brush

(27)  Tape (Black electrical and masking)

(28)  Engineer tape (To rope off area)

(29)  Tape recorder (Spare cassettes and batteries)

(30)  Hand held transceiver, if available

G.  Type of Accident.  Type of accident refers to the immediate circumstances of the accident, not its causes. Unless the FAA IIC first forms as clear a picture as possible of WHAT happened, the FAA IIC is hard to put to approach the HOW and WHY of the accident methodically. The FAA IIC should keep in mind that the NTSB determines the probable cause of the accident. Examples of types of accidents:

(1)  Collision with other aircraft

(2)  Collision with fixed object (e.g., wires, terrain, etc.)

(3)  Airframe failure in flight

(4)  Stall - Spin - Spiral

(5)  Fire or explosion in flight

(6)  Forced landing or autorotation

(7)  Ditching

(8)  Fuel Exhaustion

(9)  Weather related

H.  Safety at the Accident Site.  An area of vital importance often overlooked or not considered during the investigation is safe investigation practices and common sense safety precautions. The quality of the investigation is best served by an awareness of the need for fitness, mentally as well as physically, until the job is done. The moment the IIC takes custody of the wreckage the IIC becomes responsible for the safety of any participants as well as bystanders at the site. Bystander safety can be resolved by roping off all critical areas and having security guards control access to the site. With regard to the safety of all participants with a task at the site, the IIC's planning should include the following considerations:

(1)  Arriving at the site equipped with suitable equipment appropriate to the climate and terrain conditions.

(2)  The wearing of gloves when handling wreckage is mandatory, especially if there is a likeli­hood of coming into contact with body fluids or tissue. The use of hardhats when working inside or under the wreckage is strongly recommended.

(3)  Precaution against the shifting of wreckage on steep slopes or in deep snow.

(4)  If there is the slightest reason to suspect the presence of hazardous cargo, including radioactive materials or chemicals, delay the handling of wreckage until the necessary checks have been made by quali­fied persons and the site has been declared safe. Agricultural accidents may require coordination with state or national poison control centers.

(5)  Follow the advice of local experts such as forest rangers, mountain rescue teams, surveyors, and law enforcement personnel as to the type of protection and precautions needed in certain terrain.


(6)  Understand the effects of fatigue on individual safety long before total exhaustion takes place. Adjust workload to the circumstances.

(7)  At high elevations, have portable oxygen and other emergency equipment available.

(8)  Unexpected weather or equipment failures may isolate the investigation team in remote areas; therefore, provisions for first aid, shelter, food, water, and fuel should be made before the need arises.

(9)  Use the buddy-system and a method for the logging-in and logging-out of personnel operating in remote areas. When practicable, use a communication system to stay in contact with individuals in isolated areas.

(10)  The use of helicopters at inaccessible accident sites can be hazardous, especially for persons unaccustomed to helicopter operations. Coordination between crew and passengers is a must; the planning for serious emergencies should include the availability of a second helicopter for rescue purposes. Be aware of helicopters rotorwash which could disturb the wreckage site.

(11)  Working around heavy digging and wreckage retrieval equipment is dangerous and demands close supervision by a qualified operator.

(12)  When the crash site is in water, only fully trained and properly equipped personnel must be assigned to special missions, such as underwater recovery and photography.

(13)  The prevention of fire in and around the wreckage requires consideration of:

(a)  Ignition sources

(i)  Persons who smoke

(ii)  Batteries and electrical systems

(iii)  Explosive agents, including ammunition

(iv)  Rescue and salvage equipment

(v)  emergency generators

(vi)  Lighting equipment

(b)  Flammable materials

(i)  Fuel, oil, and hydraulic fluids

(ii)  Oxygen

(iii)  Unknown substances in cargo or luggage

(iv)  Combustible vegetation and forest

(c)  Additional hazards at the site:

(i)  Pressurized systems and components, including hydraulic, pneumatic, and oxygen systems

(ii)  Blowout (explosion) of damaged landing gear wheels when the tires are still inflated

(iii)  Loaded weapons, especially when law enforcement agencies or hunters were known to be aboard

(iv)  Sharp, jagged pieces of metal

(v)  Wreckage may be electrically charged

(vi)  On frozen water, ice may give under wreckage

(vii)  Many toxic agents present with a fire

(viii)  Possibility of dangerous animals at the site

(ix)  Agricultural chemicals

J.  Wreckage Preservation.  To the extent possible, the IIC should ensure that the wreckage site is not disturbed anymore than absolutely necessary. Removal of survivors and victims, fire fighting, removal of hazard materials, removal of wreckage for property or public protection etc., are examples of when the wreck-age might be disturbed. These comments are offered to forewarn the IIC about the complexities he or she may encounter when faced with the investigation of a catastrophic accident. In case the sequence of events cannot be readily determined, the best advice is to maintain custody of the wreckage in a secure area until all mechanical and functional aspects of the available hardware have been exam­ined to the IIC's satisfaction.


K.  Helicopter Wreckage Considerations.  Although the managerial concepts remain the same, the IIC should be aware that the investigation of a catastrophic helicopter accident may present problems that will not likely be encountered in a fixed wing accident investigation. Some of the helicopter characteristics that can complicate the IIC's task at the site are:

(1)  The propulsion system is also part of lift- generating and control systems. The interdependence of these rotating systems may obscure the search for a failure sequence, especially when the IIC is not thoroughly familiar with helicopter engineering and aerodynamics.

(2)  Rotating components that separate in flight may produce unpredictable scatter patterns. For example: separation of the tail rotor gear box can be the result as well as the cause of an in-flight breakup.

(3)  In single rotor helicopters the heavy items tend to be clustered together around and beneath the mast (e.g, transmission, engine, and fuel cells.) In a severe vertical impact, the proximity of ignition sources and combustibles (e.g., magnesium components of engine and transmission) tend to produce an intense fire that often destroys major portions of the collective, cyclic and engine control mechanisms.

(4)  In general, a helicopter is very intolerant of mechanical and maintenance deficiencies and operations outside its performance envelope. Even a minor occurrence such as the loss of a seat cushion or flight jacket through an open door or window can have disastrous consequences when it affects a rotating component.

L.  Progress Reports.  An initial telephone progress report shall be made by the FAA IIC to AAI- 100 through the Washington Headquarters Operations Center (WOC) as soon as possible after arrival at the accident location to report all available information concerning accidents of a catastrophic nature, those having a strong public interest impact, and nationally newsworthy occurrence or on request from AAI- 100. The FAA IIC will also advise AAI-100 of the location and telephone number of the NTSB command post or a telephone number at which the FAA IIC may be contacted during the investigation field phase. These calls can be initiated by use of a hand held transceiver, if available.

M.  Analysis Considerations.  During the documentation investigation process, certain evidence requires more detailed examination. The IIC is continually evaluating evidence as a possible contributing factor or accident cause.

(1)  A complete list of accident causes or contributing factors will probably never exist. Some suggestions are included here in hope of stimulating the IIC's analytical process:

(a)  Missing wing or stabilizer tips, vertical stabilizer tip, propeller or rotor tips, etc.

(b)  Missing flight control surfaces (e.g., rudder, elevators, ailerons, flaps, stabilizers, spoilers, slats, tabs, etc.)

(c)  Missing structure

(d)  Pre-impact versus post-crash fire evidence

(e)  Metal fatigue versus instantaneous breaks

(f)  In-flight breaks versus impact breaks

(g)  Positive versus negative wing or stabilizer separation

(h)  Evidence of overloading or out of center of gravity

(i)  Evidence of aircraft attitude at impact

(j)  Controlled versus uncontrolled at impact

(k)  Engine power at impact

(l)  Systems operation before impact

(m)  Evidence of impact before final terrain contact: trees, wires, buildings, terrain, poles, obstructions

(n)  Performance

(o)  Fuel contamination or exhaustion


(2)  Items (a) through (p) primarily concern anal­ysis of physical evidence as an accident cause or contributing factor. NTSB probable cause statistics indicate that a large percentage of aircraft accidents are caused by the human element. Presuming this statistic reliable indicates that IIC's must go beyond the mechanical and into the psychological cause of accidents if any meaningful accident prevention recommendations are to be made. The following is a partial list of psychological areas of consideration:

(a)  Psychological profile: reference U.S. Naval Aviation Safety Review: Approach July 1975, FAA Aviation Medicine Report AM 72-2.

(b)  Psychophysiological effects of aging: reference CAMI 77-6, 63-18, 63-33

(c)  "Get-homeitis"

(d)  Personality type/tendencies/traits: introvert, extrovert, psychotic, suicidal, over confident, overachiever, macho, neurotic; reference CAMI Reports 71-35, 72-2, 73-5

(e)  Change in routine

(f)  Circadian cycle change: CAMI Reports 65-16, 65-28, 68-8, 69-17

(g)  Risk taker

(h)  Acute situational stress

(i)  Peer group pressure or pressure to succeed, fear of failure

(j)  Biorhythms: reference Armed Forces Institute of Pathology Study

13.  Aircraft Accident Report Package.  Within 30 working days after an investigation, delegated to the faa by the ntsb, has been completed or soon as possible thereafter, the FAA IIC should submit a signed original report which contains the facts, conditions, and circumstances disclosed by the investigation. The investigation completion date should include the conduct of any post-field investigative activity. A copy of the faa iic's report when accompanied by additional faa administrative data (described in Order 8020.11) serves as the FAA report of the accident.

A.  Accident Reports.  Accident prevention is based on data contained in the accident reports; logically, then, accident prevention can be only as effective as the report is adequate. Unfortunately, the accident report often proves to be the weak link in the accident prevention chain. Therefore the IIC should take special care in the wording of the report as well as the gathering of information to complete that report.

(1)  Two instances when the FAA IIC might request a written report from a participant would be if the participant was called away from the investigation without the FAA IIC being able to discuss the participant's group activities or whenever FAA responsibilities are alleged to be involved in the accident.

(2)  The FAA IIC may enlist the aid of any or all FAA participants for the preparation of the FAA report of the accident.

B.  Non-Concurrence.  During investigations conducted by the NTSB or the military, if an FAA participant does not concur with the report, the participant informs the group chairman the reasons for non- concurrence in writing. A copy of the non-concurrence shall be furnished immediately to the FAA IIC and to AAI-100. In addition, participants must make an immediate verbal report followed as soon as possible thereafter, if requested by the FAA IIC, with a written report to the FAA IIC whenever any of the FAA areas of responsibility is involved. (Refer to Chapter 165, Introduction to Accident/Incident Related Tasks, paragraph 5B(1)(a) - (i).)

15.  Follow-up Activities.  Even when the wreckage examination reveals a probable mechanical reason for the accident (e.g., fuel starvation or a missing bolt in the elevator control linkage) the why behind the problems that bring an aircraft down can seldom be resolved at the site. Finding the missing piece of the puzzle may give great satisfaction to the IIC in that it tends to neatly wrap up the on-site activities. However, the IIC's investigation cannot serve its accident prevention purpose unless the iic identifies the characteristics of the conditions which contributed to the accident. The pursuit of this critical task sometimes requires more time and tenacity than the work at the accident site. Some of the typical activities after completion of the on-site investigation are:

(1)  Testing and tear-down of aircraft components and parts using approved design and production criteria as standards

(2)  Comparing the aircraft's certificated performance with the performance requirements under the conditions existing at the time of the accident. Simulator or actual flight tests may be required.

(3)  Reviewing all relevant certification standards (aircraft, airmen, carriers, airport facilities, schools, repair stations, etc.) for inadequacies that may have set the stage for the accident.

(4)  Documenting the pilot's flying background, experience, training and certification in the detail required by the nature of the accident. (Research ASAS, contact pilot's most recent employer, instruc­tors, schools, FBO, peers, family, friends, etc.).

(5)  Documenting the pilot's medical certification. The pilot's physical and mental performance capability at the time of the accident should be explored to the extent dictated by the circumstances of the accident.


(6)  Documenting the pilot's preparation and execution of the flight. (Contact FSS, Tower and ATC facilities involved. Obtain final transcripts of all recorded communications and reconstruct the flight track as appropriate.)

(7)  Documenting all pertinent weather data. (Pilot briefings, forecast weather, actual weather, PIREP's, SIGMET's, etc.).

(8)  Submitting safety proposals in the form of accident prevention recommendations.

17.  Downgrading an Accident to an Incident.  If at any time during the investigation, facts are revealed which would indicate the accident should be downgraded to an incident, the FAA IIC will notify the appropriate air traffic facility, AVN-120, and the NTSB by sending each office a copy of the original NTSB Form 6120.19A with the word "downgraded" written across the form and following procedures outlined in Related Task #167, Investigate an Incident.


Section 2  Procedures

1.  Prerequisites and Coordination Requirements.

A.  Prerequisites.  This task requires knowledge of related FAR and FAA policies and qualification as an Aviation Safety Inspector (Operations).

B.  Coordination.  This task requires coordination with the district office clerical personnel, operations and airworthiness unit supervisors, the Regional Oper­ations Center (ROC), and the appropriate Flight Service Station (FSS). This task may also require coordination with the Accident Prevention Program Manager (APPM), the appropriate air traffic facility, the Aircraft Certification Office (ACO), Airway Facilities, Airports, the Flight Inspection Field Office (FIFO), the appropriate National Transportation Safety Board (NTSB) Field Office, Office of Aviation Medicine (CAMI), Office of Civil Aviation Security, National Safety Data Branch, AVN-120, Aviation Standards National Field Office, AVN-1, National Weather Service (NWS), Regional Office of Public Affairs, Regional Counsel, Manufacturer's representatives, operator's representative, Military Safety Center, or state and local law enforcement officials, state or national poison control center.

3.  References, Forms, and Job Aids.

A.  References.

·        Any affected FAR

·        NTSB Part 830

·        National and office policy specific to accident investigation

·        Order 1200.23, Public Availability of Information

·        Order 2150.3, Compliance and Enforcement

·        Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting (most current edition)

·        Order 8700.1, General Aviation Operations Inspector's Handbook

·        Any office duty book/procedures

B.  Forms.

·        FAA Form 1360-33, Record of Visit, Confer­ence, or Telephone Call

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

·        FAA Form 8020-3, Facility Accident Notifica­tion Record

·        FAA Form 8020-5, Aircraft Incident Record

·        FAA Form 8020-6, Report of Aircraft Accident

·        FAA Form 8020-6-1, Report of Aircraft Acci­dent (Continuation Sheet)

·        FAA Form 8020-9, Aircraft Accident Prelimi­nary Notice

·        FAA Form 8020-10, Aircraft Accident Data Transmittal

·        FAA Form 8020-11, Incident Report

·        FAA Form 8020-16, FAA Accident Investiga­tion Record

·        FAA Form 8025-1, Aviation Medical Exam­iners Aircraft Accident Report

·        NTSB Form 6120.1, Pilot/Operator Aircraft Accident Report - General Aviation Aircraft

·        NTSB Form 6120.2, Aircraft Accident Report

·        NTSB Form 6120.3, Accident File Contents

·        NTSB Form 6120.4, Factual Report - Aviation Accident (Including Supplements A through U, as appropriate)

·        NTSB Form 6120.9, Passenger Statement

·        NTSB Form 6120.11, Statement of Witness

·        NTSB Form 6120.13, Autopsy Authorization


·        NTSB Form 6120.15, Release of Aircraft Wreckage and/or Parts

·        NTSB Form 6120.18, Part Tag

·        NTSB Form 6120.19A, Preliminary Report Aviation Accident

·        NTSB Form 6120.20, Request for Flight Recorder Readout

C.  Job Aids.

·        Electronic telephone pager ("beeper")

·        Office accident investigation kit

·        Sample figures and letters

·        Special emphasis forms as required by GENOTS, Notices, or National Policy

·        Duty book

5.  Initial Notification Phase.

A.  Initial Notification Error! Bookmark not defined. .

Use Job Aids to record the initial accident information. (Figures 168-1 and 168-2)

(1)  If notification is made by an Air Traffic (AT) Facility, verify that the AT facility has initiated:

(a)  An FAA Form 8020-9 (Figure 168-3)

(b)  The appropriate notification procedures

(c)  NTSB notification

(2)  Request from the reporting AT Facility the following:

(a)  Flight progress strips

(b)  ATC tapes

(c)  Radar printouts

(d)  Weather information

(3)  If an accident notification is made by a source other than an AT facility, notify the following:


(a)  The AT Facility, preferably a Flight Service Station and verify that the appropriate notification procedures will be initiated.

(b)  The district office manager or the appropriate office representative, in accordance with district office policies, that an accident has occurred.

(c)  The Regional Communications Center (RCC).

(d)  National Transportation Safety Board (NTSB).

(e)  Other agencies as appropriate (e.g., airports, airway facilities, etc.)

(f)  Contact the responsible AT facility, if applicable, and request that certified true copies of the following be submitted:

(i)  Flight progress strips

(ii)  ATC tapes

(iii)  Radar printouts

(iv)  Weather information

(g)  Complete FAA Form 8020-9 or record the information required to complete FAA Form 8020-9 on Figure 168-1 or 168-2, and provide this information to the nearest AT Facility, preferably a Flight Service Station, and verify that the appropriate notification procedures will be initiated.

B.  WPMS.  Open WPMS file.

C.  Determine FAA involvement in the Investigation.

(1)  If the accident investigation is to be conducted by the NTSB, follow the procedures in para­graph 7, following, as appropriate, until such time as the NTSB Investigator-In-Charge arrives.

(2)  If the accident is delegated to the FAA by the NTSB, organize the accident investigation.

D.  Organize the Delegated Accident Investigation.

(1)  Determine what specialties are required based on the initial accident information submitted (e.g., operations, airworthiness, avionics, ATC, coroner, etc.).


(2)  Request technical support from the FSDO manager or the appropriate office representative according to office policy and procedures.

(3)  Brief all participants on their responsibilities and preliminary accident information.

(4)  Designate an office coordinator at the FSDO (This may be done by the FSDO manager.)

(5)  Contact the nearest local law enforcement agency and/or airport security to provide accident site security until they can be properly relieved.

(6)  Obtain accident investigation kit from the FSDO and proceed to the accident site.

7.  FIELD PHASE.

Upon arrival at the accident site, present FAA identification to person in charge of site security. Inform this person that the FAA now accepts responsibility for the conduct of the investigation.

A.  Preliminary Investigation Error! Bookmark not defined. .

(1)  Record any additional information from the person previously in charge to complete or update NTSB Form 6120.19A.

(2)  Determine if aircraft accident site is safe for investigation procedures.

(a)  If it is determined that the aircraft accident site is not safe for the preliminary investigation, contact the appropriate state, local, or federal authorities for assistance in controlling the hazard.

(b)  If it is determined that the aircraft accident site is safe for the investigation procedures, continue with preliminary investigation.

(3)  Ensure that rescue operations have been initiated.

(a)  If rescue operations have not been initiated, take the necessary steps to begin rescue operations.


(b)  Determine if specialized personnel and/ or equipment is necessary to begin or continue rescue operations.

(4)  Determine the following:

(a)  How many people were on board

(b)  How many were crewmembers

(c)  How many were passengers

(d)  Where the people were sitting

(e)  What restraint systems were in use

(f)  The extent of any survivor's injuries

(5)  Determine the locations of all occupants (i.e., hospital, temporary morgue, etc.).

(6)  If autopsies are required, coordinate delivery and shipment of toxicology kits.

(7)  Determine if any photographic evidence--particularly that taken before rescue operations began- -is or will be available.

(8)  Ensure accident site security has been properly established. If the accident site has not been secured, take the appropriate steps necessary to secure the accident site.

(9)  Ensure that the ELT has been deactivated.

(10)  Ensure that CVR and FDR have been deactivated, if applicable.

(11)  If there were any witnesses, determine where they are and when they can be available for interview.

(12)  Establish investigative teams, as appro­priate, and conduct the on-site briefing of team members.

(a)  Assign responsibilities to each of the participants (e.g., photographic, witness statements, etc.)

(b)  Assign a time and place to meet after the preliminary investigation has been completed.


(c)  Pass out any forms, instructions, or other material necessary for each participant to accomplish their assigned duty.

(13)  Identify victims, if possible.

(14)  Obtain eyewitness and survivor (if on the scene) statements.

(a)  Secure copies of statements already made before arrival or taken by another participant.

(b)  Record names, address, and phone numbers of eyewitnesses, survivors, relatives, etc.

(15)  Determine who the medical personnel working at the accident site are.

(16)  Determine type of accident.

(17)  Conduct an aircraft wreckage investigation after all preliminary items have been completed.

B.  Wreckage Investigation.

(1)  Identify and confirm aircraft make and model and registration and serial numbers.

(2)  Photograph wreckage and any area associ­ated with the accident using a video camera and/or a 35mm camera for all close-ups to obtain an overall view of the site.

(3)  Prepare a wreckage distribution diagram which includes, if appropriate, body distribution.

(4)  Secure aircraft and pilot logbooks, if avail­able.

(5)  Retrieve CVR and FDR, if applicable.

(6)  Record external flight control positions (e.g., rudder, elevators, ailerons, flaps, slats, spoilers, stabilizers, tabs, etc.) Tag parts as necessary.

(7)  Record cockpit flight control indicators.

(8)  Document cockpit instrument readings.

(9)  Document cabin/cockpit area.


(10)  Document structural failures.

(11)  Obtain fuel, oil, and hydraulic fluid samples.

(12)  Tag personal items and ensure their security.

(13)  Determine the cargo, if any, other than passenger luggage.

(14)  Determine the type and how much flammable fluid was on board at impact.

(15)  If a fire was involved, determine how and by whom the fire is being fought or was extinguished.

(16)  Document burn pattern.

(17)  Determine the accident kinematics.

(18)  Determine if laboratory analyses are needed and how specimens will be obtained and transported.

(a)  Medical (CO, Blood Alcohol, Drugs, Lactic Acid, etc.)

(b)  Mechanical (Fatigue, Explosive, Chemical, etc.)

(19)  Determine where mechanical or aeronautical engineering assistance can be obtained.

(20)  Obtain all information gathered by participants during the wreckage investigation.

C.  Conclude Field Phase Investigation.

(1)  Obtain witness statements and survivor statements, if survivors are available. If survivors are not available, arrange interviews pending immediate medical requirements.

(2)  Determine the weather at the time of the accident and make a notation to the weather at time of preliminary investigation. Use eyewitness accounts if there are no weather reporting facilities nearby.

(3)  Use NTSB Form 6120.15 to release the wreckage to the owner or the owner's appropriate representative.


(4)  Use FAA Form 8020-2 to release wreckage when the occurrence is an incident.

(5)  Review witness statements. Re-interview important witnesses or approach additional witnesses as circumstances dictate.

(6)  Obtain preliminary findings of pathologist, coroner, or medical examiner, including crash injury information.

(7)  Obtain preliminary toxicology results by calling the FAA/CAMI laboratory.

(8)  Contact treating physician and obtain injury information of all surviving aircraft occupants, with concurrence of the victims or their relatives. Inquire about their fitness to be interviewed.

(9)  Request copies of the activity logs and investigative reports of the law enforcement agency involved, fire fighting and rescue services, and search organizations.

(10)  Obtain copies of pertinent newspaper photographs and other media recordings, and check for items that may require follow-up.

(11)  Obtain appropriate local maps (city, airport, topographical, aeronautical, etc.) or aerial photographs of the accident site.

(12)  Contact FBO at pilot's last departure point or home base. (Aircraft loading, refueling, mainte­nance, pilot's intent, etc.)

(13)  Contact pilot's relatives, friends, or peers.

(14)  Review NTSB Accident Form 6120.4 (Figure 168-4) and all applicable report supplements to ensure that all locally available data is documented or requested. This applies especially to:

(a)  Pilot training, certification, experience, background, medical condition, etc.

(b)  Aircraft registration, airworthiness, A.D.'s maintenance

(c)  ATC communications, flight tracking radar plots, etc.

(d)  Weather, including local observations at time of accident

(e)  Airport conditions at time of accident

(f)  Tower activities

(g)  Condition of pertinent NAVAIDS, ILS, etc.

(15)  Apprise parties of the field investigation of their prerogative to participate in the teardown or testing of retained parts and in other follow-up activi­ties.

(16)  Confirm obligations made by the parties to forward copies of specified documents, records, and manuals directly to the IIC, including specific product information.

(17)  Obtain information needed to satisfy finan­cial obligations concerning:

(a)  Security guard services of the accident site

(b)  Assistance from hired personnel

(c)  Rental equipment

(d)  Storage and transport of wreckage

(18)  Inform the district office about the status of the investigation; coordinate additional tasks that have to be performed including the related travel; establish the next contact point or time of return to the district office.

(19)  For delegated accidents complete NTSB Form 6120.19A (Figure 168-5) within five working days from the date of the accident or as soon thereafter as possible. Distribute as follows; original to delegating NTSB Field Office and a copy to the National Safety Data Branch, AVN-120.

(20)  For NTSB conducted investigations, obtain a completed copy of NTSB Form 6120.19A From the NTSB Investigator-In-Charge and forward to National Safety Data Branch, AVN-120.

(21)  Request copies of all pertinent notes and exhibits acquired by the NTSB during NTSB conducted investigations.

(22)  Before an FAA participant is permitted to depart the site of an accident investigation, review all information obtained and discussed in each NTSB group.


(23)  Recognize assisting volunteer personnel (e.g., local authorities, Civil Air Patrol, civil groups, State Aeronautics personnel, manufacturers, operators representatives, etc.)

(24)  Return to the district office.

(a)  Notify district office of estimated time of arrival.

(b)  Review all information, witness statements, and reports related to the accident.

(c)  Prepare accident investigation reports.

D.  Prepare Accident Investigation Reports Error! Bookmark not defined. .

(1)  If the accident investigation was conducted by the NTSB, complete such reports as requested by the NTSB group chairman.

(2)  If the accident investigation was delegated to the FAA, complete NTSB Form 6120.4 and any supplements as required. Do not release the report until all FAA deficiencies uncovered in the investiga­tion have been reviewed and comments made by the appropriate manager.

(3)  Prepare a letter of recommendations and distribute in accordance with Order 8020.11.

(4)  Prepare accident investigation report package.


E.  Assemble Accident Investigation Report Package.  Use the procedures outlined in Order 8020.11 for the contents, assembly, and submittal of the accident investigation report package.

F.  Report Distribution.  Distribute aviation accident reports in accordance with Order 8020.11.

G.  Office File.  Place a copy of all aircraft accident investigation related material in the appropriate district office file.

H.  WPMS.  Close WPMS file.

9.  Task Outcomes.

A.  Completed preliminary accident report

B.  Completed factual report of an aviation accident

C.  Letter of recommendations

11.  Future Activities.

A.  Conduct a violation investigation.

B.  Provide information to the Accident Prevention Program Manager

C.  Restock Accident Investigation Kit

D.  Disposal of investigative reports

E.  Testify at a hearing


 


FIGURE 168-1  ACCIDENT/INCIDENT REPORT JOB AID


FIGURE 168-1  ACCIDENT/INCIDENT REPORT JOB AID con'd

FIGURE 168-2  INCIDENT INFORMATION JOB AID

INSPECTOR RECEIVING NOTIFICATION:                                     DATE:                  

ASSIGNED TO:                                                        DATE:                            

PRELIMINARY INFORMATION REPORT Accident/Incident/Violations/Complaint/Other (Circle One)                    

NAME OF CALLER:                                                          PHONE: (   )              

       Address:                                                                    Time:                            

NATURE OF OCCURRENCE                                                                           

DATE OF OCCURRENCE                        TIME                  LOCATION                    

TYPE A/C                                            N#                                                                       

DAMAGE:   (Circle One) Destroyed/Substantial/Minor/None

ELT ACTIVATED:    YES           NO             DEACTIVATED:   YES              NO              

A/C OWNER/OPERATOR                                               PHONE (  )                             

       Address                                                                                           

PILOT                                                                       PHONE (  )                        

   Address                                                                                               

CERT #                             GRADE                           RATINGS                        

BFR DATE              DOB                 MEDICAL DATE                 CLASS                  

TOTAL TIME           TIME IN TYPE          FLT PLAN VFR/IFR/NONE  WX BRIEFING       

PAX #                     FATALITIES              INJURIES               SEAT BELTS            

SHOULDER HARNESS USED                   

 


FIGURE 168-2  INCIDENT INFORMATION JOB AID con'd

TYPE OF FLIGHT: Pleasure/Business/Ag/Ferry/Training/135 OPS/ 121 OPS/133 OPS (Circle)

NOTIFICATION: (NAME/DATE/TIME)

FSS                                                  WP DUTY OFFICER                                               

AME                                                   REGIONAL OFFICE                               

NTSB                                                 WASHINGTON DC                                

OFFICE RECORDS:                                  DATE             INITIALS

WPMS COMPLETED                                                                

NTSB 6120.19 COMPLETED                                                                        

NTSB 6120.1 TO PILOT                                                          

AIRMAN RECORDS                                                               

AIRCRAFT RECORDS                                                            

MEDICAL RECORDS                                                               

RECORDS OF VIOLATIONS/ACCIDENTS                                        

WITNESS STATEMENTS (#)                                                     

PICTURES (FROM)                                                  

COPY TO APPM                                                                   

FAR(s) VIOLATED                                                                                       

WPMS CODE                                                 WPMS #                                  

 


FIGURE 168-2  INCIDENT INFORMATION JOB AID con'd

DESCRIPTION (Use Additional Pages If Necessary):

 


FIGURE 168-3  FAA FORM 8020-9, AIRCRAFT ACCIDENT PRELIMINARY NOTICE


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-4 NTSB FORM 6120.4, FACTUAL AIRCRAFT ACCIDENT REPORT Con'd


FIGURE 168-5  NTSB FORM 6120.19A, PRELIMINARY REPORT OF AVIATION ACCIDENT/INCIDENT

FIGURE 168-5  NTSB FORM 6120.19A, PRELIMINARY REPORT OF AVIATION ACCIDENT/INCIDENT Con'd