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PRELIMINARY AND FINAL REPORT
Submission of preliminary and final accident report
The investigator-in-charge must submit the preliminary and final report regarding an accident investigation to the Commissioner in the format contained in this technical standard.
Format
The format of a preliminary and final report is as follows:
(1)
Title;
(2)
synopsis;
(3)
contents; and
(4)
appendices.
Title
The title of a preliminary and final report must comprise:
(1)
Name of the operator or owner;
(2)
manufacturer;
(3)
model;
(4)
nationality and registration marks of the aircraft; and
(5)
place and date of the accident.
Synopsis
(1)
A synopsis must briefly describe all relevant information regarding –
(a)
notification of accident to national and foreign authorities;
(b)
identification of the investigator-in-charge;
(c)
identification of investigators, accredited representatives and advisers;
(d)
organisation of the investigation;
(e)
authority releasing the report; and
(f)
date of publication.
(2)
A synopsis must contain a brief summary of the circumstances leading to the accident.
Contents
The contents of the preliminary and final report must comprise the following headings:
(1)
Factual information;
(2)
analysis;
(3)
conclusions; and
(4)
safety recommendations.
Appendices
The appendices must consist of all the relevant statements, documents, photographs, sketches, transcripts, drawings and information pertaining to the accident investigation concerned.
Factual information
The following factual information must be contained in the preliminary and final report:
(1)
History of the flight
A brief narrative is required giving the following information:
–
Flight number, type of operation, last point of departure, time of departure (local time or UTC), point of intended landing.
–
Flight preparation, description of the flight and events leading to the accident, including reconstruction of the significant portion of the flight path, if appropriate.
–
Location (latitude, longitude, elevation), time of the accident (local time or UTC), whether day or night.
(2)
Injuries to persons
Completion of the following (in numbers):
Injuries | Crew | Passengers | Others |
Fatal |
|
|
|
Serious |
|
|
|
Minor |
|
|
|
None |
|
|
|
(3)
Damage to aircraft
A brief statement of the damage sustained by aircraft in the accident (destroyed, substantially damaged, slight damaged, no damage).
(4)
Other damage
A brief description of damage sustained by objects other than the aircraft.
(5)
Personnel information
(a)
Pertinent information concerning each of the flight deck crew members including: age, validity of licences, ratings, mandatory checks, flying experience (total and on type) and relevant information on duty time.
(b)
Pertinent information regarding other relevant personnel, such as air traffic services, maintenance.
(6)
Aircraft information
(a)
A brief statement on airworthiness and maintenance of the aircraft (indication of deficiencies known prior to and during the flight to be included, if having any bearing on the accident).
(b)
A brief statement on performance, if relevant, and whether the mass and centre of gravity were within the prescribed limits, during the phase of operation related to the accident. (If not and if of any bearing on the accident give details.)
(c)
Type of fuel used.
(7)
Meteorological information
(a)
A brief statement on the meteorological conditions appropriate to the circumstances including both forecast and actual conditions, and the availability of meteorological information to the flight crew.
(b)
Natural light conditions at the time of the accident (sunlight, moonlight, twilight, etc.).
(8)
Aids to navigation
Pertinent information on navigation aids available, including landing aids such as ILS, MLS, NDB, PAR, VOR, visual ground aids, etc. and their effectiveness at the time.
(9)
Communications
Pertinent information on aeronautical mobile and fixed service communications and their effectiveness.
(10)
Aerodrome information
Pertinent information associated with the aerodrome, its facilities and conditions, or with the take-off or landing area if other than an aerodrome, if relevant.
(11)
Flight recorders
The location of the flight recorder installation in the aircraft, their condition on recovery and pertinent data available therefrom, if relevant.
(12)
Wreckage and impact information
General information on the site of the accident and the distribution pattern of the wreckage; detected material failures or component malfunctions. Details concerning the location and state of the different pieces of the wreckage are not normally required unless it is necessary to indicate a break-up of the aircraft prior to impact. Diagrams, charts and photographs may be included in this section or attached in the Appendices.
(13)
Medical and pathological information
Brief description of the results of the investigation undertaken and pertinent data available therefrom, if relevant.
(14)
Fire
If fire occurred, information in the nature of the occurrence, and of the fire fighting equipment used and its effectiveness, if relevant.
(15)
Survival aspects
A brief description of search, evacuation and rescue, including response time, location of crew and passengers in relation to injuries sustained, failure of structures such as seats and seat-belt attachments, if relevant.
(16)
Tests and research
Brief statements regarding the results of tests and research, if relevant.
(17)
Organisational and management information
The following information is required:
Pertinent information concerning the organisations and their management involved in influencing the operation of the aircraft. The organisations include, for example, the operator or owner; the air traffic services, airspace, aerodrome and weather service agencies; and the regulatory authority. The information could include, but not be limited to, organisational structure and functions, resources, economic status, management policies and practices, and regulatory framework.
(18)
Additional information
Any relevant information not already included in paragraphs (a) to (q) shall be included.
(19)
Useful or effective investigation techniques
When useful or effective investigation techniques have been used during the investigation, briefly indicate the reason for using these techniques and refer here to the main features as well as describing the results under the appropriate headings in paragraphs (a) to (r).
Analysis
Analyse, as appropriate, only the information documented in technical standard 12.0012(7) and which is relevant to the determination of conclusions of causes.
Conclusions
List the findings and causes established in the investigation. The list of causes must include both the immediate and the deeper systemic causes.
Safety recommendations
As appropriate, briefly state any recommendations made for the purpose of accident prevention and any resultant corrective action.
Appendices
Include, as appropriate, any other pertinent information considered necessary for the understanding of the report.
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