October 30, 2017


Introduction by Steve Bentley MD Sofema Aviation Services www.sassofia.com

During 45 plus years of commercial aviation experience I have seen a number of industry incidents and accidents and one of the aspects that makes me proud to be part of the industry is the proactive willingness to engage fully in the aftermath of an event.

Let’s start with the obvious question

Why do we investigate?

To effectively discover the hazards that led to a particular accident or incident and to implement mitigations which will aim to prevent their recurrence in a future accident or incident.

Typically In the course of that investigation, additional hazards which potentially increased the likely exposure to damage and injury (inadequate crashworthy systems, system safeguards, rescue team response, etc.) will be identified

The challenge is to develop an adequate investigative process to analyse and address the root cause and to develop appropriate mitigations which may be proposed and if implemented can potentially make future accidents less costly.

Note 1

Hazards are a normal component of aviation and it is not the hazard itself which is of particular concern rather it is the “potential” risk or exposure associated with the hazard which needs to be considered.

Note 2

It is quite possible that an investigator will discover other hazards during the course of a particular investigation, whilst it may be that the hazards which may have NOTHING to to with the accident.

Whilst such identified “additional” hazards may not belong in the accident report, they should not be ignored.

Typically they should be addressed in a separate hazard report or communicated in a fully documented way to the relevant agency corrected in some other fashion.

ICAO Difference between Accident & Incident

ICAO identifies an accident as an occurrence, where a person is fatally or seriously injured or the aircraft sustains damage or structural failure.
ICAO identifies 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.

EASA Regulation for reporting safety incidents

EASA REGULATION (EU) No 996/2010 Describes EU Obligations related to compliance with ICAO Annex 13.
According to the international standards and recommended practices set out in Annex 13 to the Chicago Convention, the investigation of accidents and serious incidents is to be conducted under the responsibility of the State where the accident or serious incident occurs, or the State of Registry when the location of the accident or serious incident cannot definitely be established as being in the territory of any State. A State may delegate the task of conducting the investigation to another State or request its assistance. Safety investigations in the Union should be conducted in a similar way.

Since November 15, 2014, Regulation (EU) 376/2014 is applicable to aviation professionals, organisations, Member States and the Agency. This regulation brings specific requirements to all aviation stakeholders on the reporting of occurrences and its subsequent processing and analysis.

The New View – Being Proactive

Experience has shown that accidents are often preceded by safety-related incidents and deficiencies revealing the existence of safety hazards. Safety information is therefore an important resource for the detection of potential safety hazards. In addition, whilst the ability to learn from an accident is crucial, purely reactive systems have been found to be of limited use in continuing to bring forward improvements. Reactive systems should therefore be complemented by proactive systems which use other types of safety information to make effective improvements in aviation safety.

Information regarding Aircraft Accident Investigation Process & Procedures course can be obtained by writing to office@sassofia.com or to review details here


accident, Aircraft Incident, EASA REGULATION, Incident Investigations