Sharing experience....

Introduction

Aircraft Accident Investigation is a complex process; from notifying the ICAO to the preparation of the investigation report. Investigation of Large Transport Aircraft is more complex due to the number of passengers, complex aircraft systems, many types of cargoes, and complex air operation activities. The most critical challenge in the investigation is to acquire as much data in the short possible time through the wreckage and debris because the vital evidence may easily perish. Therefore, the investigators must carry out the task with meticulous planning.?

Experiences

My experience in aircraft investigation goes back to the year 1990 when I was working for Airod Sdn Bhd. However, the scope of the investigation was not an obligation to the ICAO Annex 13 - Aircraft Accident and Incident Investigation. It was to assess the extent of the aircraft damage and proposed the design of repairs and part replacement to recover the aircraft. The final reports were the cost to recover the accident aircraft.

After I left Airod Sdn Bhd, I moved to Australia to work for Eagle Pty Ltd. The Eagle Pty Ltd designed and manufactured the Eagle 150 Series of aircraft. As the aircraft OEM, the obligation to the ICAO Annex 13 was to provide assistance to the investigation agency in any investigation of incidents and accidents. We were fortunate, that Eagle Aircraft has very good safety records.?

In late 1996, I came back to Malaysia and joined the Airworthiness Division of the Department of Civil Aviation, Malaysia. One of my tasks is to be an accident investigator. During 13 years serving DCA, I have been assigned by MOT as an investigator for numerous aircraft accidents and incidents. I was working under the KIKU, who was also from DCA; either from the Airworthiness or? Flight Operations Division. The AAIB did not exist during my time, the airworthiness and flight operations division officers were doing the investigation. The officers were assigned as the investigators by the MOT. Our tasks were to conduct the investigation as the state's obligation to ICAO Annex 13. We have done the investigation in accordance with Annex 13 but the investigators were from airworthiness and flight operations officers, who also issued certificates and licenses. The ICAO did not agree with that approach, Malaysia shall have an independent investigation body. The ICAO audit findings lead to the establishment of the AAIB (BSKU) Malaysia.?

Recognition

When the MH370 disappeared, Malaysia had to establish independent investigators and I was drafted into the team of airworthiness, my work more on aircraft structures. I have done most of the work on debris investigation and identifications of the MH370. I was also with the team to investigate the 1st debris found in Reunion Island. When the Australian and the Malaysian Government agreed to sign an agreement to fund the search. I was tasked to write the details planning to conduct the search before the agreement was finalized.

Training

My formal training by the ICAO sponsored by the Ministry of Foreign Affairs Singapore on “Aircraft Accident Investigation and Management” Singapore Aviation Academy helped me to work as an accident investigator and manage the investigation beyond learning at work.

Investigation Guidance?

Obligation to ICAO Annex 13 is one state's responsibility. Malaysia was fortunate because the ICAO noncompliance finding of the Malaysian investigation was not independent and was resolved by the establishment of the AAIB under the MOT.? Even though the AAIB was under staff during the initial establishment, the entity of independence was already established. ICAO Annex 13 is one of the SARPs with comprehensive guidance provided to the states by publishing Doc 9756 “Manual of Aircraft Accident and Incident Investigation”. This manual has four (4) Parts;?

Part I - Organisation and Planning ,

Part II - Procedures and Checklists,?

Part III - Investigation,?

Part IV - Reporting

The details of planning and management of the investigation are written in Part II - Procedures and Checklist. It gives step-by-step procedures to investigate any accident, which can be adapted for any size of aircraft and the extent of the accident.

When I wrote the Operational Plan for MH370 Investigation document, I considered the aircraft accident investigation as a project with the Work Breakdown Structure (WBS) contents referred from the Doc 9756 “Manual of Aircraft Accident and Incident Investigation (Part II - Procedures and Checklists)”. The investigation of the accident is a project because it fits the project triad definitions of short-term activities with start and stops, to be done within the scope, within time and cost to be able to have good reports for the accident to occur again.?When the accident is approached as a project, it allows the development of details to be done, hours required including the resources (facility and equipment) for each task. This information will translate to cost and later the budget. An investigation is not cheap,? especially for unique cases such as MH370. The current spending is just for the SAR to locate the aircraft but not the cost of conducting the investigation.

Doc 9756 “Manual of Aircraft Accident and Incident Investigation (Part II - Procedures and Checklists)” provides a detailed list of activities, which are called system events. There are 66 events listed from the initial response to the Report of the IIC. There are detailed tasks for each event depending on how extensive the events should be. The manual is a guide, therefore the investigators must adapt those tasks to the accidents. For example, in Event 2, the initial actions at the site do not have the detail, when the site is in the ocean. Therefore, we must be practical on how to secure parts and debris from the ocean.

Step 1 - Establish Team

Once the report of the incident is received, the AAIB needs to establish the team. A few models have been recommended by the ICAO. One of the initial criteria in establishing the team is to determine whether there should be a Major Accident Investigation or Smaller Investigation. They are defined as;?

1. Major Accident Investigation - An investigation into an accident involving a large aircraft and usually involving fatalities.

2. Smaller Investigation - An investigation into an incident involving any aircraft or into an accident involving a small aircraft.

Step 2 - Establish Investigation Group and Assigned Events

Once the org is established, the investigation teams are grouped into their areas of activities and expertise. Each group is assigned with the events, the total events are 66 and for the events, there are events' tasks or checklists, which are used to accomplish the investigation.?

Step 3 - Establish Event Flowchart

The events are later sequenced to ensure the investigation is properly coordinated and all the events’ tasks are completed without any tasks being missing because some tasks are impossible to redo, especially when the wreckage has been moved.?

Step 4 - Establish a Project

Develop the Project Management WBS, all the tasks or checklists for each event are established as the WBS of the Project Management Cycle; Planning, Initiation, Execution, Monitor and Control, and Closure. Place all the events and events' tasks under the appropriate project management process cycle.

For further information contact the author.