ICAO-COPAC International Safety Seminar

Madrid, 24 and 25 March, 2011

Coordination between

judicial and safety investigation

authorities

Ulf Kramer

Director BFU

Legal Basis for the Safety Investigation Authority

• REGULATION OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL

996 / 2010

• ICAO Annex 13

• National rules

After an Accident Two „Independant“ Investigations have to be Coordinated

safety investigation judicial investigation

Both autorities need to have all relevant facts

First at the Accident Site: Police, Fire Fighters, Rescue Services

Documentation?

Accident Site

Article 13 (996/2010)Preservation of evidence

• Pending the arrival of safety investigators, no person shall modify the state of the site of the accident, take any samples therefrom, undertake any movement of or sampling from the aircraft, its contents or its wreckage, move or remove it, except where such action may be required for safety reasons or to bring assistance to injured persons,

Protection (Annex 13)

• The State of Occurrence shall take all reasonable measures to protect the evidence and to maintain safe custody of the aircraft and its contents for such a period as may be necessary for the purposes of an investigation.

Protection: by Police

Investigation Team Arrived

„coordination talks“

• What was done and / or has been documented?

• “When a judicial investigation is also instituted, the investigator-in-charge shall be notified thereof” (Article 12, 996/2010)

• Further steps and responsibilties

• Press release (content and responsibility)

• Who is allowed to enter the accident site?

The Investigation TeamIIC, Acc. Reps, Advisers, Authorities

(also Judicial)

Traces (Combined Work Force)

Indentification of Parts (Combined Work Force)

Investigation

steps of safety investigation

steps of judicial investigation

to be coordinated

Continuation of safety investigation

Duties of police

Recovery of persons killed

Information

Search for Recorders (Combined Work Force)

Handling of Recorders

• Protection of flight recorder evidence requires that the recovery and handling of the recorder and its recordings be assigned only to qualified personnel(ICAO)Safety investigation authority accompanied by judicial authority (Article 12 (1) 996/2010)

Readout of Recordersinvestigation authority (and judicial authority

under secured procedures)

Reconstruction of Flight(Investigation Authority)

Further Examination of Wreckage

Article 12 996/2010

• If examination or analysis of such material may modify, alter or destroy them, without prejudice to national law, prior agreement from the judicial authorities will be required.

What is this?

Lightning

Destroyed Parts(Investigation Authority)

Which Parts were Affected?(Investigation Authority)

Wiring of the Plane(Investigation Authority)

Flight Manual(Investigation Authority)

End of Coordination

Important:

Exchange of all relevant facts

between the judicial and safety investigation authorities. The

investigation conducted from here on, can proceed without interference

from either side.

Further Areas to be Investigated by the Authorities e.g.:

safety judicialRegulations relevant? responsible for?Type certification relevant? responsible for?Maintenance relevant? responsible for?Crew training/licences relevant? responsible for?Operator relevant? responsible for?Flight Preparation relevant? responsible for?Communication/ATC relevant? responsible for?

Article 14

Protection of sensitive safety information

(1) The following records shall not be made available or used for purposes other than safety investigation:

Article 14 996/ 2010

• Statements, information collected by the safety investigation, voice and image recordings, notes, etc, etc,

5.12 Annex 13

• The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations:

Outcome without blame

• Findings

• Causes

• Contributing factors

• Safety recommendations

Safety Recommendation 1

• To the regulatorRequirement changeEquipment of airplanes with an additional artificial horizon, powered from a source independent of the electric generating system

Safety Recommendation 2

• To manufacturer and operators (flight manual)

• Information for pilotsProcedures for reconnection of the batteries and generators after total failure of the electrical power supply system

Safety Recommendation 3

• To manufacturer• Modification of the battery-bus-

relay Modification in such a way that a failure is extremly improbable

Benefits

• The recommendations have contributed to the preventation of 3 possible accidents in Germany in the 20 years after their publication.