Occurrence Incident Reporting and Investigation in EU

DIRECTORATE GENERAL FOR INTERNAL POLICIES
POLICY DEPARTMENT B: STRUCTURAL AND COHESION POLICIES
TRANSPORT AND TOURISM
OCCURRENCE REPORTING AND

ACCIDENT/INCIDENT INVESTIGATION
IN EU CIVIL AVIATION
STUDY
This document was requested by the European Parliament's Committee on Transport and
Tourism.
AUTHORS
Mr Suk Rathore
Ms Sue Cox
RESPONSIBLE ADMINISTRATORS
Mr Nils Danklefsen
Mr Piero Soave
Policy Department Structural and Cohesion Policies
European Parliament
B-1047 Brussels
E-mail: [email protected]
EDITORIAL ASSISTANCE
Ms Nora Revesz
LINGUISTIC VERSIONS
Original: EN
Translation: DE, ES, FR, IT, NL, PL
ABOUT THE EDITOR
To contact the Policy Department or to subscribe to its monthly newsletter please write to:
[email protected]
Manuscript completed in September 2010.

Brussels, © European Parliament, 2010.
This document is available on the Internet at:

http://www.europarl.europa.eu/studies
DISCLAIMER
The opinions expressed in this document are the sole responsibility of the author and do
not necessarily represent the official position of the European Parliament.
Reproduction and translation for non-commercial purposes are authorized, provided the
source is acknowledged and the publisher is given prior notice and sent a copy.
DIRECTORATE GENERAL FOR INTERNAL POLICIES
POLICY DEPARTMENT B: STRUCTURAL AND COHESION POLICIES
TRANSPORT AND TOURISM
OCCURRENCE REPORTING AND

ACCIDENT/INCIDENT INVESTIGATION
IN EU CIVIL AVIATION
STUDY
Abstract:
Independent investigation of accidents/incidents and occurrence reporting is

essential in the drive to improve aviation safety. This study will assist the European
Parliament in reviewing current EU policy for greater efficiency in civil aviation
accident investigation. This is being addressed under a proposal for a new regulation
which is an essential element of this study in assessing the existing problems and
shortcomings in the investigation and prevention of accidents and incidents in civil
aviation.
Accident investigation and occurrence reporting in EU aviation are currently

regulated separately under EC law. A concise overview of the current European legal
framework of accident/incident investigation in EU aviation, in the context of
Directive 94/56/EC, has been provided. The legal framework has been contrasted
with its practical implementation within EU aviation. Beyond accident investigation,
the crucial element of occurrence reporting has also been analysed and assessed
against its legal provisions within Directive 2003/42/EC.
IP/B/TRAN/IC/2009-024 September 2010
PE 438.605 EN
Occurrence reporting and accident/incident investigation in EU aviation
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TABLE OF CONTENTS
GLOSSARY OF TERMS AND ACRONYMS 5
EXECUTIVE SUMMARY 9
1. INTRODUCTION TO THE LEGAL FRAMEWORK OF ACCIDENT

INVESTIGATION AND OCCURRENCE REPORTING 13
1.1. International regulation for aircraft accident and incident investigation

and occurrence reporting 14
1.2. European legislation for aircraft accident and incident investigation and
occurrence reporting 18
1.3. Mandatory / Voluntary Reporting systems 26
1.4. Role of EU Institutions and other organisations/bodies 27
1.5. Safety Requirements for Third-Country Aircraft 31
1.6. Summary of the legal framework and reporting systems 32
2. CONTRAST BETWEEN LEGAL FRAMEWORK AND ITS PRACTICAL

APPLICATION IN EU AVIATION 35
2.1. Aims 35
2.2. Methodology 35
2.3. Accident/Incident Investigation 44
2.4. Roles of Actors in the Accident Investigation Process 56
2.5. Occurrence Reporting – Flow and Exchange of Safety Data 66
3. IDENTIFICATION OF PROBLEMS/SHORTCOMINGS AND BEST PRACTICES

OF CURRENT ACCIDENT INVESTIGATION AND OCCURRENCE REPORTING 81
3.1. Introduction 81
3.2. Accident Investigation 81
3.3. Occurrence Reporting 87
3.4. Summary Results of Assessment 89
4. CONCLUSIONS AND RECOMMENDATIONS 95
BIBLIOGRAPHY 103
Annex I A summary comparison between the proposed new regulation and EU

Directive 95/56/EC 107
Annex II Overview of national law within the aviation authorities for selected
Member States 112
Annex III Survey Questionnaire 118
Annex IV Summary of Survey Responses in Key Areas of Accident Investigation

and Occurrence Reporting 145
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Policy Department B: Structural and Cohesion Policies
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GLOSSARY OF TERMS AND ACRONYMS
AAIB Air Accidents Investigation Branch
Accident ‘Accident’. An occurrence 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 it comes to rest at the end of the
flight and the primary propulsion system is shut down, in which:
a) a person is fatally or seriously injured as a result of
- being in the aircraft, or
- direct contact with any part of the aircraft, including parts which
have become detached from the aircraft, or
- direct exposure to jet blast,
except when the injuries are from natural causes, self inflicted or
inflicted by other persons, or when the injuries are to stowaways hiding
outside the areas normally available to the passengers and crew; or
b) 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,
except for engine failure or damage, when the damage is limited to a
single engine, (including its cowlings or accessories), to propellers, wing
tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels,
landing gear doors, windscreens, the aircraft skin (such as small dents
or puncture holes), or for minor damages to main rotor blades, tail rotor
blades, landing gear, and those resulting from hail or bird strike
(including holes in the radome); or
c) the aircraft is missing or is completely inaccessible.
Note I. For statistical uniformity only, an injury resulting in death within
thirty days of the date of the accident is classified as a fatal injury by
ICAO.
Note 2. An aircraft is considered to be missing when the official search
has been terminated and the wreckage has not been located.
New ICAO Annex 13 definition
Accredited A person designated by a State, on the basis of his or her qualifications,

Representative for the purpose of participating in an investigation conducted by another
State. Where the State has established an accident investigation
authority, the designated accredited representative would normally be
from that authority.
AD Airworthiness Directives
ADREP ICAO Accident/Incident Data Reporting System
AIB Accident Investigation Bureau

Note: the acronyms AIB and NSIA (National Safety Investigation
Authorities) refer to the same investigating authorities.
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Annex 13 ICAO Annex 13 ‘International Standards and Recommended Practices for

Aircraft Accident and Incident Investigation’, Ninth Edition, July 2001.
ANSP Air Navigation Service Provider
ATC Air Traffic Control
ATM Air Traffic Management
CAA Civil Aviation Authority
CANSO Civil Air Navigation Services Organisation
CEASIA Council of European Aviation Safety Investigation Authorities
CFIT Controlled Flight into Terrain
Chicago Convention The Chicago Convention is the legal instrument that established the
International Civil Aviation Organisation (ICAO)
CHIRP Confidential Human Factor Incident Reporting System
CIRCA Communication & Information Resource Centre Administrator
Directive Directive 2003/42/EC of the European Parliament and of the Council of

2003/42/EC 13 June 2003 on occurrence reporting in civil aviation
Directive 94/56/EC Council Directive 94/56/EC of 21 November 1994 establishing the

fundamental principles governing the investigation of civil aviation
accidents and incidents
DNV Det Norske Veritas
DINER Data Integration Network for ECCAIRS Repositories
EASA European Aviation Safety Agency
ECAC The European Civil Aviation Conference currently consists of 44 Member

States comprising almost all the European States and has an ambitious
work programme dealing with many facets of civil aviation matters
ECCAIRS European Coordination Centre for Aviation Incident Reporting System.

ECCAIRS comprises of 3 key elements:
1. ECCAIRS Reporting System – the software framework that
enables the collection of accident and incident data
2. ECCAIRS Central Repository – the database implemented using
the ECCAIRS Reporting System
3. ECCAIRS Cooperative Network – consisting of AIBs (Accident
Investigation Bodies) and CAAs (Civil Aviation Authorities) from
all EU Member States (and Switzerland, Norway and Iceland)
ERAA European Regional Airlines Association
ERP Emergency Response Plan
ESARR2 EUROCONTROL Safety Regulatory Requirement for reporting &

assessment of safety occurrences in ATM
ESIMS ESARR Implementation Monitoring and Support Programme – mandated

by Eurocontrol
ESP European Safety Programme
EU European Union
EU Member State Member States of the European Union (27 states)
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Eurocontrol The European Organisation for the Safety of Air Navigation

(EUROCONTROL) whose primary objective is the development of a
seamless, pan-European Air Traffic Management (ATM) system.
Note – not all 27 Member States of the European Union are Member
States of Eurocontrol
EVAIR Eurocontrol Voluntary ATM Incident Reporting
FAA Federal Aviation Administration, USA
ICAO International Civil Aviation Organisation
IA Impact Assessment Study ‘SEC (2009) 1478’
Incident An occurrence, other than an accident, associated with the operation of

an aircraft which affects or could affect the safety of operation.
Note: - The type of incidents which are of main interest to the
International Civil Aviation Organisation for accident prevention studies
are listed in Attachment C (Amendment 13 of ICAO Annex 13 adopted
22 February 2010)
IIC The designated ‘Investigator-In-Charge’ (IIC) for the state conducting

the investigation is responsible for the overall supervision of the
investigation. (Annex 13 to the Convention on International Civil
Aviation, ICAO, Ninth Edition, July 2001)
Just Culture ‘A culture in which front line operators or others are not punished for
actions, omissions or decisions taken by them that are commensurate
with their experience and training, but where gross negligence, wilful
violations and destructive acts are not tolerated’
(proposed definition of ‘just culture’, presented at ICAO, Sept 2007)
MS Member States of the European Union (27 states)
MoU Memorandum of Understanding
NSIA National Safety Investigation Authority, term used in the proposed

Regulation – COM(2009)611.
NTSB National Transportation Safety Bureau, USA
Occurrence ‘Occurrence’ means an operational interruption, defect, fault or other

irregular circumstance that has or may have influenced flight safety and
that has not resulted in an accident or serious incident
Directive 2003/42/EC (Article 2)
Note: ICAO Annex 13 and Directive 94/56/EC do not make provision for
this definition and instead uses separate definitions for ‘incident’ (and
‘accident’ and ‘serious incident’)
POA Holder Production Organisation Approval Holder, typically a manufacturer of

aircraft parts
POC Point of Contact
Proposed Regulation Proposed new Regulation COM(2009)611 on the ‘investigation and

- COM (2009) 611 prevention of accidents and incidents in civil aviation’
(Impact Assessment Study SEC(2009)1478 and Co-decision Procedure
2009/0170/COD)
The aim of the proposed Regulation is to improve aviation safety by
ensuring a high level of efficiency and quality of European civil aviation
safety investigations, with the sole objective of preventing future
accidents and incidents without apportioning blame or liability.
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REC Recueil d’Evénements Confidentiel
SAFA Safety Assessment of Foreign Aircraft

SARPs International Standards and Recommended Practices
Incorporated within ICAO Annexes – Chicago Convention
Serious Incident An incident involving circumstances indicating that there was a high
probability of an accident 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 it comes to rest at the end of the
flight and the primary propulsion system is shut down.
State of Design State holding the jurisdiction over the organisation responsible for the
type design. (Annex 13 to the Convention on International Civil Aviation,
ICAO, Ninth Edition, July 2001)
State of Manufacture State having jurisdiction over the organisation responsible for the final
assembly of the aircraft. (Annex 13 to the Convention on International
Civil Aviation, ICAO, Ninth Edition, July 2001)
State of Occurrence State in the territory of which an accident or incident occurs. (Annex 13
to the Convention on International Civil Aviation, ICAO, Ninth Edition,
July 2001)
State of Operator Operator’s principal location of business or permanent place of

residence. (Annex 13 to the Convention on International Civil Aviation,
ICAO, Ninth Edition, July 2001)
State of Registry State holding the registration of the aircraft under investigation. (Annex
13 to the Convention on International Civil Aviation, ICAO, Ninth Edition,
July 2001)
SIB Safety Information Bulletins
SRC Safety Regulation Commission
TC holder Type Certificate Holder, typically the aircraft manufacturer
USOAP Universal Safety Oversight Audit Programme – developed by ICAO
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EXECUTIVE SUMMARY
Background
The European Parliament requires background information related to the current system of
accident/incident investigation and occurrence reporting in EU (European Union) civil
aviation. The European Parliament has contracted Det Norske Veritas (DNV) to conduct an
independent review of this area.
Objectives
The objective of this study is to provide members of the Committee on Transport and
Tourism with useful background information related to the current system of
accident/incident investigations and occurrence reporting and analysis, its potential
problems and shortcomings. The strengths and weaknesses of the existing systems are
identified and best practices have been highlighted. The study draws conclusions and
provides recommendations for future EU policy options.
In conducting this study, DNV has given particular attention to the current and potential
future role of the European Aviation Safety Agency (EASA).
Also, in completing the scope of the study, specific references and considerations have
been made to the proposed new regulation on the ‘investigation and prevention of
accidents and incidents in civil aviation’.
Methodology and Key Results
A comprehensive and detailed survey questionnaire has been used to identify key problems
and shortcomings as well as areas of best practice in this field. The survey has been
supplemented with relevant discussions and structured interviews with key stakeholders.
The study has identified Directive 94/56/EC as being weak in several key areas of accident
investigation. Significantly, the Directive provides inadequate legal protection to individuals
reporting accidents and incidents and in some Member States this could be a reason for the
current problem of under-reporting of incidents.
The Directive is old and no longer meets the demands and requirements of the European
Community in safeguarding civil aviation safety. A principal concern is the role of EASA
within accident investigations, for which there is currently no provision in this Directive.
EASA is responsible for airworthiness and aircraft certification on behalf of the Member
States. Its involvement in technical investigations is therefore seen as a conflict of interest
and potentially jeopardises the independence of the investigation. Relationships between
EASA and many investigating authorities are currently strained. There is a need for a clear
definition of EASA’s role within accident investigations and occurrence reporting and, in
particular, clarification on its relationship with the investigating authorities is essential.
Without these provisions within a revised legal framework the exchange of important safety
information and appropriate safety action is seriously hampered. The European Commission
has recently carried out a detailed assessment of Directive 94/56/EC and has proposed a
new regulation on accident/incident investigations (COM(2009)0611).
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Tensions exist between investigating authorities and the judicial authorities. In some
Member States, judicial authorities have significant powers of access to evidence and
memorandums of understanding (MoUs) are being effectively used to overcome difficulties
during the investigation process. However, these formal agreements must be supported by
proper measures to improve working relationships and effective exchange of safety
information between authorities.
Improvements in the current legal framework are necessary for clearer provisions related
to the establishment of a just culture within Member States. There is also a need for a
commonly accepted definition of ‘just culture’, covering both the accident investigation and
occurrence reporting instruments.
Stronger measures are needed for protecting the identity of victims and their families in the
immediate aftermath of an air crash. These important rights need to be firmly provided for
within the legal system. Also the availability of a reliable list of persons on board the
aircraft in a timely manner is an essential requirement. Currently there is no consistent
approach across Member States for dealing with such important areas of crisis
management. Some level of emergency response planning is in place within most Member
States but it is not clear how structured these plans are and whether or not they
adequately follow ICAO guidelines for crisis management.
Inconsistencies in the key definitions and apparent discrepancies in terminology at

European level have been identified as a possible problem. This may also be contributing to
the problem of under-reporting of incidents in some Member States.
In the separate assessment of occurrence reporting, Directive 2003/42/EC is largely

considered by most Member States as fit for purpose, although several have yet fully to
implement its provisions within their national law. The involvement of judicial authorities in
occurrence reporting, protection of individuals making reports and tighter definition of just
culture have been identified as areas needing improvement.
More significant is that there is no reference to EASA within Directive 2003/42/EC.

Adequate provision is needed for the role of EASA in occurrence reporting so that aviation
safety authorities are clear on their obligations for sharing important safety data with EASA
through the European central repository.
The role of Eurocontrol within ATM reporting has been reviewed. Occurrence reporting
systems currently managed by Eurocontrol are relatively well developed and working
effectively within the European ATM Community.
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INTRODUCTION TO THE STUDY
Background
Civil aviation in the EU is one of the safest modes of transport. However, with air traffic
volumes in Europe expected to double by 2030 and with increasing complexity in aircraft
systems and air traffic infrastructure, there are concerns that accident rates may increase.
Beyond the challenges within EU aviation, the Community is exposed to increased risks
when operating in regions with underdeveloped infrastructure or deficient regulatory
frameworks.
Independent investigation of accidents and effective occurrence reporting practices are

essential in the drive to improve aviation safety.
The obligation to investigate accidents is enshrined in the international legal framework

within the ICAO Chicago Convention 1944 (Annex 13) to which all EU Member States are
parties. This details standards and recommended practices for accident investigation as
well as occurrence reporting. These obligations are discharged into the current EU
regulatory framework directives.
The report focuses on two main directives which the European Commission is currently
planning to revise. The European legal framework is currently regulated under the
provisions laid down within Directive 94/56/EC on Accident/Incident Investigation and
Directive 2003/42/EC on Occurrence Reporting. Directive 94/56/EC places an obligation on
Member States to ensure every accident or serious incident is subject to an investigation by
an independent body. Directive 2003/42/EC requires Member States to report occurrences
and makes provisions to ensure aviation authorities exchange and disseminate safety
information with the purpose of supporting the identification of safety deficiencies and
learning from important safety lessons.
Accident investigation and occurrence reporting in EU aviation are currently regulated

separately under these Directives, respectively. Accordingly, the report has conducted
separate detailed assessments of accident/incident investigation and occurrence reporting
in current daily practices within EU aviation.
In 2009, the European Commission conducted preliminary consultations with relevant

stakeholders, including the European Aviation Safety Agency (EASA) and Member State
authorities, to analyse different policy options for better efficiency in civil aviation. As a
result, the European Commission has proposed a new regulation (COM(2009)0611) on
accident/incident investigation with the aim of improving aviation safety by ensuring a high
level of efficiency and quality of European civil aviation safety investigations. The study
describes and analyses the key problem definitions which support the potential reform of
Directive 94/56/EC and identifies key policy objectives of the new proposal.
Objectives
The objective of this study is to provide members of the Committee on Transport and
Tourism with useful background information related to the current system of
accident/incident reporting and analysis, its potential problems and shortcomings. The
strengths and weaknesses of the existing systems are identified and best practices have
been highlighted. The study draws conclusions and provides recommendations for future EU
policy options.
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In conducting this study, DNV has given particular attention to the current and potential
future role of the European Aviation Safety Agency (EASA).
Scope and Structure of the Study
The study scope is in four parts, outlined below:
Part 1: Concise overview of the legal framework of accident investigation and occurrence
reporting.
In particular, the study aims to answer the following questions:
 How must information related to occurrences/incidents be reported, collected,

stored, and disseminated for further analysis and for air safety improvements,
according to the current legal framework (at EU level and also as regards third
countries)? What are the information flows between the relevant actors?
 Is EASA legally entitled to participate in accident/incident investigations and if so, to
what extent?
 Which occurrences have to be reported to EASA?
 What are the reporting obligations of the Member States and of the other actors
(state of occurrence, state of registry, TC holder, POA Holder, etc.)?
Part 2: Review of the legal framework against the practical application:
 How does accident/incident investigation and occurrence reporting work in practice

at EU level?
 How is safety incident data currently exchanged between national and EU
authorities, transport operators, industry and regulators?
 How are information flows designed, organised and ensured between the relevant
actors? To what extent are the flows, the processing, and the storage of information
standardised?
 Which occurrences and which incidents are reported and which data are shared
between which actors?
 Are there any differences between Member States with regard to occurrence
reporting?
 Describe ‘Just Culture’ in occurrence reporting.
 How is EASA involved in accident/incident investigation in daily practice?
 In what ways is EASA participating in the current occurrence reporting system?
 What role does Eurocontrol play?
Part 3: Identifying potential problems and shortcomings, as well as best practices, of the
current accident investigation and occurrence reporting system
In particular, the role of the European Aviation Safety Agency (EASA) and Eurocontrol with
regard to accident investigation and occurrence reporting is considered. The strengths and
weaknesses of the current system are described.
Part 4: Conclusions and Recommendations

These are drawn from the detailed assessment in Part 3 and address the key question of:
‘How can EU policy contribute to improving the current accident/incident investigation and
occurrence reporting system?’
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1. INTRODUCTION TO THE LEGAL FRAMEWORK OF

ACCIDENT INVESTIGATION AND OCCURRENCE
REPORTING
The safety investigation of accidents and incidents
has the sole aim of promoting aviation safety and
preventing future accidents.
Accident/incident investigation and occurrence

reporting in EU aviation is currently regulated
separately under EC law. The legal framework for
occurrence reporting and accident/incident
investigation at European level is essentially based
on the basic principles within Annex 13 to the
International Civil Aviation Organisation (ICAO)
Convention of 1944 (Chicago Convention).
European aviation safety regulations based on the

provisions of the ICAO standards are transposed
into the specific national legal systems of the
Member States.
Figure 1: Member States of the
European Union
The first part of the study provides a concise overview of the existing legal framework
regarding accident investigation and occurrence reporting and covers the following:
 The international regulatory framework in accordance with ICAO Annex 13 to the

Chicago Convention. Specifically, the legal obligations of the Member States and the
roles and responsibilities of all the relevant contracting states involved in the
investigation process;
 At European level, an overview of the existing EU Directives and regulations.

Principally, this is covered by two EU instruments:
 Directive 94/56/EC establishing the fundamental principles governing the
investigation of civil aviation accidents and incidents, and
 Directive 2003/42/EC on Occurrence reporting in civil aviation.
 The legal framework within the European Aviation Safety Agency (EASA) and its
main tasks, relevant to its role in accident and incident investigation, and its role
and participation in supporting the Member States in meeting their commitments to
the Chicago Convention and the relevant EU instruments.
 The proposed new regulation COM(2009)611 on the ‘investigation and prevention of

accidents and incidents in civil aviation’ and the areas which it is intended to
address. Related documents are SEC(2009)1478 (impact assessment study) and
2009/0170/COD (co-decision procedure).
 With regards to Air Traffic Management (ATM) safety, Eurocontrol’s regulatory

requirements for the monitoring and reporting for Member States operating within
European airspace.
 Regulatory safety requirements of third-country aircraft.
 An overview of the national legislation within selected Member States.
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1.1. International regulation for aircraft accident and incident

investigation and occurrence reporting
1.1.1. ICAO Annex 13 – Aircraft Accident and Incident Investigation
Air safety investigations of accidents and serious incidents are internationally regulated
through ICAO Annex 13 to the Chicago Convention on Civil Aviation. ICAO sets the ground
rules for Member States and places a legal obligation on Member States to conduct safety
investigations, with the sole purpose of improving safety and not apportioning blame or
liability. The rules defined by ICAO Annex 13 provide the international standards and
recommended practices for aircraft accident and incident investigation.
ICAO Annex 13 requires Member States to establish a mandatory accident and incident
reporting system to facilitate the collection and dissemination of safety information which
may be useful in identifying safety deficiencies and prevent future accidents and incidents.
Article 38 of the Chicago Convention imposes an obligation according to which Member

States are required to notify ICAO of any differences between their national regulations and
practices and the international standards set out in Annex 13 to the Convention. In
addition, Member States are obliged to keep ICAO informed of any differences that may
occur subsequently.
ICAO Annex 13 provides the obligatory information applicable to the relevant actors
involved in the investigation of accidents and incidents. The principal actors likely to be
involved in the technical investigation process are: State of Occurrence; State of Operator;
State of Registry; State of Design and State of Manufacture (defined in Table 1 below).
Table 1: Principal Actors involved in Investigations of Accidents/Incidents
Actor Definition (ICAO Annex 13)

State of Occurrence The territory in which an accident or incident occurs.
Investigator-In-Charge Appointed person within the State conducting the investigation,
responsible for the overall supervision of investigation.
State of Operator Operator’s principal location of business or permanent place of
residence.
State of Registry State holding the registration of the aircraft under investigation.
State of Design State having jurisdiction over the organisation responsible for the
type design.
State of Manufacture State having jurisdiction over the organisation responsible for the
final assembly of the aircraft.
The main responsibility for ‘instituting’, meaning to begin or commence the investigation,
rests with the ‘State of Occurrence’, in other words the territory of which an accident or
incident occurs. However, the regulatory system provides powers to delegate, by mutual
consent, the whole investigation, or parts of it, to another state.
The designated ‘Investigator-In-Charge’ (IIC) for the state conducting the investigation is
responsible for the overall supervision of the investigation.
If a serious incident or accident occurs in a non-contracting state, then the State of

Registry may conduct the investigation with the cooperation, if possible, of the State of
Occurrence.
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Figure 2: Accident Investigation Team with main actors involved
TC
State of Design
Holder
(Accredited Representative)
State of Occurrence
Aircraft
State of Registry Operator
(National Safety
Investigation Authority)
Aircraft
State of Manufacturer Final
Appointed ‘Investigator In Charge’ Participation
Assembly
& in (Accredited Representative)
Technical Team Investigation
Airline
Process State of Operator
Technical
Advisors
Investigation Team
The other states, shown on the right in Figure 2, may participate in the investigation by
appointing their accredited representatives, possibly accompanied by technical advisers.
There is a legal requirement for the State of Occurrence to take all reasonable measures to
protect the evidence and to maintain safe custody of the aircraft and its contents for such a
period as is necessary for the purposes of an investigation. It must also ensure the safe
custody of the aircraft against further damage, access by unauthorised persons and general
deterioration. The IIC, in accordance with ICAO Annex 13, shall have unhindered access to
and control of the wreckage site and relevant material.
States with a particular interest in an accident by virtue of fatalities or serious injuries to

their citizens shall have specific rights and entitlements for participation in the
investigation 1 .
If, after the investigation has been closed, new and significant evidence becomes available,
the state which conducted the investigation shall re-open the investigation. However, if the
state which conducted the investigation did not ‘institute’ it, that state shall first obtain
consent of the state which instituted the investigation.
The Standards and Recommended Practices of Annex 13 for aircraft accident and incident
investigation were initially developed for cases in which the State of Registry and State of
Operator are the same. In recent years international aircraft leasing and interchanging
arrangements have been developed whereby the State of Operator is not the same as the
State of Registry. Attachment A of ICAO Annex 13 specifically covers the rights and
obligations of the State of Operator in respect of accidents and incidents involving leased,
chartered or interchanged aircraft.
1
ICAO Annex 13 Article 5.27 sets out the specific rights and entitlements for an expert appointed for the state
interested in an accident by virtue of fatalities or serious injury to it citizens. The experts shall be entitled to a)
visit the scene of the accident, b) have access to relevant factual information, c) participate in the identification
of the victims, d) assist in questioning surviving passengers who are citizens of the expert’s state, and e)
receive a copy of the Final Report.
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Figure 3: Phases of a standard aircraft accident investigation
Investigation Process
Gathering of Data Publication
Conduct of Final Report
• Further studies/examinations
crash-site (incl. Flight Data Recorder read-outs)
examination • Wreckage re-construction • Determine probable cause
of wreckage • Autopsies of accident
• Simulations • Safety recommendations
• Overview of event
• Further examinations if necessary
• Analysis and verification of alternative scenarios
Phase 1 Phase 2 Phase 3
Figure 3 illustrates the phases of a typical or standard aircraft accident / incident

investigation. Although this may vary from state to state, the investigation process usually
follows a three-phase structure, as shown.
Prior to the conclusion of the investigation in Phase 3 and as the investigation unfolds,
briefings and updates may follow and an interim report with immediate safety
recommendations may also be published.
1.1.2. ICAO Annex 13 – Occurrence Reporting
In ICAO, the term ‘occurrence’ is used to define the meaning of ‘accident’, ‘serious incident’
and ‘incident’ separately (see Glossary).
ICAO Annex 13 sets out the requirements and guidance material for occurrence reporting.
Specifically, this is covered under chapters 7 and 8 of the Annex, under ADREP
(Accident/Incident Data Reporting – section 1.3.1) and Accident Prevention Measures,
respectively.
Reporting Requirements
Provisions have been made for the state conducting the investigation on the reporting
obligations of accidents and incidents. These are addressed separately within ICAO under
requirements for a preliminary report and an accident/incident data report.
For international occurrences (see Section 2.4.1), the State of Occurrence has a
responsibility to provide notification of an accident or serious incident within the shortest
possible time to the State of Registry, the State of the Operator, the State of Design, the
State of Manufacture and ICAO (where the aircraft involved in the occurrence has a
maximum mass of over 2 250kg). These states are then obliged to acknowledge receipt of
the notification.
For accidents to aircraft over 2 250kg, the state conducting the investigation is required to
send the preliminary and accident data reports to ICAO as soon as is practicable after the
investigation. In addition, the state in charge of the investigation must submit to ICAO an
Incident Data Report where an investigation is conducted into incidents involving aircraft
over 5 700kg.
ICAO recommends that the state conducting the investigation should also send to other
states, upon request, pertinent information additional to that made available in the ADREP
report.
16
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Guidance Material
ICAO has provided guidance for states on preparing the preliminary and ADREP reports
within the ICAO Manual of Aircraft Accident and Incident Investigation, Doc 9756 2 .
Collection, Analysis and Exchange of Information
Specific measures to promote accident prevention are set out in ICAO Annex 13 (chapter
8). These facilitate the collection and analysis of accident/incident data and exchange of
safety information.
States are required to establish a mandatory incident reporting system to facilitate

information relating to safety deficiencies. In addition, ICAO recommends that a voluntary
incident reporting system be established by states to collect any information which may not
be captured by the mandatory system.
ICAO also recommends that states have in place an accident/incident database in

standardised formats to facilitate data exchange. The information contained within the
accident/incident reports should then be analysed by the state to determine appropriate
preventative action. Safety information sharing networks are encouraged within states to
promote accident prevention measures through identification of safety deficiencies.
1.1.3. Adoption of Amendment to Annex 13
The mechanism for the adoption of Amendment 3 to Annex 13 is summarised below:
 Amendments to ICAO Annex 13 are adopted at a meeting of the Conference of

Government Parties of the Chicago Convention. The content of the proposed
Amendment is communicated to the Parties at least six months in advance of the
meeting.
 Acceptance of the proposed Amendment is reached by overall consensus by the

parties in attendance at the Conference meeting. However, if there is dissent and an
agreement is not reached, then the Amendment is adopted by a three-quarters
majority vote of the parties.
 Ratification and acceptance of amendments is notified by the Depository 4 in writing

and will be circulated to all parties for their acceptance.
 ‘Instruments of acceptance’ of the Amendment are then collated by the Depository.
 The Amendment adopted in accordance with the above mechanism will then enter
into force for those parties having accepted it on the 19th day after the date of
receipt by the Depository.
2
Manual of Aircraft Accident and Incident Investigation (chapter IV) provides guidance on notification of
accidents and incidents. Appendix 1 also provides examples of notifications of occurrences.
3
The ongoing procedure within ICAO for Amendment 12 to Annex 13 to the Chicago Convention.
4
‘Depository’ of the Convention is the ‘Secretary-General of the United Nations’.
17
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1.2. European legislation for aircraft accident and incident

investigation and occurrence reporting
1.2.1. Directives and Regulations
Currently, at EU level, accident and incident investigation and occurrence reporting are
regulated separately, through two main Directives (see Glossary for definitions):
1. Council Directive 94/56/EC on accident/incident investigation

2. Council and Parliament Directive 2003/42/EC on occurrence reporting
Member States are legally bound by the aims of these Directives, but their implementation
is delegated to the national civil aviation authority within each Member State. There can be
some differences between national regulations whilst still achieving the aims of the
Directives. An overview of these Directives is given below in 1.2.2 and 1.2.4, respectively.
In October 2009, the European Commission put forward new rules on the investigation and
prevention of accidents and incidents in civil aviation by presenting the proposal
COM(2009)611 for a new regulation replacing Directive 94/56/EC, which is 15 years old.
This future regulation will provide for the support for voluntary cooperation, coupled with a
number of important principles enshrined in a legally binding framework 5 , to more
effectively meet the requirements within the EU and coordinate the practice of the Member
States.
Relevant elements of the COM(2009)611 proposal are detailed in Section 1.2.3.
1.2.2. EU Directive 94/56/EC on accident/incident investigation
Council Directive 94/56/EC mainly reflects the rules of ICAO Annex 13. There is a legal
obligation, as laid down in Directive 94/56/EC, for all Member States to investigate every
accident and serious incident within their national law. A list of examples of serious
incidents is included in the Annex of this Directive.
In addition, other incidents should also be investigated by Member States, where it is

deemed by the investigating body that this will contribute positively to safety improvement
(Article 4.1).
The investigating body of the respective Member State is responsible for determining the
extent of the investigation and the procedure it decides to follow, providing this is in
accordance with the principles and objectives of this Directive. In addition, this should also
take into account the expectations in safety improvements to prevent future accidents and
incidents (Article 4.2).
The legal status of the investigation must be defined within the Member State’s internal
legislative system, so that an independent investigation can be conducted in the most
efficient manner and within the shortest time (Article 5.1). In accordance with the legal
system of the respective Member State, the investigation authority, shall be authorised to
have appropriate and adequate access to the accident/serious incident site, its contents,
relevant equipment and the results of examinations of victims (Article 5.2).
5
EP OEIL COD/2009/0170 - Civil aviation safety: investigation and prevention of accidents and incidents (repeal.
Directive 94/56/EC), EP position, 1st reading T7-0321/2010.
18
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The Directive sets out the following fundamental principles governing the investigation of
civil aviation accidents and incidents:
 The technical investigation shall, in accordance with ICAO Annex 13, be conducted
under the responsibility of the state in which the accident occurred;
 If the investigation of a serious incident is not conducted by the State of
Occurrence, it should be carried out by the State of Registry;
 Investigations of accidents and serious incidents should be conducted in a similar
way;
 The scope of investigations should reflect the benefits that can be expected for the
purpose of improving air safety;
 Investigations are to be carried out in the shortest possible time and accomplish the
necessary activities without hindrance;
 Member States must ensure that those responsible for carrying out the technical
enquires related to the investigation are able to do in the most suitable conditions
possible;
 Investigation of accidents/incidents should be carried out by an independent body
to avoid any conflict of interest;
 The investigating body should be suitably equipped and if necessary should request
assistance from other accident experts;
 Member States must be able to delegate the investigation task to another Member
State;
 The findings of the investigation must be made public as soon as possible if this is
considered likely to assist accident prevention in the future;
 Member States should consider the nature of the incidents when circulating the
findings of the respective investigations;
 Member States should take into account any safety recommendations resulting
from the investigation;
 The sole aim of the investigation is to prevent future accidents and incidents by
learning lessons to improve safety, without apportioning blame or liability.
The following table summarises the mandatory requirements with respect to the
investigating body, as outlined in Article 6 of this Directive:
Table 2: EU Directive 94/56/EC - Mandatory Requirements
Item Council Directive 94/56/EC – Investigating Body

1. Each Member State is responsible for ensuring that safety investigations are
performed and supervised by a permanent civil aviation body which must be
independent from responsibilities for airworthiness, flight operations, certification,
licensing, Air Traffic Control (ATC), airport operations or any area which may have
a conflict of interest with the technical investigation.
2. The investigating body’s activities will include gathering and analysing safety data,
as long as these activities do not impact upon the body’s independent stance and
there is no involvement in associated regulatory, administrative or standards
matters.
3. The investigating body must be provided with the necessary means and resources
to carry out its investigation, independently of the national aviation authorities.
4. The investigating body may, if necessary, call for the assistance of other bodies
from other Member States (if possible, free of charge) for:
a) installations, facilities and equipment for the technical investigation of wreckage,
aircraft and avionics equipment and the storage/evaluation of accident data.
b) support from accident investigation experts following a major accident.
5. A Member State may delegate the task of conducting the accident/incident
investigation to another Member State.
19
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1.2.3. Proposed new Regulation COM(2009)611 on the ‘investigation and

prevention of accidents and incidents in civil aviation’
Aims of the proposal
The overall aim of this new regulation, COM(2009)611 6 on accident/incident investigation,

is to improve aviation safety by ensuring a high level of efficiency and quality of European
civil aviation safety investigations (Article 1).
The proposal aims to strengthen the current area of voluntary cooperation under the
current legal framework, in terms of the protection of confidential safety data, rights and
obligations of the National Safety Investigation Authorities (NSIAs), EASA’s involvement in
accident investigation and setting requirements for safety recommendations.
Currently, the level of coordination between EASA and the NSIAs varies widely across the
Member States. Some well-established NSIAs have regular contact with EASA, while other
smaller countries with fewer resources currently have little or no communication with EASA.
To ensure that the flow of safety information is not hampered, it is important to clarify the
mutual rights and obligations of EASA and the investigating authorities.
The new proposal aims to improve the current system by attaching legal obligations to
complement the existing informal cooperation of the NSIAs.
Reasons for a new proposal
The proposal states that this new regulation is the result of detailed consultation with
stakeholders and Member States and analysis of the current regulatory framework for
dealing with accident investigation. It also states that whilst there are shortcomings in both
aviation accident investigation and occurrence reporting in the EU, there has been a
general consensus that the focus at this stage should be on improving the efficiency of the
regulatory framework for accident investigation.
There are several reasons, identified in the proposal, why a reform of Directive 94/56/EC is
necessary:
 The current Directive 94/56/EC, adopted in 1994, is considered out of date and no
longer meets the requirements of the Community and its Member States.
 The air transport sector is much more complex now and this necessitates a lot more
divergence in terms of the capacity for aviation investigations in Member States. The
current Directive 94/56/EC on accident investigation no longer provides this.
 Since the adoption of Directive 94/56/EC, the establishment of the European

Aviation Safety Agency (EASA) in 2002 has formed a vital component of the
European aviation safety architecture. EASA supports the European Commission in
implementing a common set of safety standards and rules as well as providing a key
role in supporting Member States with technical advice, inspection, training and the
handling of third-party aircraft.
6
Commission proposal with Impact Assessment Study SEC(2009)1478 and future new regulation via ordinary
legislative procedure 2009/0170/COD, EP position, 1st reading T7-0321/2010.
20
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Related Policy Objectives
The important policy objectives for this proposed regulation are to:
1. Promote voluntary cooperation between the Member States;
2. Ensure cooperation between National Safety Investigation Authorities (NSIA) and
EASA;
3. Reduce tensions between safety and judiciary investigation;
4. Improve the assistance provided to the victims of an aircraft crash and their
families.
Formal recognition of a European ‘Network’
The proposal builds upon the existing informal system in place within national investigation
authorities for voluntary cooperation.
This informal cooperation will become more structured through the formal recognition of
the ‘European network of civil aviation safety investigation authorities’, simply referred to
as the ‘Network’ (Article 7). The goal of the Network will be to promote better cooperation
between the NSIAs, the European Commission and EASA. This will contribute to increased
uniformity and ensure that legislation for civil aviation accident investigation is being
enforced and implemented fully. The Network will operate in an advisory and coordinating
role.
The Network is the basic and favoured policy option of the European Commission. This
policy option relies on the promotion of voluntary cooperation, the objectives of which
would be enshrined in a legally binding framework.
The Network, which has no legal personality under EU law, can be viewed as a body
pursuing an aim of general European interest (Article 8.3), within the meaning of
Regulation (EC) 1605/2002 7 , provided with advisory and coordination tasks within the
framework of a clearly defined mandate.
Role of EASA
Under the existing regulatory framework for accident investigation, there are no legal
obligations for EASA to participate in accident investigations and the agency’s role within
the accident investigation community is unclear.
EASA is, however, in accordance with Article 20 of Regulation (EC) 216/2008, required to
carry out on behalf of Member States the tasks of the State of Design when related to
design approval. Article 4(1)(a) and (b) of Regulation (EC) 216/2008 states that these
tasks must be in relation to aircraft designed or manufactured by an organisation for which
EASA, or a Member State in which it is registered, ensures safety oversight.
The new proposal specifically provides clarification on EASA’s role in safety investigations
and makes provisions for a legal obligation on EASA to contribute in safety investigations
(Article 9). However, the relationship between EASA and NSIAs has to be clearly defined in
the new regulation, since a specific problem identified in the Commission’s impact
assessment was the ‘unclear role of the Community in safety investigations’.
Under the proposed regulation, the extent to which EASA is able to participate will be
limited to the scope of its competency, as stated in ICAO Annex 8 on Airworthiness of
Aircraft.
7
Regulation (EC) No. 1605/2002 Article 108(1)(b) which would allow the Community to support its activities
with an annual grant.
21
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In particular, EASA’s legal entitlement will be to:

 have access to safety information from the safety investigation authority (Article
9.1(a));
 participate as an expert in safety investigations carried out in a third country 8
(Article 9.1(b));
 have particular rights to participate in all aspects of investigation under the control
of the investigator-in-charge (Article 9.2);
 support and provide information, experts and equipment, as requested by the safety
investigation authority in charge of the investigation (Article 9.3);
 gain the right to participate in the exchange and analysis of information stored in
the central repository of occurrences (Article 15.3).
A summary comparison between the proposed new regulation and EU Directive 94/56/EC is
provided in Annex I.
Specific objectives to address problem areas identified
Table 3 below highlights the problem definition areas and the key benefits of the proposed
regulation as identified in the Commission impact assessment - SEC (2009) 1478’. These
have been the result of an independent external impact assessment (IA) through
consultations with relevant stakeholders, aviation authorities in Member States and the
general public.
Table 3: Key Problem Definition Areas addressed by the Proposed Regulation
Key Problem Definition Areas

Proposed Regulation
(under discussion)
Investigating capacity is not Promote effective cooperation between safety investigation authorities between Member
uniform across EU member States to better coordinate the use of shared resources. The formal recognition of the
states ‘European Network of civil aviation safety investigation authorities’ (the ‘Network’) will
achieve greater uniformity and help facilitate the effective use of resources between
Member States. Training and qualification requirements for investigators shall be
harmonised across Member States.
Better protection of the rights To improve management of passenger manifests for the identification of persons on-
of air crash victims and their board the aircraft under investigation and of their families. Appropriate assistance will
families be provided to the victims of the air accident and to their families.
Tensions between safety The proposal enforces the coordination of inquiries between the national investigation
investigations and other authority and the judicial authorities and specifically states the entitlement rights of the
procedures safety investigation authority.
Lack of clarity and concerns Clarify EASA’s representation and participation in safety investigations with aviation
on EASA’ s participation in authorities, without compromising independence of safty investigations and within the
safety investigations scope of its competence
Weaknesses in the Provide a consistent approach amongst Member States, towards issuing, processing,
implementation of safety implementation and the monitoring of safety recommendations for air safety
recommendations improvements. The national investigation authority shall record all safety
recommendations in a central depositry database, including those from third countries.
Bring up to date the key provisions of the existing Directive 94/56/EC to take into
account ongoing ICAO Annex 13 revisions.
Strengthen the protection of evidence and sensitive safety information in relation to
accident investigations, in accordance with Annex 13.
Strengthen the protection of occurrence reporting so that they are only used in safety-
related proceedings.
To build on the existing Directive 94/56/EC to include in the new regulation, the
anonymity of persons involved in air accidents as well as incidents.
8
Refer to Article 9.1(b) of Proposal COM(2009)611
22
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1.2.4. EU Directive 2003/42/EC on occurrence reporting in civil aviation
EU Directive 2003/42/EC, enforced in 2003, sets out to improve aviation safety by ensuring
that safety-critical information is reported, collected, stored, protected and disseminated in
order to facilitate its effective analysis and follow-up, with a view to preventing future
accidents and incidents. This Directive covers occurrences that could, if not corrected,
endanger an aircraft, its occupants or any other person related to the occurrence. An
occurrence in the context of this Directive means an operational interruption, defect, fault
or other irregular circumstance that actually has or potentially may have influenced flight
safety but has not resulted in an accident or serious incident.
The Annexes in the Directive provide lists of occurrences to be reported:
 Annex 1 – List of aircraft operations, maintenance, repair and manufacture-related

occurrences to be reported
 Annex 2 - List of air navigation services-related occurrences to be reported
Directive 2003/42/EC requires national occurrence reporting systems to be established, in

order to ensure that relevant information on air safety is reported, collected, stored,
protected and disseminated.
Each Member State must entrust the task of occurrence reporting to a competent,
independent authority (Article 5.1). As points of contact, the responsibility for managing
the collection and exchange of information according to Article 5 of Directive 2003/42/EC
may be entrusted to the following bodies:
 the national aviation authority and/or;

 the investigating body and/or;
 an entity established under Article 6 of Directive 94/56/EC and/or;
 any other independent body or entity entrusted with this function.
Also, in accordance with Commission Regulation (EC) 1330/2007, the points of contact are
the organisations which should be contacted by parties interested in obtaining information
related to the collected civil aviation occurrences.
In Europe, Directive 2003/42/EC (Articles 4 and 5) establishes provisions for Member

States to carry out mandatory reporting of occurrences which, if not corrected, would
endanger the safety of aircraft, its occupants or any other person.
In addition, the Directive makes provision (Article 9) for Member States to designate one or
more bodies or entities to put in place a system of voluntary reporting to collect and
analyse information on observed deficiencies in aviation which are not required to be
reported under the system of mandatory reporting but are perceived by the reporter as an
actual or potential hazard.
The Directive therefore encourages and supports Member States to establish a voluntary
occurrence reporting system. However, in this context there are also provisions (Article
9/2) for ensuring that voluntary reports are dis-identified. Specific information directly
identifying the operator or aircraft subject to an occurrence report must be excluded to
maintain confidentiality.
Provisions are made, under this Directive, to ensure an efficient means for the exchange of
information reported on civil aviation safety. This is supplemented by laying down
implementing rules for the integration of this information into a central repository, under
EC Regulation 1321/2007.
23
____________________________________________________________________________________________
European Commission Regulation (EC) 1330/2007
Regulation EC No 1330/2007, adopted on 24 September 2007, lays down measures

concerning the dissemination of the information on occurrences exchanged by Member
States, in accordance with Article 6(1) of Directive 2003/42/EC, with the objective of
providing information needed to improve civil aviation safety.
European Commission Regulation (EC) 1321/2007
Regulation EC No 1321/2007, adopted on 12 of November 2007, requires the European

Commission to set up and manage a central repository to store all information received
from the Member States in accordance with Article 6(1) of Directive 2003/42/EC.
Section 1.3.2 describes how this regulatory requirement for data integration is met in
practice by the EU Member States using the European Central Repository. This database
utilises the ECCAIRS (European Coordination Centre for Accident and Incident Reporting
Systems) system, which provides the software framework enabling the collection and
integration of accident and incident data by Member States into the database repository.
EU Regulation (EC) 216/2008
Regulation EC No 216/2008 was adopted on 20 February and entered into force on

8 April 2008. This regulation provides common rules in the field of civil aviation and
establishes a new basic act for EASA. It requires the national aviation authorities to
exchange, disseminate and analyse occurrence information in the context of this regulation.
Further information relating to this Directive and the role of EASA is discussed in Section
1.4.1.
This Regulation sets the objectives and means for establishing and maintaining a high
uniform level of civil aviation safety in Europe. This is achieved through proper application
of necessary acts and recognition of appropriate documentation in accordance with this
Regulation (Article 2.3). Also, within the respective areas of responsibility, there must be
uniform implementation of all necessary acts by the national aviation authorities and by
EASA.
Figure 4 (bottom shutter) illustrates the legal bases for the collection, integration and
dissemination of safety occurrence-related information. The EC regulations enforce the
requirements of EC Directive 2003/42. The figure also illustrates the general interactions
between EASA, the European Commission and the National Aviation Authorities.
24
____________________________________________________________________________________________
Figure 4: EC regulations for Civil Aviation Occurrence Reporting
EU Directive
2003/42/EC
on occurrence reporting
in civil aviation
Regulation (EC) Regulation (EC)

No 1321/2007 No. 1330/2007
Regulation EC
No 216/2008
Regulation 1321/2007 states ‘the Commission shall set up & Regulation 1330/2007 lays down measures concerning
manage a central repository to store all information received dissemination of occurrence information to interested parties,
from Member States in accordance with Directive 2003/42/EC’. exchanged by Member States to improve civil aviation safety.
National
European National European Aviation
Commission Aviation Commission Authorities
Authorities
ECCAIRS EASA
ECCAIRS provides means and methods to collect, share and EASA has a key role to identify safety deficiencies and disseminate
analyse accident and incident reports at a Member State related information to Member States. EASA also needs occurrence
and European level. information to fulfil its obligation to meet its airworthiness duties.
Regulation No. 216/2008 sets common rules on civil aviation and

establishes a ‘European Aviation Safety Agency’ (EASA).
European National
Commission Aviation
Authorities
Under this Regulation,

EASA also conducts,
EASA undertakes tasks
on behalf of Member
and assists the European
States, functions and
Commission to implement
tasks as ascribed to
the Regulation, in EASA them under the
particular on technical
Chicago Convention.
rules relating to
construction, design and
operational aspects.
25
____________________________________________________________________________________________
1.3. Mandatory / Voluntary Reporting systems
1.3.1. Accident / Incident Data Reporting (ADREP)
ICAO Annex 13 on Aircraft Accident and Incident Investigation imposes a mandatory

requirement upon Member States to establish a system for the reporting of safety accidents
and incidents worldwide. The ICAO ADREP, in place since 1974, has been implemented by
ICAO to centralise safety data on the circumstances and causes of accidents and incidents,
as determined by the national authorities. This safety data is then disseminated to the
Member States, with the purpose of preventing future accidents and incidents.
The ADREP system has evolved to keep pace with the changes in information technology
and the aviation industry. The new generation ICAO system in current use is ADREP 2000.
Since 2004, ICAO has adopted the ECCAIRS system (see Section 1.3.2) as the basis for
their new-generation ADREP 2000 system using a common reporting taxonomy.
1.3.2. European Co-ordination Centre for Aviation Incident Reporting Systems

(ECCAIRS)
ECCAIRS is a mandatory reporting system (as of 4 July 2005), based upon EU Directive
2003/42 on occurrence reporting in civil aviation.
ECCAIRS provides a European standard for aviation safety data exchange with a mission ‘to
assist National and European transport entities in collecting, sharing and analysing their
safety information in order to improve public transport safety’.
Each EU Member State must collect data on mandatory reportable occurrences and
designate a competent authority (typically, the national aviation authority or investigating
body) to enforce the procedures for collecting and processing the occurrence reports. These
mandatory occurrences are covered under Directive 2003/42 (Article 3.1) as those
occurrences which endanger or which, if not corrected, would endanger an aircraft, its
occupants or any other person. Examples include: complete loss of avionics cooling, failure
of the auto flight system to achieve the intended operation while engaged, total loss of
communication in flight and loss of the electrical distribution system. A more complete list
of examples is provided in Annex I and II of this Directive.
The ECCAIRS reporting system is a set of tools which facilitates the exchange and
integration of these occurrences. At European level, data can be collected and held in a
central repository which can be accessed locally by each Member State. This is a regulatory
requirement within article 2 of EU Regulation 1321/2007, covered in section 1.2.4. The
compatible data format provided by ECCAIRS enables Member States to exchange data
with each other.
Due to the lack of sophisticated tools and limited resources available in many organisations
world-wide, ECCAIRS has received interest outside EU borders. ICAO has now adopted the
ECCAIRS information system as a basis for their new generation ADREP system. ECCAIRS
is fully compatible with ICAO’s ADREP taxonomy.
The ECCAIRS community is a cooperative network of European transport authorities and

accident investigation bodies. The project is managed by the Joint Research Centre for the
European Commission.
Further development of the ECCAIRS reporting system is determined by the work of the
ECCAIRS Steering Committee, which is formed of representatives of EU organisations as
well as involvement from ICAO, EASA and Eurocontrol. The Steering Committee guides the
26
____________________________________________________________________________________________
European Commission on how to implement and maintain an efficient and effective data
collection, integration and exchange network for transport safety information.
The ECCAIRS Steering Committee now includes 24 of the 30 participating States (EU
Member States + Iceland, Norway and Switzerland). The Steering Committee meets once a
year and is open to EU organisations which are currently using or are planning to use the
ECCAIRS reporting system 9 .
1.3.3. Other Reporting Systems
There are two other reporting systems of note:
 EUROCONTROL Voluntary ATM Incident Reporting (EVAIR)

 Reporting and Assessment of Safety Occurrences in ATM (ESARR 2).
The ESARR 2 system has both mandatory and voluntary elements.
These systems are discussed later, in Section 1.4.2.
1.4. Role of EU Institutions and other organisations/bodies
1.4.1. European Aviation Safety Agency (EASA)
EASA is, by law, an administratively and financially self-governed, specialised and

decentralised agency of the European Union, which has its own legal personality and has
been provided with specific regulatory tasks in the field of aviation safety. EASA was
established by EU Regulation (EC) 1592/2002 (now Regulation (EC) 216/2008) and
launched in 2003.
The Agency has an obligation to inform the public of the general safety level in the field of
aviation. To accomplish this it provides annual safety reviews 10 as required by Regulation
(EC) 216/2008 (Article 15.4).
The Agency is tasked with developing common safety and environmental rules at European
level. It is responsible for monitoring the implementation of standards through carrying out
inspections in the Member States as well as providing technical advice, training and
research.
The Agency’s principal activities include:
 monitoring potential safety issues related to daily operations of approved type

designs by analysing reported in-service difficulties and occurrences;
 performing regular airworthiness reviews with Type Certificate (TC) holders;
 involvement in accident and incident investigation and responding to safety
recommendations;
 investigating and resolving all proven and suspected unsafe conditions;
 exchanging safety data with foreign authorities in line with bilateral agreements and
working arrangements;
 reviewing and approving appropriate corrective action developed by TC holders;
 reviewing TC holders´risk assessments and decision-making on their acceptability;
9
For access to the ECCAIRS web portal see: http://eccairsportal.jrc/.ec.europa/News-items.eu
10
EASA Annual Safety Review 2007 provides an overview of aviation safety measures taken in different EASA
Directorates
27
____________________________________________________________________________________________
 drafting, publishing and disseminating relevant safety information in the form of

Airworthiness Directives (ADs) and Safety Information Bulletins (SIBs).
For EASA to achieve these activities it is dependent upon complete, unambiguous and
reliable data, such as occurrence reports and other safety-related information available
from, for example, accident and incident investigations or National Safety Investigation
Authorities (NSIAs),
EASA is governed under European Law and is responsible for the airworthiness of aircraft
(EU Regulation EC No. 216/2008, Art.20). It must therefore be appropriately represented in
safety investigations to meet its obligation under ICAO Annex 13, which requires the State
of Design and State of Manufacture to appoint an accredited representative in accordance
with the requirement in Annex 8 regarding airworthiness of aircraft.
In the future, the Agency will also be responsible for safety regulations regarding airports
and air traffic management systems.
EU Regulation (EC) No 216/2008
The EASA regulatory system has been rebuilt by Regulation (EC). 216/2008 (repealing
Regulation (EC) 1592/2002), the principal objective of which is to establish and maintain a
high uniform level of civil aviation safety in Europe (Art.2.1).
Under Regulation (EC) No. 216/2008 (as amended by Regulation (EC) 1108/2009), EASA
has a specific objective to assist Member States in fulfilling their obligations under the
Chicago Convention, by providing a basis for a common interpretation and uniform
implementation of its provisions, and by ensuring that its provisions are duly taken into
account in this Regulation and in the rules drawn up for its implementation (Art.17 e).
EASA has an important role to promote the aviation community views and rules regarding
civil aviation standards across the world, by establishing an appropriate level of cooperation
with third countries and international organisations. The legal basis for this function is
covered under Article 27 of this Regulation, under ‘International relations’.
In the preamble of the Basic Regulation 216/2008, it is stated that the results of air
accident investigations should be acted upon by EASA as a matter of urgency, in particular
when they relate to defective aircraft design or operational matters.
Regulation (EC) No 859/2008 (EU OPS)
The ‘EU OPS’ Regulation is essentially the transposition into Community law of the Joint
Aviation Requirements (JAR), established after consultations between the EU and Joint
Aviation Authorities in 1997. Specifically, these are the rules of JAR-OPS-1 on defining
harmonised rules on commercial and administrative operations in the field of civil
aviation 11 .
The EU-OPS Regulation, last amended on 20 August 2008 by Regulation No 859/2008 12 , is

administered by EASA on behalf of the European Commission. The system supplements (or
completes) Regulation 216/2008 in relation to a uniform level of civil aviation safety in
Europe), as well as containing elements of the ICAO State Safety Programme (Annex 6
‘standards and recommended practices on safety management system for air operators’).
11
Regulation (EEC) No 3922/21 on the harmonisation of technical requirements and administrative procedures
in the field of civil aviation (with Annex III replaced).
12
Regulation (EC) No 859/2008 on common technical requirements and administrative procedures applicable
to commercial transportation by aeroplane.
28
____________________________________________________________________________________________
EASA’s legal obligations in accident/incident investigation and occurrence

reporting
The responsibilities of the Community in safeguarding civil aviation safety have significantly
increased over the past 10 years. Responsibilities have moved from state level to European
level, particularly in the State of Design. However, the legislation has not been updated
adequately to reflect these changes.
In accordance with EC Regulation EC No 216/2008, EASA issues Airworthiness Directives on

behalf of the European Community, its Member States and the European third-countries
that participate in EASA activities (under Article 66 of the Regulation). In particular, in
ensuring ‘Airworthiness Directives’ under ICAO Annex 8, EASA must carry out tasks of the
States of Design, Manufacturer and Registry, related to ‘Aircraft Design Approval’.
In meeting its airworthiness responsibility, EASA clearly has an interest in having access to
important safety-relevant data and being represented in accident investigations, so that it
can take appropriate safety action, if necessary. Furthermore, EASA has a legal
responsibility on behalf of the Member States to review and accept safety recommendations
on the design aspects of EU-registered aircraft, as appropriate.
Articles 9.1 and 9.2 of the proposed new Regulation COM(2009)611 make provisions for
EASA’s potential participation in safety investigations in contributing to the improvement of
air safety (Directive 2003/42/EC, Article 1).
Article 10 states that accredited representatives for the State of Design, within the scope of
ICAO Annex 13, shall be appointed by the NSIA of the Member State. This could reinforce
EASA’s participation in safety investigations, under Article 9.1, if the Member State invites
EASA to be represented within the scope of its competence.
1.4.2. Eurocontrol
The European Organisation for the Safety of Air Navigation (Eurocontrol) is an international
organisation, founded in 1963, whose primary objective is the development of a seamless,
pan-European air traffic management (ATM) system. This civil organisation currently has 38
Member States and its headquarters are in Brussels.
The goal of Eurocontrol is to develop, coordinate and plan for implementation of pan-
European air traffic management strategies and their associated action plans. To help
achieve this goal, involvement is needed from national aviation authorities, air navigation
service providers, civil and military airspace users, airports, industry, professional
organisations and the relevant European institutions.
It is important for safety regulation to keep pace with the development of the ATM system
as a whole. This requires a firm focus on system safety across the Member States and the
establishment of appropriate regulatory measures in line with future safety challenges. ATM
safety oversight capabilities in Member States are audited through mandatory audit
programmes established to identify safety deficiencies in Member States.
Under the current mandate given by Eurocontrol, the ESIMS (ESARR Implementation
Monitoring and Support) Programme activities provide important safety information for use
by all stakeholders to allow safety improvements in ATM across Europe. The ESIMS
Programme covers areas such as ATM safety regulations and works in line with the ICAO
Universal Safety Oversight Audit Programme (USOAP). The objective of USOAP is to
promote global aviation safety by auditing states and assessing critical elements of safety
oversight.
29
____________________________________________________________________________________________
The future extension of EASA competences to ATM would give EASA a key role in the
standardisation of inspections in ATM.
Safety Regulation Commission (SRC)
The Eurocontrol bodies that monitor ATM safety in the European Civil Aviation Conference
(ECAC) Airspace on behalf of the Eurocontrol Provisional Council are the Safety Regulation
Commission (SRC), composed of States’ safety regulators, and an ATM safety team
comprising safety managers from air navigation service providers (ANSPs).
The SRC was established in 1998 and one of its key tasks is to collect and analyse public
data describing ATM accidents and incidents. This involves collating specific national safety
data from Member States to complement the outcome of the assessment of the safety data
made publically available by third parties.
Reporting and Assessment of Safety Occurrences in ATM (ESARR 2)
ESARR 2 is a Eurocontrol safety regulatory requirement which covers the implementation

by Member States of an occurrence-reporting and assessment scheme for ATM safety. Its
rationale is to promote successful implementation of harmonised occurrence reporting and
assessments.
The requirement applies to the Member States belonging to Eurocontrol. Each Member
State is responsible for ensuring that the necessary provisions of this requirement are met
by determining their own national institutional arrangements.
ESARR 2 has both a mandatory and a voluntary element. The mandatory element includes
those occurrences that are predefined and listed within the ESARR2 (Appendix II), whereas
the voluntary element enables personnel to report any occurrence that they consider to be
worthy of investigation by the safety department.
Eurocontrol Voluntary ATM Incident Reporting (EVAIR)
The Eurocontrol Voluntary ATM Incident Reporting (EVAIR) is part of the European Safety
Programme (ESP) which deals with incident reporting and data sharing. The activities of
EVAIR started in November 2006, to bring rationalisation in European ATM safety data
collation and analysis.
The main aim of EVAIR is to enable key stakeholders (airlines and ANSPs) and their safety
management systems to be proactive in fixing safety problems. The effectiveness of this
reporting system relies on three key areas:
 Collection and analysis of ATM incident reports from airlines and ANSPs;
 Feedback channel for the provision of replies on incidents submitted and a quick fix
of problems;
 Monitoring and customised analysis to support safety activities of outside
stakeholders and different Eurocontrol Agency programmes and projects.
The majority of ATM incident reports are generated from the airlines’ safety management
systems. EVAIR is the agreed and established feedback channel for the provision of replies
on the incidents submitted. The feedback channel enables there to be a direct link between
the safety management systems of both the ANSPs and the airlines.
30
____________________________________________________________________________________________
Under-Reporting of ATM Incidents
The pattern of ATM-related accidents and incidents reported under ESARR2 (Eurocontrol
Safety Regulation Commission Annual Safety Report 2009) is similar to the overall pattern
in ECCAIRS.
The annual numbers of ATM-related accidents and risk-bearing incidents (comprising

incident categories A and B, which are the most severe) declined from 2005 to 2008, and
this is believed to show a genuine improvement in safety. Meanwhile, the total annual
numbers of ATM-related incidents (categories C to E, which are the least severe) have
continued to increase, and this is believed to result from an increase in reporting. As with
the ECCAIRS data, the change in reporting levels makes interpretation of data trends
extremely difficult and limits the utility of the data.
In 2008, 29 out of 44 ECAC states submitted ATM-related data. This has increased since
2005 but still represents far from full coverage. Nevertheless, it does include most of the
larger ECAC States.
Among the reporting states, the level of reporting is not uniform. Eurocontrol determined
this by comparing the number of ATM-related incidents with the number of flight hours in
each country. In 2008, the best-reporting states were reporting at a level nearly four times
the ECAC average. Eurocontrol estimated that if all ECAC States experienced the same level
of incidents, the number currently reported would be only 25-30% of the total. In other
words, even in this relatively mature reporting environment, incidents may be under-
reported by a factor of 3 to 4.
1.5. Safety Requirements for Third-Country Aircraft
1.5.1. EU Regulation (EC). 216/2008

This Regulation establishes a comprehensive legal framework for the safety of third-country
aircraft using airports within EU Member States.
It requires third-country aircraft operated in EU Member States to be subject to an

appropriate level of compliance with ICAO standards.
1.5.2. SAFA (Safety Assessment of Foreign Aircraft) Directive 2004/36/CE

This Directive introduces a harmonised approach to the enforcement of international safety
standards within the Community by harmonising the rules and procedures for ramp
inspections of third-country aircraft landing at airports located in the Member States.
Aircraft landing in the Member States undergo an inspection if it is suspected that they do
not comply with international safety standards.
The competent authorities of the Member States participate in a mutual exchange of

information with regards ramp inspection reports. The European Commission can take
appropriate measures to cooperate with and assist third countries to improve their safety
oversight capabilities.
Under Directive 2004/36/CE, ramp inspections focus on aircraft where:

 information indicates poor maintenance, damage or defects;
 there are reports of their performing abnormal manoeuvres;
 deficiencies have been revealed from previous ramp inspections;
 the competent authorities of the ‘State of Registry’ have not exercised proper safety
oversight;
 Information indicates cause for concern about the Operator.
31
____________________________________________________________________________________________
1.5.3. Blacklist of air carriers subject to an operating ban within the Community –
Regulation (EC) No 2111/2005
Regulation (EC) 2111/2005 defines the provisions on the preparation and publication of the
list of air carriers that are subject to an EC-wide operating ban because they do not meet
the safety requirements.
The Annex in Regulation 2111/2005 lays down the common criteria for imposing an
operating ban for safety reasons at Community level. An air operator will be put on the
blacklist if:
1. there is verified evidence of serious safety deficiencies on the part of an air carrier;
2. the carrier lacks the ability and/or willingness to address the deficiencies or;
3. the responsible authorities lack the ability and/or willingness to address the safety
deficiencies and enforce the safety standards or oversee the aircraft used in
accordance with its obligations under the Chicago Convention.
1.6. Summary of the legal framework and reporting systems
Table 4 below provides a summary of the legal framework and the associated regulations
and Directives as well as the main reporting systems, as covered in this report.
Table 4: Summary of the legal framework for aviation accident investigation

& reporting
Legislative & Regulatory Framework (International & EU Level)
Regulatory
Legislative Provision
Standard
ICAO Annex 13 – Defines the international standards and recommended practices and is the
Chicago Convention fundamental document relating to Aircraft Accident and Incident Investigation.
EU Directive Establishes the fundamental principles governing the investigation of civil
94/56/EC aviation accidents and incidents. This Directive transposes the main provisions
of ICAO Annex 13 in EU legislation.
EU Directive This Directive (enforced in July 2003) deals with occurrence reporting in civil
2003/42/EC aviation. It encourages voluntary reporting within Member States and makes
provisions for the exchange and dissemination of information between Member
State aviation authorities and the European Commission.
Regulation (EC) No This lays down the implementing rules for the integration into a central
1321/2007 repository of information on civil aviation occurrences exchanged in accordance
with Directive 2003/42/EC.
Regulation (EC) No This lays down measures concerning the dissemination of information on
1330/2007 occurrences exchanged by Member States in accordance with Directive
2003/42/EC.
New Basic Enforced in April 2008, this new Basic Regulation repealed the previous
Regulation (EC) No regulation 1592/2002. EC No 216/2008 provides common rules in the field of
216/2008 civil aviation and establishes a European Aviation Safety Agency.
Directive This is the applicable legislation for the ‘Safety Assessment Of Foreign Aircraft’
2004/36/CE (EC SAFA Programme). The Directive was adopted in April 2004. This Directive
enforces international safety standards within the EU Community by means of
ramp inspections on ‘third-country’ aircraft landing at airports located in the
Member States. The Directive provides a legal requirement for EU Member
States to perform inspections and as such participate in the EC SAFA
programme.
Regulation (EC) No Regulation on a common ‘blacklist’ of air carriers subject to an operating ban
32
____________________________________________________________________________________________
Legislative & Regulatory Framework (International & EU Level)
Regulatory
Legislative Provision
Standard
2111/2005 within the Community.
New Proposed Proposal for a Regulation on investigation and prevention of accidents and
Regulation COM incidents in civil aviation. This should promote improved uniformity in
(2009) 611 investigating capacity in the EU and back voluntary reporting by a legal
obligation. It will also make provision for a new legal and institutional
environment with the entitled of EASA to support and participate in safety
investigations.
Regulation (EC) No Common technical requirements and administrative procedures applicable to
859/2008 commercial transportation by aeroplane.
Regulation (EC) No Regulation on common rules in the field of civil aviation and establishing a
1592/2002 European Aviation Safety Agency (repealed by new basic regulation EC No
216/2008).
Regulation (EC) No Regulation on the Financial Regulation applicable to the general budget of the
1605/2002 European Communities.
Regulation (EC) No Regulation for the airworthiness and environmental certification of aircraft and
1702/2003 related products, parts and appliances, as well as for the design and production
organisations.
ICAO ADREP The ADREP system has been implemented by ICAO to centralise safety data on
(Accident / Incident the circumstances and causes of accidents and incidents, as determined by the
Data Reporting) national authorities within Member States.
ECCAIRS (European
ECCAIRS is a mandatory reporting system (as at 4 July 2005), based on EU
Co-ordination centre
Directive 2003/42 on occurrence reporting in civil aviation. ECCAIRS is a set of
for Aviation Incident
tools which facilitates the exchange and integration of occurrence reporting
Reporting Systems)
with EU Member States.
ESARR 2 This Requirement covers the implementation by Member States of an
(Eurocontrol Safety occurrence reporting and assessment scheme for Air Traffic Management (ATM)
Regulatory Safety. It applies to all Member States of Eurocontrol.
Requirement)
EVAIR (Eurocontrol Introduced in November 2006, this is a Eurocontrol voluntary reporting system
Voluntary ATM aimed at airlines and ANSPs for incident reporting and data sharing to
Incident Reporting) rationalise European ATM safety data collation and analysis.
33
____________________________________________________________________________________________
34
____________________________________________________________________________________________
2. CONTRAST BETWEEN LEGAL FRAMEWORK AND ITS

PRACTICAL APPLICATION IN EU AVIATION
2.1. Aims
The aim of this part of the study is to assess the practical application, in current daily
practice, of the system of accident/incident investigation and occurrence reporting in civil
aviation within EU Member States. From the results of a detailed assessment, key
conclusions and recommendations for EU Policy are made for improving safety.
2.2. Methodology
A comprehensive survey tool has been developed to collect statements of fact and opinion
from the national aviation authorities of the Member States (the 27 Member States of the
European Union). Part 2 of the study provides an overview of the development process, the
questionnaire style and the survey process. The survey responses have been analysed and
the key findings are presented here.
In addition to the survey process, interviews were conducted with key organisations. The
findings have been combined with the legal framework presented in Part 1. This information
has been used to supplement the survey responses.
Where necessary, data collection and research has been carried out through further
literature reviews and interviews. The survey is used as a supporting tool for the
description and analysis of current daily practice.
The survey tool is in the form of a questionnaire. This has been used to gather information
and opinion from the main actors and key stakeholders. The data gathered has been
collated to provide necessary information to support Parts 2 and 3 of the project.
Key findings from the survey responses have been used to support a detailed analytical
account of accident/incident investigation and occurrence reporting in current daily
practice.
The findings are supported by the legal framework review detailed in Part 1. Principally,
these are based around the context of three primary pieces of legislation; ICAO Annex 13,
Directive 94/56/EC and Directive 2003/42/EC. ICAO Annex 13 incorporates requirements
for both accident investigation and notification of occurrences, whilst these issues are
regulated separately in the EU through Directive 94/56/EC and Directive 2003/42/EC.
For clarity and consistency with Part 1 of the report, the analysis has been presented here
under separate headings: accident investigation (Section 2.3) and occurrence reporting
(Section 2.5).
Examples of specific responses are included in Annex IV of this report.
2.2.1. Style and Format of the Survey Questionnaire
The survey questionnaire was developed in MS Word format and is completed electronically
by the respondent.
The questions are primarily aimed at accident investigation bureaus but are also
appropriate for ANSPs (Air Navigation Service Providers), CAAs (Civil Aviation Authorities)
35
____________________________________________________________________________________________
and other relevant organisations. The questions range mostly from open questions,
requiring free-text responses in the form of general information and statements of fact, to
the provision of opinion on the respondent’s perception of issues. There are also some
closed questions, where appropriate.
Our approach has been to ensure that all respondents can see all the questions and can
respond to any as they wish. The survey questionnaire can be found in Annex III.
The questions are grouped under the following categories:
1. Policy, Strategy & Regulations

2. Cooperation with Other Organisations and Member States
3. Resources
4. Definitions used in Accidents/Incidents Investigation & Reporting
5. Processes, Procedures and Systems
6. Organisational Structure, Roles & Responsibilities
7. Reporting
Figure 5 provides an overview of the survey approach.
Figure 5: Overview of Survey Approach

European Level
European Aviation
EUROCONTROL ECCAIRS
Safety Agency
Member State Level
Accident
Civil Aviation Air Navigation
Investigation
Authorities Service Providers
Authorities
“One survey generated”

POC Established/ Follow-up email/ Telecon /
Introduction Email/
Initial Survey receipt supplementary Return of Survey
Request for POC
Request Sent confirmation (opt.) assistance (opt.)
The aviation community network has been used to identify points of contact within national
authorities to direct the survey to a named point of contact (POC). Specific contacts were
made with the Civil Aviation Authorities, Air Navigation Service Providers and National
Safety Investigation Authorities (Accident Investigation Bureau/Authority) for all 27
Member States of the EU. In addition, several airlines and airline community unions were
invited to participate.
Initial surveys were sent out via email, with numerous follow-up requests. In order to
conduct a timely and balanced analysis, responses that were not received within a set time
36
____________________________________________________________________________________________
frame 13 have not been incorporated within the current analysis for this study.
Supplementary clarification was provided on questions to those organisations that
requested assistance. Provision was made for the option of a telephone interview for all
organisations, and a number of survey responses were completed in this manner.
2.2.2. Survey Interviews
In addition to the use of the survey tool, telephone and video conference interviews with
the following key organisations were carried out:
 EASA
 Eurocontrol
 ECCAIRS (European Co-ordination Centre for Aviation Incident Reporting System)
Also there were discussions with representatives from the European Regional Airlines
Association (ERAA).
These interviews dealt with the question areas covered by the questionnaire and were also
used to gather additional opinion on the topics covered by the project.
2.2.3. Confidentiality and Anonymity
The individual survey results are confidential and anonymous. Where statements have been
extracted from the survey responses, these have been sanitised to remove references to
specific Member States and organisations, thereby maintaining confidentiality and the
anonymity of the respondents. Some of the statements made contained minor
spelling/grammar errors and these have been corrected in the text presented in this report
for clarity.
2.2.4. Survey Responses
Figure 6 provides a breakdown of the completed surveys received, by organisational type.

In total 32 responses were received at national level and a further 4 at European
level. Responses were received from 19 of the 27 Member States.
Note:
The statistical analysis charts illustrated in this part of the study are based on the
percentage of actual responses received to the survey
13
A date for receipt of all survey responses to be returned to DNV was agreed with all the Member States.
37
____________________________________________________________________________________________
Figure 6 : Breakdown of Stakeholder Responses by Organisational Type
11%
3%
40%
27%
19%
NSIA CAA ANSP Airlines Other Key EU Institutions
Table 5 details which national organisations submitted survey responses by 30th April 2010.
Although a number of key Member States have either not replied or only partially replied to
the survey, the responses received to date have been considered as being representative of
EU aviation. Some Member States responded after the analysis was carried out and these
responses are indicated in the Table as ‘late response received’.
Table 5: Overview of Responses
Member State NSIA CAA ANSP
Austria No response received No response received Late response received

Belgium Response received No response received No response received
Bulgaria Response received No response received No response received
Cyprus Late response received No response received No response received
Czech Republic Response received Response received No response received
Denmark Response received No response received Response received
Estonia(1) Late response received No response received No response received
Finland No response received Response received Response received
France Response received No response received No response received
Germany No response received No response received Response received
Greece Response received No response received No response received
Hungary No response received No response received No response received
Ireland No response received No response received No response received
Italy Response received No response received No response received
Latvia Response received Response received No response received
Lithuania Response received Response received Response received
Luxembourg Response received No response received No response received
Malta No response received No response received Response received
Netherlands No response received No response received No response received
Poland No response received No response received No response received
Portugal Response received No response received No response received
Romania Response received No response received Response received
Slovakia Response received Response received Response received
Slovenia No response received No response received Late response received
Spain No response received Response received Response received
Sweden Response received No response received Response received
United Kingdom Response received Response received Response received
(1)
Response submitted from Estonia Airlines
For two of the Member States, a combined national response has been provided,
incorporating comments from the CAA, NSIA and ANSP. During the analysis, where
38
____________________________________________________________________________________________
possible, these comments have been split to attribute comments to a specific organisation,
e.g. to an NSIA.
2.2.5. Information on National Safety Investigation Authorities
This section presents information on the make-up of the NSIAs for 21 of the Member
States. The information is presented to complement the traffic and accident data presented
in the previous section. Table 6 provides an overview of the National Safety Investigating
Authorities in place in 21 Member States, including:
 who they report to,

 the number of personnel; and
 the scope of activities.
39
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Table 6: Status of National Safety Investigation Authorities
Country Date Who does it Permanence Scope Staffing

established report to
Belgium Ad-hoc
organization
The Chairman of
the Board of the
Permanent Only aviation
 Currently 2 (1
Air Accident But works ‘in tech/ 1 non-
within the Federal Public
Investigation good tech);
CAA since Service Mobility
Unit 1930, then and Transport cooperation’
permanent (Ministry of with the other  Budget
enquiry sections approved for
with the transport)
(railroad, 4 (3 tech /1
designation
essentially) non-tech)
of a full time
investigator.
Since 1998 -
an entity
independent
from CAA
Bulgaria 2001 Part of the Ministry

of Transport,
It is
permanent
a The accident
investigation is
 The aviation
Aircraft, investigation
Information organization multimodal –
Maritime & has 6
technologies and aviation,
Railway permanent
Communications maritime and
Accident members + 1
railway transport
Investigation outside expert
Czech The
was
AAII - The AAII is the
permanent
The AAII
responsible only
is
 The AAII has
Air Accident a total staff of
established authority for Accidents/
Investigation 13 (10
on 1.1.2003 Incidents in the
Institute investigators,
aviation sector
(AAII) including
engineers,
pilots and
former ATC
personnel)
Denmark 1 January
1979
The Minister of
Transportation
Permanent Rail and aviation
 14 including
Accident administrative
Investigation staff, railway
Board unit and
aviation unit.
 7 in the
aviation unit,
one chief
inspector,
three
operational
(pilots) and
three
technical
inspectors
Estonia 2003 Part of the Ministry

of Communication
Permanent Solely
responsible for
 Number of
Aircraft active staff 3
and Economics aviation-related
Accident incidents and
Investigation accidents
Unit
40
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Finland The AIB of

Finland was
Ministry of Justice The AIB of
Finland is a
The AIB of
Finland also
 Permanent
Accident staff of 11
founded in permanent investigates rail,
Investigation 1996 authority maritime and
Board (AIB) of other serious
 Administration
Finland and 7
accidents
investigators
+ about 90
external
experts
(about 30 for
aviation) were
used in 2009
France
The BEA
(Bureau
The Investigation
Authority does not
It is a
permanent
The BEA deals
with civil
 117 persons
work at the
Bureau d’Enquêtes have to report to authority aviation
BEA
Enquêtes - d’Accidents) anybody as it is an (Article R 711- incidents and
Accidents was founded independent 1) accidents  About 60 are
(BEA) in 1947. Its authority. Its technical staff
new status reports are public
(Bureau
d’Enquêtes
et d’Anlyses
pour la
sécurité de
l’aviation
civile) was
created in
2001
Germany
The Federal
Bureau of
Authority
responsible to the
The BFU is a
permanent
The BFU
investigates
 Staff of about
34, including
Aircraft Ministry of authority on accidents and
staff for
Accident Transport duty 24/7 serious incidents
records,
Investigation to civil aircraft in
analyses,
(BFU) was Germany
administration
established
, investigators
on 1
and wreckage
September
hangar
1998
Greece Founded
2001
Reports to the
Minister of
Permanent
entity
Solely
responsible for
 Total staff: six
Air Accident (6),
Transport aviation
Investigation
& Aviation  Technical
Safety Board staff: two (2)
but can hire
technical staff on a
case-by-case basis
Ireland The Air

Accident
Reports to the
Department
The AAIU is
the permanent
Responsible for
the investigation
 Permanent
staff of 8
Investigation (Minister) of civil aviation of aircraft
including one
Unit (AAIU) Transport body accidents and
Chief
was serious incidents
Inspector of
established within Ireland
Accidents, 5
in 1993 and in certain
Inspectors of
cases to Irish-
Accidents and
registered
2 Secretariat.
aircraft abroad
41
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Italy In 1999 Presidency of the

Council of
Permanent Aviation sector
only
 Total staff: 46
Agenzia Ministers and
Nazionale Parliament
 Breakdown:
Sicurezza Del 27 staff (plus
Volo (ANSV) President,
ANSV board
members,
general
secretary
 Investigators:
12
Latvia Since 01.01.

2006. as
The civil aviation
authorities,
Permanent Authority is
multimodal (with
 Total 7
Transport separate services, aircraft aviation and rail
Accident & entity operators and departments)
 Technical/non
Incident - technical
physical entities
Investigation 4/3
Bureau
Lithuania Founded in Part of the Ministry Permanent Chief The investigation

2001 of Transport and investigator is authority consists
Aircraft Communications solely of one chief
Accident responsible for investigator
Investigation aviation
Bureau
Luxembourg 1 June 2008 Separate entity, It is a full-time It is multi-modal 2 technical staff

attached to the 24/7, all-year- (aviation, rail, currently handle
Accident Ministry for round maritime) but the accident
Investigation- Sustainable administration. does not include investigation for
Administration Development and road aviation, rail and
des Enquêtes Infrastructures maritime
Techniques transport.
Netherlands Since 1992 The Board reports Permanent The Board is The Dutch Safety
to the parties currently active Board consists of
Safety Board involved and to the in the following 5 permanent
general public sectors: board members
aviation,
shipping, rail
transport, road
transport,
defence,
healthcare
(human and
animal welfare),
industry and
networks,
pipelines,
construction and
services, water,
and crisis
management
and aid
provision
42
____________________________________________________________________________________________

Portugal Formally
established
Reports to
Assistant Secretary
Permanently
established as
It is exclusively
dedicated to air
 1 Director of
Gabinete de thetechnical
on 29 of State for Public an official and accident and
Prevenção e department
August 2000 Works and independent incident
Investigação Communications. air safety investigations
de Acidentes It is part of the branch
 4 Safety
com investigators
Ministry of
Aeronaves Transport
(GPIAA)  1 Senior
official
 Secretariat:
3 Admin staff
Romania 1994 Part of the Ministry

of Transport and
Permanent Aviation only
 Number of
Department staff: 5
Infrastructure
of Air
Transport - in process of  Number of
Investigation becoming a technical
separate entity. staff: 3
Slovakia Investigation
Authority
Reports directly to
the Minister of
Permanent Responsible for
accident/incident
 1 head of
Accidents & office
(UOVLNaI) Transport, Posts investigation in
Incidents founded 19 and civil aviation.
Investigation June 2009. Telecommunication
 3 internal
Board investigation
S.R.
(Before then staff,
the
Investigation  several
Authority external ad-
was part of hoc experts
the Civil
Aviation
Authority
S.R.)
Spain Established
by Royal
Reports to the
Spanish Aviation
Permanent The CIAIAC
investigates all
 14 in total,
Civil Aviation including 6
Decree in Safety Agency civil aircraft
Accident & Aeronautical
November (AESA) which is accidents and
Incident Engineers, 2
2005; attached to the incidents that
Investigation Airline
operational Ministry of Public take place in
Commission Business
since March Works and Spanish territory
(CIAIAC) personnel, 3
2006. Transport
Admin staff, 2
ATCOs and 1
Pilot.
Sweden 1978 The government Permanent SHK is

multimodal.
 Total staff 22
Board of Investigates all
Accident kinds of
 Aviation 3.5
Investigation staff
accidents – both
civilian and
military
UK 1915 Secretary of State

for Transport, part
Permanent Aviation only
 35 Inspectors
Air Accidents of Department of
Investigation Transport
 20 support
Branch (AAIB) staff
Table 6 shows that there is a significant range in the number of personnel and the length of
time the organisations have been in place.
43
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2.3. Accident/Incident Investigation
2.3.1. Implementation of ICAO Annex 13 requirements
ICAO Annex 13 provides ‘International Standards and Recommended Practices for Aircraft
Accident and Incident Investigation’. All the investigating authorities have either fully or
partially incorporated the requirements of Annex 13. The filing of deviations was given as
the reason for stating partial compliance with the requirements.
Over half of the Member States represented have filed deviations against ICAO Annex 13
requirements (Figure 7), the majority of which relate to ‘Non-disclosure of Records’. In
some cases, where it is considered that judiciary requirements outweigh the investigation
process, there is no guarantee that records will not be disclosed for purposes other than
accident investigation.
In this regard, where judicial authorities have priority rights over access to the site and
evidence, cooperation agreements between investigation and judicial authorities are
sometimes used to allow appropriate access to information needed for the investigation. If
no such agreements are in place and the judicial authority conducts its own investigation,
this can sometimes result in significant delay in the accident investigation.
Figure 7: Member States filing for deviations under ICAO Annex 13
No response given
21%
Yes, we have filed

differences under
Annex 13
requirements
53%
No, we have not filed

deviations under
Annex 13
requirements
26%
2.3.2. Application of Directive 94/56/EC
Directive 94/56/EC was adopted in 1994 and sets out the fundamental principles governing
the investigations of civil aviation accidents and incidents.
The investigation authorities are divided in their opinion on whether or not they consider
Directive 94/56/EC as being fit for purpose (Figure 8). Some believe that, as this Directive
is 15 years old and needs updating, it no longer meets their specific requirements for
accident investigations.
Since 1994, when this Directive was adopted, aircraft and their avionics systems have
become increasingly complex. Member States therefore recognise a need for more
diversified expertise and resources in meeting the necessary investigation capacity.
Currently, this appears to be concentrated in only a few well-established Member States.
44
____________________________________________________________________________________________
Another important criticism of the Directive is that it does not allow a uniform and balanced
implementation of principles between the investigation authority and judicial authorities.
For example, there is inadequate provision for the investigation authority to maintain
appropriate custody of evidence and the wreckage site, which can result in tensions
between the authorities.
Figure 8: Member States stating Directive 94/56/EC is fit for purpose
No response
given
16% Yes, Directive
94/56/EC is fit for
purpose
42%
No, Directive
94/56/EC is not fit
for purpose
42%
The survey specifically raised the issue of the protection measures for those individuals
reporting accidents and incidents. Figure 9 illustrates this with respect to NSIAs, CAAs and
ANSPs.
Figure 9: Breakdown of Organisations stating Directive 94/56/EC provides

adequate protection of individuals reporting accidents or serious incidents
No, Directive 94/56/EC does

not provide adequate
protection for those reporting
No response given accidents and incidents
38% 34%
Yes, Directive 94/56/EC

provides adequate protection
for those reporting accidents
and incidents
28%
Directive 94/56/EC does not specifically contain any measures to protect individuals
reporting accidents or incidents. Full implementation of Annex 13 was stated as a means
for providing adequate protection for individuals reporting accidents and incidents.
2.3.3. Supplementary Regulations at National Level
Additional or supplementary regulations have been introduced in some states to support

implementation of Directive 94/56/EC (Figure 10). Sometimes this can be effective in
addressing previous shortcomings in regulations and making resolutions at national level.
45
____________________________________________________________________________________________
However, this additional legislation can also result in differences at national level in
complying satisfactorily with the objectives and aims of the Directives.
Figure 10: Member States with Supplementary Regulations
No, member state does No response given

not have supplementary 5%
regs.
16%
Yes, member state has

supplementary regs.
79%
Whilst one of the aims of Annex 13 and the EU directives is to provide standardisation of
practices and processes, this high percentage of additional local regulations may indicate
that there are differences at national level. This is explained further in Section 2.5.7 on the
standardisation of processes.
2.3.4. Definitions
Most Member States have indicated that their use of definitions for accident, serious
incident and incident are in accordance with those provided in Directive 94/56/EC and ICAO
Annex 13 (Figure 11).
Figure 11: Member States with Definitions in line with Directive 94/56/EC and
ICAO Annex 13
No response
given
16%
Yes, definitions
used are in line
with Directive
94/56/EC and
ICAO Annex 13
84%
Although the analysis confirms that the use of relevant definitions is generally clearly
understood, some states expressed some confusion over the definition for ‘serious incident’
and ‘incident’. This is because sometimes ‘incident’ is used in lieu of ‘serious incident’.
46
____________________________________________________________________________________________
Inconsistencies in the interpretation of definitions can lead to problems with respect to

reporting and result in misleading statistics. Section 2.4.6 illustrates this point in relation to
the under-reporting of incidents. There is a risk that the misinterpretation of definitions can
result in safety critical data not being reported. For example, a serious incident
misinterpreted as an incident by the investigating authority may not be reported, which
could then lead to the risk to aviation safety not being identified. ICAO Annex 13 does not
place an obligation on Member States to report incidents unless it is expected that
important safety lessons can be drawn from them (see Table 7 below).
Table 7 indicates the different types of occurrences (accidents, serious incidents, incidents
and other occurrences) prescribed by ICAO and EU Directives.
Table 7: Reporting Obligations under the Prescribed Regulation
Accident & Serious

Regulation/Directive Incidents Other occurrences
Incidents
ICAO Annex 13 Yes No No
EU 2003/42/EC No Yes Yes
ESARR 2 Yes Yes Yes
EU 94/56/EC Yes No No
There is some confusion caused by apparent discrepancies in the terminology used in the
EU Directives, ESARR2 and ICAO Annex 13. This primarily concerns the definitions related
to an ‘occurrence’.
The different meanings of ‘occurrence’ have been further clarified as follows:
 Under ICAO Annex 13, Directive 94/56/EC and the proposed EC Regulation, the
word ‘occurrence’ is used in the definition of an ‘accident’ and ‘incident’.
 Under Directive 2003/42/EC the term ‘occurrence’ is used to define an event or a
condition that has NOT resulted in an accident or serious incident.
 Under Eurocontrol taxonomy, ESARR 2 uses the term ‘occurrence’ in a broader
sense to encompass ATM accidents and incidents as well as other ATM-specific events.
Figure 12 highlights the difficulties associated with ‘occurrence reporting’.
A key problem lies in the fact that there is no obligation to report occurrences of accidents
or serious incidents at EU level under Directive 94/56/EC. The final accident reports
received from Member States are made public (Article 7). Reports on the investigation of
incidents are also circulated, but only to parties likely to benefit from their findings with
regard to safety (Article 8). These reports and, where appropriate, the safety
recommendations are communicated to the undertakings or national authorities concerned
and copies are forwarded to the Commission (Article 9).
Directive 2003/42/EC places an obligation to report only incidents but not accidents or
serious incidents. However, EC Commission Regulation No 1321/2007 (Section 2.5.4)
provides that ‘basic factual information on accidents and serious incidents shall be
transferred to the central repository while an investigation thereon is on-going. When the
investigation is completed, all information including, when available, a summary in English
of the final investigation report shall be added’ (Article 3).
Besides, under the ICAO Annex, Member States are obliged to notify accidents and serious
incidents using the ADREP 2000 database system (Section 2.5.3).
47
____________________________________________________________________________________________
Figure 12 clearly illustrates the problems related to discrepancies in the occurrence

reporting structure. Specifically, it helps to visualise better the problems due to these
apparent discrepancies and illustrates the reporting obligations under the various
classification systems for the ICAO, EU and Eurocontrol taxonomy.
It is essential that these inconsistencies between the EU and ICAO taxonomy as regards
occurrence reporting are appropriately addressed in order to minimise the risk of incorrect
reporting or misreporting which may have an adverse impact on aviation safety.
Figure 12: Definitions reported under ICAO, EU and Eurocontrol Taxonomy
A = Accidents
S.I. = Serious Incidents
ICAO ADREP taxonomy
‘occurrences’ NSI = Non-Serious Incidents
= obligation under
prescribed regulation
ICAO Annex 13 A S.I. NSI • ‘Occurrence’ is used in definitions for ‘accident’, serious incident and
(ADREP 2000) incident’
I N C ID E N T S
• Under ICAO, there is an obligation for Member States to report

accidents and serious incidents to ICAO using ADREP 2000 database
‘circulate occurrence reports’ • Under 94/56/EC, there is NO provision for reporting occurrences of
accidents, serious incidents or incidents, but there is an obligation to
94/56/EC circulate accident/incident reports received from accident investigation
(Accident/Incident A S.I. NSI authorities in EU Member States
Report)
EU taxonomy
I N C ID E N T S
Note: differences in reporting obligations

stored in database under ‘occurrences’ between these two Directives
EC Reg. 1321/2007’
• ‘Occurrence’ means an operational interruption, defect, fault or
2003/42/EC other irregular circumstance that has or may have influenced flight
(ECCAIRS) A S.I. NSI safety and that has NOT resulted in an accident or serious incident
I N C I D E N T S
• ‘Other Occurrences’ are any incidents that are NOT normally
considered reportable but could form a potential hazard.
Eurocontrol taxonomy
‘occurrences’
• ESARR 2 is under Eurocontrol competence

ESARR 2 A S.I. NSI
• ‘Occurrence’ is used in a broader sense to encompass ATM
I N C I D E N T S
accidents, incidents as well as other ATM-specific events.
Under the Eurocontrol (ESARR 2) taxonomy, the definition of terms in the ATM data is not
always clear. While some accidents (e.g. mid-air collisions) are clearly ATM-related, it is
difficult to determine whether aircraft-ground collisions are ATM-related. This depends on
the definition of ATM itself, and on the treatment of ‘problem’ accidents with minor ATM
contributions. Eurocontrol uses terms such as ‘direct ATM contribution’ and ‘indirect ATM
contribution’, but these do not simply relate to any available causal models. Clarity could be
obtained by identifying individual accidents, but this is not done due to confidentiality
restrictions. The absence of a clear definition makes this data difficult to use.
The definition of ‘ATM-related incident’ is clearer, because it covers relatively well-defined

incidents such as infringements of separation minima, near-controlled flight into terrain
(near CFIT), runway incursions, runway excursions, level bust, unauthorised penetration of
airspace, aircraft deviation from ATC clearance and aircraft deviation from applicable ATM
regulation. Despite the problems of under-reporting, this incident data has proved useful
for safety assessment in the ATM field.
48
____________________________________________________________________________________________
The ATM data also includes ‘occurrences’ related to ATM support functions. These comprise
events in communication, surveillance, data processing, navigation and information
functions. These are clearly less serious than the reported incidents and so may not be
quite consistent with the definitions used by ECCAIRS. It is likely that the reporting of these
occurrences is much less complete and consistent than for ATM-related incidents and
accidents. This makes this data unsuitable for use at present.
Figure 13: Member States with definitions in line with Directive 94/56/EC and
ICAO Annex 13
No response
given
16%
Yes, definitions
used are in line
with Directive
94/56/EC and
ICAO Annex 13
84%
2.3.5. Relationships with the Judicial Authorities
After a major accident, representatives from many jurisdictions have legitimate reasons for
accessing the accident site, for example, police, fire fighters, medical team and coroners to
deal with fatalities. The investigation authority will have some responsibility for the
coordination of the activities involving these stakeholders.
On the whole there are no major challenges reported with respect to the working
relationships between investigating authorities and their respective judicial authorities.
However, there remain areas of dispute which are creating problems. In some cases, this
relates to the custody of accident evidence data and wreckage site. Access to such
information in a timely manner is considered essential to conducting the investigation and
problems in obtaining this can sometimes lead to delays and complications. For example,
issues have been raised about judicial authorities not permitting the analysis of site
wreckage, flight recorders or documentation related to the investigation.
Another disputed issue concerned the police and legal prosecutors having the power to use
the final report of the investigation and demanding the investigation team to be summoned
to give evidence in court.
2.3.6. Memorandums of Understanding (MoUs)
Memorandums of Understanding (MoUs) are essential because they help define

responsibilities and improve communications interoperability. Investigating authorities in
most Member States recognise the importance of MoUs in overcoming difficulties in working
practices and relationships with judicial authorities and other organisations. Indeed, where
49
____________________________________________________________________________________________
problems in dealing with judicial authorities have been highlighted by Member States, it
was interesting to note that almost all of these NSIAs did not currently have MoUs in place.
The national investigation authorities have established various agreements with their
respective organisations, such as the police, crown prosecution services, military
investigation units, airlines and fire and rescue services.
Many Member States already have MoUs in place or are in the process of drafting such
cooperation agreements (Figure 14). Structural changes affecting how judicial authorities
handle air accidents have also driven the need for MoUs.
Obtaining official signatory agreement has in some cases proven to be a lengthy process
and the delay in getting this signed-off can create challenges in ensuring effective
interactions during the investigations.
In some instances, there is no specific agreement between the investigation authority and
the judicial authority, but the basic cooperation is established in the national legislation.
Others rely on their good working relationships and do not feel the need to introduce formal
agreements.
Figure 14: Member States with Memorandums of Understanding in place
No response
given
21%
Yes, MoUs are

place
47%
No, MoUs are not

in place
32%
2.3.7. Relationships with other Investigating Authorities
The ECAC (European Civil Aviation Conference) Code of Conduct and participation in regular
meetings are considered by most Member States as the primary means of networking
between Member States. The majority of Member States have signed the Code of Conduct
on Cooperation in the field of Civil Aviation Accident/Incident Investigation between ECAC
Member States. This allows the investigating authorities to utilise support from other
Member States, particularly in the case of a serious incident or accident. For example,
some smaller NSIAs which may lack sufficient resources need support in the readouts of
flight data recordings and technical evaluation of other specific components.
Table 8 provides a list of Member States that have signed the Code of Conduct on
Cooperation in the Field of Civil Aviation Accident/Incident Investigation:
50
____________________________________________________________________________________________
Table 8: Signatories of Code of Conduct on Cooperation in the field of Civil

Aviation Accident/Incident Investigation
Signed Code Signed Code

Member State Member State
of Conduct of Conduct
1 Austria Yes (2007) 14 Italy Yes (2007)
2 Belgium Yes (2006) 15 Latvia Yes (2006)
3 Bulgaria Yes (2008) 16 Lithuania Yes (2006)
4 Cyprus Yes (2006) 17 Luxembourg Yes (2008)
5 Czech Republic Yes (2006) 18 Malta Yes (2007)
6 Denmark Yes (2006) 19 Netherlands Yes (2006)
7 Estonia 20 Poland Yes (2006)
8 Finland Yes (2006) 21 Portugal Yes (2006)
9 France Yes (2006) 22 Romania Yes (2006)
10 Germany 23 Slovakia Yes (2009)
11 Greece Yes (2006) 24 Slovenia Yes (2006)
12 Hungary Yes (2006) 25 Spain Yes (2006)
13 Ireland Yes (2006) 26 Sweden
27 United Kingdom Yes (2006)
The existing cooperation between EU NSIAs has recently been strengthened by the
establishment of the Council of European Safety Investigation Authorities (the Council) and
the CIRCA-based information bank (CIRCA – (Communication & Information Resource Centre
Administrator). The Council is composed of the Heads of the NSIAs of the EU Member States
and coordinates and harmonises the activities of the NSIAs without affecting the
independence of their investigations.
Some Member States have identified the fact that strong cooperation and sharing
information with other investigating authorities is an effective means towards solving safety
problems and saving on time and the amount allocated to a particular investigation.
Improved cooperation will be particularly helpful in the sharing of resource expertise and
equipment such as flight data recorders as well as the exchange of important safety data.
These elements are related to the current Commission proposal to formalise the
establishment of the European Network, described in Section 2.3.8 below. Specifically, the
Network will promote the sharing of investigation resources available in the Member States,
provide capacity to establish technical groups for dealing with specific issues such as access
to flight recorders and facilitate the exchange of safety-related information between the
NSIAs.
There are also more informal networks in place, as for example, the Nordic relationships
with some North Atlantic countries (Sweden, Norway, Finland, Iceland, Canada and
Denmark). Annual meetings are held to discuss common challenges.
51
____________________________________________________________________________________________
2.3.8. European Network of Civil Aviation Safety Investigation Authorities

Under the Commission’s proposed regulation the informal cooperation in place between
accident investigation authorities will be formally transformed into a ‘European Network of
Civil Aviation Safety Investigation Authorities’ (Article 7). The purpose of the Network will
be to provide important functions that would potentially contribute to promoting aviation
safety through independent safety investigations.
The proposed regulation recognises the responsibilities of the Network to be limited to

advisory and coordination tasks and without any legal obligation under Community law.
Principally, the Network will advise the Community institutions on all aspects related to the
development and implementation of accident and incident investigation policy (Article 7.3).
The Network will aim to provide greater uniformity better implementation and enforcement
of the Community civil aviation accident investigation legislation. It would coordinate
training within NSIAs, organise peer reviews of NSIAs to promote standardisation on a
voluntary basis and promote a European database of safety recommendations and
exchange of safety data between EU aviation authorities. A common EU accident
investigation methodology would be developed by using the Network as a central hub for
NSIAs requesting assistance and support as well as developing a mechanism for sharing
resources between NSIAs.
The important tasks intended to support specific functions of the Network would be to:
 Coordinate and strengthen the cooperation and exchange of information between

NSIAs (Article 7.1);
 Provide a framework for facilitating the sharing of resources between NSIAs and
make available a list of investigators in other Member States (Article 6.1);
 Provide an effective mechanism to promote dialogue and structured cooperation
between NSIAs and other authorities, e.g. judicial, police;
 Facilitate the delegation of carrying out an investigation to another NSIA (Article
6.2)
 Set up training for investigators;
 Issue recommendations to promote good practices to develop and implement
European accident investigation policy and methodology (Article 7.3);
 Encourage NSIAs from third countries to participate and be involved in the work of
the Network (Article 8.5).
The Network will also aim to strengthen the investigative capacity of the EU and the
preventive function of accident investigation by promoting a more structured cooperation
between the NSIAs, the Commission and EASA, while fully retaining an independent status.
It is envisaged that the Network will hold meetings with its expert working groups and will
invite the Commission and EASA. However, such participation would only be allowed where
it is clear that no conflict of interest exists in the subject matter being discussed at the
meeting (Article 8.2).
52
____________________________________________________________________________________________
Figure 15 shows that a high number of Member States agree with the benefits described
from formal recognition of the Network.
Figure 15: Member States responding that the Network would be beneficial
No response
given
21%
Yes, the
No, the 'Network' 'Network' would
would not be be beneficial
beneficial 58%
21%
2.3.9. Publishing Summary Reports
Most Member States publish periodic summary reports containing data on events reported
by the investigation authority.
However, the level of detail and format of these reports varies widely across Member
States. Some NSIAs provide an annual report providing brief descriptions and statistical
data for accidents and serious incidents only. Others include safety recommendations and
responses in their annual reporting. Monthly publications offering the option to subscribe
electronically have been used in some States as a means for providing access to safety
reports.
2.3.10. Resources available to the NSIAs and Traffic Levels
The NSIAs in different Member States vary widely in their resources. This is to be expected,
because aviation traffic also varies widely, as do the resulting numbers of accidents and
incidents. However, it is also possible that some NSIAs are inadequately resourced. This
section uses the available data to investigate this.
Several indicators of resources could be considered, but the best available indicator from
the survey is the number of technical staff in the NSIA (Table 6). This varied between 1 and
60 staff in NSIAs which responded to the survey.
In order to evaluate the adequacy of resourcing, it would be desirable to compare

resources to the risk of accidents and incidents, as revealed by recent experience.
However, such a comparison may be misleading because the recorded numbers of incidents
may be under-reported (Section 2.4.6). The data are likely to be more comprehensive for
accidents, especially fatal accidents, but then the numbers of such accidents are too small
to obtain reliable statistics for smaller NSIAs.
53
____________________________________________________________________________________________
Therefore the most appropriate comparison is with the traffic level in the country. Because
most accidents are associated with take-offs and landings rather than over-flights, it is
appropriate to use data on airport movements. The present analysis uses data for
commercial movements at major airports in Europe in 2003 (unpublished data supplied by
ICAO). This varies by a factor of over 100 between different Member States.
As expected, the comparison shows that Member States with greater traffic levels have
NSIAs with more technical staff. It is therefore more informative to look at the number of
technical staff per million flights, as shown in Figure 16.
The downward trend in this plot shows that there is an ‘economy of scale’, in which Member
States with more traffic have fewer technical staff for each flight, and hence for each
expected accident and incident. This might mean that they are under-resourced, but it is
likely that they are working more efficiently. Smaller NSIAs may experience relatively few
accidents, and hence may have less opportunity to test processes and learn lessons from
the investigations. It is possible that cooperation between smaller NSIAs might allow them
to make some of the efficiency gains that have been made by the larger ones.
Figure 16: NSIA Resources Compared to Traffic Levels in Member States
1000
NSIA TECHNICAL STAF
PER MILLION FLIGHTS
Data
Trendline
100
10
1
10,000 100,000 1,000,000 10,000,000
TRAFFIC (flights per year)
There is also significant variation (by a factor of up to 10) between Member States with
similar traffic levels. This may be because of differences in staffing practices, but it is likely
that some NSIAs are under-resourced. Because this analysis is preliminary, it is not
appropriate to identify specific NSIAs with seemingly low resources. However, the analysis
does indicate the potential to develop benchmarks that would be suitable for this purpose.
2.3.11. Effectiveness of Accident Investigation
There is clear consensus from the investigating authorities that current practices for
accident investigation are effective. In terms of the steps within the accident investigation
process, there are varying approaches on techniques and specific tools used in the
notification, gathering, recording and analysis of all available information on an
accident/incident, determining the causes, issuing safety recommendations and completing
the final report.
54
____________________________________________________________________________________________
2.3.12. Just Culture
Most national aviation authorities have their own internal policy on just culture 14 . These
include the non-disclosure of individuals’ names, anonymous reporting systems and well-
established safety management systems. These best practices are backed by appropriate
measures and legislation to ensure a just, blame-free reporting system.
Some NSIAs confirm that their national legislation clearly states that no enforcement
processes shall be initiated as a result of the information collected by the occurrence
reporting system. However, the level of legal protection provided in this context varies
widely across Members States, and national law in some investigating authorities still does
not provide adequate protection and can lead to fear of criminalisation amongst individuals.
Specific recommendations on this issue have been made by the European Regional Airlines
Association (ERAA) in its Policy Paper 15 . The ERAA advocates strengthening occurrence
reporting by improving the likelihood of respecting the confidentiality of those submitting or
otherwise identified in reports. To facilitate this development, the ERAA and some NSIAs
recommend specific improvements to Directive 2003/42/EC, particularly regarding clearer
terminology specifying topics such as cases of wilful and gross negligence, as well as a
clearer definition of just culture.
The findings showed that there are interesting differences within Member States with
regard to the concept of just culture, some of which have arisen through different customs
and mentalities. For example, some States place greater emphasis on protection for
reporting, in order to prevent possible criminal punishment. Others see the importance of
anonymous reporting as an effective means of protection. The establishment of an effective
reporting culture in some NSIAs is viewed as the prime driver for ensuring just culture. It is
not clear how strongly the principles of just culture are addressed in the organisation’s
safety management system and supported by a clear and robust internal policy.
2.3.13. Availability of the Passenger Manifest
The Spanair accident at Barajas airport in 2008 raised specific concerns about the
management of passenger manifests. The issue has recently been identified by the
European Parliament as being of particular interest.
The rapid availability of a reliable passenger manifest for the identification of persons on
board the aircraft under investigation and their families is considered an essential element
of the investigation process. Delays in obtaining lists of passengers on board the aircraft
under investigation can adversely affect search and rescue operations and the identification
of victims of air accidents.
The Commission’s proposed regulation (Article 22.1) makes provision for airlines to
implement appropriate procedures to produce a list of all the persons on board an aircraft
within one hour of the notification of an accident.
14
Proposed definition of ‘Just Culture’ (ICAO, Montreal, October 2008): ‘A culture in which front line operators
or others are not punished for actions, omissions or decisions taken by them that are commensurate with
their experience and training, but where gross negligence, wilful violations and destructive acts are not
tolerated’.
15
ERAA Draft Policy Paper on EC Proposal for a regulation on investigation and prevention of accidents and
incidents in civil aviation (COM(2009)611).
55
____________________________________________________________________________________________
2.3.14. Assistance for Victims and their Families
Most NSIAs support the need for dedicated assistance to families in the case of an accident
with victims. This is dealt with to some extent within some states, while other Member
States and their respective airlines need to do more to adopt appropriate support measures
through a robust crisis management programme or emergency responses planning. To
meet this important obligation, the Commission’s proposed regulation makes specific
provision under Article 3.1 for ensuring that a plan for the assistance of victims of civil
aviation accidents and their families is set up at national level.
There is also an obligation for NSIAs regarding data protection. There is a relatively small
proportion of NSIAs which consider there is no need for a specific provision to protect
victims and their families. There is still a need to strengthen data protection rights in some
Member States.
2.3.15. Crisis Management Plans
A crisis management plan is needed for managing emergency situations in the aftermath of
an accident or other emergency, e.g. a bomb alert or a hijack. Effective crisis management
plans should ensure that proper measures are in place for dealing with such circumstances,
with contingency planning as part of the larger framework of crisis management.
ICAO recommends that any organisation conducting or supporting flight operations should
have in place a crisis management plan, sometimes referred to as an emergency response
plan (ERP). The ERP should normally be documented in the format of a manual.
Across the EU Member States there does not appear to be a consistent approach to
handling crisis management. The scope tends to vary widely and some plans are managed
by a range of different organisations. For example, in some cases there are general crisis
management plans at ministerial level which address all events related to any kind of
transport. Such plans are referenced under different headings such as the ‘national human
search and rescue plan’, which can be implemented in the event of an aircraft or ship
accident.
Some Member States have no formal crisis plan but have procedures which are supported
by national regulation and are considered appropriate to deal with a large scale accident.
Others are still in the process of drafting contingency plans and communication instructions
for contingency planning for dealing with special crisis circumstances.
ICAO recommends that emergency planning should form part of the organisation’s safety
management system in order to learn and apply safety lessons and minimise damage or
injury. The findings suggest that some crisis management plans may not be adequately
addressing the important guidelines provided within the ICAO safety management
manual 16 .
2.4. Roles of Actors in the Accident Investigation Process
There are a number of different roles in the accident investigation process. This section
outlines these roles, particularly the accredited representative, advisers and technical
experts, with reference to ICAO Annex 13. Comment is made regarding the role of EASA.
16
CAO Safety Management Manual – Doc 9859, chapter 11 provides guidelines on Emergency Response
Planning
56
____________________________________________________________________________________________
Information is also provided regarding the roles of the FAA (Federal Aviation
Administration) and NTSB (National Transportation Safety Bureau) in the US.
Examples of air accidents have been provided in Section 2.4.4 to illustrate the specific
involvement of some of the actors, including EASA.
2.4.1. Notification of Differences to ICAO
Over the years, the ICAO Council has developed Annexes to the Chicago Convention which
incorporate the International Standards and Recommended Practices (SARPs).
Specifically, ICAO identifies the role of ‘Contracting States’ 17 in relation to aircraft accident
and incident investigation in Annex 13 of the Chicago Convention. Annex 13 requires
contracting states to notify ICAO of any differences between their national regulations and
the SARPs contained in Annex 13, although this is not a legally binding requirement. The
formal process of filing and approval of this notification of differences to ICAO is covered in
section 1.1.3.
The Annex 13 regulations specify a series of roles and their part in the accident
investigation process. The following table 9 outlines the notification requirements for
accidents and serious incidents:
Table 9: Notification - Accidents and Serious Incidents, ICAO Annex 13
For International Occurrences for all aircraft:
State of Occurrence Notifies

State of Registry
State of Operator
State of Design
State of Manufacture
ICAO (for aircraft over 2 250kg)
For Domestic and other occurrences for aircraft over 2 250kg:
State of Registry Notifies State of Operator

State of Design
State of Manufacture
ICAO (for aircraft over 2 250kg)
2.4.2. Accredited Representative, Advisers and Technical Experts
ICAO Annex 13 makes provision for the role of Accredited Representative 18 from the State
of Registry, State of Operator, State of Design or State of Manufacture. The Accredited
Representatives can also appoint advisers and technical experts to support their role in the
investigation. The Accredited Representatives can participate fully in the investigation,
under the control of the Investigator-in-Charge, who is appointed by the State of
Occurrence. An Accredited Representative can appoint advisers to provide assistance and
can participate by:
 Visiting the scene of the accident

 Examining the wreckage
17
ICAO Contracting States are signatories or adherents to the Chicago Convention (International Civil Aviation
Organisation Convention of 1944)
18
Accredited Representative - a person designated by a state, on the basis of his or her qualifications, for the
purpose of participating in an investigation conducted by another state. Annex 13 to the Convention on
International Civil Aviation, ICAO, Ninth Edition, July 2001.
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 Obtaining witness information and suggesting areas of questioning

 Having full access to all relevant evidence as soon as possible
 Receiving copies of all pertinent documents
 Participating in read-outs of recorded media
 Participating in off-scene investigation activities
 Participating in investigation progress meetings
 Making submissions with respect to various elements of the investigation.
It is also recognised that a state may have a special interest in an accident by virtue of
fatalities or serious injuries to its citizens. Specific rights are provided through the
appointment of an expert to represent the country affected.
2.4.3. Role of EASA in Accident Investigation
EASA is the competent authority in the European Union with responsibility for the
airworthiness of all aeronautical products. It develops common safety rules at European
level and is also responsible for type-certification.
There is a need for a non-ambiguous definition to support a legitimate need for EASA
participation in accident investigations.
Without a clear definition of the relationship between EASA and NSIAs significant problems
are encountered in the current system in terms of exchanging important safety information
so that EASA can act appropriately on safety deficiencies. This is highlighted in the
examples illustrated in Section 2.4.4 on recent aircraft investigations.
The proposed regulation (Article 9.1 and 9.2) on EASA participation with NSIAs would
support the development of improved relationships and make a clearer definition of EASA’s
rights and obligations in safety investigations.
Indeed, most investigating authorities respect this argument but at the same time are
concerned that this could jeopardise the independence of the investigating body. The
extent of EASA involvement should be within the boundaries defined by its responsibilities
governed by its capacity as the Design Approval Authority.
The Commission’s proposed regulation (Article 9.1) sets out provisions for the participation
of EASA in safety investigations and specifically for NSIAs to invite EASA to be represented
within the scope of its competence.
However, Figure 17 illustrates that the majority of Member States do not support the view
that EASA should have a more significant role in accident investigation. There is a
consensus that EASA is already afforded all the rights of participation as ‘Advisers’ in
accordance with ICAO Annex 13. The overriding reason why Member States do not favour
EASA in accident investigations is to protect the independence of the investigation.
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Figure 17: Member States responding that EASA should have a more significant
role in accident investigation
Yes, EASA
should have a
more significant
role in accident
No response investigation
given 13%
28%
No, EASA
should not have
a more
significant role in
accident
investigation
59%
From a European perspective, it is clear that for EASA to undertake their airworthiness
responsibilities, EASA should be recognised in an advisory role to the Accredited
Representative for the State of Design 19 . EASA is governed by European law and is
responsible for the airworthiness of aircraft under EU Regulation (EC) 216/2008, Article 20.
Refer to section 1.4.1 for details on EASA’s legal obligation under this legislation.
Prior to the formation of EASA, Member States took full responsibility for the State of
Design as the approving authority for different aircraft platforms: for example, France was
the State of Design for all major European products (Airbus, Eurocopter, ATR, Dassault).
The investigation authority has historically taken on responsibility for the provision of an
Accredited Representative and has enabled the Member State CAA to fulfil its obligations
regarding the airworthiness of aircraft. This is similar to the way in which the NTSB and FAA
operate in the United States, as described in section 2.4.5.
EASA has a requirement, under Regulation (EC) 216/2008 (Article 20), to carry out design
approval functions and to review and approve, as appropriate, safety recommendations
made by Member States resulting from the investigation. Yet it does not have the right to
participate in the investigation as an Accredited Representative of the State of Design,
under ICAO Annex 13. However, EASA is usually invited to participate in the role of a
technical expert, but this does not transfer the full rights of Accredited Representative.
Problems must be solved with regard to EASA’s current participation in investigations, as
highlighted by some of the air accident examples below.
The scope of EASA’s role in investigations is clearly defined in the Commission’s proposed
regulation (Article 9).
It has been found that there is currently no structured approach to support effective
working arrangements between EASA, the NSIAs and the Commission. This is important
when reviewing or making amendments to the relevant legislation. The proposed regulation
(Article 7.2) would promote this need for structured cooperation through the formal
establishment of the Network of Safety Investigating Authorities.
19
In accordance with Article 10 (Participation of the State of Design in safety investigations) of the Proposed
Regulation COM (2009) 611
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From time to time EASA is faced with having to make important decisions regarding
aviation safety in terms of meeting its airworthiness responsibility. To do this, access to
relevant factual information, including the flight number of the operator and registration
mark of the aircraft, is sometimes necessary for EASA to take the appropriate steps and
sometimes issue an Airworthiness Directive. This requirement for a minimum flow of
information is not always forthcoming from NSIAs and, indeed, current regulation does not
permit EASA to have full access to specific data identifying the aircraft and operator
involved in the accident. EASA request that they be granted full access to the European
central repository within ECCAIRS.
In particular, EASA is interested in flight recordings which relate to the design of the
aircraft avionics and could potentially affect the safe operation of the aircraft.
EASA request that they be granted full access to the European central repository within
ECCAIRS. This is addressed by the proposed regulation (Article 9.2) which gives EASA
particular rights and obligations for full access to safety information and equipment
(including read-outs from flight recorders). In addition, specific provision is made under
Article 15.3 for EASA to be given access to data identifying the aircraft and operator related
to the occurrence reported.
2.4.4. Assignment of Roles in Aircraft Crash Investigations – Examples
To further understand how these roles are assigned, recent aircraft crash investigations have been used
as examples. In particular, EASA’s involvement in accident/incident investigation is illustrated here
(Table 10).
Table 10: Aircraft Crash Investigations involving EASA
Fokker F28 Serious incident, Oslo, January 2007:

The crew lost control during take-off, presumably due to icing. A previous loss of control of a Fokker
F28 F-GMPG in January 2007 in Pau led to a recommendation to improve certification specification in
order to increase the safety margin for contaminated wing profiles. It is understood that access to
recordings was not provided for the EASA group working on this safety concern, with a corresponding
negative impact on the evaluation of remedial action in the light of this occurrence. Assessing the
safety benefit of enhanced regulations requires a proper evaluation of the benefit based on known in-
service occurrences.
Boeing 777 aircraft crash, London, January 2008:
A Boeing B777 crashed short of runway at London Heathrow. The cause was determined as ice
accumulation restricting fuel flow to the engines.
Notification and assignment of roles:
 In accordance with the established international arrangements, the National Transportation

Safety Board (NTSB) of the USA, representing the State of Design and State of Manufacture of
the aircraft, was informed of the event.
 The NTSB appointed an accredited representative to lead a team from the USA made up of
investigators from the NTSB, the FAA (Federal Aviation Administration) and Boeing.
 Rolls-Royce, the engine manufacturer, supported the investigation, joining the AAIB team.
 The Civil Aviation Authority (CAA) and the European Aviation Safety Agency (EASA) were kept
informed of developments.
The UK AAIB (Aviation Accident Investigation Bureau) led the investigation, as the accident occurred
in the UK (State of Occurrence).
As the investigation developed, statements were released by the AAIB, including an Initial Statement
and an Interim Report. In total, 18 recommendations were made.
Whilst EASA was not assigned a role as Accredited Representative, EASA cabin safety experts were
involved in the examination of the wreckage to review the hazards faced during the evacuation and as
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such were able to provide a judgment on the safety recommendations issued following completion of
the investigation.
The investigation identified issues associated with airworthiness, as well as other issues. EASA has the
role of approving safety recommendations and considering future rulemaking. EASA’s participation in
this investigation was considered important in order for it fully to undertake its airworthiness
responsibilities.
On 28 November 2008, a Delta Airlines Boeing 777 suffered a similar ice problem while flying over the
USA, which prompted an investigation by US NTSB, with the AAIB having an Accredited
Representative at the investigation.
MD82 air accident, Madrid, August 2008:
The aircraft took off with flaps retracted and stalled shortly after lift-off. Participating or getting a copy
of the MD80 Operating Manual was not possible because it was considered as confidential data
restricted to the investigation only. While waiting for the final conclusions of the report, EASA
published an Airworthiness Directive mandating, for all MD80 Flight Manuals, configuration checks at
start-up in order to prevent further omissions.
It can be noted that a similar event where the crew took off with flaps retracted, happened on a MD83
OE-LMM on 5 June 2007 in Lanzarote. This was not reported until the second accident happened. This
may be an example of under-reporting of incidents. Getting access to data reported in the central
European repository could enable risk assessment based on known precursors. The findings of the
audit conducted by EASA in Spain are also disclosed by EASA in the scope of this investigation.
A330 Incident, Australia, October 2008:

While in cruise mode, the aircraft experienced two severe pitch-down movements due to corrupted
signals provided to the flight system and propagating among the numerous flight computers. EASA
was not involved but Flight Data was shared. This enabled a review of the system failures and the
publication of two Airworthiness Directives to mitigate the risk with operational procedures.
The Flight Recorder Data enabled a comparison of the system behaviour with the safety system
assessment approved during the certification process. A design change is in progress. Flight Data
Recorders are a key element in modern aviation for approving modifications in highly complex
computer systems whenever the investigation points out a design deficiency.
A320 accident, New York in Hudson river, January 2009:
The NTSB aircraft performance investigation group, whose activity is based on flight data, questioned
the logic behind A320 flight envelope protection during the ditching and the extent of the damage
observed. EASA was among the witnesses asked by the NTSB to participate to their Public Hearing on
09/06/2009.
Airbus A330 Incident during cruise from Hong Kong to Tokyo on June 2009 and A330
during cruise from Miami to Sao Paulo on May 2009:
Both events investigated by the NTSB relate to airspeed fluctuations and were considered in the scope
of the A330 accident in the Atlantic Ocean mentioned below. Data was provided to the manufacturer
and accident investigation bodies but it is understood this was not made available to EASA at a critical
time where airworthiness actions were considered of prime importance. It is believed that EASA
managed to get the data recordings a few months later, which significantly hampered the decision-
making process. While the investigation is on-going, the Agency is actively monitoring progress,
especially related to the cockpit feedbacks provided to the crew, which are defined by certification
specifications.
A330 Accident, Atlantic Ocean, June 2009:
The aircraft was lost and ACARS messages indicated airspeed fluctuations. A full testing campaign on
Pitot tubes qualifications had to be conducted both for airworthiness and investigation purposes.
Considering the poor availability and cost of a wind tunnel capable of providing icing conditions, a
single testing campaign was made involving both the regulators (FAA and EASA) and investigators.
Following this evaluation, EASA has mandated the replacement of some Pitot tubes and has improved
the qualification criteria for future design. However, prior to this, it is understood that EASA was under
scrutiny for having allowed the specific probes (manufactured by Thales) to continue in service. This
followed EASA and Air France having reported they had experienced difficulties in obtaining
clarification from Airbus on how to handle problems with the probes. It has been reported that this
resulted in delaying EASA’s issue of the Airworthiness Directive stating the Thales probes should be
replaced.
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2.4.5. Relationship between the NTSB and FAA
The working relationship between the NTSB and FAA in conducting overseas investigations
is considered here with the aim of providing a useful analogy for the European context.
The NTSB carries out a range of roles in foreign aviation investigations:
 that of NTSB US Accredited Representative and NTSB Staff Members

 that of FAA Advisers
 that of Operator Advisers
 that of Manufacture Advisers
Provisions made in accordance with the US Code of Federal Regulations, under NTSB Part
831, govern all accident or incident investigation procedures, in accordance with US Law.
Section 831.11 specifies the legal obligation for the FAA to be party to the investigation.
 Within the European context, EASA’s relationship with the investigating authorities
within EU states is not clearly defined under the existing regulation and mutual
rights and obligations need clarification. The proposed regulation makes provisions
for the participation of EASA in safety investigations, under Article 9.
The investigator in charge designates parties (Advisers) to participate in the investigation

and its control. This means the FAA would be involved in the investigations under the
control of the investigator in charge.
 The right of EASA to participate in investigations would be exercised in a similar way

under the proposed regulation (Article 9.2).
Advisers are limited to those persons, government agencies, companies, and associations
whose employees, functions, activities, or products were involved in the accident or
incident and who can provide suitable qualified technical personnel actively to assist in the
investigation. Other than the FAA in aviation cases, no other entity is afforded the right to
participate in Board investigations.
 Under the current EU system, EASA does not share the same right as the FAA to
participate in Board investigations.
The FAA and those other entities that meet these requirements can be Advisers to the
investigation with the same rights and privileges and subject to the same limitations as
other parties. All party representatives, except the FAA, in aviation investigations need to
sign the ‘Statement of Party Representatives to NTSB Investigation’.
The NTSB is responsible, consistent with the US Department of State requirements, for
fulfilling the obligations of the United States presented in Annex 13.
 Similarly, the investigation authority within an EU Member State has an obligation to

meet Annex 13 requirements through their transposition into European Law and
implementation by the investigating authorities at national level.
For an accident or incident in a foreign state involving a civil aircraft of a US operator or of

US registry or manufacture, whilst the State of Occurrence is responsible for the
investigation, the US Government participates through an NTSB-appointed Accredited
Representative and a team of advisers named by the NTSB.
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 In the EU system, EASA may be invited by the investigation authority as an adviser

in third-country investigations; however, there is no provision for national
governmental participation.
The NTSB is also responsible for the provision of Accredited Representative leadership that
enables the FAA to fulfil the obligations of the United States as presented in Annex 8 of the
Chicago Convention, Airworthiness of Aircraft.
 Similarly, under the proposed regulation (Article 10) for the EU, the safety
investigation authority of the Member State is responsible for appointing Accredited
Representatives for the State of Design.
In accordance with Annex 8, Paragraph 4 ‘Continuing Airworthiness of Aircraft’, the State of

Design of an aircraft must maintain a system to receive airworthiness information from
user states, decide when action is needed to maintain continuing airworthiness and the safe
operation of the aircraft, and transmit appropriate information to user states. The NTSB
Accredited Representative and advisers from FAA and industry participate in foreign
accident investigations to fulfil this obligation and to gain air safety information to protect
the travelling public.
2.4.6. Under-Reporting of Incidents
Safety investigating authorities have an obligation to investigate and report incidents as

well as accidents and serious incidents. Directive 94/56/EC (Article 4.1) and the proposed
regulation (Article 4.3) both make this provision for investigating incidents under the
national legislation of Member States when they expect to draw safety lessons from them
(see Section 1.2.4 for details on the type of incidents reported under Directive
2003/42/EC).
If accident and incident data is to be useful for trend monitoring and developing safety
improvement initiatives, as in Section 2.3.10, it must be comprehensively reported within a
defined threshold. Any significant under-reporting may result in incorrect conclusions being
drawn from the data. This is a well-known problem of all accident and incident databases
and significantly limits their utility. Under-reporting may result from inconsistent
interpretation of reporting requirements (including definitions), non-standard reporting
thresholds and lack of just culture.
This section uses available data to investigate the significance of this problem in EU
aviation.
Because the pattern of accidents and incidents is complex and difficult to predict, it can be
difficult to tell whether a lack of accident and incident reports is due to low risks or under-
reporting. In general, reporting is more comprehensive for more severe events, so it can be
assumed that the records are likely to be most comprehensive for fatal accidents. The
ratios of incidents to accidents and of non-fatal to fatal accidents may vary between
countries for complex reasons, but large differences in these ratios may result from under-
reporting of less severe events. Large data collections are needed to eliminate the
fluctuations due to the random nature of events. In order to remove variations due to
differences in the type and extent of general aviation, the present analysis uses data for
commercial operations in Europe during 1990-2006 (unpublished data supplied by
ECCAIRS).
Table 11 presents the numbers of accidents and incidents in tabular form, in declining order
of commercial traffic volume (unpublished data supplied by ICAO, as used above).
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Table 11: Traffic, Accidents and Incidents in Member States
Traffic Accidents Incidents

(ICAO 2003) (1990-2006) (1990-2006)
UK 2,102,720 103 278
Germany 1,796,392 53 232
France 1,430,561 48 103
Spain 1,337,556 34 32
Italy 1,301,248 22 54
Netherlands 425,110 14 28
Sweden 313,711 9 46
Denmark 255,855 8 30
Belgium 253,339 3 20
Portugal 224,866 12 13
Ireland 223,270 10 44
Austria 195,067 4 9
Poland 155,469 3 11
Finland 155,417 6 5
Greece 152,453 16 10
Czech Rep 144,162 1 9
Hungary 88,471 0 18
Romania 72,648 8 7
Cyprus 58,558 0 4
Luxembourg 49,039 2 5
Bulgaria 32,301 1 2
Malta 29,407 1 1
Lithuania 23,597 0 2
Slovakia 20,447 1 2
Estonia 19,397 1 2
Slovenia 19,256 0
Latvia 18,458 0 2
This Table 11 shows that the number of incidents reported in several countries (e.g. Spain,
Finland, Greece, Romania, Malta) is similar to the number of accidents reported. This is not
necessarily erroneous, because incidents and accidents are mutually exclusive (see
glossary), but it is certainly surprising, because in general incidents would be expected to
be far more numerous than accidents. It suggests that there may be an under-reporting
problem. However, because the number of events is small for the smaller Member States, it
is difficult to be sure.
Figure 18 shows an analysis of the data for the 5 largest Member States. It presents
‘accident pyramids’, showing the numbers of non-fatal accidents and incidents for each
fatal accident. It shows that Germany and the UK report much higher proportions of
incidents and slightly higher proportions of non-fatal accidents than the EU average.
Conversely, France, Italy and Spain report much lower proportions of incidents and non-
fatal accidents. The number of incidents per fatal accident varies by a factor of 10 between
these countries, and the number of non-fatal accidents per fatal accident varies by a factor
of 3. The most likely explanation for these differences is varying levels of reporting.
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Figure 18: Relative Proportions of Incidents and Accidents in Member States
France
Germany
Italy Fatal accidents
Non-fatal accidents
Spain Incidents
United Kingdom
All Europe
0 10 20 30 40 50 60
Number of reported events for each fatal accident
This makes the data potentially misleading. Countries such as the UK and Germany, which
report large numbers of accidents and incidents, both in absolute terms (see Table 11) and
as a rate per flight, should not be interpreted as having high risks, but as having a good
‘just culture’.
Efforts to improve reporting may complicate the picture, and hence trend data may also be
misleading. Figure 19 shows the trends in numbers of accidents and incidents in Europe
since 1990. Although the total appears to be increasing, this is mainly a change in the
number of incidents, while the number of accidents is relatively constant. This implies that
reporting is improving while risks remain roughly constant in annual terms. Since traffic has
also increased in the period, the risk per flight has reduced significantly.
Figure 19: Trend in Numbers of Incidents and Accidents in Europe
200
Incident
EVENTS PER YEAR
150 Non-fatal accident

Fatal accident
100
50
0
1990 1995 2000 2005
It can be concluded that there are severe limitations in the quality of data that is currently
available in the ECCAIRS accident and incident database for Europe. It appears that the
number of incidents may be under-reported by a factor of 10 in some Member States, while
the number of non-fatal accidents may be under-reported by a factor of 3. More incidents
have been reported in recent years, but as yet there is no clear evidence that the under-
reporting problem has been solved.
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2.5. Occurrence Reporting – Flow and Exchange of Safety Data
2.5.1. Application of Directive 2003/42/EC
Directive 2003/42/EC is the primary legislative vehicle for mandatory occurrence reporting.
Whilst it is mandatory to report accidents and serious incidents, the reporting of incidents is
discretionary. Investigations are typically undertaken by the NSIA or CAA, although internal
investigations may also be carried out by ANSPs, airlines and related organisations.
A significant proportion of Member States have still not fully implemented this Directive. In
fact, some Member States have only recently (2005-2007) transposed this Directive within
their respective national legislations. From those that have, over 70% confirm it is fit for
purpose, illustrated in Figure 20 below.
Figure 20: Member States stating Directive 2003/42/EC is fit for purpose
No response given
11%
No, Directive
2003/42/EC is not fit
for purpose
17%
Yes, Directive
2003/42/EC is fit for
purpose
72%
Shortcomings and potential areas of improvement for the Directive have been identified by
some states. The current level of protection for individuals making reports is considered
weak by some authorities, especially in relation to protecting personnel from prejudice
within their organisations. Another area of concern is the lack of detailed provisions
regarding the involvement of the judiciary authorities. Some states feel the Directive does
not make adequate provision for the establishment of a ‘just culture’ at national level.
Although the Directive is considered fit for purpose by most at national level, this may not
be so at European level. Indeed EASA have expressed some dissatisfaction at only having
partial access to safety-related data on accidents and incidents. Section 2.5.4 on ECCAIRS
provides further clarification on this specific issue.
Table 12 identifies those Member States which have confirmed they have transposed
Directive 2003/42/EC into national legislation.
Note: ‘unconfirmed’ status does not explicitly suggest that the Directive has not been
transposed by the Member State.
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Table 12: Transposition of Directive 2003/42/EC into National Legislation
2003/42/EC 2003/42/EC
EU EU
Member State transposed into Member State transposed into
State national law State national law
1 Austria Unconfirmed
14 Italy Yes
2 Belgium Yes
15 Latvia Unconfirmed
3 Bulgaria Unconfirmed
16 Lithuania Unconfirmed
4 Cyprus Unconfirmed
17 Luxembourg Yes
5 Czech Republic Unconfirmed

18 Malta Yes
6 Denmark Yes
19 Netherlands Yes
7 Estonia Unconfirmed
20 Poland Unconfirmed
8 Finland Yes
21 Portugal Yes
9 France Yes
22 Romania Yes
10 Germany Unconfirmed
23 Slovakia Yes
11 Greece Unconfirmed
24 Slovenia Yes
12 Hungary Unconfirmed
25 Spain Unconfirmed
13 Ireland Unconfirmed
26 Sweden Unconfirmed
27 United Kingdom Unconfirmed
2.5.2. Processes in Occurrence Reporting
Occurrences are reported through national systems and then data is reported from national
level to European and ICAO level. There are also several European systems for reporting
and some organisations report directly to these at national level. ECCAIRS is now used as a
common means for this reporting process.
It is difficult to ensure that these processes are working effectively. There are a number of
factors which can influence whether processes in the occurrence reporting are being
followed correctly. The possible fear of punishment at organisational level together with the
fear of prosecution can impact on whether an occurrence is reported. At an organisational
level, individuals need to see the benefit in reporting. These issues need to be addressed to
complement structured processes.
At the data-user end of the process, there is significant frustration at the quality and level
of detail provided in the system. There is also an issue associated with the usability of the
reporting system.
There are a number of systems through which individuals report: through ADREP to ICAO,
to Eurocontrol through ESARR2, and into ECCAIRS at national and European levels. The
following sections (2.5.3 to 2.5.8) outline how the various information flows have been
designed, organised and ensured within the occurrence reporting. This also describes how
standardised the processes are, in terms of information flows, processing and storage.
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Simple diagrams are included for each of the major systems, highlighting:
 Who provides data input
 Who accesses data
 The direction of the information flow
2.5.3. ICAO Accident/Incident Data Reporting System (ADREP)
The Accident/Incident Data Reporting (ADREP) system in ICAO is used to store information
on accidents and incidents to aircraft over 2 250 kg maximum certificated take-off mass.
Figure 21 provides a simple overview of the ADREP system. This is a mandatory system for
reporting accidents and incidents as defined in ICAO Annex 13. In January 2004, the
ADREP system was upgraded (ADREP 2000) by using a software platform developed for
ECCAIRS (see Section 2.5.4). Similar data is reported by these databases under a common
taxonomy (Section 2.5.11, Table 14). This has allowed states to report occurrences to ICAO
in ECCAIRS format. The taxonomy for the ATM sector is harmonised between ICAO ADREP
and ESARR 2 also through cooperation between ICAO and Eurocontrol.
The ADREP system receives, stores and provides states with occurrence data. In this
context, the term ‘occurrence’ includes both accidents and incidents.
Annex 13 places a mandatory requirement upon Member States to establish a system for
reporting worldwide safety occurrences. The aim of the ADREP system is to centralise
safety data on the circumstances and causes of accident and incidents. The causes are
determined by national authorities. This safety data is then disseminated to the Member
States with the purpose of preventing future accidents and incidents.
As of January 2009, some 45 States (Contracting States) and 7 international organisations

had installed the ECCAIRS software and reported occurrences in the ECCAIRS format to
ICAO.
Figure 21: ICAO Accident / Incident Data Reporting System (ADREP)
2.5.4. ECCAIRS (European Co-ordination Centre for Aviation Incident Reporting

Systems)
Data reported within ECCAIRS is similar to that reported to ICAO via the ADREP 2000
database. As described in Section 2.5.3, the ICAO ADREP taxonomy has been implemented
in ECCAIRS. This common use of taxonomy classification allows similar data to be reported
and analysed within both database systems.
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ECCAIRS Reporting System
Member States use the ECCAIRS reporting system to collect and exchange safety
information related to accidents and incidents. This tool is the subject of article 6.3 of
Directive 2003/42/EC, covered in section 1.2.4. Each Member State must collect mandatory
reportable occurrences (see section 1.3.2 for examples), as defined in Directive
2003/42/EC. A designated body (typically the national aviation authority or investigating
body) enforces the procedures for collecting and processing the occurrence reports.
European Central Repository
The Member States use a database called the European Central Repository (using ECCAIRS
software) to contain all the accident and incident reports from the Member States. This
database is the subject of article 2 of EU Regulation 1321/2007 20 , covered in section 1.2.4
of this report. Member States should not only collect and exchange the safety information,
they also need to integrate this information into the European Central Repository.
Information provided by ECCAIRS 21 confirms that, as of the end of 2009, 20 of the 30
states which are members are able to successfully integrate safety data within the ECCAIRS
system. However, Table 14 illustrates the number of investigating authorities currently
operating or evaluating the ECCAIRS database.
ICAO is now using the same ECCAIRS-based information system to implement their ADREP
role, so European Member States using ECCAIRS can fulfil their Annex 13 obligations.
An upgrade to the ECCAIRS system is planned which will improve the data contained within
the software, but this will still be limited by the fact that not all countries are able to use
ECCAIRS.
Figure 22 shows that Member States can input and also exchange data with ECCAIRS.
Figure 22: European Co-ordination Centre for Aviation Incident Reporting System
(ECCAIRS)
Uses Taxonomy of ADREP 2000
20
1321/2007 – EU Regulation on dissemination of information on occurrences exchanged by Member States
in accordance with Directive 2003/42/EC.
21
ECCAIRS in Aviation by W Post, 12th February 2010, Joint Research Centre (JRC) of the European
Commission.
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EASA access to ECCAIRS
At European level, EASA is running an in-house database based on the ECCAIRS software,
specifically used to store accident and incident information received from European and
international sources. This database is directly synchronised with the ICAO ADREP database
and the US and Canadian reported data.
For the exchange and sharing of information with Member States, EASA also has access to
the European Central Repository. EASA believes that the sharing of relevant fields in the
European Central Repository would enable it to run safety analysis at European level with a
better level of information than in the case of the accidents or incidents reported to ICAO.
EASA currently has limited access to the ECCAIRS Central European Repository. Regulation
(EC) 1321/2007, described in section 1.2.4, requires Member States to enter only basic
factual data into the database while the investigation is ongoing. Full information should
then be stored once the investigation is complete. Under Article 2.3 of the regulation, EASA
is entitled to access information in the central repository but not specific data which directly
identifies the operator (registration/serial number of aircraft). To access such information
for safety analysis reasons, EASA would need to request authorisation from the Member
State which supplied the information.
Consequently, EASA is unable to identify safety issues for particular aircraft types or verify
classifications of the occurrence made by the reporter. This limitation of occurrence
reporting in ECCAIRS does not assist EASA in fulfilling its airworthiness responsibilities
vested in it by the legislation under Regulation (EC) 216/2008 (Article 20). This issue is
currently the subject of discussions and negotiations within the aviation community.
ECCAIRS Cooperative Network

There is an ECCAIRS Cooperative Network of Accident Investigation Bodies and/or Civil
Aviation Authorities from all EU Member States. This network is coordinated by an ECCAIRS
steering committee chaired by the Commission and meets once a year. The ECCAIRS
community has a web portal with over 600 registered users.
Table 13 shows a snapshot taken from the ECCAIRS Portal showing which NSIAs are using
or actively evaluating the ECCAIRS software. Taking into consideration all the 27 EU States,
this implies that about 60% of NSIAs are currently using ECCAIRS.
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Table 13: Use of ECCAIRS by NSIAs in EU Member States
EU ECCAIRS EU ECCAIRS
NSIA NSIA
State Status State Status
1 Austria Operating
14 Italy
2 Belgium
15 Latvia Operating
3 Bulgaria Operating
16 Lithuania
4 Cyprus
17 Luxembourg
5 Czech Republic Operating

18 Malta
6 Denmark Operating
19 Netherlands Operating
7 Estonia Operating
20 Poland
8 Finland Evaluating
21 Portugal
9 France Operating
22 Romania Operating
10 Germany Operating
23 Slovakia Evaluating
11 Greece
24 Slovenia Operating
12 Hungary Operating
25 Spain Operating
13 Ireland Operating
26 Sweden
27 United Kingdom
2.5.5. ESARR 2
ESARR2 (Eurocontrol Safety Regulatory Requirement for Reporting and Assessment of

Safety Occurrences in ATM) is a Eurocontrol safety regulatory requirement, with both
voluntary and mandatory elements applicable to all states which are members of
Eurocontrol. For details of the regulatory requirement see section 1.4.2.
ESARR 2 differs from ECCAIRS in that it is specifically aimed at the European ATM
community. Similar data may be reported through ESARR 2 but their classification is under
ATM-related occurrences (Section 2.5.11, Table 14). ECCAIRS has become a viable
alternative for specific reporting tools used in ATM. As an example, a mid-air collision would
be reported through ESARR 2 as an ATM-related occurrence, as well as using the ADREP
and ECCAIRS databases.
Sections 1.3.2 and 1.4.2 separately describe the specific aims of the ECCAIRS and ESARR 2
systems, respectively.
The ESARR 2 system has significantly improved in the last 5 years, in terms of the quantity
and quality of reporting. This improvement has been achieved through education and
training rather than through tighter regulation.
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Figure 23: ESARR 2 (Eurocontrol Safety regulatory requirement for Reporting and
Assessment of Safety Occurrences in ATM)
Supplied: - Received:-
Mandatory and voluntary Mandatory and voluntary
ATM occurrence data ATM occurrence data
ESSAR 2
Eurocontrol Safety
Member State Regulatory Requirement
for “reporting & EUROCONTROL
(ANSP) assessment of safety
occurrences in ATM
Figure 23 shows that Member States report ATM-related occurrences to Eurocontrol

through the ESARR2 database. This flow of information is one-way. It is typically the ANSPs
which will report this data. Eurocontrol extracts the data and disseminates its findings back
into the wider aviation community.
2.5.6. EVAIR
Another reporting system is EVAIR (Eurocontrol Voluntary ATM Incident Reporting). This is
part of the European Safety Programme and is a voluntary reporting system dealing with
incident reporting and data sharing. The main aim of EVAIR is to enable key stakeholders
(Airlines and ANSPs) to be proactive in fixing safety problems. The majority of ATM incident
reports are generated directly from the airlines safety management system.
Figure 24 shows that airlines and ANSPs can input and extract data from EVAIR.
Figure 24: EVAIR (Eurocontrol Voluntary ATM Incident Reporting)
Key areas of EVAIR are highlighted in section 1.4.2. on page 33
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2.5.7. Standardisation of Processes
For accident investigation, the information flow processes are designed around the
requirements of Annex 13. For example, standard report templates are used and standard
notification processes are in place. ECCAIRS is now used as a means for meeting
requirements under Annex 13.
For occurrence reporting, the use of ECCAIRS is a means to ensure a common taxonomy
and some standardisation in reporting systems. ECCAIRS is commonly used, but it needs to
be used more widely by EU Member States to ensure a consistent reporting structure.
Currently there are differences at national level associated with the use of local databases.
Some investigating authorities are using both ECCAIRS and an additional local database
dedicated to meeting their specific requirements. For example, the ECCAIRS central
repository is used to facilitate the collating and exchange of occurrence safety data while a
local database is dedicated specifically to recording safety recommendations. Sometimes a
separate database is used for voluntary reporting.
The data contained within these local electronic systems is categorised and subsequently
used for reasons such as statistical trend analysis and to conduct safety studies and
periodic reporting publications.
2.5.8. Data Integration, Storage and Exchange
Safety data in the form of occurrence reports are stored in a range of systems. All Member
States have national systems, solely using ECCAIRS or having in place a separate local
database as well as entering data into ECCAIRS. As stated previously there are still some
states which are not using the ECCAIRS software.
The process of collecting data from the Member States into a single European database is
called data integration. DINER (Data Integration Network for ECCAIRS Repositories) allows
Member States to contribute their data by email or other means.
Analysis of this data occurs at national level, with various reports and safety data
disseminated between the national aviation authorities.
Some data exchange is occurring at European level from country to country, although this
is currently not systematic. Many users are waiting for the next upgrade to ECCAIRS, which
is seen as a means to improve the usefulness of the system. It can be inferred that this
upgrade will improve the quality and level of detail of the entries, which will in turn increase
the usefulness of the safety records.
From EASA’s perspective, there is an existing source of data on occurrences to which they
have only limited access. This is explained in the earlier Section 2.5.4 on ECCAIRS.
2.5.9. Voluntary Reporting
A significant number of Member States have in place voluntary reporting systems in place
(Figure 25). Most are an offshoot of the existing reporting systems. In some Member
States, such as the UK, there are separate systems like the CHIRP (Confidential Human
Factors Incident Reporting Programme) system. In France, the investigation authority, BEA,
has been running the REC (Recueil d’Evénements Confidentiel), which is a voluntary
reporting system specialised for general aviation occurrences. Reports are received on a
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regular basis. They are de-identified and entered into a database and some reports are
published in safety bulletins (as REC Info).
Other States that currently have voluntary reporting systems include Belgium, Bulgaria,
Cyprus, Estonia, Germany, Hungary, Italy, Latvia, Lithuania, Luxembourg, Malta, Slovakia,
Slovenia, Spain and Sweden.
Of those that do not have voluntary systems in place, some confirmed that they were
looking to implement systems in the future.
Considering other voluntary reporting systems, discussions with Eurocontrol have indicated
that the increased use of ESARR2 and EVAIR has been brought about through education
and training and a general encouragement to adopt just culture principles. The data are
now at a level where trends can be identified. Eurocontrol also believes that voluntary data
flows are improving, with airlines actively reporting on a voluntary basis through existing
networks.
Figure 25: Member States with Voluntary Reporting Systems
No, member state

No response given
does not have a
5%
voluntary reporting
system
21%
Yes, member state

has a voluntary
reporting system
74%
The majority of Member States employ effective voluntary systems (Figure 25). To ensure
confidentiality, the reporting is de-identified and entered into a database and, where
appropriate, published in safety bulletins. Some Member States have reported a rising
number of voluntary reports, indicating that the system is working. It is worth noting that
the regulatory authorities reportedly have the most effective level of voluntary systems in
place, as illustrated by Figure 26 below.
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Figure 26: Member States (with voluntary systems) confirming voluntary

reporting systems are effective
No response
given
27%
No, member Yes, member

state voluntary state voluntary
system is not system is
effective effective
13% 60%
However, not all authorities share this level of confidence. There are some concerns about
being clear on what occurrences to report, and there is a feeling that some form of
guidance material would be beneficial.
There is also a strong feeling that the system is less effective because of the lack of just
culture. Inadequate protection for individuals making reports and insufficient measures to
support a just, blame-free reporting system have led to voluntary occurrence reports being
quite rare in some Member States.
Lack of clearly defined just culture principles at European level has in some cases meant
that measures to promote just culture are either not included within national legislation or
are still under development. There are differences between states in terms of their
mentality towards the benefits of a voluntary reporting system. In some EU Member
States, reporting is considered mandatory and failure to report can mean punishment or
even a fine. Others have highlighted problems of promoting a just, blame-free culture
external to their own safety investigation department. In particular, when dealing with
other authorities, e.g. judicial, which may have a different mind-set on how just culture can
promote voluntary reporting.
The above statistical analysis on the effectiveness of voluntary reporting is the aggregate of
the following data in Figures 27, 28 and 29 provided for the ANSPs, NSIAs, CAAs,
respectively.
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Figure 27: Effectiveness of Voluntary Reporting - ANSPs
No response given
25%
Yes, voluntary system

within ANSPs is effective
62%
No, voluntary system within

ANSPs is not effective
13%
Figure 28: Effectiveness of Voluntary Reporting - NSIAs

within NSIAs is effective
41%
No response given
42%
No, voluntary system

within NSIAs is not
effective
17%
Figure 29: Effectiveness of Voluntary Reporting - CAAs
No response given
0%
No, voluntary system within
CAAs is not effective
20%

within CAAs is effective
80%
Changing voluntary reporting systems to mandatory in order to improve reporting has

raised mixed opinions amongst Member States. While some believe this would increase the
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quantity of reported records and improve the system overall, over half do not feel the move
from voluntary to mandatory would make it more effective (Figure 30).
Furthermore, it is felt that this change may prevent reporting of certain types of
occurrence, and the focus will be on the more visible (technical) incidents, which may result
in some depreciation in the reports that encourage best practices.
Figure 30: Member States stating that changing voluntary reporting systems to
mandatory would improve reporting
Yes, changing
voluntary reporting
to mandatory will
No response given improve reporting
35% 6%
No, changing
voluntary reporting
to mandatory will
not improve
reporting
59%
2.5.10. EASA’s role in the current Occurrence Reporting System
The benefit of an occurrence reporting system is to provide direct feedback on the level of
safety and deficiencies.
Each individual Member State has a national occurrence reporting system for assessing the
risk at national level but is not competent to act on design deficiency and rulemaking
activities. EASA is the only competent authority at European level with regard to design
deficiency and rulemaking activity. However, EASA has limited access to reported safety
deficiencies. In order to act and decide what action should be taken, a clear knowledge of
reported deficiencies is crucial.
EASA has an established communications procedure for notifying occurrences in accordance

with Regulation (EC) 1702/2003 22 . This reporting is focused on airworthiness issues after
filtering by the TC holder (Type Certificate holder), who highlights only potentially unsafe
events. This reporting is mandatory for TC holders, who must report within 72 hours.
Voluntary occurrences reported by the TC holder have no time frame. The TC holder is
typically the aircraft manufacturer, e.g. Boeing, Airbus.
Upon notification of an accident or incident, reported by the TC holder, EASA attempts to

open a dialogue with the investigation authority in charge in order to negotiate an
involvement on a voluntary basis.
22
Regulation (EC)1702/2003 for the airworthiness and environmental certification of aircraft and related
products, parts and appliances, as well as for the design and production organisations.
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Aircraft Operators and approved maintenance organisations provide reports on

defects/malfunctions and maintenance-related data to the TC holder. The POA holder 23 also
forwards relevant information on potentially unsafe events (in accordance with Part 21 of
Regulation 1702/2003).
EASA communicates safety occurrence data to the aviation industry through safety bulletin
information notes whenever a safety concern has been identified. In addition the Agency
issues Airworthiness Directives on identified safety issues.
An overview of this occurrence reporting process is presented in Figure 31.
Figure 31: Occurrences reported by EASA
2.5.11. Similar Data reported under different Occurrence Databases
Table 14 below illustrates identical or comparable data categories reported under the three
databases: ECCAIRS, ADREP 2000 and ESARR 2.
Note: Table 14 lists categories for the majority of reportable occurrences for each database
and should not be considered as being completely comprehensive.
23
The POA Holder is a company holding Production Organisation Approval and has the approval to build and
certify aircraft parts, e.g. Rolls Royce.
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Table 14: Occurrence Reporting of Similar Data under different Databases
Occurrence (Accident/Incident) Category ADREP

ECCAIRS ESARR 2
ACCIDENTS 2000
Collision on the ground between aircraft ? ? ?
Collision between an airborne aircraft & vehicle/another aircraft on the ground ? ? ?
Collision on the ground between aircraft & vehicle/person/obstruction ? ? ?
Loss of aircraft control while inflight (e.g. due to wake-vortex & meteorological conditions) ? ? ?
Loss of aircraft control while inflight for other reasons ? ?
Loss of aircraft control while aircraft is on ground ? ?
Collision with obstacles/terrain while operating near surface (intentionally) ? ?
Aerodrome design, service or functionality (e.g. construction interference, lighting failure) ? ?
Abrupt manoeuvre resulting in loss of control (e.g. to avoid collision with terrain/obstacles) ? ?
Landing or take-off involving abnormal runway contact ? ?
Cabin Safety accidents ? ?
Evacuation resulting in fatality ? ?
Fire/smoke related accidents (with aircraft inflight or on ground) ? ?
Runway excursion (a veer off or overrun of runway surface) ? ?
Runway incursion with vehicle, aircraft/person/animal on runway ? ? ?
Collision while taxing to or from a runway in use ? ? ?
Icing-related accidents ? ?
Ground handling operations resulting in accident ? ?
Failure or malfunction of an aircraft system/component ? ?
Criminal/security acts resulting in accidents ? ?
INCIDENTS
Operation of aircraft (Take-off & landing incidents, flight control & stability problems)) ? ?
Terrain & obstacle clearance incidents ? ?
Emergencies (e.g. fires, smoke, explosion, depressurisation) ? ?
Flight crew incapacitation (e.g. due to reduced medical fitness) ? ?
Injury (significant injury to passengers/crew but not considered reportable as an accident) ? ?
Security ? ? ?
Aircraft structural failures (e.g. incorrect assembly parts, hot bleed air leak) ? ?
System failures (malfunctions, redundant system failures) ? ?
Human factors (inadequacy of aircraft design which could have led to an error of use) ?
Potential for collision or near-collision ? ? ?
ATM-specific occurrences (e.g. inability to provide ATM/ATS, communication/surveillance failures) ? ? ?
Aerodrome & aerodrome facilities (fuel-related incidents) ? ?
Aircraft ground handling & services (passenger, baggage & cargo) ? ?
Bird-strike ? ?
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3. IDENTIFICATION OF PROBLEMS/SHORTCOMINGS
AND BEST PRACTICES OF CURRENT ACCIDENT
INVESTIGATION AND OCCURRENCE REPORTING
3.1. Introduction
Based on the legal framework review and key findings presented in Parts 1 and 2,
respectively, a detailed assessment identifying potential problems and shortcomings in
current accident investigation and occurrence reporting practices within EU aviation is
summarised here.
Particular attention has been paid to the roles of the European Aviation Safety Agency
(EASA) and Eurocontrol with regard to accident investigation and occurrence reporting,
respectively.
For clarity and to maintain consistency with previous sections of the report, the following
summary uses separate sections for accident investigation and occurrence reporting.
The main results of this assessment summarising the strengths and weaknesses and areas
of best practice in this field are illustrated in Table 15.
3.2. Accident Investigation
3.2.1. Legislation
ICAO Annex 13 to the Chicago Convention contains the basic principles on accident and
incident investigation and defines standard practices and requirements for Contracting
States at national level. ICAO requirements are reflected within Directive 94/56/EC which
defines the fundamental principles governing accident/incident investigation at European
level. EU Member States have transposed the requirements from Annex 13 and Directive
94/56/EC into national legislation for their practical application.
Use of regulations in a consistent manner across Member States
Annex 13 requirements should be implemented across all Member States, although in

practice, the relevant provisions of ICAO in some Member States have only partially been
transposed into their specific national legislation. This deficiency can lead to significant
safety flaws in European and international aviation.
In addition to the transposition of Directive 94/56/EC and Annex 13 into national

legislation, supplementary regulations have been widely introduced in EU Member States.
While this can be effective in resolving previous shortcomings, it can also highlight
inconsistencies and differences amongst States for compliance with the Directives and ICAO
requirements.
Directive 94/56/EC
Directive 94/56/EC is largely considered too old and out of date with the current complexity
of aircraft systems and air traffic infrastructure in Europe. It no longer meets the
requirements of some Member States. In particular, it has been identified as being weak in
its provisions with regard to a balanced relationship between the investigating bodies and
judicial authorities. Also, there do not appear to be adequate measures in the Directive for
protecting individuals reporting accidents and incidents. States mostly rely on ICAO Annex
13 recommendations for implementing national legislation to tackle this issue.
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While some of the well-established NSIAs have stated that the Directive is fit for purpose,
this is generally confined to the national level. Directive 94/56/EC predates EASA, which
means that at EU level there is no provision made for the role of EASA in accident
investigation. As such there is no provision in the State’s national regulations for EASA.
Consequently, the relations between NSIAs and EASA are not defined, which presents
concerns in respect of exchange of important safety information between the Agency and
NSIAs.
The Commission’s proposed regulation has addressed these shortcomings and makes
provision to meet the requirements of current accident/incident investigations in EU
aviation. Also importantly, the proposal defines the rights and obligations of EASA in safety
investigations.
3.2.2. Role of EASA in Accident Investigation
Under the current legal framework, specifically Regulation (EC) 216/2008, EASA is
responsible for airworthiness responsibilities and carries out, on behalf of the Member
States, tasks related to design approval, as specified in the Chicago Convention. This
means EASA’s involvement in any technical investigation could have a conflict of interest.
The consensus amongst Member States is that EASA’s involvement should be strictly in an
advisory capacity to the Accredited Representative for the State of Design.
Relationships with national safety investigating authorities (NSIAs)
The analysis results of this report indicate that the relationships between many Member
States and EASA are strained. Most Member States recognise the benefits to be gained
from seeking the technical expertise the Agency can bring, but greater involvement in the
accident investigation process is not supported. The underlying reason for this is to respect
the independent nature of an accident investigation with no conflict of interest. Currently
there is no clear definition of the relationship between EASA and NSIAs. This presents
significant problems in the current system in terms of exchanging important safety
information so that EASA can act appropriately on safety deficiencies. The proposed
regulation (Article 9.1 and 9.2) on EASA participation with NSIAs would support the
development of improving relationships and provides a clearer definition of EASA’s rights
and obligations in safety investigations.
Cooperation with NSIAs and the Commission
When reviewing and discussing potential changes related to existing regulation or adopting
new legislation, there is a need for effective cooperation between relevant bodies. For
example, the establishment of EASA and its scope of participation rights in safety
investigations has been an important subject debated by the NSIAs, the Commission and
EASA.
To facilitate more structured cooperation between EASA, NSIAs and the Commission, the
Network would play a key coordinating role while retaining a completely independent
status.
Access to important safety information and equipment
Since 2002, EASA has become the responsible authority for certifying aircraft in the EU.
Access to relevant factual information including the flight number of the operator and
registration mark of aircraft is sometimes necessary for EASA to take timely action. This
information could be crucial when EASA needs to make a decision to recall an aircraft from
service or request change of an avionics part on the aircraft or on the entire fleet. There is
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therefore a need to make provision for a minimum information flow to EASA related to
airworthiness.
To maintain the airworthiness of an aircraft and its parts, EASA needs data on any avionics
product whose design could potentially have contributed to an accident. In particular EASA
would have a specific interest in flight data recordings which identify problems related to
design, for example, system or engine failures and performance.
Recent air accident investigations, described in Section 2.4.4, clearly highlight some of the
challenges EASA has encountered in meeting its airworthiness duties. Examples include
limited access to factual safety data in the central repository and access to flight data
recordings. In some cases, these problems have reportedly led to delays in the
investigation and in EASA being able to take important safety action on airworthiness.
The proposed regulation (Article 9.2) grants particular rights and obligations for EASA to be
given full access to safety information and equipment (including read-outs of flight
recorders). In addition, specific provision is made under Article 15.3 for EASA to be given
access to data identifying the aircraft and operator related to the occurrence reported.
(Note: Articles referenced here refer to that in the Commission Proposal COM (2009)0611
prior to any amendments made by the European Parliament.)
Participation rights in EU investigations
Under the existing legal framework, there is no definition to support the involvement of
EASA or indeed to justify a legitimate need for EASA participation in accident investigations.
Consequently, investigating authorities do not recognise an obligation to make provision for
EASA within their national legislation and hence in their daily practices when conducting
investigations.
The Commission’s proposed regulation (Article 9.1) makes provision for the participation of
EASA in safety investigations and specifically for NSIAs to invite EASA to be represented
within the scope of its competence.
EASA should adopt and maintain a completely independent stance during the investigation.
In foreign investigations, EASA should act as an adviser to the Accredited Representative.
Regardless of whether EASA operates in European or foreign investigations, its participation
needs to be controlled by the investigation authority in charge.
By ensuring EASA appropriately exercises its rights under the control of the investigator-in-
charge at all times during the investigation, the proposed regulation (Articles 9.1b and 9.2)
ensures that EASA participation is regulated uniformly in investigations across the EU as
well as in foreign investigations.
3.2.3. Relationships and Cooperation between Authorities
Relationships between NSIAs and judicial authorities
In some states, judicial authorities have significant powers of access to evidence, which
suggests that the judicial investigation takes precedence over the technical investigation.
Whilst this has only been identified in a few isolated cases, the issue has raised tensions
between NSIAs and judicial authorities.
Most NSIAs have in place memorandums of understanding (MoUs), typically prepared at

national level, providing a basis for effective working relationships and processes between
different authorities and organisations. In particular, MoUs have been used to overcome
difficulties with judicial authorities in dealing with issues such as access to the wreckage
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site and custody of evidence data. The importance of such cooperation agreements
becomes apparent in circumstances where the judicial authority believes an obligation to
sanction criminal activities should supersede safety considerations.
Relationships between NSIAs and judicial authorities could also be developed through the
European Network, through the respective head of the NSIA for the Member State. In
particular, the Network, with its independent status, would help promote dialogue between
NSIAs and judicial authorities to better coordinate involvement in accident investigations
and assistance in resolving disputes.
Resource sharing and assistance from NSIAs in other Member States
There are wide variations in traffic levels over Europe and consequently in accident/incident
frequencies. It is not surprising, therefore, that NSIAs in different Member States vary
widely in terms of their resources. A comparative analysis between resource availability in
NSIAs and traffic data based on aircraft movements has been carried out in Section 2.3.10.
This suggests some NSIAs may be under-resourced. It also highlights the fact that smaller
NSIAs may experience relatively few accidents and hence may have less opportunity to test
processes and learn lessons from the investigations. In terms of best practice, cooperation
between smaller NSIAs might allow them to make some of the efficiency gains that have
been made by the larger ones.
It is also worth noting that while all NSIAs operate independently, they report to a range of
government structures. This means some NSIAs deal solely with aviation accidents, while
others cover accidents in other transport sectors. The number of dedicated technical
personnel for aviation-related accident investigation may therefore depend upon the
availability of staff at the time of the accident.
Some smaller NSIAs have MoUs in place with other more prominent NSIAs so that they can
receive support for technical resources in the event of an accident. Basic cooperation
between NSIAs and judicial authorities through MoUs and good working relationships
should be encouraged and considered as best practice.
Improved cooperation between NSIAs needs to be developed through EU regulation, and an

effective mechanism for sharing investigation resources is necessary to help strengthen the
investigating capacity of some NSIAs.
The proposed regulation (Article 6) fulfils the legal obligation for support and assistance
between NSIAs. This would be coordinated through the proposal to establish the Network,
under Article 7. Furthermore, it would also contribute to promoting best practices towards
developing a common EU accident investigation methodology.
Protection of sensitive and confidential information
Some information gathered during an investigation is likely to be of a sensitive nature and

therefore must be protected from being disclosed to certain bodies and authorities. Such
information may include witness testimonies and statements. There have been concerns on
inappropriate use of sensitive information, for example to direct blame or punishment. This
has in some cases led to consequences involving mistrust and a fear amongst individuals of
sharing information in future investigations.
The Police and other judicial authorities have sometimes required all the evidence to be
passed to them so they can conduct their own investigations for criminal proceedings. In
such instances, and before disclosing confidential information, there should be clear
evidence that the information provided may be related to a criminal act.
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In principle, sensitive and confidential information should only be used where it is

considered to contribute to the safety analysis and add value to the safety investigation.
The proposed regulation (Article 15.1 and 15.2) sets out specific provisions for the
protection of sensitive information.
Also, there is a need for protection of individual records. For example, tighter controls are
needed to protect the principle of non-disclosure of individual victims’ names following
notification to families by the judicial authorities.
3.2.4. Assistance for Victims and their Families
There are weaknesses in the current system relating to the handling of the investigation in
the immediate aftermath of an air accident.
Arrangements for adequate assistance through crisis management
There is a need in some EU States to be better prepared and equipped for ensuring fast
and adequate assistance to victims and their families of an air accident. The appropriate
level of assistance needs to be assured through a proper emergency response plan at
national level within every Member State.
Discussions and interviews conducted with specific Member States indicate that currently
there is no consistent approach to crisis management. While larger and more established
States do have effective crisis management plans to deal with emergency situations, others
address this through internal procedures backed by national regulation. It is not confirmed
whether or not these procedures adequately follow the ICAO guidelines and
recommendations within its provisions for a safety management system.
The proposed regulation (Article 23) contains the important provision for Member States to
have in place a crisis management plan which specifically includes procedures for the
assistance of victims of civil aviation accidents and their families.
In addition, victims and their families should be guaranteed the right to reliable information
about the progress of an ongoing investigation. It would be helpful to have a focal point of
contact responsible for collating and coordinating information for the families of the
passengers.
3.2.5. Availability of Passenger Manifest
Delays in identifying persons on board an aircraft subject to an accident
There is a need to improve the information in passenger manifests and make available a
list of the persons on board the aircraft being investigated as quickly as possible following
an accident.
The proposed regulation (Article 22.1) defines a legal obligation for airlines to make
available the passenger manifest within one hour of notification of the accident.
3.2.6. The Network
The European Network of Civil Aviation Safety Investigation Authorities (the Network) is
one of the most important elements of the Commission’s proposal (Article 7). Its formal
recognition is needed to provide the framework for it to act in a coordinating role for NSIAs
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and should alleviate some of their problems experienced under the current legislation for
accident/incident investigation.
The Network could benefit the smaller NSIAs in terms of strengthening their investigation
capacity by providing a central mechanism for coordinating the sharing of resources
between States (Article 6.1). It would also support the need for coordinated training within
NSIAs and aim to organise peer reviews of NSIAs to promote standardisation on a
voluntary basis.
A central independent network is necessary to promote good working relationships between

NSIAs and judicial authorities in order to help resolve disputes. The important tasks of the
Network are detailed in Section 2.3.8).
3.2.7. Reporting of Incidents
The analysis in Section 2.4.6 of accident and incident data for commercial operations in
Europe during 1990-2006 has identified that there is a significant problem of under-
reporting of incidents in some Member States. This suggests a severe lack of quality of data
currently available in the ECCAIRS accident and incident database for Europe. Possible
reasons for the under-reporting levels of incidents may be inconsistent interpretation of
reporting requirements (including definitions), non-standard reporting thresholds, a lack of
a just culture or differences in aviation cultures within some Member States.
There is no obligation to report incidents which are not considered by the NSIAs to
contribute towards drawing safety lessons 24 . Directive 2003/42/EC (Annex I) provides a list
of categories within aircraft flight operations under which incidents are required to be
reported. These categories are operation of the aircraft, emergencies, crew incapacitation,
injury, meteorology, security, other occurrences.
3.2.8. Definitions
There is some confusion on the use of key definitions. Although the survey findings indicate
that relevant definitions are used consistently and in accordance with Directive 94/56/EC or
Annex 13, it is unclear whether some authorities are comprehensively reporting certain
incidents and serious incidents. Also of concern is whether the word ‘occurrence’ is being
used in lieu of an ‘accident or incident’ and this is not apparent from the analysis.
Inconsistent interpretation of definitions can result in problems of under-reporting, as
identified in Section 2.4.6.
Discrepancies in terminology
Apparent discrepancies in the terminology used in the Directives, ESARR2, ECCAIRS and
ICAO Annex 13 have been identified as causing some confusion. Figure 12 in Section 2.3.4
describes the discrepancies and illustrates how this can lead to problems.
These are primarily in relation to definitions for ‘incidents’ and ‘occurrences’. For example,
for ATM data, ESARR2 also includes ‘occurrences’ related to ATM support functions. These
comprise events in communication, surveillance, data processing, navigation and
information functions. These are clearly less serious than the reported incidents and so may
not be quite consistent with the definitions used by ECCAIRS.
24
There is no obligation for States to conduct an investigation into an incident. However, if a state has
found an incident significant enough to warrant an investigation, then an Incident Data Report should be
sent – ICAO Doc 9156.
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There is a need to develop specific guidelines on the use of terms and definitions for
reporting occurrences.
3.3. Occurrence Reporting
3.3.1. Legislation
The majority of states accept that Directive 2003/42/EC meets their purpose and have
implemented provisions within national law on occurrence reporting. However, numerous
States have still not successfully achieved this transposition and therefore do not currently
report accident and incident data in a compatible format in the European central repository.
For details on states having confirmed they have transposed the Directive, see Section
2.5.1.
There is no mandatory obligation under Directive 2003/42/EC to report accidents and

serious incidents. As ECCAIRS is subject to this EU Directive, this presents a significant
shortcoming in the current occurrence reporting system in that no database exists for the
mandatory reporting of accidents and serious incidents at EU level. This is a problem that
needs to be addressed in occurrence reporting and made consistent in accordance with
ICAO.
3.3.2. Just Culture
At national level, a few key problem areas have been highlighted. Reporters and the
information they supply must be protected in order to guarantee free and confidential
reporting. Some states feel that currently an inadequate level of protection for individuals
making reports is provided by the Directive. They also highlight that this protection should
be extended to cover those persons involved in the reported event and not just the
reporter.
Protection for confidential reporting
Anonymous reporting systems, non-disclosure of individual names and robust safety

management systems are good examples of just-culture best practices which most Member
States have incorporated within their internal policy. However, inadequate protection for
confidential reporting has been identified as a shortcoming within the existing legal
framework. Directive 2003/42/EC lacks detailed provisions for protecting personnel from
prejudice within the organisations.
Establishment of just culture in Member States
Adequate provision for the establishment of a just culture is lacking, and there does not
appear to be a commonly accepted definition for this across Member States. This is
important so that Member States can be encouraged to promote just culture principles at
national level.
3.3.3. Role of EASA in Occurrence Reporting
At European level, Directive 2003/42/EC is not considered fit for purpose. In particular,
EASA considers that the current legal framework does not support a well-structured
occurrence reporting structure. The formulation of Directive 2003/42/EC did not have the
establishment of EASA in mind and therefore does not reflect the new systems affecting the
Agency, which are established by Regulation (EC) 216/2008.
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Difficulties materialise in terms of access to data. Currently, EASA relies largely on TC

holder information, although TC holders are not obliged to forward all available occurrence
reports to the Agency.
Unrestricted access to safety data within ECCAIRS database
EASA has limited use of the ECCAIRS central repository, which holds aviation safety data
reported by the Member States. Regulation (EC) 1321/2007 restricts EASA to basic factual
data through dis-identification of operator-specific data and, as such, EASA is unable to
identify safety issues related to particular aircraft types. Each reporting state can delete the
fields that can identify the operator. So the basic principle is to remove the aircraft
registration, the serial number, the operator and the call sign as well as any narrative. This
has been identified by EASA as an additional barrier to fulfilling its airworthiness
responsibility, vested in it by the legislator under Regulation (EC) 216/2008.
Article 15.3 of the Commission’s proposed regulation gives full online access to EASA and
includes data which identifies the operator and the aircraft subject to an occurrence report.
Exchange and analysis of safety data at European level
Currently the data contained within the ECCAIRS central repository is not analysed at
European level. Data analysis is essential in being able to detect trends and deficiencies in
aviation safety and to take appropriate action to prevent future accidents. As the
competent authority, there is a need for EASA to collaborate with Member States and
ECCAIRS to facilitate the exchange and analysis of data to improve safety.
3.3.4. Role of Eurocontrol
Eurocontrol has established a robust system for handling ATM-related occurrences, but it
has taken considerable time and effort to achieve this level of confidence and performance.
ESARR2 and EVAIR systems are being used effectively by the ATM community in reporting
safety occurrences. Discussions with Eurocontrol suggest their success is largely achieved
through years of education, training and a robust just-culture policy.
However, there is a need for better integration and harmonisation of standards within the
field of ATM under European law.
Harmonisation of safety regulatory processes across EU aviation
Positive steps have already been taken towards completely integrated EU legislation on
aviation safety through relevant directives and regulations. In this respect, EASA is the
principal regulatory authority with regard to aviation safety.
To ensure that safety within the European air traffic management (ATM) system is
harmonised and regulated under Community law, EASA's competences as regards safety in
the field of ATM will need to be extended. This will lead to a step-by-step process of
adopting standards and procedures concerning safety developed by Eurocontrol under
ESARR (Eurocontrol Safety Regulatory Requirement) into Community law.
3.3.5. Standardisation & Exchange of Safety Data
There is a need for improving the standardisation of processes across Member States.
While ECCAIRS clearly provides a useful mechanism for achieving this, wider usage of
ECCAIRS is necessary across all Member States to ensure a more consistent approach to
occurrence reporting. Currently, some NSIAs use only ECCAIRS while others tend to use
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ECCAIRS in conjunction with local databases to store different types of safety information
separately. These differences can lead to adverse affects in the consistency and quality of
data entries and ultimately the use of ECCAIRS to improve safety.
Member States with more mature reporting systems recognise that there are issues of data
quality and are waiting for planned improvements to ECCAIRS to provide better collection
of data and effectively facilitate data sharing.
Exchange of safety occurrence data between states is happening to some extent but is not
systematic. Safety data is being exchanged in a number of ways. At national level, Member
States have systems to comply with regulations and designated authorities input this data
into European level systems, primarily ECCAIRS and ESARR2. In addition there are national
voluntary systems and also European voluntary systems, e.g. EVAIR. Finally, there are
global systems such as the ICAO ADREP.
At a high level, these systems are able to provide an overview of safety performance. At
the detailed level, issues of confidentiality and robustness of data can prevent the
performance of detailed analysis. Whilst there is a clearly defined need for each of the
systems, it should be noted that there are multiple systems, with some areas of overlap. It
is envisaged that over time, these systems will be gradually integrated with some level of
common taxonomy and compatibility.
3.4. Summary Results of Assessment
Table 15 provides a comprehensive summary of the main results of the above assessment.
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Table 15: Summary of Main Results of Assessment
Summary of Main Results of Assessment
Strength/
Weakness/
ACCIDENT INVESTIGATION Best
Problem
Practice
 Partial implementation of ICAO Annex 13 provisions in some MSs √

 Deviations filed against ICAO Annex 13 by most MSs where appropriate √
√
 Directive 94/56/EC is too old & out of date & does not meet requirements of some MSs
 Inadequate provisions for relationship between NSIAs & Judicial Authorities √

Legislation
 Inadequate protection for individuals making reports √
 No provision for role of EASA in Directive 94/56/EC & national legislations √

 No defined relationship between NSIAs & EASA in Directive 94/56/EC
√
 High number of supplementary regulations can result in differences in practice at national level
√
 EASA’s role in investigations unclear and not clearly defined √
Role of EASA  EASA’s relationship with some NSIAs is currently strained and needs formal clarification √
 Limited access to safety data related to aircraft operator/type (registration/serial number)
√
Relationship &  Tensions exist between NSIAs and judicial authorities √

cooperation
between  Most NSIAs have in place MoUs / cooperation agreements to overcome difficulties with judicial authorities
authorities √
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 Smaller NSIAs have MoUs in place with the bigger, established NSIAs for technical resource support
√
 Formalisation of a central Network is considered beneficial by most MSs for providing better cooperation and
networking
√
 Most MSs have good internal policy in place to encourage and promote a just culture
√
Just Culture  Inadequate legal protection for reporting √
 Inadequate provision in legal framework for establishment of just culture at national level √
Protection of  Non-disclosure of victims & families' names is not adequately protected √

victims &
families  Availability of passenger manifesto in specific timeframe or formalised procedure √
 Inconsistent approach amongst some MSs to handling crisis situations √

Crisis
management  Uncertainty over whether internal procedures / mechanisms appropriately follow ICAO √
recommendations for a crisis management plan
 Possibility of under-resourcing in some NSIAs √
 Smaller NSIAs with fewer accidents lack the opportunity to test & learn from investigations √
Resource levels
in NSIAs
 Better cooperation between smaller NSIAs is needed to promote efficient best practices √
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 Some confusion remains in the interpretation of key definitions leading to a danger of √

Definitions
inconsistencies in reporting
Strength/
Weakness/
OCCURRENCE REPORTING Best
Problem
Practice
 Most MSs feel Directive 2003/42/EC is fit for their purpose at national level √
 Some MSs have still not implemented Directive 2003/42/EC in national legislation
√
 Involvement of judicial authorities in occurrence reporting is unclear
√
Legislation
 Inadequate provision in the Directive for protecting individuals making reports
√
 Inadequate provision for establishing a just culture at national level
√
 No commonly accepted definition of just culture in the legal framework for occurrence reporting
√
 Provisions for EASA’s role is not clear in the legal framework for occurrence reporting and does
not reflect its establishment requirements stated in regulation (EC) 216/2008 √
Role of EASA
 EASA has limited access to specific safety data fields within the central repository, which
hampers its effectiveness in accomplishing its airworthiness responsibility √
 Reporting of ATM-related occurrences is well established and effective under the current
√
Eurocontrol systems
Role of
Eurocontrol
 ESSAR and EVAIR reporting systems are being used effectively and encourage national voluntary
√
reporting within MSs
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 ECCAIRS provides a useful platform for standardising reporting practices if used effectively and
√
more widely across MSs
ECCAIRS &
 Standardised processes for occurrence reporting are not properly developed amongst some MSs
standardisation √
 There are differences amongst MSs in the use of ECCAIRS & local databases for occurrence
√
reporting
 ECCAIRS is being used to some extent for data sharing between MSs √
Exchange of
safety data
 No systematic approach for exchanging safety data between MSs
√
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4. CONCLUSIONS AND RECOMMENDATIONS
How can EU policy contribute to improving the current accident / incident

investigation and occurrence reporting system?
This part of the study draws conclusions and makes recommendations based on an
assessment of the detailed analysis in Parts 2 and 3 of this study. The recommendations
have been supported here by conclusive arguments for EU policy to improve the current
accident / incident investigation and occurrence reporting system.
Recommendation 1:
Role of EASA in accident investigations should be defined as ‘advisory’, working

under the control of the investigator in charge at all times.
EASA is the competent authority in the European Union with responsibility for the
airworthiness of all aeronautical products. It develops common safety rules at European
level and is also responsible for type-certification. Regulation (EC) 216/2008 stipulates that
‘results of air accident investigations should be acted upon as a matter of urgency, in
particular when they relate to defective aircraft design and/or operational matters, in order
to ensure consumer confidence in air transport’. To ensure safety of aircraft design, EASA
should be represented during safety investigations. The extent to which EASA should be
involved in accident investigations must be within the boundaries defined by its
responsibilities.
However, under the existing legal framework, there is no provision to support the
involvement of EASA or indeed to justify a legitimate need for EASA participation in
accident investigations. Given both sides of the argument, there is clearly a need for a non-
ambiguous definition to support EASA participation in accident investigations.
This study concludes that the majority of Member States do not support the view that EASA
should have a more significant role in accident investigation, since they feel this could
jeopardise the independence of the investigating body. The consensus among Member
States is that EASA involvement should be strictly in an advisory capacity. Working as an
adviser under the control of the investigator in charge, EASA would guarantee the
independence of the investigation while also keeping the roles of regulator and investigator
separate.
This approach would be similar to US law, in which there is a legal obligation for the FAA to
be a party in the investigation. The investigator in charge designates parties (Advisers) to
participate in the investigation under its control. This means the FAA would be involved in
the investigations under the control of the investigator in charge.
By allowing EASA similar advisory rights during an accident investigation, it would be able
to exercise its airworthiness responsibilities and act upon design-related safety deficiencies
in an appropriate and timely manner.
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Recommendation 2:
EASA should have unrestricted access to relevant aviation safety data relating to
airworthiness during accident investigations.
EASA has to make important decisions regarding aviation safety in meeting its
airworthiness responsibilities. This involves taking appropriate safety actions, facilitating
safety recommendations and issuing Airworthiness Directives. This necessitates access to
relevant factual information during a safety investigation. EASA needs data on any avionics
product whose design could potentially have contributed to an accident. In particular, EASA
is interested in flight recordings which relate to the design of aircraft avionics which could
potentially affect the safe operation of the aircraft.
However, this requirement for a minimum flow of information is not always fulfilled by
national investigating authorities, and EASA has encountered some challenges in recent air
accident investigations (described in Section 2.4.4 of this report). For example, limited
access to flight data recordings which relate to the design of the aircraft avionics could
potentially affect the safe operation of the aircraft. In some cases, these problems have led
to delays in EASA being able to take important safety action on airworthiness.
Timely access to aviation design-related safety data is important to EASA. This can be
crucial in helping it make a decision to recall an aircraft from service or request that an
avionics part on the aircraft or on the entire fleet be changed. There is therefore a need to
make provision for unrestricted access to safety data through a minimum information flow
to EASA related to airworthiness.
Recommendation 3:
EASA, in collaboration with EU Member States and other ECCAIRS stakeholders,

should contribute to and facilitate improvements in data reporting and analysis of
recurrent incidents through ECCAIRS.
The detailed analysis of incident and accident reporting in Part 2 of this study concludes
there are severe limitations in the quality of data that is currently available in the ECCAIRS
accident and incident database. The analysis also identified a significant problem of under-
reporting of incidents in some Member States. Improvements are necessary in both these
areas in order to have a high level of integrity for data analysis to detect trends and
deficiencies in aviation safety and to take appropriate action to prevent future accidents.
Currently there is no safety data analysis of the ECCAIRS central repository at European
level. EASA, as the competent authority, should collaborate with the aviation authorities
across the EU in a regular exchange and analysis of safety information. By doing this, EASA
will be actively facilitating improvements in the quality and consistency of data reported by
Member States by ensuring an appropriate level of stakeholder engagement, in particular
from the ECCAIRS Steering Committee.
Specific measures to achieve these improvements would be to develop and maintain

relevant guidance material so that Member States are clear on what data needs to be
reported; to facilitate and support regular workshops based on guidance provided; and to
contribute to ECCAIRS training sessions on a regular basis. In addition, EASA should
consider the benefits of sharing in-house data quality verification and analysis tools with
Member States and stakeholders.
The overall objective of this collaborative approach is to improve the level of reporting,
quality and analysis of safety data within ECCAIRS and thus allow EASA to identify trends,
deficiencies and take appropriate action for improving safety.
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Recommendation 4:
EASA should be granted unrestricted access to important safety data in ECCAIRS,

including identification of the aircraft and its operator.
EASA is the responsible authority for certifying aircraft in the EU and therefore has
responsibility for acting on aircraft design deficiencies. Access to relevant factual
information is sometimes necessary for EASA to take timely action. This information could
be crucial when EASA needs to make a decision to recall an aircraft from service or request
that an avionics part on the aircraft or on the entire fleet be changed.
For the exchange and sharing of safety information with Member States, EASA has access
to the ECCAIRS European Central Repository. However, under current legislation, this
access is currently restricted to basic factual data through dis-identification of operator-
specific data. This means each reporting state can simply delete the fields that can identify
the operator. So the practice is to remove the aircraft registration, the serial number, the
operator, the call sign as well as any narrative. To obtain this specific information, EASA
would need to request authorisation from the Member State which initially supplied the
information. This could result in significant delays and an additional barrier to acquiring the
necessary data. Consequently, EASA is sometimes unable to identify safety issues related
to particular aircraft types.
This limitation of occurrence reporting in ECCAIRS does not assist EASA in fulfilling its
airworthiness responsibilities. To overcome these difficulties, Member States should share
Operator specific data fields within the ECCAIRS European central repository. This would
enable EASA to run safety analysis at European level and act on safety deficiencies and
detect trends for particular aircraft types in a timely and efficient manner.
Recommendation 5:
Establish a formally recognised European Network of Civil Aviation Safety

Investigation Authorities to strengthen uniformity in the investigating capacity
across the EU by sharing knowledge between different Member States.
The analysis results of this study highlight a number of areas, with respect to the national
investigating authorities, which need to be strengthened or further developed. These
include:
 Coordination and cooperation in the exchange of safety information between

Member States;
 Facilitate the sharing of resources between NSIAs;
 Relationships between NSIAs and judicial authorities;
 Recommendations to promote good safety practices;
 Training and standardization of qualifications for investigators.
There is currently no central mechanism for ensuring these issues are adequately
addressed and implemented efficiently. A comparative analysis conducted in this study has
shown that some NSIAs may be under-resourced. Smaller NSIAs, in particular, would
benefit from assistance and support from larger, more established NSIAs. Sometimes this
is not forthcoming because the availability of equipment and investigators is unclear or not
always made apparent. Better flow of information exchange between Member States needs
to be encouraged and properly coordinated to promote feedback and communicate lessons
learned through best practice from the investigations.
The study has identified tensions between NSIAs and judicial authorities across the EU .
Sometimes this may relate to difficulties in obtaining access to equipment and wreckage
sites. Although some Member States have managed to deal with this through national
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agreements, there is a need to develop good working relationships and minimise the need
for such formal arrangements.
In some cases, more could be done to improve the skills and expertise of the investigators.
This would be achieved through better coordination and development of common training
and qualifications guidelines for investigators.
To help achieve these improvements, a central independent body is necessary to ensure

better implementation of these tasks and to act in a coordinating role for NSIAs. This
should alleviate some of the problems experienced under the current legislation for
accident/incident investigation. Having in place a central mechanism would promote the
sharing of resources between states. It would coordinate training within NSIAs and
organise peer reviews of NSIAs to promote standardisation on a voluntary basis and the
exchange of safety data between EU aviation authorities.
The creation of a centralised European body, with no legal capacity, would bring clear
benefits in terms of communicating good practices, issuing recommendations where
appropriate and contributing to the overall aim of improving safety. This would be achieved
by a formally recognised European Network of Civil Aviation Investigating Authorities
(referred to as the ‘the Network’ in this report).
Recommendation 6:
Protect sensitive safety information, such as witness evidence, by limiting its

disclosure to the judicial authorities for use in criminal investigations, unless the
competent authority in that Member State determines that there is an overriding
public interest in its disclosure.
Factual information gathered by the safety investigation team may be useful to other
authorities and be shared to support their administrative, judicial or other specific tasks.
However, during the course of an accident investigation, some information such as witness
testimonies and statements is likely to be of a sensitive nature and therefore must be
protected from being disclosed.
Consequently, there have been concerns from some Member States on the inappropriate
use of sensitive information, for example to direct blame or punishment. This has, in some
cases, led to mistrust and a fear amongst individuals of sharing information in future
investigations. It is important, therefore, to ensure that the sharing and analysing of safety
information is used solely for accident prevention purposes and not for passing blame or for
prosecuting individuals making reports or other non-safety related purposes.
Disclosing sensitive information to the police and other judicial authorities can be seen by
some aviation professionals as a threat to voluntary reporting. In some instances, the
police and other judicial authorities insist on all evidence being passed to them so they can
conduct their own investigations for criminal proceedings. However, before disclosing
confidential information, there should be a convincing argument from the competent
authority that the information provided may be related to a criminal act. Also, the
disclosure of individuals’ personal records, when sensitive safety information is used in
criminal prosecutions, must be better protected and these should not be made available or
used for purposes other than safety investigations.
Directive 2009/18/EC establishes fundamental principles governing investigation of

accidents in the maritime sector. This makes clear provisions for protection of sensitive
safety information, and similar principles should apply to safety investigations in the
aviation sector. To support this, proper guidelines should be established in order to define
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under what conditions such sensitive information can be disclosed to the judicial
authorities.
In principle, sensitive and confidential information should not be disclosed unless it is

considered to contribute or add value to the safety investigation.
Recommendation 7:
Airlines departing from an EU airport should provide a list of passengers on board

as soon as possible and no later than two hours after an accident.
The rapid availability of a reliable passenger manifest for the identification of persons on
board an aircraft under investigation and their families is an essential element of the
investigation process. Delays in obtaining lists of passengers on board the aircraft under
investigation can adversely affect search and rescue operations and the identification of
victims of air accidents.
In the immediate aftermath of an accident there is no standardised practice for ensuring

availability of reliable passenger manifests. In EU aviation there is currently no specific
timeframe agreed on availability of the passenger manifest to identify the persons on board
the aircraft.
There is a need to improve the information on passenger manifests and make available a
list of the persons on board the aircraft being investigated as quickly as possible following
an accident. The passenger manifest should be processed in line with European data
protection rules and should not be disclosed without the consent of the victims and families
concerned.
Recommendation 8:
Member States and their respective airlines should have in place a dedicated crisis
management plan, in accordance with ICAO requirements, for providing
assistance to victims and their families involved in an air accident.
There is a need in some EU Member States to be better prepared and equipped for ensuring
fast and adequate assistance to victims and families of victims of an air accident. The
appropriate level of assistance needs to be assured through a proper emergency response
plan at national level within every Member State.
In the EU, some Member States do not appear to have a consistent approach to handling
crisis management. The scope tends to vary widely and some plans are managed by a
range of different organisations. Other Member States have no formal crisis plan but have
procedures which are supported by national regulations and are considered appropriate to
deal with a large scale accident. However, it is not clear whether these internal procedures
adequately follow the ICAO guidelines and recommendations within its provisions for a
safety management system.
Other Member States are still in the process of drafting contingency plans and
communication instructions for contingency planning for dealing with special crisis
circumstances.
The study identified that some investigating authorities have general crisis management
plans at ministerial level which address all events related to any kind of transport. Such
plans are referenced under different headings such as the ‘national human search and
rescue plan’, which can be implemented in the event of an aircraft or ship accident.
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ICAO recommends that any organisation conducting or supporting flight operations should
have in place a crisis management plan. ICAO also recommends that emergency planning
should form part of the organisation’s safety management system in order to learn and
apply safety lessons and minimise damage or injury.
Member States and airlines established on their territory should, in line with ICAO
requirements, have appropriate emergency response plans for ensuring assistance to the
victims of civil aviation accidents and their families.
Recommendation 9:
EASA should develop implementing rules to extend its competences in the domain
of air navigation services and air traffic management, in accordance with the
provisions in the current legislation.
With the ongoing growth in air traffic, not only do safety levels need to be maintained but
also further improvements need to be considered. One important initiative already
addressing this is to create a ‘Single European Sky’ which will ensure common standards
for interoperability of air navigations services and air traffic management across Europe.
A further extension of EASA competences would support this initiative by ensuring a

common regulatory framework of rules across Europe. It can also be argued that there
would be a positive impact on the environment through common standards. This would
provide a fully integrated safety system across all elements of the aviation safety domain.
The intended transfer of ATM functions and tasks of the Member States, through
cooperation with EUROCONTROL, to EASA has already been addressed in Regulation (EC)
1108/2009 of 21 October 2009. This study supports this provision to extend the tasks of
EASA towards a ‘total system approach’ to airport safety and interoperability, air navigation
services and air traffic management.
Recommendation 10:
Occurrence reporting under the ICAO and EU taxonomies should be consistent

towards an obligation to report accidents and serious incidents using a common
terminology of definitions across all taxonomies (including Eurocontrol ESAAR 2).
The study (Section 2.3.4) highlights how inconsistencies in the interpretation of definitions
can lead to problems with respect to reporting and misleading statistics. At EU level, there
is some confusion with the definitions for ‘serious incident’ and ‘incident’ and there have
been instances where the term ‘incident’ may have been used in lieu of ‘serious incident’.
Under the Eurocontrol taxonomy, ESARR 2 uses the term ‘occurrence’ in a broader sense to
encompass ATM accidents, incidents and other ATM–specific events. However, uncertainty
as to what is ‘ATM-related’ can also lead to difficulties in ensuring that suitable and
meaningful data are available for use in statistical analysis.
The study concludes that the current European legal framework for occurrence reporting
needs to be better structured. The reporting system governed by the separate EU
Directives and Commission Regulations appears to be operating independently, is
fragmented and is only partially interlinked. As well as the apparent discrepancies in the
terminology used for definitions, the associated inconsistencies in obligations to report
occurrences under the different taxonomies are a key concern.
Under ICAO, Member States are obliged to notify accidents and serious incidents using the
ADREP 2000 database system (Section 2.5.3).
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At EU level, Directive 94/56/EC (Article 7) does not make provision for reporting
occurrences and only enforces an obligation to make public the final accident reports
produced by the national accident investigation authorities. Reports on the investigation of
incidents are also circulated, but only to parties likely to benefit from their findings with
regard to safety. Directive 2003/42/EC imposes an obligation to report incidents, but not
accidents or serious incidents. However, the implementing rules for ECCAIRS in
Commission Regulation (EC) No 1321/2007 provide that, during an on-going investigation,
only basic factual data should be entered into the databases while full information on these
accidents and serious incidents would be stored once the investigation is completed. This is
a significant shortcoming in the occurrence reporting structure which creates a risk of
confusion.
It is essential that the relevant terminology is clearly and accurately defined and that there
are clear reporting obligations under the ICAO and EU taxonomies to ensure that
misinterpretations and inconsistencies do not pose a risk to aviation safety.
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July 2002 on common rules in the field of civil aviation and establishing a European
Aviation Safety Agency (repealed by new basic regulation (EC) No 216/2008).

December 2005 on the establishment of a Community list of air carriers subject to
an operating ban within the Community.

February 2008 on common rules in the field of civil aviation and establishing a
European Aviation Safety Agency, and repealing Council Directive 91/670/EEC,
Regulation (EC) No 1592/2002 and Directive 2004/36/EC.
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Proposed Regulations & Related Documentation
 Impact Assessment SEC(2009) 1478 on investigation and prevention of accidents

and incidents in civil aviation (Study Ref: page 22).
 Impact Assessment TREN-IA-016-TR 14923 on the modification of Directives

94/56/EC & 2003/42/EC, ECORYS Nederland BV, 20 July 2007.
 Proposal COM(2009) 611 - 2009/0170 (COD) of the European Parliament and of the
Council on investigation and prevention of accidents and incidents in civil aviation
(Study Ref: Section 1.2.3, page 22).
Other Documentation
 ECCAIRS (European Co-ordination Centre for Aviation Incident Reporting Systems)

Brochure & ECCAIRS in Aviation (February 2010), Joint Research Centre (JRC) of the
European Commission, Post, Wietse (Study Ref: page 69).
 EVAIR – Eurocontrol Voluntary ATM Incident Reporting, part of the European Safety
Programme (ESP) for incident reporting and data sharing (Study Ref: Section 2.5.6,
page 73).
 ICAO Guidance on Assistance to Aircraft Accident Victims and their Families (ICAO
Circular 285-AN/166), 2001.
 ICAO Letter on ‘Adoption of Amendment 12 to ICAO Annex 13’, Secretary General, 9

April 2009.
 ICAO Manual of Aircraft Accident and Incident Investigation (ICAO Doc 9756
AN/965, First Edition, 2000) on guidance on notification of accidents and incidents)
(Study Ref: Section 1.1.2, page 19 – Guidance Material).
 ICAO Safety Management Manual (SMM), 2nd Edition, 2009, ICAO Doc 9859,
Chapter 11 – guidelines on Emergency Response Planning (Study Ref: Section
2.3.15, page 57).
 ICAO Training Guidelines for Aircraft Accident Investigators (ICAO Circular 298-
AN/172), June 2003.
Study Papers and Reference Material
 EASA Annual Safety Review 2007 – Overview of aviation safety measures taken in
different EASA Directorates (Study Ref: Section 1.4.1, page 29).
 EASA News – February 2010: ‘Continuing Airworthiness and Occurrence Reporting’

by the EASA Certification Directorate.
 ERAA (European Regional Airlines Association) Draft Policy Paper on EC Proposal

(COM(2009) 611), (Study Ref: Section 2.3.12, page 56).
 Europe Air Sports, Position Paper on ‘Proposal for a Regulation on investigation and
prevention of accidents and incidents in civil aviation (2009/0170 (COD)), 1
February 2010.
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 ICAO, Montreal, October 2008, Working paper (AIG/08-WP/33) on Just Culture;

Definition and implementation of a Just Culture concept.
 TRANNews – Newsletters from the European Parliament Committee on Transport

and Tourism (1 March 2010, 27-28 April 2010, 31 May – 1 June 2010); EP Press
release 21.9.10, Rapporteur: Ms Christine de Veyrac (EPP, FR).
Websites
 ECCAIRS (European Commission - Joint Research Centre) available at:
http://eccairsportal.jrc.ec.europa.eu/
 ESARR 2:
http://www.eurocontrol.int/src/gallery/content/public/documents/deliverables/esarr
2_e3.0_ri.pdf
 EVAIR (Eurocontrol Voluntary ATM Reporting):

http://www.eurocontrol.int/esp/public/standard_page/evair.html
Accident Investigation Reports
 Airbus A320, “Loss of Thrust in Both Engines After Encountering a Flock of Birds and
Subsequent Ditching on the Hudson River, US Airways Flight 1549, Airbus A320-214,
N106US Weehawken, New Jersey, January 15, 2009”, National Transportation
Safety Board, Accident Report NTSB/AAR-10/03, 4 May 2010 (Study ref: Section
2.4.4, page 61).
 Airbus A330 Incidents, Miami to Sao Paulo, TAM, May 2009 and Hong-Kong to
Tokyo, Northwest Airlines, June 2009 (Study Ref: Section 2.4.4, page 62).
 Airbus A330-203, “Interim Report n°2 on the accident on 1 June 2009 to the Airbus
A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro –
Paris”, Bureau d'Enquêtes et d'Analyses, France, Report BEA f-cp090601ae2, 17
December 2009 (Study Ref: Section 2.4.4, page 62).
 Airbus A330-303, “In-flight upset, VH-QPA, 154 km west of Learmonth, Western

Australia, 7 October 2008”, Australian Transport Safety Bureau, Interim Factual
Report, 6 March 2009 (Study ref: Section 2.4.4 page 62).
 Boeing 777 incident, USA, Delta Airlines, November 2008 (Study Ref: Section 2.4.4,
page 61 in text of Boeing 777 air crash, January 2008).
 Boeing 777-236ER, “Report on the accident to Boeing 777-236ER, G-YMMM, at

London Heathrow Airport on 17 January 2008”, Air Accident Investigation Branch,
Department of Transport, Aircraft Accident Report 1/2010 (Study Ref: Section 2.4.4
page 61).
 Fokker F28 Serious Incident, Oslo, January 2008 (Study Ref: Section 2.4.4. page
61).
 MD82, “Accident involving McDonnell Douglas DC-9-82 (MD-82) aircraft, registration

EC-HFP, operated by Spanair, at Madrid-Barajas Airport on 20 August 2008”,
Comisión de Investigación de Accidentes e Incidentes de Aviación Civil, Report
CIAIAC A-032/2008, 17 August 2009 (Study Ref: Section 2.3.13, page 56 and
Section 2.4.4 page 61).
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 MD83 serious incident, Lanzarote, June 2007 (Study Ref: Section 2.4.4, page 61 in
text of MD82 air accident, August 2008).
List of consulted stakeholders/parties
 Air Accidents Investigation Branch (AAIB), Chief Inspector for the UK AAIB –
Discussions & Survey Interviews, November 2009.
 Air Navigation Service Providers (ANSPs) in all EU Member States, consulted

between November 2009 and April 2010.
 Civil Aviation Authorities (CAAs) in all EU Member States, consulted between

November 2009 and April 2010.
 ECCAIRS Reporting System - Action Leader ECCAIRS for Joint Research Centre of
the European Commission, Wietse Post, Telephone & email discussions, February
2010.
 Eurocontrol – ‘ATM Network Support & Services Business Area’, Survey interview &
teleconference, November 2009.
 European Aviation Safety Agency (EASA) – Survey interview & video-conference /

email discussions with Accident Investigation Manager (Safety Analysis & Research
Department) & Certification Director, Jan – Feb 2010.
 European Regional Airlines Association (ERAA) – Adviser for Air Transport Policy on
Draft Policy Paper on the proposal by the European Commission (EC) to amend the
accident investigation Directive, November 2009.
 National Safety Investigation Authorities (NSIAs) in all EU Member States, consulted

between November 2009 and April 2010.
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Annex I A summary comparison between the proposed

new regulation and EU Directive 94/56/EC
Commission Proposal COM

(2009)0611 for a New Regulation Directive 94/56/EC – establishing
New Regulation on the investigation and fundamental principles governing
Article heading prevention of accidents and the investigation of civil accidents
incidents in civil aviation & incidents
Obligation to To investigate every accident / serious

investigate incident and other incidents (if safety
benefit expected). Extent of investigation As covered in new regulation.
(Article 4) and procedures to be determined by
investigation authority and will be without
blame or liability.
Safety investigations shall be independent

from and without prejudice to any judicial
or administrative proceedings to apportion Not specifically addressed.
blame or liability.
Civil Aviation Safety investigations are to be conducted

Safety or supervised by a permanent investigation
Investigation authority without external interference and
Authority independently of any other parties who
may have conflict of interest or influence
(Article 5) its objectivity. Activities may include As covered in new regulation.
gathering and analysis of safety-related
data as long this does not affect the
authority’s independence and it is able to
obtain sufficient resources to carry out its
responsibilities, in particular:
- Investigation authority must have at
least one investigator able to act as
investigator-in-charge in event of
major accident
- Head of safety investigation must be

experienced & competent.
- Investigators’ status must be such as
to guarantee them independence
- Investigation authority shall have a
dedicated budget allocated Not specifically addressed.
- Investigation authority shall have
qualified personnel & adequate
facilities for storage, examination of
aircraft and contents, etc.
In performing its duties, the authority must
not take instructions from anybody and
must have unrestricted authority to
conduct the investigation.
Cooperation Assistance can be requested from one

between Safety national investigation authority to another,
Investigation at no cost. The Member State may
Authorities delegate another Member State to conduct As covered in new regulation.
the investigation.
(Article 6)
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The investigation authority may also be Not specifically addressed.

assisted by the Network of civil aviation
safety investigation authorities.
European Network European Network of Civil Aviation Safety

of Civil Aviation Investigation Authorities shall comprise of
Safety respective heads from Member States. The
Investigation network shall coordinate, exchange
Authorities information and facilitate cooperation
between Member States, the Commission Not specifically addressed.
(Article 7) & EASA. The Network shall advise and
recommend on accident investigation
policy and regulation. It shall submit an
annual report to the European Parliament,
the Council and the Commission and then
make this public.
Organisation of The main key elements under this new

the work of the regulation:
Network
- election of chairperson from its
(Article 8) members (up to 5 years)
- involve EASA and the Commission,
providing there is no conflict of
interests
- serve in the general European interest
& receive grant approval from
Community budget, based on annual
Not specifically addressed.
work programme
- permit participation of European third-
countries and members of
investigation authorities to attend
meetings
- permit participation of investigation
authorities in exchanges of
information, while ensuring national
state confidentiality
- work with the Commission to ensure
confidentiality of sensitive information
Participation of Within the scope of its competence and

EASA in safety under the control of the investigator in
recommendations charge, EASA shall be invited by Not specifically addressed.
investigation authorities of Member States
(Article 9)
Participation of The investigation authority of the Member

the State of State within which the aircraft design
Design in safety certificate holder is located shall appoint an Not specifically addressed.
investigations accredited representative for the State of
Design (in accordance with Annex 13 of
(Article 10) Chicago Convention)
Obligation to Any person shall notify the investigation

notify of accidents authority of an accident / serious incident
and serious within the scope of the regulation. The Not specifically addressed.
incidents investigation authority must then notify,
accordingly, the Commission, EASA and
(Article 11) the Member States concerned immediately.
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Status of the The appointed investigator-in-charge shall Details will be in accordance with the
safety ensure safe control of evidence material, national law of the Member State & in
investigators safe custody of aircraft and its contents cooperation with judicial authorities.
and wreckage and take measures to satisfy
(Article 12) the investigation.
The regulation defines authorisation for
investigators e.g. to have free & immediate
access to accident site, wreckage, flight
recorders and examination results of
victims & of people involved in aircraft
As covered in new regulation.
operation.
The investigator-in-charge shall extend to

its experts and advisers, as necessary,
such assistance as will enable effective Not specifically addressed
participation in the safety investigation.
Coordination of The investigator-in-charge shall coordinate

enquiries with the judicial authority, without
prejudice, in handling inquiries related to Not specifically addressed
(Article 13) the accident safety investigation as well as
the investigation into the causes of these
accidents/incidents.
Preservation of The necessary steps must be taken to

evidence ensure preservation of documents,
material and recordings, unless such action Not specifically addressed
(Article 14) is necessary for safety reasons and/or to
help the injured.
Protection of The regulation defines which safety records

sensitive safety shall not be made available or used other
information than for safety investigation or with the
purpose of improving aviation safety.
(Article 15)
However, the Member State administration
authority may decide there are benefits in
its disclosure to the public.
EASA’s role in the protection of sensitive Not specifically addressed.
safety information shall be as follows:
- participate in exchange & analysis of
information covered in Directive
2003/42EC
- have access to all information in
central repository (Regulation (EC)
1321/2007)
- ensure confidentiality of such
information & limit its use
Use of recordings Voice/image recordings & transcripts shall

only be used for purposes of the safety
(Article 16) investigation and with consent of all crew
members concerned. The regulation also Not specifically addressed.
stipulates the availability & usage of flight
data recorders under certain
circumstances.
Publication of Only information relevant to the analysis of Not specifically addressed.

information accident/incident will be made public in the
final report of the safety investigation.
(Article 17)
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Communication of The regulation, under Article 18, states:

information
- safety investigation authority staff /
(Article 18) adviser participating in safety
investigation shall be legally bound by Not specifically addressed.
‘professional secrecy under the
relevant Member State’s law
- Head of safety investigation authority
shall inform other aviation safety
authorities, as appropriate
- Head of safety investigation authority
has authorisation to inform victims &
family as well as make public the
factual observations of the
investigation
Investigation Specific regulatory points relating to the

report investigation report have been defined.
These include inclusion of safety
(Article 19) recommendations, anonymity protection of Not specifically addressed.
people involved, prior disclosure of
information, release of an interim report
and the provision of the reports to the
Commission & EASA.
All safety investigations shall be the

subject of a report in a form appropriate to
the type and seriousness of the accident or
incident. As covered in new regulation.
The safety investigation authority shall
make public the final report in the shortest
possible time and if possible within 12
months of the date of the accident at the
latest.
Safety The safety investigation authority shall

recommendations formally recommend to its own authorities,
other Member States or third countries,
(Article 20) any preventive action considered necessary
for prompt action.
Not specifically addressed.
Safety recommendations may be issued by
the investigation authority based on
studies or analysis of a series of
investigations / activities.
The safety recommendation shall not As covered in new regulation.

create a presumption of blame or liability
for an accident or incident. Member States shall take into
consideration and act upon safety
recommendations, without presumption of
blame or liability.
Follow-up to Article 21 defines legal requirements for

safety transmit and receipt of safety
recommendations recommendations between the safety
and safety investigation authority and the addressee. Not specifically addressed.
recommendations
database These include the procedures, monitoring
and the recording of safety
(Article 21) recommendations in a repository database.
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Availability of Airlines departing from an airport that is in

passenger lists the territory of a Member State shall have
procedures in place to produce a list of all Not specifically addressed.
(Article 22) passengers on board an aircraft within 1
hour of the notification of the occurrence of
an accident involving this aircraft.
Assistance to the Within each Member State, a plan for

victims of air assistance to victims of civil aviation
accidents and accidents shall be set up. Also, Member Not specifically addressed.
their families States with a special interest in an accident
may appoint an expert to visit the site and
(Article 23) shall have the right to see relevant safety
information as well as the final report.
The expert may assist in the identification
of victims and communications with
survivors of its state.
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Annex II Overview of national law as it affects the

aviation authorities for selected Member States
This section provides a brief overview of the authorities and national laws in place for
accident investigation and occurrence reporting in 10 selected Member States.
Table II.1: United Kingdom
United Kingdom
National Civil Aviation Regulator The Civil Aviation Authority (CAA)
Operates independently and oversees and regulates all aspects of

aviation in the UK.
Administers a mandatory occurrence reporting system under Articles 142

of the Air Navigation Order (ANO) which implements EU Directive
2003/42/EC.
Investigation authority Air Accidents Investigation Branch (AAIB)
Independent part of the Department for Transport, responsible for the

investigation of civil aircraft accidents and serious incidents within the
UK.
Works closely with the CAA to ensure any occurrences reported to the
AAIB are appropriately passed onto the CAA for its records.
Applicable national regulation: UK Statutory Instrument for the
Investigation of Civil Air Accidents & Incidents. This regulation
incorporates requirements of Directive 94/56/EC.
Air Navigation Service Provider National Air Traffic Services (NATS)
NATS monitors safety performance through its incident reporting and

investigation process.
Relationship between technical UK AAIB has memorandums of understanding (MoUs) with the police
and judiciary authorities service of Scotland and the Crown Prosecution Service – details
unavailable at this time.
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Table II.2: Czech Republic
Czech Republic
National Civil Aviation Regulator Civil Aviation Authority of Czech Republic (CAA CZ)
CAA CZ is established by Section 3 of the Act No 49/1997 Coll. on civil

aviation.
CAA CZ has had new responsibilities since July 2006 in accordance with
Act No 225/2006 Coll. (amending Act No 49/1997 Coll.). These are
specifically with regard to Flight Operations Division and ATM and
Aerodromes Department.
Investigation authority Air Accident Investigation Institute
Independent investigation authority for aviation accident investigation.
Accidents and incidents that concern both civil and military aircraft are
handled with the Institute cooperating with the Ministry of Defence.
Applicable national legislation: ACT of the Czech Republic No 49/1997

Coll. on civil aviation.
Directive 94/56/EC - fully transposed into Act No 49/1997 on Civil

Aviation, as amended (28 Jun 2002).
Directive 2003/42/EC - fully transposed into Act No 49/1997 on Civil

Aviation, as amended (1 July 2006).
Air Navigation Service Provider ANS CR (Air Navigation Services of the Czech Republic)
ESARR 2 implemented through national regulation L13.
Relationship between technical No specifically agreement between the AAII and Judicial authorities.
and judiciary authorities Basic cooperation is established in Act No 49/1997 on Civil Aviation, as
amended.
Table II.3: Denmark
Denmark
National Civil Aviation Regulator Danish Civil Aviation Administration (CAA-DK)
The Danish Air Navigation Act provides the framework for the regulation
of civil aviation in Denmark. The Act authorises the Ministry of Transport
& Energy to set regulations for civil aviation. This authority has been
delegated to the CAA-DK.
CAA-DK issues regulations for civil aviation (referred to as BL). These

cover different safety aspects of the air transport system.
CAA-DK BL 8-10: Regulations on mandatory reporting of flight safety

occurrences
Investigation authority The Danish Accident Investigation Board (AIB)
Independent institution under the Ministry of Transport.
Investigates accidents & serious incidents for both civil aviation &
railways. AIB investigations within civil aviation include Greenland and
the Faroe Islands. The AIB may represent Denmark in investigations
involving Danish Aircraft/passengers in a foreign State.
The AIB coordinates with military authorities to agree on accident /

incident investigations involving military aircraft.
Directive 94/56/EC transposed - Air Navigation Act Section 134 to 144

(Provision No 1484 of 19 December 2005).
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Directive 2003/42/EC transposed - BL 8-10 (10 February 2009) and BL

5-40 (30 April 1997). BL 8-10 describes the mandatory occurrence
reporting system
Air Navigation Service Provider Danish Air Navigation Services (NAVAIR)
National regulations under BL-07 series cover legislation applicable to

provision & operation of air traffic services.
Relationship between technical The AIB DK has drafted and discussed a MoU with the authorities, but it
and judiciary authorities has not been signed by the police yet as they are evaluating it.
Table II.4: Portugal
Portugal
National Civil Aviation Regulator INAC (Instituto Nacional de Aviacao Civil)
Investigation authority GPIAA-Gabinete de Prevencao e Investigacao de Acidentes com

Aeronaves
In terms of hierarchy and administration, GPIAA is part of the Ministry of

Transport. The Cabinet of Aircraft Accidents Prevention and Investigation
– (The Portuguese AIB).
GPIAA is permanently established as an official and independent air

safety branch.
Directive 94/56: transposed into national law, through Decree No 318/99

of 11th of August 1999, and amended by Decree No 149/2007 of 27th of
April 2007, and it had been fully implemented.
Air Navigation Service Provider NAV Portugal
Certified in December 2006.
Relationship between technical GPIAA cooperates with judicial authorities and has good mutual
and judiciary authorities cooperation with all entities related to air safety.
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Table II.5: Estonia
Estonia
National Civil Aviation Regulator Estonian Civil Aviation Authority (Estonian CAA)
The Estonian CAA ensures aviation safety & execution of aviation policy
at national level. It is part of the Ministry of Economic Affairs &
Communications.
The state administration of civil aviation is exercised by the CAA within

the scope of the national Aviation Act which came into force in
September 1999.
The Aviation Act extends to military aviation operations.
Investigation authority Aircraft Accident Investigation Department
The investigating entity is the Crisis Management Department, which is

also part of the Ministry of Economic Affairs & Communications.
Directive 94/56/EC – full implemented.

Air Navigation Service Provider Estonian Air Navigation Services (EANS)
Framework agreement (September 2009) between EANS and Tallinn

Airport specified handover of air navigation services to EANS with the
cooperation of regional airports.
Relationship between technical
and judiciary authorities
Table II.6: Germany
Germany
National Civil Aviation Regulator Luftfahrt-Bundesamt (LBA)
Responsible for the regulation and oversight of air transportation in

Germany and subordinated to the Federal Ministry of Transport, Building
& Housing (BMVBW).
It is based on the national Air Traffic Law.

Investigation authority German Federal Bureau of Aircraft Accident Investigation
(Bundesstelle fur Flugunfalluntersuchung (BFU)
Subordinated to the Federal Ministry of Transport and responsible for

investigation of civil accidents and serious incidents.
Applicable national legislation: Directives 94/56/EC and 2003/42/EC have

both been transposed into German national law through the German
Aviation Order. This is also harmonised with ICAO Annex 13.
Air Navigation Service Provider German Air Navigation Services (DFS)
Responsible for air traffic control in Germany and operates under private
law, 100% owned by the Federal Republic of Germany.
DFS is responsible for handling both civil and military air traffic.
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Table II.7: France
France
National Civil Aviation Regulator Direction General de l’ Aviation Civile (DGAC) of the Ministry of
Equipment, Transport, Building & Housing
Investigation authority Bureau d’Enquêtes et d’Analyses (BEA), part of the same Ministry
The BEA is the French body responsible for technical investigations into
civil aviation accidents or incidents.
Directive 94/56/EC transposed through Decree in Nov. 2001.

Directive 2003/42/EC transposed by law in Jan. 2006.
Air Navigation Service Provider DSNA – Direction des Services de la Navigation Aerienne
DSNA includes all the operational, technical and administrative

organisations contributing to the provision of French air navigation
services, in France and overseas.
ESARR 2 full implemented and transposed into national legislation.

Table II.8: Romania
Romania
National Civil Aviation Regulator RCAA – Romanian CAA
Investigation authority Ministry of Transport and Infrastructure Department of Air

Transport Investigation
Investigation Authority is independent and reports directly to the Ministry

of Transport and Infrastructure.
Directive 94/56/EC transposed into national legislation through

Government Ordinance No 51/1999 for technical investigation of
accidents and incidents in civil aviation.
Directive 2003/42/EC transposed into national legislation by Ministry of

Transport Ordinance No 159/2006
Air Navigation Service Provider Romanian Air Traffic Administration R.A. (ROMATSA R.A.)
ESARR 2 implemented
Relationship between technical Cooperation between judicial authorities and technical investigation is in
and judiciary authorities accordance with national legislation, 399/2005 Law - Air Code and
Government Order 26/2009.
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Table II.9: Netherlands
Netherlands
National Civil Aviation Regulator CAA-NL (Civil Aviation Authority – Netherlands)
CAA-NL – part of the Netherlands’ Transport and Water Inspectorate.

Investigation authority Dutch Transport Safety Board
Safety Investigation Board Act came into force in Feb. 2005.
Directives 94/56/EC & 2003/42/EC both transposed in 2005.

Air Navigation Service Provider LVNL – Dutch ANSP & Maastricht UAC of EUROCONTROL
Netherlands airspace has 2 main civil service providers:

- LVNL (lower airspace & airports)
- Maastricht UAC (upper airspace)
ESARR 2 implemented.
Relationship between technical Judiciary authorities may have full access to investigations and data from
and judiciary authorities safety reports.
Judiciary is particularly strong on prosecution in all safety occurrences

resulting from gross negligence/misconduct.
Table II.10: Spain
Spain
National Civil Aviation Regulator Spanish Aviation Safety Agency (AESA)
Investigation authority Accident & Incident Investigation Commission (CIAIAC)
Directive 94/56/EC transposed (Royal Decree 389/1998).
Directive 2003/42/EC transposed (1334/2003) – November 2005.

Air Navigation Service Provider AENA – Safety Division / Air Navigation Directorate
ESARR 2 implemented but not transposed into national legislation due to

military concerns.

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Annex III Survey Questionnaire

This is a blank copy of the survey questionnaire which was sent to all EU Member States to assess the practical application of the system of
accident/incident investigation and occurrence reporting in civil aviation within the EU Member States. For further details on how this survey
was used see Section 2.0 of this report.
Survey
Survey Respondent Details:
Please provide details requested below:
Survey Record Sheet
COUNTRY:
Organisation
/Department and
Company:
Name of
Respondent(s):
Position/Job Title
(Brief Description):
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1. Policy, Strategy &

Specific Focus (Findings/Evidence) Comments
Regulations
ICAO Annex 13  To what extent have ICAO Annex 13 standards and

recommended practices been incorporated into national
law?
(Not incorporated/partially incorporated/fully
incorporated)
 To what extent are the standards and recommended

practices contained within ICAO Annex 13 followed by
the national aviation authorities?
(Fully/partially/not followed).
 Are there deviations from the Annex 13 provisions?

Where there are deviations what are the reasons and
how are they reported to ICAO?
Directive 94/56/EC  Has 94/56/EC been transposed into national law

(provide date and relevant details) and been fully
implemented?
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Regulations
 Do you think Directive 94/56/EC fully meets the
requirements of the state?
If not, please state reason.
 Is adequate protection provided under the Directive for

individuals involved in reporting an accident or serious
incident?
Directive  Has 2003/42/EC been transposed into national law

2003/EC/42 (provide date and relevant details) and been fully
implemented?
 Is Directive 2003/EC/42 fit for purpose? Please state

any significant shortcomings
 What protection is provided to individuals reporting

accidents and incidents?
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Regulations
National  Who does the Investigation Authority report to?

Investigation  Is the Investigation Authority Independent?
Authority
 Is the Investigation Authority part of the Ministry of
Transport or does it operate as a separate entity within
the Member State?
 When was the Investigation Authority founded?
 What is the size of the Investigation Authority

organisation (number of staff, number of technical/non-
technical)?
 How permanent is it?

E.g. Authority is permanently formed or only brought
together when there is an incident.
 Is the accident investigation authority solely

responsible for aviation or does it also investigate
accidents/incidents for other sectors? (e.g. rail,
maritime)
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Regulations
 Does the State have a freedom of information act in

‘Freedom of place?
Information Act’
 If not, then what national legislation, if any, exists for
the confidential reporting of accidents/incidents?
 Do you have in place any additional national legislation

Additional National or practices which supplement the requirements of
Regulations / ICAO Annex 13 and Directives 2003/EC/42 and
Practices 94/56/EC?
Additional Please make any additional comments relating to Policy, Strategy & Regulations
Comments
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2. Cooperation with
other Organisations and Specific Focus (Findings/Evidence) Comments
Member States
Relationship and  Please identify any specific issues/problems of concern

relating to working practices between the national
Cooperation between investigation authority and other organisations (e.g.
the national aviation police, search and rescue, etc)
investigation
authority and other  Please state any MoUs (memorandums of understanding)
or other agreements in place with other organisations.
organisations
 How effective are the measures in place to manage the

following interactions:
 With judicial authorities
 With airlines
 With airport authorities
 With other organisations
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2. Cooperation with
other Organisations and Specific Focus (Findings/Evidence) Comments
Member States
Comment on the following:

Relationship between
your Investigation  To what extent, if at all, does the investigation
authority and authority cooperate with other investigation
investigation authorities?
authorities from
 Do you think a central European network acting as a
other Member States coordinator between national aviation authorities
would be beneficial?
 Under what circumstances, if any, is the assistance

of another Member State requested in the technical
investigation?
Additional Comments Please state any additional comments relating to Cooperation with other Organisations and Member States
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3. Resources Specific Focus (Findings/Evidence) Comments
Aviation Safety Database  Does the investigation authority have an established

and repository system database system used to facilitate the effective
analysis and exchange of aviation accident/incident
safety data?
 Does the investigation authority have a central

repository system to record all safety
recommendations?
 Do you hold a database of reported incidents?
 Do you hold a database of investigated incidents and

the results of inquiries?
 If so, how is this data used?
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Departmental Resource  Does the investigation authority have sufficient

capability to conduct resources to conduct its own safety investigations?
investigations  To what extent, if any, does the national regulator
get involved in investigations internally, and does it
have sufficient resources for this?
 To what extent, if any, does the ANSP get involved in

investigations internally, and does it have sufficient
resources for this?
 Are there cases where several investigations are run

in parallel, i.e. where the investigation authority, the
CAA and the ANSP each run their separate
investigations?
 In such cases where the regulator / ANSP are also

involved, does this impose any issues for the
investigation authority to meet the requirement
(Directive 94/56/EC) for national independent
investigations?
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Use of Flight Recorders in  What measures are in place for the handling and use
the investigation of flight data recorders in the investigation?
 Are facilities available to process the flight

recordings?
 What additional resources can be provided?
 What measures are in place to ensure all crew

members concerned are appropriately consulted prior
to making available the recordings / transcripts for
safety investigation?
Investigation Authority  Are there any issues / concerns relating to the

Resource Provision provision of an adequate budget to support the
investigation process?
 Is the national investigation authority allocated a

dedicated budget to enable the payment of technical
examinations and travel expenses?
 Are there any other resource concerns, such as

insufficient personnel, limited technical expertise,
internal organisational arrangements etc?
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Additional Comments Please state any additional comments relating to Resources
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4. Definitions used in
Accident/Incident Specific Focus (Findings/Evidence) Comments
Investigation & Reporting
‘Accident’
 Means an occurrence
associated with the operation
of an aircraft which takes
place between the time any  Do you use the definition provided in
person boards the aircraft Directive 94/56/EC? If not, please provide
with the intention of flight the definition used.
until such time as all such
persons have disembarked, in
which:
- a person is fatally or seriously

injured
- the aircraft sustains damage
or structural failure
- the aircraft is missing or is  If you use a different definition, please
completely inaccessible state the reason why.
Reference Directive
94/56/EC
‘Incident’  Do you use the definition provided in

 Means an occurrence, other Directive 94/56/EC? If not, please provide
than an accident, associated the definition used.
with the operation of an
aircraft which affects or would
affect the safety of operation.
Reference Directive  If you use a different definition, please

94/56/EC state the reason why.
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‘Serious Incident’
 Means an incident involving  Do you use the definition provided in
circumstances indicating that Directive 94/56/EC? If not, please provide
an accident nearly occurred. the definition used.
Reference Directive
94/56/EC  If you use a different definition, please
state the reason why.
Access to national accident

definitions  Are there national accident and incident
definitions available to all relevant parties?
If so, how are they accessed/published?
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Additional Comments Please state any additional comments relating to Definitions used in Accident/Incident Investigation &
Reporting.
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5. Accident/Incident
Investigation – Processes, Specific Focus (Findings/Evidence) Comments
Procedures and Systems
Notification of an accident or  Who is the initial point of contact for reporting?

serious incident
 Is there an agreed timeframe for providing
notification?
 How is the notification of an accident or serious

incident issued (e.g. verbal communication, in
writing, report, other)?
Steps following notification Upon receiving notification of an accident (e.g. from

of an accident aircraft operator/pilot or air service provider), what are
the immediate actions by the following:
 The investigation authority
 National civil regulator
 Service provider (ANSP)
 Other authorities (airlines, airport operator)
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Availability of and access to What measures are in place for:

appropriate processes and  Gathering, recording and analysing all available
tools for conducting the information on the accident/incident
accident investigation
 Issuing safety recommendations
 Determining the causes
 The completion of the final report
Are these measures effective? If not, please state your

reasons.
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Communicating aviation What procedures and mechanisms are in place for the
safety data to key aviation investigation authority to communicate relevant data to
the following?
safety authorities
 EASA
 EUROCONTROL
 Aircraft operators
 Aircraft equipment manufactures
 The National Regulator (CAA)
 The Service Provider (ANSP)
 Others
Is there a periodic (e.g. annual) summary safety report

published containing data on events reported by the
investigation authority?
Measures in place during the What measures are in place to ensure the following:
safety investigation.
 The proper conduct of independent safety
investigations
 Access to accident/incident property (aircraft,

equipment etc) and documentation
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 Please identify any specific issues/problems of

concern relating to the authorities’ access to safety
data (e.g. fear of possible criminal action)?
 To what extent is the disclosure of evidence

prohibited outside your investigation authority? Can
information be passed over to others, e.g. the police
or other criminal investigators?
 Are there any additional measures that may further

ensure the independence of safety investigations?
Unlawful interference in  What process (if any) currently exists to prevent

safety investigation and deal with suspected acts of unlawful
interference during the safety investigation?
Legal powers granted to the  What specific powers are given to the safety
investigator? E.g. gathering of evidence, interviews,
Safety Investigator powers of entry, etc.
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Adequate protection for  Does the current investigation reporting system

victims of air accidents adequately protect the rights of the victims of air
accidents and their families?
 Is the level of protection provided by the state’s

current judicial system sufficient?
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Third-party aircraft  Briefly outline the procedures and processes in

(Non-EU Aircraft operators) place for conducting inspections on third-party
aircraft landing at the state’s airports which are
suspected of not complying with international safety
standards (ref: Directive 2004/36/EC).
 Are ramp inspections carried out?
 How is the relevant safety data collected and made

available to the other authorities (CAA, ANSP,
airport authority, airlines)?
 How is this information communicated to the

following:
o European Commission
o EASA
o EUROCONTROL
o Others
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‘Incident’ investigations  What measures and procedures does the

investigation authority have in place for specifically
investigating ‘incidents’ in addition to accidents and
serious incidents?
Additional Comments Please state any additional comments relating to the Accident/Incident Investigation – Process, Procedures
and Systems.
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6. Organisational Structure,
Roles & Responsibilities
Involvement of the  What is the level and nature of the support your
‘European Aviation Safety organisation receives from EASA? Is this fit for
purpose?
Agency (EASA)’
 Are there appropriate procedures in place for
reporting results of air accident/incident
investigations to EASA?
 To what extent, if any, are EASA experts included in

the independent investigation of accidents and
incidents?
 Do you think EASA should play a more significant role

in the investigation process?
 If so, then please state what this role may be, as well
as why EASA should take on a more significant role.
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6. Organisational Structure,
Roles & Responsibilities
Involvement of  What is the level and nature of support your

‘EUROCONTROL’ organisation receives from EUROCONTROL? Is this fit
for purpose?
 To what level has ESARR2 (EUROCONTROL Safety

Regulatory Requirement for Reporting & Assessment
of Safety Occurrences in ATM) been implemented
within the ANSP’s system?
 If not fully implemented, what are the main issues

preventing this, e.g. lack of guidance material,
availability of reporting tools, processes/procedures?
 Is there a nominated focal point within your

organisation for providing regular relevant safety
information to EUROCONTROL?
Additional Comments Please state any additional comments relating to Organisational Structure, Roles and Responsibilities
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7. Reporting Specific Focus (Findings/Evidence) Comments
‘Just, open and blame-free  What measures are in place to ensure a just, blame-
safety reporting culture’ free reporting system?
 Are the findings of accident and incident

investigations made public, and by what process?
 Are reports available only on request?
 What additional measures could be put in place to

ensure a just, open and blame-free culture?
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Use of the ‘European Co- The ECCAIRS reporting system is the central European
ordination Centre for database for aviation safety. It is a set of tools made
available by the European Commission, which facilitates
Aviation Incident Reporting the exchange and integration of occurrence reports.
System (ECCAIRS)’
 Is ECCAIRS used within your organisation? If so,
how is it used?
 Is ECCAIRS effective for mutually exchanging safety

data with other Member States? Is the information
disseminated among interested parties within the
Member States?
 What measures could be taken to improve the

effectiveness of ECCAIRS?
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Voluntary Reporting System  Does your organisation use a voluntary reporting

system to collect and analyse information on those
observed deficiencies in aviation which are not
required to be reported under the mandatory
reporting?
 Is this voluntary system effective?
 Could the system be improved if the voluntary

requirements were made mandatory? Would this
make the system more effective?
Additional Comments Please state any additional comments relating to reporting.
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ADDITIONAL INFORMATION:
Please provide any additional information on other areas, not covered in the survey, that you feel would be beneficial to this
study.
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Annex IV Summary of Survey Responses in Key Areas of Accident Investigation and

Occurrence Reporting
Annex V presents the findings of the survey responses in Tables 16 and 17 on Accident Investigation and Occurrence Reporting,
respectively.
This highlights key words and phrases in the extracted survey responses to improve clarity. To prevent the extracts being identified to a
particular organisation or country, names of organisations, etc. have been removed. To ensure that the extracts do not lose their
meaning, the following approach has been used:
 [STATE] – used to replace a Member State

 [INVESTIGATION AUTHORITY ] – used to replace the name of an Investigation authority (NSIA)
 [CIVIL AVIATION AUTHORITY] – used to replace the name of a CAA
 [ANSP] – used to replace the name of an ANSP
 [LEGISLATION] – used to replace the title of a national regulation
 [DATE] – used to replace certain date references
The responses have also been updated to remove typing or grammatical errors, where appropriate.
The survey findings have been grouped together on the basis of focus areas, rather than on the basis of survey responses.
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Table 16: Survey Responses on ‘Accident Investigation’ Issues
Survey Issue Survey Responses from National Aviation Authorities in EU Member States
The respondents indicated the following filed deviations under Annex 13: -
‘No absolute guarantee can be given that the records will be not disclosed for purposes other than
accident investigation, as [STATE] legislation determines its disclosure to the [STATE] Courts, whenever the
judicial authority considers that their disclosure outweighs the adverse effects on the investigation process.
All practicable steps will be taken to minimize the extent and occurrence of such disclosures.’
‘[STATE] Judicial authorities have priority rights over access to site and evidence supporting
documentation. The [INVESTIGATION AUTHORITY] has a ‘cooperation agreement’ which allows them access to
the required information needed for the investigation.’
Member States filing ‘[STATE] legislation requires that all documents be made available for criminal proceedings.’
deviations under ICAO
Annex 13 ‘[LEGISLATION] our national legislation, from which a judicial authority can decide to use records in court.
It has never happened so far, but it cannot be fully guaranteed not to happen.’
‘Due to the inconsistency with the constitutional Freedom of Information in [STATE], deviations have been
filed’.
Furthermore, one state reported: -
‘If the judicial authority conducts its investigation, [INVESTIGATION AUTHORITY] access to the elements of the
investigation may be significantly delayed or even prevented. This issue was raised during the ICAO ‘Safety
oversight audit of the Civil Aviation System of [STATE]’, performed in 2006.’
There was a mixed response to the issue of whether Directive 94/56/EC was fit for purpose. On a Member
State basis there was an equal split. A similar split was seen in the NSIA responses, with 53% stating the
Directive is fit for purpose and 47% saying it is not.
Is Directive 94/56 ‘fit It should be noted that many of the non-NSIA respondents did not answer this question. Some of the
for purpose’? responses received replicated the findings made in the impact assessment 25 for the proposed new
regulation.
The responses from the NSIAs were equally split, with all respondents providing an opinion. The responses
from one particular Member State were also split, with the NSIA saying the measures were not adequate,
yet the ANSP replied that they were satisfactory. Some respondents raised the differences between Annex
25
Impact Assessment Study ‘SEC (2009) 1478’
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13 and the Directive, stating that Annex 13 requirements were used to fill the gap in the current directive.
Some respondents stated that the Directive was not fit for purpose on the basis of the age of the Directive:-
‘No. The Directive 94/56/EC is too old (15 years) and it has never been updated. Besides it no longer
meets the present [STATE] requirements.
‘Directive 94/56/EC partly meets the requirements of the state, but because the Directive is 15 years old and
since 1994 aircraft and their systems are becoming increasingly complex and by this reason
Investigation of Aviation accidents requires more diversified expertise and resources’
Others quoted differences with Annex 13. One response stated that the Directive was being used to justify the number
of technical personnel in the NSIA, since the Directive refers to the investigator-in-charge, which was interpreted as
requiring only one investigator in the NSIA: -
‘Article 6 determines that the investigating body or entity shall comprise at least one investigator able to
perform the function of investigator-in-charge in the event of an aircraft accident or serious incident. It allows
the state to limit the structure of the investigating body to one permanent investigator, which is
insufficient to perform the state’s obligations in accident investigation.’
Others claim that the Directive remains fit for purpose, stating:-
‘Yes the Directive is fit for purpose, when it comes to reporting and investigation. When it comes to the
structure of aviation industry, the introduction of EASA has made a mess of the system.’
Only two respondents raised the possible issue of the balance between the technical and judicial investigation: -
‘No, the Directive is not fit for purpose, most notably where the relationship between the technical and
judicial investigation is concerned.’
‘No it is not fit for purpose, because safety investigation is subordinated to the judicial investigation (if any).’
Does Directive
One response indicated that whilst there remained a possible loophole, this could be exploited: -
94/56/EC provide
adequate protection ‘The Directive is not fit for purpose, as now a go around has been left. i.e. in [STATE] police can retrieve all
for individuals info from [INVESTIGATION AUTHORITY] and use against individuals’
reporting accidents or
serious incidents?
The majority of responses indicating that supplementary regulations were in place, but the need for additional
Supplementary
regulation were not stated. Some indicated that this additional regulation contradicted areas of the Directives, but
Regulations at
specific examples were not provided.
National level
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The survey raised the issue of the definitions of accident, serious incident and incident. All those surveyed confirmed
that the definitions for accident, serious incident and incident were in line with those provided in Directive 94/56/EC and
ICAO Annex 13. However, one respondent did indicate a modified definition for ‘serious incident’.
‘The [STATE] definition for a ‘serious incident’ is: Serious incident means an ‘incident’ involving circumstances
Are ‘Definitions’ in line indicating that an accident nearly occurred, considering as such and including those in the list published in the
with those provided in [LEGISLATION]. The difference between an accident and a serious incident lies in its consequences.’
Directive 94/56 /EC The majority of respondents confirmed that the definitions were clearly understood, although some respondents did
and ICAO annex 13? comment on this issue:
‘The use of ‘Incident’ is somewhat confusing, because sometimes ‘Incident’ is used in lieu of ‘Serious
incident’; nevertheless we are forced to classify all occurrences, even birdstrikes as ‘Incidents’ according to
ECCAIRS taxonomy.’
The majority of respondents did not indicate any issues with working practices and relationships with the judicial
authorities. Only 20% of NSIAs indicated there were issues with judicial authorities. Considering all the responses this
number falls to 16% stating there is an issue.
The majority of the investigating authorities did not express concern with respect to the working relationships with their
respective judicial authorities:
‘Up to now, [INVESTIGATION AUTHORITY] has received full cooperation of those entities (judicial
authorities).’
‘No issues with judicial authorities as this is covered by a ‘cooperation agreement’ in place with the judicial
Issues with working authorities which allows [INVESTIGATION AUTHORITY] to obtain access to site/evidence documentation without
practices/relationships delay if necessary.’
with judicial
‘Not identified any problem in current time.’
authorities
‘Investigation authority has full power to conduct independent investigation.’
However, it is worth noting that a small number of respondents did raise this issue.
‘There are still problems with judicial investigation concerning evidence custody and wreckage.’
As stated the majority of respondents did not indicate difficulties between the judicial and the technical investigation,
which can be demonstrated by the response below:
‘Other than the prerogatives of justice in investigation (which in practice seldom cause concern), there
are no structural problems between [INVESTIGATION AUTHORITY and other organisations (judicial
authorities)’
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One respondent proposed a provision for the new regulation: -
‘In case of an accident with fatalities and in some other cases, the final report issued by the investigation
commission is used by the police and prosecutors and in court. The Chief Investigator is called in evidence. It
would be very good practice to have a provision in the new EU Regulation for not allowing use of the final report by
judicial authorities.’
Nearly half the Member States that responded confirmed that they had MoUs in place with other authorities and
organisations.
Among the 20% of NSIAs which stated that there were issues with the working practices/relationships with the judicial
authorities, only one of the NSIAs had MoUs in place.
Those respondents which stated that they had MoUs in place confirmed that they were with a range of organisations:
‘[STATE] investigation authority signed MoUs at European level’.
‘The protocols/MoU presently signed with other organisations, are as follows:
At national level: [STATE] Non schedule Airline; [STATE] Meteorological Institute; [STATE] Air Traffic
Management; [STATE] Schedule Airline; [STATE] Civilian Aviation Authority; [STATE] Pilots
Member States with Professional Association; [STATE] University – Aeronautical Engineering’.
memorandums of
understanding in place ‘MoU between Investigation authority and CAA’
‘Technical cooperation agreement with the military Investigation Section. Technical cooperation with the
[ANSP]’
‘[STATE] [INVESTIGATION AUTHORITY] has MoUs with the police service of [STATE] and the Crown
Prosecution Service.’
‘MoUs with [STATE] Judicial authorities, European Commission, airlines (for incidents), NTSB and many
other safety organisations.’
Other respondents confirmed that they were engaged in preparing MoUs: -

‘Memorandum of Understanding between [INVESTIGATION AUTHORITY] and Ministry [STATE] is in
preparation, should be signed by end of February 2010.’
‘[INVESTIGATION AUTHORITY ] is implementing, but not yet signed with other organisations: [STATE] Air
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Force; [STATE] Schedule Airline’
‘An MoU with the police [STATE] is presently in draft.’
Others confirmed that no agreements were in place or that cooperation was ensured through national regulation:
‘There is no specific agreement between the [INVESTIGATION AUTHORITY] and judicial authorities. The
basic cooperation is established in the [LEGISLATION] on Civil Aviation, as amended.
‘No specific agreement outside of the [INVESTIGATION AUTHORITY] legal basis.’
‘No MoUs’ were signed with other organisations.’
The majority of respondents stated the ECAC (European Civil Aviation Conference) Code of Conduct and participation in
regular meetings were the primary means of networking between investigation authorities.
‘The investigation authority participates in the meetings of the Group of Experts on Accident
Investigation within ECAC. It has signed the Code of Conduct on Cooperation in the Field of Civil Aviation
Relationships with Accident/Incident Investigation between ECAC Member States.’
other Investigating
‘[STATE] has signed a cooperation agreement with ECAC Member States as of [DATE], so in the event of
Authorities serious accident, [INVESTIGATION AUTHORITY] may use support from other Member States’
There are also more ‘informal’ networks in place; one respondent stated the following:
‘There are Nordic relationships with some North Atlantic countries (Sweden, Norway, Finland, Iceland,
Canada and Denmark). We meet once every year to discuss common challenges.’
The survey responses indicated over half of those responding thought a network would be beneficial.
The majority of NSIAs indicated that such a network would be of benefit, but expressed reservations:
Benefits of the Some raised concerns about the benefit and role of the Network:
European Network of
Civil Aviation Safety ‘No evidence was presented to show that a formal network would be beneficial’
Investigation ‘Central coordination can create additional time problems.’
Authorities
‘As a forum for discussions of mutual interest - yes. As a coordinator- no.’
‘This depends on the mandate of the network. If it is in the same spirit as the CEASIA we believe that will be
beneficial’
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‘The Network already exists. It is called the Council of European Aviation Safety Investigation
Authorities. It facilitates mutual cooperation’
Some raised concerns that such a network would lead to the introduction of a new entity: -
‘A central European network based on voluntary cooperation within a binding framework may be
beneficial. Such a network may strengthen cooperation and exchange of information among the safety
investigation authorities. We believe that the coordinator of the network should be the ECAC/CEASIA, to avoid
introducing a new entity.’
A number of respondents looked to restrict the access/membership of such a group: -
‘A central European network will be useful if it includes (or is made up of) exclusively air safety branches
and air safety personnel. No other aviation authorities (of any kind) should be part of such a network.’
One respondent stated the Network could be used to address legal issues: -
‘Yes, but on the legal side, a common Aviation Court.’
The majority of respondents confirmed that periodic summary reports were published, containing data on events
reported by the investigation authority. From the responses, this is typically an annual publication, but the format
varies:-
‘The annual report of the safety section includes the information required.’
‘Yes, AIB has an annual report which provides brief description & statistical data for accidents and serious
incidents only.
Publishing Summary ‘Yes. There is a monthly publication and the possibility to subscribe electronically to any report published.’
Reports ‘Progress report on safety recommendations and the responses published annually.’
‘Yes, the [STATE] publishes an Annual Report which contains Safety Recommendations and Responses
received.’
‘The [STATE] establishes annual statistics.’
One respondent indicated that they were unable to publish: -
‘At this moment we do not have capabilities for publishing.’
Issues related to the

Most of the NSIAs confirmed that there was sufficient budget available to deal with the current level of
resources available to
accidents and incidents recorded, although some raised the issue of travel expenses. Many of the smaller
the NSIAs
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NSIAs highlighted the issue of being a small team and the difficulties of limited technical resources in the
event of a major accident.
Many of the smaller NSIAs highlighted the issue of being a small team and the difficulties of limited technical resources
in the event of a major accident.
‘No issues / concerns are present relating to the provision of an adequate budget’
‘No. The [INVESTIGATION AUTHORITY] has the possibility to ask for extra appropriation and so far the Ministry
of Transportation has granted it’.
‘[INVESTIGATION AUTHORITY] makes do with current budget and can get additional funding if required,
although the process for doing this can be lengthy.’
Some respondents stated the following with respect to the provision of travel expenses:
‘Yes, in case of expenses largely exceeding the expectations of the normal operation.’
‘There is no special budget dedicated for the payments of technical examinations and travel expenses.’
In addition, the following comments were made regarding provision of additional technical support: -
‘Yes, insufficient personnel, limited technical expertise.’
‘Some free vacancies for technical staff’
‘There aren’t sufficient in-house permanent personnel and technical expertise.’
‘Yes, more people needed for [INVESTIGATION AUTHORITY] department. Fortunately, number of accidents is
very few and department is small, so dedicated facilities for [INVESTIGATION AUTHORITY] can’t really be
justified at this stage.’
All respondents indicated that there are measures in place to ensure a just, blame-free reporting system. The responses
ranged from stating basic regulations to supplementary measures and internal policies:
‘Non-disclosure of names of individuals, operators and others involved so all focus is on the safety result
Issues related to and not on blaming somebody.’
‘Just Culture’
‘Anonymous reporting system via e-mail is operational, which prevents the identification of the reporter
and encourages anonymous occurrence reporting.’
‘[LEGISLATION] on mandatory reporting is in place. It gives the reporter a certain level of protection but
not enough.’
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‘[INVESTIGATION AUTHORITY] informs personnel involved that the sole objective of the safety investigation of
an accident or incident is the prevention of accidents and incidents. It is not the purpose of this activity to
apportion blame or liability.’
‘[INVESTIGATION AUTHORITY] tries to promote this, but with judicial colleagues, this can prove difficult as
they have a different mind-set.’
‘[ANSP] has a voluntary reporting process and operates a just culture. Measures are agreed with
Regulator and with Staff Associations.’
‘From [ANSP] point of view, our SMS establishes a non-punitive reporting system’
‘[LEGISLATION] indicated that no enforcement processes will be initiated by information collected by the
occurrence reporting system’.
‘[ANSP] internal Just Culture Policy.’
‘Basically yes, but there is no legal protection or wish to address this issue in [STATE]’
‘No administrative, disciplinary or professional sanctions may be taken against a person who has
reported an accident or incident in civil aviation or an event, as defined in [LEGISLATION], except where that
person is guilty of a deliberate or repeated failure to observe safety regulations.’
Furthermore they state:

‘Additional occurrence reporting can be encouraged by the adoption of ‘just culture’ principles, under
which any person making the report, or named in the report, is generally immune from disciplinary action, but
under which the wilful disregard of standard operating procedures and the misuse of alcohol or other stimulants
can be suitably addressed.’
Some respondents indicated a range of possible measures to improve ‘Just Culture’:-
‘It is desirable that all these topics will be extensively developed in the occurrence reporting legislation,
specifying topics like the concrete definition of the cases of wilful and gross negligence, the organisation to
decide on such matters, ways in which measures has to be issued and proposed as a result of the incident
investigations, etc.’
‘Non-punitive action for aircraft accidents and aircraft incidents.’
‘Basically nothing. There are only marginal improvements left to be made’
‘This will come with time. Maybe through additional training/experience. The culture is ok internally but when
dealing with external depts. e.g. judicial authorities, this can pose a problem.’
‘An agreement with the judicial authorities to accept the concept of just culture.’
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‘Informing the public and media that appointing blame and liability do not prevent accidents in the long
run. For that reason they should trust the [INVESTIGATION AUTHORITY] with non-disclosure. Having straight
lines when it comes to roles in aviation – not mixing up the roles of the [INVESTIGATION AUTHORITY] and the
regulators as they have the power of revoking certificates etc.’
The majority of respondents indicated that there were sufficient measures in place in the current investigation reporting
system to adequately protect the rights of the victims of air accidents and of their families, yet is it worth noting that
this was identified as a key problem area in the Impact Assessment for the proposed regulation. Some respondents
indicated the nature of the rights covered: -
‘Formally, yes, but is hindered by the morbid attitude of the press’

‘Yes. Personnel identification is never disclosed.’
‘Yes, all individuals’ names are part of non-disclosure within the [INVESTIGATION AUTHORITY], but not
Protection of Victims outside the [INVESTIGATION AUTHORITY]. E.g. when the victims’ families have been notified by the police,
there is no guarantee that the names are not made public by the operator or others.’
Others indicated that there were no specific provision to protect victims and their families:
‘No specific protection for this within the investigation reporting system.’
When asked the same question relating to the judicial system the responses were very mixed. Many were unable to
comment specifically on the effectiveness of the judicial system.
Of those respondents who provided a response to this issue, almost all the responses stated that EASA should not have
a greater role in accident investigation, to ensure the independence of the investigation.
‘Investigation must be provided independently of EASA’
Role of EASA in
accident investigations ‘As provider of labs etc. yes! As part of the investigation – definitely not. Not consistent with the
independence of the investigation body’
‘No – EASA are afforded all the rights of participation as Advisers in accordance with Annex 13’
‘EASA has the (potential) role of adviser to the Accredited Representative of the State of Design’
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‘The role of the investigation agency and the regulation authority must not be mixed up. It will confuse
the industry and properly damage the objectives of the investigations. ‘
‘Maybe as an observer, EASA can take part and get information, but the problem is they would affect the
independence of the investigation, so EASA involvement in the investigation would be difficult’
‘EASA as a regulator should have relevant information in order to take appropriate measures and its role
should be significant. However, the independence of the investigation should be assured.’
‘The boundaries of the role EASA can play in an investigation are defined by its involvement in the Design
Approval process. This is consistent with the need for independence (from interested parties) of the
investigation process.’
Some respondents did state that EASA did need to be involved in the accident investigation process:
‘EASA has a legitimate need for safety data to carry out its regulatory obligations. EASA must also provide
information to support the investigation on certification and other matters within its competence.’
Some indicated that EASAs should play a more significant role in the implementation of safety recommendations:
‘EASA should play a more significant role so as to provide and implement the Safety Recommendations of
AIB.’
Some thought EASA would be better focusing on managing safety data rather than the accident investigation process:
‘With regard to incident investigation, EASA should play a more significant role by administering the Central
European Repository and managing a European pool of analysts from the CAAs.’
Ten responses were received, of which only one confirmed that the passenger manifesto would be available within 1 hr.
All the other responses confirmed that no time limit was in place:
‘Passenger name list is always on board the aircraft and also available in electronic form in the computer
Availability of system. There is no time delay in receiving the passenger manifest. In the computer system there is also more
Passenger Manifesto information available about passengers (phone numbers etc) than on the paper copy which is printed out and
handed over to the crew and kept with the flight trip file for at least 3 months.’
‘The passenger manifesto is needed rapidly; we would suggest within 2 hrs. Note that this period is more crucial
for contacts with the families/relatives of the victims than for the investigation process itself.’
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‘No, there is no such time limit.’
‘There is no time limit for making available the passenger manifesto.’
‘Passenger lists are available through our air carriers and their reservation systems. We suppose lists will be
delivered ASAP and as is practicable, but no time limit is in place.’
‘No time limit for making passenger manifest available’
‘No, we don’t have established a time limit for making available the passenger manifest.’
‘No’
‘No provision’
The respondent stating that the passenger manifest is available within 1 hr does not state whether this is mandatory:
‘The passenger manifest is available from the Operator within 1 hr’
It should be noted that one respondent stated the following:
‘This issue is presently being discussed in the European Parliament and the Council of the European Union
[Proposal for a Regulation of the European Parliament and of the Council on investigation and prevention of
accidents and incidents in civil aviation] and consequently it shall be implemented by [STATE] as soon as it
has been officially approved by the EU.’
Ten responses were received. The majority of those responding indicated that such plans were either in place, being
drafted or implemented in the future. The scope of these plans is likely to vary and it should be noted they are managed
by a range of organisations:-
Crisis Management ‘Yes, we have Emergency Response Plan and Manual in place with detailed instructions, checklists and
Plans contacts. Our organisation has been audited by [STATE] 3 times and recently by ‘airline’, who were all satisfied
with existing procedures and manuals. Emergency Response plan may be activated in other cases also like
epidemic situation on board, bomb warning, hijack situation or in case of serious incident.’
‘The main business of the [INVESTIGATION AUTHORITY] is the investigation of accidents and serious incidents.
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This process is applied for each accident being investigated, A crisis management plan is indeed activated by the
organisation not having accidents as their main business (Airline, Airport), and of course the territorial
organisations with the competence for dealing with crises (province, state); in the latter case, there are crisis
management plans issued).’
‘We have a regulation [LEGISLATION] for aircraft accident investigation and a procedures manual for aircraft
accident investigation, which contains basic elements of crisis management for our organisation’
‘[STATE] has is a crisis management plan in place, which is called ‘National human search and rescue plan
in the event of an aircraft or ship accident in the area of responsibility of [STATE]’. This provides for actions and
interactions of different public institutions such as the police, Customs Dept, firefighters, etc.’
‘General crisis management plan is provided at ministerial level. This is a general plan addressing all
transport events.’
‘No official crisis management plan in place. However, there are procedures in place in the event of a
large scale accident.’
‘Looking to implement in future’
‘International airport has a crisis management plan in the event of an accident.’
‘Due to reorganisation, [STATE] does not yet have a crisis management plan for the new organisation, but a
contingency plan and communication instructions for crises or special circumstances are current being
drafted.’
‘A comprehensive crisis management plan has already been established and it shall be implemented in case
of any aircraft accident occurrence. Manual is being improved and is in an updating phase.’
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Table 17: Survey Responses on 'Occurrence Reporting' Issues
The majority of responses confirm that this directive for implementation of an occurrence reporting system is fit for
purpose.
However, a number of respondents indicated shortcomings or potential areas for improvement: -
‘Yes, Directive 2003/42/EC is fit for purpose for [STATE]. As potential shortcomings of the Directive:
• Lack of detailed provisions regarding the involvement of the judiciary with the occurrence reporting system.
• Guidelines to define which cases can be considered wilful or gross negligence and the definition of the
competent organisation to decide in this matter.
• Detailed provisions in the Directive regarding the establishment of a just culture at national level.
• Detailed provisions as to how the CAAs have to protect individuals from prejudice within their companies
regarding occurrences reported to the CAA.
• Lack of coordination with the reporting established by other EU Regulations (EU-OPS-1, Reg. 1702/2003,
Is Directive 2042/2003),’
2003/42/EC fit for ‘Too weak as far as protection for individuals involved in reporting is concerned’
purpose?
Other comments indicate that it can be subjective:
‘The reporting requirements are always subject to judgment, but it is impossible to specify all possibilities of
occurrence.’
In terms of the protection for individuals reporting occurrences there is a mix of responses. Most confirm that measures
are in place to protect the identity of individuals:
‘Names or addresses of individual persons shall not be recorded on the national database of
accidents and incidents. [STATE] ensures the employees, who report incidents of which they may have
knowledge, shall not be subjected to any prejudice by their employer.’
‘Confidentiality. Names or addresses of individual persons are never recorded on any database. Non-
punitive principle. Individuals could not be penalised or prosecuted with regard to the information they have
provided, except in case of gross negligence.’
Another response indicates that whilst the reporter is protected, other might not be so protected:
‘Only for the one who reports, not for those involved’
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Whilst the individual Member States confirm that the Directive is fit for purpose at national level, this may not be
consistent at European level. EASA stated the following:
‘Directive 2003/42/EC fits the scope of national reporting. However, at European level, Regulation (EC)
1321/2007 on data integration requires the removal of identifying information so that narratives and
registration/serial numbers are hidden. Consequently, no identification of safety issues for specific aircraft
types is possible, nor is it possible to verify the classifications of the occurrence made by the reporter.’
The majority of respondents indicated that the Member State CAAs hold databases of incident records. In some cases
data is directly stored in ECCAIRS ‘European Co-ordination Centre for Aviation Incident Reporting System’ which is a
software system. Others use local databases and upload data into ECCAIRS as required.
‘Every reported occurrence (including incidents and accidents) is entered into ECCAIRS. If a report is not
within the framework, it is stored in the electronic archive system. A mandatory report outside the framework
of Annex 13 is recorded and stored in the [CIVIL AVIATION AUTHORITY] database.’
‘[ANSP] holds a database of reported incidents reported to [ANSP]’
Mandatory Reporting The responses stated that this data is used at national level and is analysed to identify local trends
of Occurrences
‘The data is continuously used for trend monitoring and to reveal similarities within e.g. incidents in general
aviation.’
at National Level
‘The information is used to make aggregate analyses which are published in Information Bulletins and
Annual Analysis on aviation occurrence.’
From an ANSP perspective: -
‘[ANSP] records all safety events reported by its staff. All such reports are investigated. Appropriate actions
are taken and tracked. All reports are analysed for trends. Safety performance measures are in place and
tracked.’
The responses indicated that at national level, there is much use of the accident and incident data recorded, including
analysis and identification of any trends.
Mandatory Reporting The majority of the responses indicated that they used the ECCAIRS software as a means of meeting legal requirements,
of Occurrences but when asked whether they used ECCAIRS beyond a national level the responses were very mixed. Analysis of the
responses on a Member State basis indicated that two Member States were not using ECCAIRS. Of these, one indicated
Use of ECCAIRS that it was in the process of implementing the use of the ECCAIRS software system.
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Overall the responses were positive with respect to ECCAIRS but stated some reservations:
‘ECCAIRS is a good system, but it needs to be used more widely by the EU Member States.’
Some indicated that responses can be sent and that data is used:
‘Yes, queries can be sent to other Member States and the response can be analysed and compared to
national data.’
‘Yes it is effective, furthermore, [STATE] CAA has in place agreements with several European CAAs to exchange
information regarding the information registered in the ECCAIRS data base.’
‘Yes, ECCAIRS is used to exchange electronic records with other Member States.’
‘We sometimes use ECCAIRS to exchange safety data with ICAO only.’
Others suggested that once improvements were made, ECCAIRS would become more useful:
‘With the narrative unavailable at this time, ECCAIRS is not particularly useful for your purposes. Once
the text is available, this will be a more useful tool for sharing information.’
Others indicated that data was entered but that they had not seen any evidence of feedback from this data:
‘Not aware of any: maybe at state level, never seen any feedback from it, a ‘black hole’ ‘
Some see ECCAIRS as a double reporting system:
‘A DOUBLE reporting system, [ANSP] through EUROCONTROL also to EC, what for? Yes, a useless reporting
system with no feed-back to ANSP’
One respondent indicated that ECCAIRS was used by the NSIA, but not by their CAA. Another respondent indicated that
is was used for information purposes only, another indicated that it would be used in the future.
Many provided suggestions for improvement, some of which are planned:
‘The next release, ECCAIRS 4.3 (recently renamed release 5), will provide more flexibility in the interface. It will
also contain more guidance material in relation to the occurrence categories.’
‘If confidentiality is guaranteed, it could be used for broader analysis to find key risk areas and foster safety
improvements in these areas.’
‘Make it less subjective, less interpretative. Improvement of the applications that allow the information
registered in the database to be extracted in a better, more effective way. Specified modules that allow the user
to do a follow-up of the potential measures taken after an incident is investigated and such measures have been
decided.’
‘Use of tools associated with it (which is being done). Add risk grading (should be implemented with next
version of ECCAIRS)’
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One respondent asked that ECCAIRS be easier to use:-

‘ECCAIRS is far too complicated to use for a non-frequent user.’
One ANSP response highlighted the multiple systems in place and suggested a single reporting system:
‘Decide on one robust reporting system: there are too many of them and feedback is very poor. (ECCAIRS,
EUROCONTROL AST & EVAIR and CANSO all ask for information from ANSP) ECCAIRS difficult to operate,
opaque, not user friendly’
Finally, a number of responses indicated that the data would be beneficial to many different organisations: -
‘Better interface to exchange and/or collecting of the data with/from different reporting systems in the
country.’
‘Make it available for all’
‘Passive/ read only access to airlines.’
‘Accessibility to database at a local level’
‘Central repository where someone should really make use of it’.
Fifteen of the nineteen Member States represented by the survey responses confirmed that they have voluntary
reporting systems in place. Of those Member States with voluntary systems, 60% responded that these systems were
effective.
Of those states without voluntary systems in place, many confirmed that they were planning to implement voluntary
systems shortly.
Voluntary Reporting In terms of changing the balance between voluntary and mandatory reporting, a number of respondents expressed
Systems concern. The majority of those responding (60%) confirmed that in their opinion making the current voluntary
requirements mandatory would not improve the effectiveness of reporting. Only 6% believed that there would be an
improvement, mainly through the increase in the number of incidents reported.
Two Member States expressed the opinion that voluntary systems are needed to ensure that a certain type of
occurrence is reported. This opinion is put forward by those states with established reporting systems:
‘It would be difficult to improve the system if voluntary reports were made mandatory. Generally, mandatory
systems capture visible (and technical) incidents while voluntary reports deal with human factors and
occurrences that are generally only known by the frontline actors.’
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When asked to consider whether voluntary reporting systems were effective, the responses were informative. Some
indicated that the current system was effective:-
‘Yes, reports are received on a regular basis. They are de-identified and entered into a database. Some
reports are published in safety bulletins’
‘It is effective to a certain extent. As it is voluntary it depends on the individuals concerned.’
Some confirmed the systems are effective due to the rise in the number of reports: -
‘Yes, we think it is, because number of voluntary reports is rising.’
‘Yes it is, even though is a relatively young one, it shows a consistent growing pattern, with widespread
confidence in it.’
Some raised concerns about knowing ‘what’ to report, others raised the issue of ‘just culture’: -
‘This system is less effective because of the lack of ‘just culture’. Voluntary reports on occurrences are quite
rare.’
‘Fairly effective. But the reporting system itself is currently not much different from mandatory (the only
difference is the occurrence itself – whether it is in the list of reportable occurrences or not). Some form of
guidance material would be of great benefit.’
‘Not effective due to safety culture openness.’
Others confirmed that the systems were not working due to limited reporting:
‘Not really working yet - have seen only one report in three years.’
Over half the respondents stated that moves to change voluntary reporting systems to mandatory would not improve
reporting. There was a difference of opinion in the responses for one Member State, with the ANSP stating that a move
would improve reporting, yet the CAA stated that it would not. The NSIA, CAA and ANSP of another Member State all
confirmed that such a move would improve the level of reporting.
Those respondents that stated the system would improve indicated that a change from voluntary to mandatory reporting
would increase the quantity of records. Other respondents believed that this would prevent reporting of certain types of
occurrence:
‘It is likely that the effectiveness of the system would increase, at least because of the increased number
of reports.’
‘Yes this will improve the system.’
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Whereas: -
‘We believe that the current balance between what is mandatory and what is voluntary should be kept as it is
now, and with flexibility , in order to protect this delicate system.’
‘It would be difficult to improve the system if voluntary reports were made mandatory. Generally, mandatory
systems capture visible (and technical) incidents while voluntary reports deal with human factors and
occurrences that are generally only known by the frontline actors.’
Others raised the issue of promoting a ‘just culture’ as a means to improve the level of voluntary reporting:
‘No, just need to give people better protection so that people want to report voluntarily.’
‘No, there is mandatory system in place already. Improve Safety Culture’
The responses show that all the Member States which responded are fully compliant with ESARR2. In an
interview with Eurocontrol, they stated that originally only 9 states were using ESARR2, and that this has
now increased to 30 states (Member States of Eurocontrol).
Overall the relationship between the ANSPs and Eurocontrol appears to be positive:
ESARR 2 /
Relationship with ‘There is close cooperation between [STATE] CAA and Eurocontrol, mainly through participation in working
Eurocontrol groups developed by Eurocontrol in which deliverables/measures are being taken.
‘SASI programme, ESP programme, ESSIP, all other Eurocontrol programmes concerning ESARRs and EC
requirement implementation. Training, guidance material, advisory support.’
‘If and when needed, [STATE] requests support from EUROCONTROL, which is duly received. This support mainly
consists of conducting courses and attendance at workshops organised by ECTL.’
‘We regularly receive safety guidance and other safety-relevant information’
163

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DIRECTORATE GENERAL FOR INTERNAL POLICIES

POLICY DEPARTMENT B: STRUCTURAL AND COHESION POLICIES

TRANSPORT AND TOURISM

OCCURRENCE REPORTING AND

ABOUT THE EDITOR

Manuscript completed in September 2010.

This document is available on the Internet at:

TRANSPORT AND TOURISM

OCCURRENCE REPORTING AND

Independent investigation of accidents/incidents and occurrence reporting is

Accident investigation and occurrence reporting in EU aviation are currently

IP/B/TRAN/IC/2009-024 September 2010

GLOSSARY OF TERMS AND ACRONYMS 5

1. INTRODUCTION TO THE LEGAL FRAMEWORK OF ACCIDENT

1.1. International regulation for aircraft accident and incident investigation

2. CONTRAST BETWEEN LEGAL FRAMEWORK AND ITS PRACTICAL

3. IDENTIFICATION OF PROBLEMS/SHORTCOMINGS AND BEST PRACTICES

4. CONCLUSIONS AND RECOMMENDATIONS 95

Annex I A summary comparison between the proposed new regulation and EU

Annex III Survey Questionnaire 118

Annex IV Summary of Survey Responses in Key Areas of Accident Investigation

GLOSSARY OF TERMS AND ACRONYMS

AAIB Air Accidents Investigation Branch

Accident ‘Accident’. An occurrence associated with the operation of an aircraft

Accredited A person designated by a State, on the basis of his or her qualifications,

ADREP ICAO Accident/Incident Data Reporting System

AIB Accident Investigation Bureau

Annex 13 ICAO Annex 13 ‘International Standards and Recommended Practices for

ANSP Air Navigation Service Provider

ATC Air Traffic Control

ATM Air Traffic Management

CAA Civil Aviation Authority

CANSO Civil Air Navigation Services Organisation

CEASIA Council of European Aviation Safety Investigation Authorities

CFIT Controlled Flight into Terrain

CHIRP Confidential Human Factor Incident Reporting System

CIRCA Communication & Information Resource Centre Administrator

Directive Directive 2003/42/EC of the European Parliament and of the Council of

Directive 94/56/EC Council Directive 94/56/EC of 21 November 1994 establishing the

DNV Det Norske Veritas

DINER Data Integration Network for ECCAIRS Repositories

EASA European Aviation Safety Agency

ECAC The European Civil Aviation Conference currently consists of 44 Member

ECCAIRS European Coordination Centre for Aviation Incident Reporting System.

ERAA European Regional Airlines Association

ERP Emergency Response Plan

ESARR2 EUROCONTROL Safety Regulatory Requirement for reporting &

ESIMS ESARR Implementation Monitoring and Support Programme – mandated

ESP European Safety Programme

EU Member State Member States of the European Union (27 states)

Eurocontrol The European Organisation for the Safety of Air Navigation

EVAIR Eurocontrol Voluntary ATM Incident Reporting

FAA Federal Aviation Administration, USA

ICAO International Civil Aviation Organisation

IA Impact Assessment Study ‘SEC (2009) 1478’

Incident An occurrence, other than an accident, associated with the operation of

IIC The designated ‘Investigator-In-Charge’ (IIC) for the state conducting

MS Member States of the European Union (27 states)