OCCURRENCE REPORTING AND ACCIDENT/INCIDENT INVESTIGATION IN EU CIVIL AVIATION

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3 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

4 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 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: Manuscript completed in September Brussels, European Parliament, This document is available on the Internet at: 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.

5 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/ September 2010 PE EN

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7 Occurrence reporting and accident/incident investigation in EU aviation TABLE OF CONTENTS GLOSSARY OF TERMS AND ACRONYMS 5 EXECUTIVE SUMMARY 9 1. INTRODUCTION TO THE LEGAL FRAMEWORK OF ACCIDENT INVESTIGATION AND OCCURRENCE REPORTING International regulation for aircraft accident and incident investigation and occurrence reporting European legislation for aircraft accident and incident investigation and occurrence reporting Mandatory / Voluntary Reporting systems Role of EU Institutions and other organisations/bodies Safety Requirements for Third-Country Aircraft Summary of the legal framework and reporting systems CONTRAST BETWEEN LEGAL FRAMEWORK AND ITS PRACTICAL APPLICATION IN EU AVIATION Aims Methodology Accident/Incident Investigation Roles of Actors in the Accident Investigation Process Occurrence Reporting Flow and Exchange of Safety Data IDENTIFICATION OF PROBLEMS/SHORTCOMINGS AND BEST PRACTICES OF CURRENT ACCIDENT INVESTIGATION AND OCCURRENCE REPORTING Introduction Accident Investigation Occurrence Reporting Summary Results of Assessment CONCLUSIONS AND RECOMMENDATIONS 95 BIBLIOGRAPHY 103 Annex I Annex II A summary comparison between the proposed new regulation and EU Directive 95/56/EC 107 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 3

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9 Occurrence reporting and accident/incident investigation in EU aviation 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: Accredited Representative 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 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. Where the State has established an accident investigation authority, the designated accredited representative would normally be from that authority. New ICAO Annex 13 definition 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. 5

10 Policy Department B: Structural and Cohesion Policies Annex 13 ICAO Annex 13 International Standards and Recommended Practices for Aircraft Accident and Incident Investigation, Ninth Edition, July 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 2003/42/EC Directive 2003/42/EC of the European Parliament and of the Council of 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) 6

11 Occurrence reporting and accident/incident investigation in EU aviation 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 - COM (2009) 611 Proposed new Regulation COM(2009)611 on the investigation and 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. 7

12 Policy Department B: Structural and Cohesion Policies 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. New ICAO Annex 13 definition 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 8

13 Occurrence reporting and accident/incident investigation in EU aviation 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). 9

14 Policy Department B: Structural and Cohesion Policies 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. 10

15 Occurrence reporting and accident/incident investigation in EU aviation 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. 11

16 Policy Department B: Structural and Cohesion Policies 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? 12

17 Occurrence reporting and accident/incident investigation in EU aviation 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. 13

18 Policy Department B: Structural and Cohesion Policies 1.1. International regulation for aircraft accident and incident investigation and occurrence reporting 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. 14

19 Occurrence reporting and accident/incident investigation in EU aviation Figure 2: Accident Investigation Team with main actors involved State of Occurrence (National Safety Investigation Authority) Appointed Investigator In Charge & Technical Team Investigation Team Participation in Investigation Process State of Design (Accredited Representative) State of Registry (Accredited Representative) State of Manufacturer (Accredited Representative) State of Operator (Accredited Representative) TC Holder Aircraft Operator Aircraft Final Assembly Airline Technical Advisors 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. 15

20 Policy Department B: Structural and Cohesion Policies Figure 3: Phases of a standard aircraft accident investigation Investigation Process Conduct crash-site examination of wreckage Gathering of Data Further studies/examinations (incl. Flight Data Recorder read-outs) Wreckage re-construction Autopsies Simulations Overview of event Further examinations if necessary Analysis and verification of alternative scenarios Publication of Final Report Determine probable cause of accident Safety recommendations 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 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

21 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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 19 th day after the date of receipt by the Depository 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. The ongoing procedure within ICAO for Amendment 12 to Annex 13 to the Chicago Convention. Depository of the Convention is the Secretary-General of the United Nations. 17

22 Policy Department B: Structural and Cohesion Policies 1.2. European legislation for aircraft accident and incident investigation and occurrence reporting 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 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 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/ Civil aviation safety: investigation and prevention of accidents and incidents (repeal. Directive 94/56/EC), EP position, 1st reading T7-0321/

23 Occurrence reporting and accident/incident investigation in EU aviation 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

24 Policy Department B: Structural and Cohesion Policies 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/

25 Occurrence reporting and accident/incident investigation in EU aviation 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

26 Policy Department B: Structural and Cohesion Policies 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) 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 (under discussion) Proposed Regulation Investigating capacity is not uniform across EU member states Promote effective cooperation between safety investigation authorities between Member States to better coordinate the use of shared resources. The formal recognition of the 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 onboard the aircraft under investigation and of their families. Appropriate assistance will of air crash victims and their families be provided to the victims of the air accident and to their families. Tensions between safety investigations and other procedures Lack of clarity and concerns on EASA s participation in safety investigations Weaknesses in the implementation of safety recommendations The proposal enforces the coordination of inquiries between the national investigation authority and the judicial authorities and specifically states the entitlement rights of the safety investigation authority. Clarify EASA s representation and participation in safety investigations with aviation authorities, without compromising independence of safty investigations and within the scope of its competence Provide a consistent approach amongst Member States, towards issuing, processing, implementation and the monitoring of safety recommendations for air safety 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 safetyrelated 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

27 Occurrence reporting and accident/incident investigation in EU aviation 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/

28 Policy Department B: Structural and Cohesion Policies 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 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 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 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

29 Occurrence reporting and accident/incident investigation in EU aviation Figure 4: EC regulations for Civil Aviation Occurrence Reporting EU Directive 2003/42/EC on occurrence reporting in civil aviation Regulation (EC) No 1321/2007 Regulation EC No 216/2008 Regulation (EC) No. 1330/2007 Regulation 1321/2007 states the Commission shall set up & manage a central repository to store all information received from Member States in accordance with Directive 2003/42/EC. Regulation 1330/2007 lays down measures concerning dissemination of occurrence information to interested parties, exchanged by Member States to improve civil aviation safety. European Commission National Aviation Authorities European Commission National Aviation Authorities ECCAIRS EASA ECCAIRS provides means and methods to collect, share and analyse accident and incident reports at a Member State and European level. EASA has a key role to identify safety deficiencies and disseminate related information to Member States. EASA also needs occurrence 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 Commission National Aviation Authorities Under this Regulation, EASA undertakes tasks and assists the European Commission to implement the Regulation, in particular on technical rules relating to construction, design and operational aspects. EASA EASA also conducts, on behalf of Member States, functions and tasks as ascribed to them under the Chicago Convention. 25

30 Policy Department B: Structural and Cohesion Policies 1.3. Mandatory / Voluntary Reporting systems 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 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 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 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

31 Occurrence reporting and accident/incident investigation in EU aviation 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 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 Role of EU Institutions and other organisations/bodies 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 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: 10 EASA Annual Safety Review 2007 provides an overview of aviation safety measures taken in different EASA Directorates 27

32 Policy Department B: Structural and Cohesion Policies 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 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/ , 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 ) Regulation (EEC) No 3922/21 on the harmonisation of technical requirements and administrative procedures in the field of civil aviation (with Annex III replaced). Regulation (EC) No 859/2008 on common technical requirements and administrative procedures applicable to commercial transportation by aeroplane. 28

33 Occurrence reporting and accident/incident investigation in EU aviation 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 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

34 Policy Department B: Structural and Cohesion Policies 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

35 Occurrence reporting and accident/incident investigation in EU aviation 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 underreported by a factor of 3 to Safety Requirements for Third-Country Aircraft 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 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

36 Policy Department B: Structural and Cohesion Policies 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 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 Standard ICAO Annex 13 Chicago Convention EU Directive 94/56/EC EU Directive 2003/42/EC Regulation (EC) No 1321/2007 Regulation (EC) No 1330/2007 New Basic Regulation (EC) No 216/2008 Directive 2004/36/CE Regulation (EC) No Legislative Provision Defines the international standards and recommended practices and is the fundamental document relating to Aircraft Accident and Incident Investigation. Establishes the fundamental principles governing the investigation of civil aviation accidents and incidents. This Directive transposes the main provisions of ICAO Annex 13 in EU legislation. This Directive (enforced in July 2003) deals with occurrence reporting in civil 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. This lays down the implementing rules for the integration into a central repository of information on civil aviation occurrences exchanged in accordance with Directive 2003/42/EC. This lays down measures concerning the dissemination of information on occurrences exchanged by Member States in accordance with Directive 2003/42/EC. Enforced in April 2008, this new Basic Regulation repealed the previous regulation 1592/2002. EC No 216/2008 provides common rules in the field of civil aviation and establishes a European Aviation Safety Agency. This is the applicable legislation for the Safety Assessment Of Foreign Aircraft (EC SAFA Programme). The Directive was adopted in April 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 on a common blacklist of air carriers subject to an operating ban 32

37 Occurrence reporting and accident/incident investigation in EU aviation 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 859/2008 Common technical requirements and administrative procedures applicable to commercial transportation by aeroplane. Regulation (EC) No 1592/2002 Regulation (EC) No 1605/2002 Regulation (EC) No 1702/2003 ICAO ADREP (Accident / Incident Data Reporting) ECCAIRS (European Co-ordination centre for Aviation Incident Reporting Systems) ESARR 2 (Eurocontrol Safety Regulatory Requirement) EVAIR (Eurocontrol Voluntary ATM Incident Reporting) Regulation 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). Regulation on the Financial Regulation applicable to the general budget of the European Communities. Regulation for the airworthiness and environmental certification of aircraft and related products, parts and appliances, as well as for the design and production organisations. The ADREP system has been implemented by ICAO to centralise safety data on the circumstances and causes of accidents and incidents, as determined by the national authorities within Member States. ECCAIRS is a mandatory reporting system (as at 4 July 2005), based on EU Directive 2003/42 on occurrence reporting in civil aviation. ECCAIRS is a set of tools which facilitates the exchange and integration of occurrence reporting with EU Member States. This Requirement covers the implementation by Member States of an occurrence reporting and assessment scheme for Air Traffic Management (ATM) Safety. It applies to all Member States of Eurocontrol. Introduced in November 2006, this is a Eurocontrol voluntary reporting system aimed at airlines and ANSPs for incident reporting and data sharing to rationalise European ATM safety data collation and analysis. 33

38 Policy Department B: Structural and Cohesion Policies 34

39 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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

40 Policy Department B: Structural and Cohesion Policies 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 Member State Level European Level European Aviation Safety Agency Accident Investigation Authorities EUROCONTROL Civil Aviation Authorities ECCAIRS Air Navigation Service Providers One survey generated Introduction / Request for POC POC Established/ Initial Survey Request Sent Follow-up / receipt confirmation (opt.) Telecon / supplementary assistance (opt.) Return of Survey 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 , with numerous follow-up requests. In order to conduct a timely and balanced analysis, responses that were not received within a set time 36

41 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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 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

42 Policy Department B: Structural and Cohesion Policies Figure 6 : Breakdown of Stakeholder Responses by Organisational Type 3% 11% 40% 27% 19% NSIA CAA ANSP Airlines Other Key EU Institutions Table 5 details which national organisations submitted survey responses by 30 th April 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

43 Occurrence reporting and accident/incident investigation in EU aviation possible, these comments have been split to attribute comments to a specific organisation, e.g. to an NSIA 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

44 Policy Department B: Structural and Cohesion Policies Table 6: Status of National Safety Investigation Authorities Country Date established Who does it report to Permanence Scope Staffing Belgium Air Accident Investigation Unit Ad-hoc organization within the CAA since 1930, then permanent with the designation of a full time investigator. Since an entity independent from CAA The Chairman of the Board of the Federal Public Service Mobility and Transport (Ministry of transport) Permanent Only aviation But works in good cooperation with the other enquiry sections (railroad, essentially) Currently 2 (1 tech/ 1 nontech); Budget approved for 4 (3 tech /1 non-tech) Bulgaria Aircraft, Maritime & Railway Accident Investigation 2001 Part of the Ministry of Transport, Information technologies and Communications It is a permanent organization The accident investigation is multimodal aviation, maritime and railway transport The aviation investigation has 6 permanent members + 1 outside expert Czech Air Accident Investigation Institute (AAII) The AAII was established on The AAII is the permanent authority The AAII is responsible only for Accidents/ Incidents in the aviation sector The AAII has a total staff of 13 (10 investigators, including engineers, pilots and former ATC personnel) Denmark Accident Investigation Board Estonia Aircraft Accident Investigation Unit 1 January 1979 The Minister of Transportation 2003 Part of the Ministry of Communication and Economics Permanent Rail and aviation 14 including administrative staff, railway unit and aviation unit. Permanent Solely responsible for aviation-related incidents and accidents 7 in the aviation unit, one chief inspector, three operational (pilots) and three technical inspectors Number of active staff 3 40

45 Occurrence reporting and accident/incident investigation in EU aviation Country Date Who does it Permanence Scope Staffing established report to Finland Accident Investigation Board (AIB) of Finland France Bureau Enquêtes - Accidents (BEA) The AIB of Finland was founded in 1996 The BEA (Bureau d Enquêtes d Accidents) was founded in Its new status (Bureau d Enquêtes et d Anlyses pour la sécurité de l aviation civile) was created in 2001 Ministry of Justice The Investigation Authority does not have to report to anybody as it is an independent authority. Its reports are public The AIB of Finland is a permanent authority It is a permanent authority (Article R 711-1) The AIB of Finland also investigates rail, maritime and other serious accidents The BEA deals with civil aviation incidents and accidents Permanent staff of 11 Administration and 7 investigators + about 90 external experts (about 30 for aviation) were used in persons work at the BEA About 60 are technical staff Germany The Federal Bureau of Aircraft Accident Investigation (BFU) was established on 1 September 1998 Authority responsible to the Ministry of Transport The BFU is a permanent authority on duty 24/7 The BFU investigates accidents and serious incidents to civil aircraft in Germany Staff of about 34, including staff for records, analyses, administration, investigators and wreckage hangar Greece Air Accident Investigation & Aviation Safety Board Founded 2001 Reports to the Minister of Transport Permanent entity Solely responsible for aviation Total staff: six (6), Technical staff: two (2) but can hire technical staff on a case-by-case basis Ireland The Air Accident Investigation Unit (AAIU) was established in 1993 Reports to the Department (Minister) of Transport The AAIU is the permanent civil aviation body Responsible for the investigation of aircraft accidents and serious incidents within Ireland and in certain cases to Irishregistered aircraft abroad Permanent staff of 8 including one Chief Inspector of Accidents, 5 Inspectors of Accidents and 2 Secretariat. 41

46 Policy Department B: Structural and Cohesion Policies Country Date Who does it Permanence Scope Staffing established report to Italy Agenzia Nazionale Sicurezza Del Volo (ANSV) In 1999 Presidency of the Council of Ministers and Parliament Permanent Aviation sector only Total staff: 46 Breakdown: 27 staff (plus President, ANSV board members, general secretary Investigators: 12 Latvia Transport Accident & Incident Investigation Bureau Since as separate entity The civil aviation authorities, services, aircraft operators and physical entities Permanent Authority is multimodal (with aviation and rail departments) Total 7 Technical/non - technical 4/3 Lithuania Aircraft Accident Investigation Bureau Founded in 2001 Part of the Ministry of Transport and Communications Permanent Chief investigator is solely responsible for aviation The investigation authority consists of one chief investigator Luxembourg Accident Investigation- Administration des Enquêtes Techniques 1 June 2008 Separate entity, attached to the Ministry for Sustainable Development and Infrastructures It is a full-time 24/7, all-yearround administration. It is multi-modal (aviation, rail, maritime) but does not include road 2 technical staff currently handle the accident investigation for aviation, rail and maritime transport. Netherlands Safety Board Since 1992 The Board reports to the parties involved and to the general public Permanent The Board is currently active in the following sectors: 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 The Dutch Safety Board consists of 5 permanent board members 42

47 Occurrence reporting and accident/incident investigation in EU aviation Country Date established Who does it report to Permanence Scope Staffing Portugal Gabinete de Prevenção e Investigação de Acidentes com Aeronaves (GPIAA) Formally established on 29 August 2000 Reports to Assistant Secretary of State for Public Works and Communications. It is part of the Ministry of Transport Permanently established as an official and independent air safety branch It is exclusively dedicated to air accident and incident investigations 1 Director of thetechnical department 4 Safety investigators 1 Senior official Secretariat: 3 Admin staff Romania Department of Air Transport Investigation Slovakia Accidents & Incidents Investigation Board Spain Civil Aviation Accident & Incident Investigation Commission (CIAIAC) 1994 Part of the Ministry of Transport and Infrastructure Investigation Authority (UOVLNaI) founded 19 June (Before then the Investigation Authority was part of the Civil Aviation Authority S.R.) Established by Royal Decree in November 2005; operational since March in process of becoming a separate entity. Reports directly to the Minister of Transport, Posts and Telecommunication S.R. Reports to the Spanish Aviation Safety Agency (AESA) which is attached to the Ministry of Public Works and Transport Permanent Aviation only Number of staff: 5 Permanent Permanent Responsible for accident/incident investigation in civil aviation. The CIAIAC investigates all civil aircraft accidents and incidents that take place in Spanish territory Number of technical staff: 3 1 head of office 3 internal investigation staff, several external adhoc experts 14 in total, including 6 Aeronautical Engineers, 2 Airline Business personnel, 3 Admin staff, 2 ATCOs and 1 Pilot. Sweden Board of Accident Investigation 1978 The government Permanent SHK is multimodal. Investigates all kinds of accidents both civilian and military Total staff 22 Aviation 3.5 staff UK Air Accidents Investigation Branch (AAIB) 1915 Secretary of State for Transport, part of Department of Transport Permanent Aviation only 35 Inspectors 20 support 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

48 Policy Department B: Structural and Cohesion Policies 2.3. Accident/Incident Investigation 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% 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

49 Occurrence reporting and accident/incident investigation in EU aviation 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 response given 38% No, Directive 94/56/EC does not provide adequate protection for those reporting accidents and incidents 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 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

50 Policy Department B: Structural and Cohesion Policies 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 not have supplementary regs. 16% No response given 5% 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 on the standardisation of processes 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

51 Occurrence reporting and accident/incident investigation in EU aviation Inconsistencies in the interpretation of definitions can lead to problems with respect to reporting and result in misleading statistics. Section 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 Regulation/Directive Accident & Serious Incidents Incidents Other occurrences 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

52 Policy Department B: Structural and Cohesion Policies 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 ICAO ADREP taxonomy EU taxonomy Eurocontrol taxonomy ICAO Annex 13 (ADREP 2000) 94/56/EC (Accident/Incident Report) 2003/42/EC (ECCAIRS) ESARR 2 A S.I. NSI A S.I. NSI A occurrences I N C I D E N T S circulate occurrence reports I N C I D E N T S stored in database under occurrences EC Reg. 1321/2007 S.I. NSI I N C I D E N T S occurrences A S.I. NSI I N C I D E N T S A = Accidents S.I. = Serious Incidents NSI = Non-Serious Incidents = obligation under prescribed regulation Occurrence is used in definitions for accident, serious incident and incident Under ICAO, there is an obligation for Member States to report accidents and serious incidents to ICAO using ADREP 2000 database Under 94/56/EC, there is NO provision for reporting occurrences of accidents, serious incidents or incidents, but there is an obligation to circulate accident/incident reports received from accident investigation authorities in EU Member States Note: differences in reporting obligations between these two Directives 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 Other Occurrences are any incidents that are NOT normally considered reportable but could form a potential hazard. ESARR 2 is under Eurocontrol competence Occurrence is used in a broader sense to encompass ATM 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

53 Occurrence reporting and accident/incident investigation in EU aviation 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% 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 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

54 Policy Department B: Structural and Cohesion Policies 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% 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

55 Occurrence reporting and accident/incident investigation in EU aviation Table 8: Signatories of Code of Conduct on Cooperation in the field of Civil Aviation Accident/Incident Investigation Member State Signed Code of Conduct 1 Austria Yes (2007) 2 Belgium Yes (2006) 3 Bulgaria Yes (2008) 4 Cyprus Yes (2006) 5 Czech Republic Yes (2006) 6 Denmark Yes (2006) 7 Estonia 20 8 Finland Yes (2006) 21 9 France Yes (2006) Germany Greece Yes (2006) Hungary Yes (2006) Ireland Yes (2006) Member State Signed Code of Conduct Italy Yes (2007) Latvia Yes (2006) Lithuania Yes (2006) Luxembourg Yes (2008) Malta Yes (2007) Netherlands Yes (2006) Poland Yes (2006) Portugal Yes (2006) Romania Yes (2006) Slovakia Yes (2009) Slovenia Yes (2006) Spain Yes (2006) 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 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

56 Policy Department B: Structural and Cohesion Policies 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

57 Occurrence reporting and accident/incident investigation in EU aviation 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% No, the 'Network' would not be beneficial 21% Yes, the 'Network' would be beneficial 58% 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 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

58 Policy Department B: Structural and Cohesion Policies 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 NSIA TECHNICAL STAF PER MILLION FLIGHTS 1000 Data Trendline , ,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 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

59 Occurrence reporting and accident/incident investigation in EU aviation 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 wellestablished 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 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 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. 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

60 Policy Department B: Structural and Cohesion Policies 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 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 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

61 Occurrence reporting and accident/incident investigation in EU aviation 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 to illustrate the specific involvement of some of the actors, including EASA 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 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) 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 ICAO Contracting States are signatories or adherents to the Chicago Convention (International Civil Aviation Organisation Convention of 1944) 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

62 Policy Department B: Structural and Cohesion Policies 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 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 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. 58

63 Occurrence reporting and accident/incident investigation in EU aviation Figure 17: Member States responding that EASA should have a more significant role in accident investigation No response given 28% Yes, EASA should have a more significant role in accident investigation 13% 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 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 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)

64 Policy Department B: Structural and Cohesion Policies 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 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 inservice 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 60

65 Occurrence reporting and accident/incident investigation in EU aviation 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 decisionmaking 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. 61

66 Policy Department B: Structural and Cohesion Policies 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 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. 62

67 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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 , 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 underreporting. 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 underreporting 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 (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). 63

68 Policy Department B: Structural and Cohesion Policies Table 11: Traffic, Accidents and Incidents in Member States Traffic (ICAO 2003) Accidents ( ) Incidents ( ) UK 2,102, Germany 1,796, France 1,430, Spain 1,337, Italy 1,301, Netherlands 425, Sweden 313, Denmark 255, Belgium 253, Portugal 224, Ireland 223, Austria 195, Poland 155, Finland 155, Greece 152, Czech Rep 144, Hungary 88, Romania 72, Cyprus 58, Luxembourg 49, Bulgaria 32, Malta 29, Lithuania 23, Slovakia 20, Estonia 19, Slovenia 19,256 0 Latvia 18, 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 nonfatal 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. 64

69 Occurrence reporting and accident/incident investigation in EU aviation Figure 18: Relative Proportions of Incidents and Accidents in Member States France Germany Italy Spain Fatal accidents Non-fatal accidents Incidents United Kingdom All Europe 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 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 EVENTS PER YEAR Incident Non-fatal accident Fatal accident 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 underreporting problem has been solved. 65

70 Policy Department B: Structural and Cohesion Policies 2.5. Occurrence Reporting Flow and Exchange of Safety Data 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 ( ) 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, Directive 2003/42/EC is not fit for purpose 17% No response given 11% 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 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. 66

71 Occurrence reporting and accident/incident investigation in EU aviation Table 12: Transposition of Directive 2003/42/EC into National Legislation EU State Member State 2003/42/EC transposed into national law EU State Member State 2003/42/EC transposed into 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 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. 67

72 Policy Department B: Structural and Cohesion Policies Simple diagrams are included for each of the major systems, highlighting: Who provides data input Who accesses data The direction of the information flow 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 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 , 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) 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. 68

73 Occurrence reporting and accident/incident investigation in EU aviation 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 Each Member State must collect mandatory reportable occurrences (see section 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/ , covered in section 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 /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, 12 th February 2010, Joint Research Centre (JRC) of the European Commission. 69

74 Policy Department B: Structural and Cohesion Policies 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. 70

75 Occurrence reporting and accident/incident investigation in EU aviation Table 13: Use of ECCAIRS by NSIAs in EU Member States EU State NSIA ECCAIRS Status EU State NSIA ECCAIRS 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 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 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 , 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 and 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. 71

76 Policy Department B: Structural and Cohesion Policies Figure 23: ESARR 2 (Eurocontrol Safety regulatory requirement for Reporting and Assessment of Safety Occurrences in ATM) Member State (ANSP) Supplied: - Mandatory and voluntary ATM occurrence data ESSAR 2 Eurocontrol Safety Regulatory Requirement for reporting & assessment of safety occurrences in ATM Received:- Mandatory and voluntary ATM occurrence data EUROCONTROL 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 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 on page 33 72

77 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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 on ECCAIRS 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 73

78 Policy Department B: Structural and Cohesion Policies 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 does not have a voluntary reporting system 21% No response given 5% 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. 74

79 Occurrence reporting and accident/incident investigation in EU aviation Figure 26: Member States (with voluntary systems) confirming voluntary reporting systems are effective No response given 27% No, member state voluntary system is not effective 13% Yes, member state voluntary system is effective 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. 75

80 Policy Department B: Structural and Cohesion Policies 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 No response given 42% Yes, voluntary system within NSIAs is effective 41% No, voluntary system within NSIAs is not effective 17% Figure 29: Effectiveness of Voluntary Reporting - CAAs No, voluntary system within CAAs is not effective 20% No response given 0% Yes, voluntary system 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 76

81 Occurrence reporting and accident/incident investigation in EU aviation 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 No response given 35% Yes, changing voluntary reporting to mandatory will improve reporting 6% No, changing voluntary reporting to mandatory will not improve reporting 59% 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/ 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. 77

82 Policy Department B: Structural and Cohesion Policies 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 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. 78

83 Occurrence reporting and accident/incident investigation in EU aviation 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?? 79

84 Policy Department B: Structural and Cohesion Policies 80

85 Occurrence reporting and accident/incident investigation in EU aviation 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 Accident Investigation 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. 81

86 Policy Department B: Structural and Cohesion Policies 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 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 82

87 Occurrence reporting and accident/incident investigation in EU aviation 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-incharge 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 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 83

88 Policy Department B: Structural and Cohesion Policies 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 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. 84

89 Occurrence reporting and accident/incident investigation in EU aviation 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 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 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 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 85

90 Policy Department B: Structural and Cohesion Policies 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) Reporting of Incidents The analysis in Section of accident and incident data for commercial operations in Europe during has identified that there is a significant problem of underreporting 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 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 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 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

91 Occurrence reporting and accident/incident investigation in EU aviation There is a need to develop specific guidelines on the use of terms and definitions for reporting occurrences Occurrence Reporting 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 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 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 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/

92 Policy Department B: Structural and Cohesion Policies 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 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 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 88

93 Occurrence reporting and accident/incident investigation in EU aviation 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 Summary Results of Assessment Table 15 provides a comprehensive summary of the main results of the above assessment. 89

94 Policy Department B: Structural and Cohesion Policies Table 15: Summary of Main Results of Assessment Summary of Main Results of Assessment ACCIDENT INVESTIGATION Strength/ Best Practice Weakness/ Problem 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 & cooperation between authorities Tensions exist between NSIAs and judicial authorities Most NSIAs have in place MoUs / cooperation agreements to overcome difficulties with judicial authorities 90

95 Occurrence reporting and accident/incident investigation in EU aviation Summary of Main Results of Assessment 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 victims & families Non-disclosure of victims & families' names is not adequately protected Availability of passenger manifesto in specific timeframe or formalised procedure Crisis management Inconsistent approach amongst some MSs to handling crisis situations Uncertainty over whether internal procedures / mechanisms appropriately follow ICAO recommendations for a crisis management plan Possibility of under-resourcing in some NSIAs Resource levels in NSIAs Smaller NSIAs with fewer accidents lack the opportunity to test & learn from investigations Better cooperation between smaller NSIAs is needed to promote efficient best practices 91

96 Policy Department B: Structural and Cohesion Policies Summary of Main Results of Assessment Definitions Some confusion remains in the interpretation of key definitions leading to a danger of inconsistencies in reporting OCCURRENCE REPORTING Strength/ Best Practice Weakness/ Problem 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 Legislation Involvement of judicial authorities in occurrence reporting is unclear 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 Role of EASA 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 EASA has limited access to specific safety data fields within the central repository, which hampers its effectiveness in accomplishing its airworthiness responsibility Role of Eurocontrol Reporting of ATM-related occurrences is well established and effective under the current Eurocontrol systems ESSAR and EVAIR reporting systems are being used effectively and encourage national voluntary reporting within MSs 92

97 Occurrence reporting and accident/incident investigation in EU aviation Summary of Main Results of Assessment ECCAIRS provides a useful platform for standardising reporting practices if used effectively and more widely across MSs ECCAIRS & standardisation Standardised processes for occurrence reporting are not properly developed amongst some MSs There are differences amongst MSs in the use of ECCAIRS & local databases for occurrence reporting Exchange of safety data ECCAIRS is being used to some extent for data sharing between MSs No systematic approach for exchanging safety data between MSs 93

98 Policy Department B: Structural and Cohesion Policies 94

99 Occurrence reporting and accident/incident investigation in EU aviation 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 nonambiguous 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. 95

100 Policy Department B: Structural and Cohesion Policies 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 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 underreporting 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. 96

101 Occurrence reporting and accident/incident investigation in EU aviation 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 operatorspecific 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 97

102 Policy Department B: Structural and Cohesion Policies 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 98

103 Occurrence reporting and accident/incident investigation in EU aviation 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. 99

104 Policy Department B: Structural and Cohesion Policies 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 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). 100

105 Occurrence reporting and accident/incident investigation in EU aviation 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. 101

106 Policy Department B: Structural and Cohesion Policies 102

107 Occurrence reporting and accident/incident investigation in EU aviation Bibliography Legislation Commission Regulation (EC) No 1321/2007 of 12 November 2007 laying down implementing rules for the integration into a central repository of information on civil aviation occurrences exchanged in accordance with Directive 2003/42/EC of the European Parliament and of the Council. Commission Regulation (EC) No 1330/2007 of 24 September 2007 laying down implementing rules for the dissemination to interested parties of information on civil aviation occurrences referred to in Article 7(2) of Directive 2003/42/EC of the European Parliament and of the Council. Commission Regulation (EC) No 1702/2003 of 24 September 2003 laying down implementing rules for the airworthiness and environmental certification of aircraft and related products, parts and appliances, as well as for the certification of design and production organisations. Commission Regulation (EC) No 859/2008 of 20 August 2008 amending Council Regulation (EEC) No 3922/91 as regards common technical requirements and administrative procedures applicable to commercial transportation by aeroplane. Council Regulation (EC, Euratom) No 1605/2002 of 25 June 2002 on the Financial Regulation applicable to the general budget of the European Communities. Council Regulation (EEC) No 3922/21 on the harmonization of technical requirements and administrative procedures in the field of civil aviation (with Annex III replaced). Directive 2003/42/EC of the European Parliament and of the Council of 13 June 2003 on occurrence reporting in civil aviation. Directive 2004/36/EC of the European Parliament and of the Council of 21 April 2004 on the safety of third-country aircraft using Community airports. Directive 94/56/EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents. ICAO Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, 9 th Edition, July Regulation (EC) No 1592/2002 of the European Parliament and of the Council of 15 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). Regulation (EC) No 2111/2005 of the European Parliament and of the Council of 14 December 2005 on the establishment of a Community list of air carriers subject to an operating ban within the Community. Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 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. 103

108 Policy Department B: Structural and Cohesion Policies 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 on the modification of Directives 94/56/EC & 2003/42/EC, ECORYS Nederland BV, 20 July Proposal COM(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), ICAO Letter on Adoption of Amendment 12 to ICAO Annex 13, Secretary General, 9 April 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), 2 nd Edition, 2009, ICAO Doc 9859, Chapter 11 guidelines on Emergency Response Planning (Study Ref: Section , page 57). ICAO Training Guidelines for Aircraft Accident Investigators (ICAO Circular 298- AN/172), June 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 , 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

109 Occurrence reporting and accident/incident investigation in EU aviation 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, April 2010, 31 May 1 June 2010); EP Press release , Rapporteur: Ms Christine de Veyrac (EPP, FR). Websites ECCAIRS (European Commission - Joint Research Centre) available at: ESARR 2: 2_e3.0_ri.pdf EVAIR (Eurocontrol Voluntary ATM Reporting): 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 A , 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 A , Interim Report n 2 on the accident on 1 June 2009 to the Airbus A 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 A , 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 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 ER, Report on the accident to Boeing ER, 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 page 61). Fokker F28 Serious Incident, Oslo, January 2008 (Study Ref: Section 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 , page 56 and Section page 61). 105

110 Policy Department B: Structural and Cohesion Policies 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 Air Navigation Service Providers (ANSPs) in all EU Member States, consulted between November 2009 and April Civil Aviation Authorities (CAAs) in all EU Member States, consulted between November 2009 and April ECCAIRS Reporting System - Action Leader ECCAIRS for Joint Research Centre of the European Commission, Wietse Post, Telephone & discussions, February Eurocontrol ATM Network Support & Services Business Area, Survey interview & teleconference, November European Aviation Safety Agency (EASA) Survey interview & video-conference / discussions with Accident Investigation Manager (Safety Analysis & Research Department) & Certification Director, Jan Feb 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 National Safety Investigation Authorities (NSIAs) in all EU Member States, consulted between November 2009 and April

111 Occurrence reporting and accident/incident investigation in EU aviation Annex I A summary comparison between the proposed new regulation and EU Directive 94/56/EC New Regulation Article heading Obligation to investigate (Article 4) Commission Proposal COM (2009)0611 for a New Regulation on the investigation and prevention of accidents and incidents in civil aviation To investigate every accident / serious incident and other incidents (if safety benefit expected). Extent of investigation and procedures to be determined by investigation authority and will be without blame or liability. Directive 94/56/EC establishing fundamental principles governing the investigation of civil accidents & incidents As covered in new regulation. Safety investigations shall be independent from and without prejudice to any judicial or administrative proceedings to apportion blame or liability. Not specifically addressed. Civil Aviation Safety Investigation Authority (Article 5) Safety investigations are to be conducted or supervised by a permanent investigation authority without external interference and independently of any other parties who may have conflict of interest or influence its objectivity. Activities may include 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 As covered in new regulation. Cooperation between Safety Investigation Authorities (Article 6) - 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 - 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. Assistance can be requested from one national investigation authority to another, at no cost. The Member State may delegate another Member State to conduct the investigation. Not specifically addressed. As covered in new regulation. 107

112 Policy Department B: Structural and Cohesion Policies New Regulation Article heading European Network of Civil Aviation Safety Investigation Authorities (Article 7) Organisation of the work of the Network (Article 8) Participation of EASA in safety recommendations (Article 9) Participation of the State of Design in safety investigations (Article 10) Obligation to notify of accidents and serious incidents (Article 11) Commission Proposal COM (2009)0611 for a New Regulation on the investigation and prevention of accidents and incidents in civil aviation The investigation authority may also be assisted by the Network of civil aviation safety investigation authorities. European Network of Civil Aviation Safety Investigation Authorities shall comprise of respective heads from Member States. The network shall coordinate, exchange information and facilitate cooperation between Member States, the Commission & 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. The main key elements under this new regulation: - election of chairperson from its 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 work programme - permit participation of European thirdcountries 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 Within the scope of its competence and under the control of the investigator in charge, EASA shall be invited by investigation authorities of Member States The investigation authority of the Member State within which the aircraft design certificate holder is located shall appoint an accredited representative for the State of Design (in accordance with Annex 13 of Chicago Convention) Any person shall notify the investigation authority of an accident / serious incident within the scope of the regulation. The investigation authority must then notify, accordingly, the Commission, EASA and the Member States concerned immediately. Directive 94/56/EC establishing fundamental principles governing the investigation of civil accidents & incidents Not specifically addressed. Not specifically addressed. Not specifically addressed. Not specifically addressed. Not specifically addressed. Not specifically addressed. 108

113 Occurrence reporting and accident/incident investigation in EU aviation New Regulation Article heading Status of the safety investigators (Article 12) Commission Proposal COM (2009)0611 for a New Regulation on the investigation and prevention of accidents and incidents in civil aviation The appointed investigator-in-charge shall ensure safe control of evidence material, safe custody of aircraft and its contents and wreckage and take measures to satisfy 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 operation. Directive 94/56/EC establishing fundamental principles governing the investigation of civil accidents & incidents Details will be in accordance with the national law of the Member State & in cooperation with judicial authorities. As covered in new regulation. Coordination of enquiries (Article 13) Preservation of evidence (Article 14) Protection of sensitive safety information (Article 15) Use of recordings (Article 16) Publication of information (Article 17) The investigator-in-charge shall extend to its experts and advisers, as necessary, such assistance as will enable effective participation in the safety investigation. The investigator-in-charge shall coordinate with the judicial authority, without prejudice, in handling inquiries related to the accident safety investigation as well as the investigation into the causes of these accidents/incidents. The necessary steps must be taken to ensure preservation of documents, material and recordings, unless such action is necessary for safety reasons and/or to help the injured. The regulation defines which safety records shall not be made available or used other than for safety investigation or with the purpose of improving aviation safety. 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 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 Voice/image recordings & transcripts shall only be used for purposes of the safety investigation and with consent of all crew members concerned. The regulation also stipulates the availability & usage of flight data recorders under certain circumstances. Only information relevant to the analysis of accident/incident will be made public in the final report of the safety investigation. Not specifically addressed Not specifically addressed Not specifically addressed Not specifically addressed. Not specifically addressed. Not specifically addressed. 109

114 Policy Department B: Structural and Cohesion Policies New Regulation Article heading Communication of information (Article 18) Investigation report (Article 19) Commission Proposal COM (2009)0611 for a New Regulation on the investigation and prevention of accidents and incidents in civil aviation The regulation, under Article 18, states: - safety investigation authority staff / adviser participating in safety investigation shall be legally bound by 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 Specific regulatory points relating to the investigation report have been defined. These include inclusion of safety recommendations, anonymity protection of people involved, prior disclosure of information, release of an interim report and the provision of the reports to the Commission & EASA. Directive 94/56/EC establishing fundamental principles governing the investigation of civil accidents & incidents Not specifically addressed. Not specifically addressed. Safety recommendations (Article 20) All safety investigations shall be the subject of a report in a form appropriate to the type and seriousness of the accident or incident. 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. The safety investigation authority shall formally recommend to its own authorities, other Member States or third countries, any preventive action considered necessary for prompt action. Safety recommendations may be issued by the investigation authority based on studies or analysis of a series of investigations / activities. As covered in new regulation. Not specifically addressed. Follow-up to safety recommendations and safety recommendations database (Article 21) The safety recommendation shall not create a presumption of blame or liability for an accident or incident. Article 21 defines legal requirements for transmit and receipt of safety recommendations between the safety investigation authority and the addressee. These include the procedures, monitoring and the recording of safety recommendations in a repository database. As covered in new regulation. Member States shall take into consideration and act upon safety recommendations, without presumption of blame or liability. Not specifically addressed. 110

115 Occurrence reporting and accident/incident investigation in EU aviation New Regulation Article heading Availability of passenger lists (Article 22) Assistance to the victims of air accidents and their families (Article 23) Commission Proposal COM (2009)0611 for a New Regulation on the investigation and prevention of accidents and incidents in civil aviation Airlines departing from an airport that is in the territory of a Member State shall have procedures in place to produce a list of all passengers on board an aircraft within 1 hour of the notification of the occurrence of an accident involving this aircraft. Within each Member State, a plan for assistance to victims of civil aviation accidents shall be set up. Also, Member States with a special interest in an accident may appoint an expert to visit the site and 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. Directive 94/56/EC establishing fundamental principles governing the investigation of civil accidents & incidents Not specifically addressed. Not specifically addressed. 111

116 Policy Department B: Structural and Cohesion Policies 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 National Civil Aviation Regulator United Kingdom The Civil Aviation Authority (CAA) Operates independently and oversees and regulates all aspects of aviation in the UK. Investigation authority Air Navigation Service Provider Relationship between technical and judiciary authorities Administers a mandatory occurrence reporting system under Articles 142 of the Air Navigation Order (ANO) which implements EU Directive 2003/42/EC. 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. National Air Traffic Services (NATS) NATS monitors safety performance through its incident reporting and investigation process. UK AAIB has memorandums of understanding (MoUs) with the police service of Scotland and the Crown Prosecution Service details unavailable at this time. 112

117 Occurrence reporting and accident/incident investigation in EU aviation Table II.2: Czech Republic National Civil Aviation Regulator Czech Republic 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. Investigation authority 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. 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 and judiciary authorities No specifically agreement between the AAII and Judicial authorities. Basic cooperation is established in Act No 49/1997 on Civil Aviation, as amended. Table II.3: Denmark National Civil Aviation Regulator Denmark 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. Investigation authority CAA-DK BL 8-10: Regulations on mandatory reporting of flight safety occurrences 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). 113

118 Policy Department B: Structural and Cohesion Policies 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 and judiciary authorities The AIB DK has drafted and discussed a MoU with the authorities, but it has not been signed by the police yet as they are evaluating it. Table II.4: Portugal National Civil Aviation Regulator Portugal 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. Air Navigation Service Provider 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. NAV Portugal Certified in December Relationship between technical and judiciary authorities GPIAA cooperates with judicial authorities and has good mutual cooperation with all entities related to air safety. 114

119 Occurrence reporting and accident/incident investigation in EU aviation Table II.5: Estonia National Civil Aviation Regulator Estonia 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 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. Air Navigation Service Provider Relationship between technical and judiciary authorities Directive 94/56/EC full implemented. 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. Table II.6: Germany National Civil Aviation Regulator Germany 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. Air Navigation Service Provider 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. 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. Relationship between technical and judiciary authorities DFS is responsible for handling both civil and military air traffic. 115

120 Policy Department B: Structural and Cohesion Policies Table II.7: France National Civil Aviation Regulator France 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 Directive 2003/42/EC transposed by law in Jan 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. Relationship between technical and judiciary authorities Table II.8: Romania National Civil Aviation Regulator Romania 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. Air Navigation Service Provider Directive 2003/42/EC transposed into national legislation by Ministry of Transport Ordinance No 159/2006 Romanian Air Traffic Administration R.A. (ROMATSA R.A.) ESARR 2 implemented Relationship between technical and judiciary authorities Cooperation between judicial authorities and technical investigation is in accordance with national legislation, 399/2005 Law - Air Code and Government Order 26/

121 Occurrence reporting and accident/incident investigation in EU aviation Table II.9: Netherlands National Civil Aviation Regulator Investigation authority Netherlands CAA-NL (Civil Aviation Authority Netherlands) CAA-NL part of the Netherlands Transport and Water Inspectorate. Dutch Transport Safety Board Safety Investigation Board Act came into force in Feb Air Navigation Service Provider Directives 94/56/EC & 2003/42/EC both transposed in 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 and judiciary authorities Judiciary authorities may have full access to investigations and data from safety reports. Judiciary is particularly strong on prosecution in all safety occurrences resulting from gross negligence/misconduct. Table II.10: Spain National Civil Aviation Regulator Spain Spanish Aviation Safety Agency (AESA) Investigation authority Accident & Incident Investigation Commission (CIAIAC) Directive 94/56/EC transposed (Royal Decree 389/1998). Air Navigation Service Provider Directive 2003/42/EC transposed (1334/2003) November AENA Safety Division / Air Navigation Directorate ESARR 2 implemented but not transposed into national legislation due to military concerns. Relationship between technical and judiciary authorities 117

122 Policy Department B: Structural and Cohesion Policies 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. Please provide details requested below: Survey Survey Respondent Details: Survey Record Sheet COUNTRY: Organisation /Department and Company: Name of Respondent(s): Position/Job Title (Brief Description): 118

123 Occurrence reporting and accident/incident investigation in EU aviation 1. Policy, Strategy & Regulations Specific Focus (Findings/Evidence) Comments 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? 119

124 Policy Department B: Structural and Cohesion Policies 1. Policy, Strategy & Regulations Specific Focus Do you think Directive 94/56/EC fully meets the requirements of the state? If not, please state reason. (Findings/Evidence) Comments Is adequate protection provided under the Directive for individuals involved in reporting an accident or serious incident? Directive 2003/EC/42 Has 2003/42/EC been transposed into national law (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? 120

125 Occurrence reporting and accident/incident investigation in EU aviation 1. Policy, Strategy & Regulations Specific Focus (Findings/Evidence) Comments National Investigation Authority Who does the Investigation Authority report to? Is the Investigation Authority Independent? 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/nontechnical)? 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) 121

126 Policy Department B: Structural and Cohesion Policies 1. Policy, Strategy & Regulations Specific Focus (Findings/Evidence) Comments Freedom of Information Act Does the State have a freedom of information act in place? If not, then what national legislation, if any, exists for the confidential reporting of accidents/incidents? Additional National Regulations / Practices Do you have in place any additional national legislation or practices which supplement the requirements of ICAO Annex 13 and Directives 2003/EC/42 and 94/56/EC? Additional Comments Please make any additional comments relating to Policy, Strategy & Regulations 122

127 Occurrence reporting and accident/incident investigation in EU aviation 2. Cooperation with other Organisations and Member States Specific Focus (Findings/Evidence) Comments Relationship and Cooperation between the national aviation investigation authority and other organisations Please identify any specific issues/problems of concern relating to working practices between the national investigation authority and other organisations (e.g. police, search and rescue, etc) Please state any MoUs (memorandums of understanding) or other agreements in place with other organisations. How effective are the measures in place to manage the following interactions: With judicial authorities With airlines With airport authorities With other organisations 123

128 Policy Department B: Structural and Cohesion Policies 2. Cooperation with other Organisations and Specific Focus (Findings/Evidence) Comments Member States Relationship between your Investigation authority and investigation authorities from other Member States Comment on the following: To what extent, if at all, does the investigation authority cooperate with other investigation authorities? Do you think a central European network acting as a 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 124

129 Occurrence reporting and accident/incident investigation in EU aviation 3. Resources Specific Focus (Findings/Evidence) Comments Aviation Safety Database and repository system Does the investigation authority have an established 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? 125

130 Policy Department B: Structural and Cohesion Policies 3. Resources Specific Focus (Findings/Evidence) Comments Departmental Resource capability to conduct investigations Does the investigation authority have sufficient resources to conduct its own safety 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? 126

131 Occurrence reporting and accident/incident investigation in EU aviation 3. Resources Specific Focus (Findings/Evidence) Comments Use of Flight Recorders in the investigation What measures are in place for the handling and use 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 Resource Provision Are there any issues / concerns relating to the 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? 127

132 Policy Department B: Structural and Cohesion Policies 3. Resources Specific Focus (Findings/Evidence) Comments Additional Comments Please state any additional comments relating to Resources 128

133 Occurrence reporting and accident/incident investigation in EU aviation 4. Definitions used in Accident/Incident Investigation & Reporting Specific Focus (Findings/Evidence) Comments Accident Means an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: - a person is fatally or seriously injured - the aircraft sustains damage or structural failure - the aircraft is missing or is completely inaccessible Do you use the definition provided in Directive 94/56/EC? If not, please provide the definition used. If you use a different definition, please state the reason why. Reference Directive 94/56/EC Incident Means an occurrence, other than an accident, associated with the operation of an aircraft which affects or would affect the safety of operation. Reference Directive 94/56/EC Do you use the definition provided in Directive 94/56/EC? If not, please provide the definition used. If you use a different definition, please state the reason why. 129

134 Policy Department B: Structural and Cohesion Policies 4. Definitions used in Accident/Incident Specific Focus (Findings/Evidence) Comments Investigation & Reporting Serious Incident Means an incident involving circumstances indicating that an accident nearly occurred. Reference Directive 94/56/EC Do you use the definition provided in Directive 94/56/EC? If not, please provide the definition used. 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? 130

135 Occurrence reporting and accident/incident investigation in EU aviation 4. Definitions used in Accident/Incident Specific Focus (Findings/Evidence) Comments Investigation & Reporting Additional Comments Please state any additional comments relating to Definitions used in Accident/Incident Investigation & Reporting. 131

136 Policy Department B: Structural and Cohesion Policies 5. Accident/Incident Investigation Processes, Procedures and Systems Specific Focus (Findings/Evidence) Comments Notification of an accident or serious incident Who is the initial point of contact for reporting? 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 of an accident Upon receiving notification of an accident (e.g. from 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) 132

137 Occurrence reporting and accident/incident investigation in EU aviation 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems Availability of and access to appropriate processes and tools for conducting the accident investigation What measures are in place for: Gathering, recording and analysing all available information on the accident/incident Issuing safety recommendations Determining the causes The completion of the final report Are these measures effective? If not, please state your reasons. 133

138 Policy Department B: Structural and Cohesion Policies 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems Communicating aviation safety data to key aviation safety authorities What procedures and mechanisms are in place for the investigation authority to communicate relevant data to the following? 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 safety investigation. What measures are in place to ensure the following: The proper conduct of independent safety investigations Access to accident/incident property (aircraft, equipment etc) and documentation 134

139 Occurrence reporting and accident/incident investigation in EU aviation 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems 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 safety investigation What process (if any) currently exists to prevent and deal with suspected acts of unlawful interference during the safety investigation? Legal powers granted to the Safety Investigator What specific powers are given to the safety investigator? E.g. gathering of evidence, interviews, powers of entry, etc. 135

140 Policy Department B: Structural and Cohesion Policies 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems Adequate protection for victims of air accidents Does the current investigation reporting system 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? 136

141 Occurrence reporting and accident/incident investigation in EU aviation 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems Third-party aircraft (Non-EU Aircraft operators) Briefly outline the procedures and processes in 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 o o o European Commission EASA EUROCONTROL Others 137

142 Policy Department B: Structural and Cohesion Policies 5. Accident/Incident Investigation Processes, Specific Focus (Findings/Evidence) Comments Procedures and Systems 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. 138

143 Occurrence reporting and accident/incident investigation in EU aviation 6. Organisational Structure, Roles & Responsibilities Specific Focus (Findings/Evidence) Comments Involvement of the European Aviation Safety Agency (EASA) What is the level and nature of the support your organisation receives from EASA? Is this fit for purpose? 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. 139

144 Policy Department B: Structural and Cohesion Policies 6. Organisational Structure, Roles & Responsibilities Specific Focus (Findings/Evidence) Comments Involvement of EUROCONTROL What is the level and nature of support your 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 140

145 Occurrence reporting and accident/incident investigation in EU aviation 7. Reporting Specific Focus (Findings/Evidence) Comments Just, open and blame-free safety reporting culture What measures are in place to ensure a just, blamefree 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? 141

146 Policy Department B: Structural and Cohesion Policies 7. Reporting Specific Focus (Findings/Evidence) Comments Use of the European Coordination Centre for Aviation Incident Reporting System (ECCAIRS) The ECCAIRS reporting system is the central European database for aviation safety. It is a set of tools made available by the European Commission, which facilitates the exchange and integration of occurrence reports. 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? 142

147 Occurrence reporting and accident/incident investigation in EU aviation 7. Reporting Specific Focus (Findings/Evidence) Comments 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. 143

148 Policy Department B: Structural and Cohesion Policies ADDITIONAL INFORMATION: Please provide any additional information on other areas, not covered in the survey, that you feel would be beneficial to this study. 144

149 Occurrence reporting and accident/incident investigation in EU aviation 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. 145

150 Policy Department B: Structural and Cohesion Policies Table 16: Survey Responses on Accident Investigation Issues Survey Issue Member States filing deviations under ICAO Annex 13 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. [STATE] legislation requires that all documents be made available for criminal proceedings. [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 Is Directive 94/56 fit for purpose? 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. It should be noted that many of the non-nsia respondents did not answer this question. Some of the 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)

151 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Does Directive 94/56/EC provide adequate protection for individuals reporting accidents or serious incidents? Supplementary Regulations at National level Survey Responses from National Aviation Authorities in EU Member States 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). One response indicated that whilst there remained a possible loophole, this could be exploited: - The Directive is not fit for purpose, as now a go around has been left. i.e. in [STATE] police can retrieve all info from [INVESTIGATION AUTHORITY] and use against individuals The majority of responses indicating that supplementary regulations were in place, but the need for additional regulation were not stated. Some indicated that this additional regulation contradicted areas of the Directives, but specific examples were not provided. 147

152 Policy Department B: Structural and Cohesion Policies Survey Issue Are Definitions in line with those provided in Directive 94/56 /EC and ICAO annex 13? Survey Responses from National Aviation Authorities in EU Member States 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 indicating that an accident nearly occurred, considering as such and including those in the list published in the [LEGISLATION]. The difference between an accident and a serious incident lies in its consequences. The majority of respondents confirmed that the definitions were clearly understood, although some respondents did 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). Issues with working practices/relationships with judicial authorities No issues with judicial authorities as this is covered by a cooperation agreement in place with the judicial authorities which allows [INVESTIGATION AUTHORITY] to obtain access to site/evidence documentation without delay if necessary. Not identified any problem in current time. 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) 148

153 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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: Member States with memorandums of understanding in place At national level: [STATE] Non schedule Airline; [STATE] Meteorological Institute; [STATE] Air Traffic Management; [STATE] Schedule Airline; [STATE] Civilian Aviation Authority; [STATE] Pilots Professional Association; [STATE] University Aeronautical Engineering. 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 [INVESTIGATION AUTHORITY ] is implementing, but not yet signed with other organisations: [STATE] Air 149

154 Policy Department B: Structural and Cohesion Policies Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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. Relationships with other Investigating 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 Accident/Incident Investigation between ECAC Member States. [STATE] has signed a cooperation agreement with ECAC Member States as of [DATE], so in the event of 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. Benefits of the European Network of Civil Aviation Safety Investigation Authorities The majority of NSIAs indicated that such a network would be of benefit, but expressed reservations: Some raised concerns about the benefit and role of the Network: No evidence was presented to show that a formal network would be beneficial Central coordination can create additional time problems. 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 150

155 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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 Reports Issues related to the resources available to the NSIAs Yes. There is a monthly publication and the possibility to subscribe electronically to any report published. 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. Most of the NSIAs confirmed that there was sufficient budget available to deal with the current level of accidents and incidents recorded, although some raised the issue of travel expenses. Many of the smaller 151

156 Policy Department B: Structural and Cohesion Policies Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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: Issues related to Just Culture Non-disclosure of names of individuals, operators and others involved so all focus is on the safety result and not on blaming somebody. Anonymous reporting system via 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. 152

157 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Survey Responses from National Aviation Authorities in EU Member States [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. 153

158 Policy Department B: Structural and Cohesion Policies Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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. Protection of Victims Yes, all individuals names are part of non-disclosure within the [INVESTIGATION AUTHORITY], but not 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. Role of EASA in accident investigations Investigation must be provided independently of EASA 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 154

159 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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: Availability of Passenger Manifesto Passenger name list is always on board the aircraft and also available in electronic form in the computer system. There is no time delay in receiving the passenger manifest. In the computer system there is also more 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. 155

160 Policy Department B: Structural and Cohesion Policies Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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 Plans Yes, we have Emergency Response Plan and Manual in place with detailed instructions, checklists and 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. 156

161 Occurrence reporting and accident/incident investigation in EU aviation Survey Issue Survey Responses from National Aviation Authorities in EU Member States 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. 157

162 Policy Department B: Structural and Cohesion Policies Table 17: Survey Responses on 'Occurrence Reporting' Issues Survey Issue Is Directive 2003/42/EC fit for purpose? Survey Responses from National Aviation Authorities in EU Member States 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, 2042/2003), Too weak as far as protection for individuals involved in reporting is concerned 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. Nonpunitive 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 158

163 Occurrence reporting and accident/incident investigation in EU aviation 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 of Occurrences at National Level The responses stated that this data is used at national level and is analysed to identify local trends The data is continuously used for trend monitoring and to reveal similarities within e.g. incidents in general aviation. 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. Mandatory Reporting of Occurrences Use of ECCAIRS 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. The majority of the responses indicated that they used the ECCAIRS software as a means of meeting legal requirements, 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 that it was in the process of implementing the use of the ECCAIRS software system. 159

164 Policy Department B: Structural and Cohesion Policies 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) 160

165 Occurrence reporting and accident/incident investigation in EU aviation 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 Systems In terms of changing the balance between voluntary and mandatory reporting, a number of respondents expressed 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. 161

166 Policy Department B: Structural and Cohesion Policies 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. 162

167 Occurrence reporting and accident/incident investigation in EU aviation 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). ESARR 2 / Relationship with Eurocontrol Overall the relationship between the ANSPs and Eurocontrol appears to be positive: There is close cooperation between [STATE] CAA and Eurocontrol, mainly through participation in working 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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