1. Roles and Responsibilities

1.1 Purpose of Aircraft Occurrence Investigation

The Aviation Act, No. 74 of 1962 as amended requires the South African Civil Aviation Authority (CAA) to regulate the safety of:

1. Civil air operations in the South African territory.
2. South African registered aircraft operating outside the South African territory.

Aircraft occurrence investigation by the CAA is exercised in terms of section 12 of the Aviation Act. Additionally, as a signatory to the Chicago Convention (1944) on International Civil Aviation, it is required by Annex 13 (Chapter 5) to the convention on International Civil Aviation, that the state of occurrence shall institute an investigation into the circumstances of an accident or serious incident.

Annex 13 to the Convention on International Civil Aviation prescribes the international standards and recommended practices for the investigation of aircraft occurrences.

The aircraft occurrence investigation section of the South African CAA has priority in the investigation of air safety occurrences that take place in the South African territory. The main purpose of the section’s investigations is as follows:

1. To investigate occurrences in order to determine the cause of the occurrence and strive to prevent their reoccurrence.
2. To monitor trends regarding aircraft occurrences and identify potential problem areas and possible safety deficiencies.
3. To propose safety recommendations to the regulatory body.
4. To promote safety in aviation by developing safety programs.

The CAA, as the regulating body, must strongly consider the recommendations and take necessary action if deemed appropriate. Investigation outcomes could lead to appropriate action for example, reconsideration of appropriateness of Civil Aviation Regulations, reconsideration of the procedures prescribed in operating procedures or consideration of the implications for similar aircraft types.

Depending on the circumstances, the project manager and/or investigator on first stand-by duty shall, in exercising their obligations under the Aviation Act, decide which occurrences the aircraft occurrence investigation section of the CAA will investigate. In doing so they will give consideration to the safety significance of the occurrence and the available resources

CAA officers shall, when investigating occurrences, adhere to the procedures in this manual.

The CAA responsibilities in occurrence investigations are to determine which of the following factors were involved:

1. Airworthiness of aircraft.
2. Competency of flight crew and/or maintenance personnel.
3. Performance of CAA functions.
4. Performance of air traffic services or navigational aids.
5. The Civil Aviation Act, Regulations or Orders were adequate.
6. Aerodrome safety standards and/or operational procedures.
7. Flight crew medical qualifications.
8. Breach of the Civil Aviation Act or Regulations.
9. Other.

1.2 Legal Considerations

While conducting an investigation of an aircraft occurrence, any appropriately appointed investigators might be required to have access to aircraft, aerodromes, premises or documents. However, inspectors do not have general right of access under common law, simply because they happen to be officials of the CAA. Any right of access must be conferred by the Aviation Act 1962 as amended.

The Aviation Act 1962 as amended and the Civil Aviation Regulations do contain several provisions which confer statutory power on officers, enabling them to have access to aircraft, aerodromes, premises and documents. When an inspector wishes to gain access under these provisions, he or she must comply with any statutory restrictions or limitations that are imposed by the relevant provision.

1.2.1 Litigation

Investigators, in preparing a report on the results of an aviation safety occurrence, should be aware of possible litigation action by persons and/or organisations mentioned in the report. Investigators, when preparing a report should be aware that CAA officers are protected while carrying out their duties subject to the following:

Statements in the report are reasonable and within the scope of the Investigator's duties

Statements in the report relate directly to the subject of the investigation, and, do not deliberately contain material, which is false or malicious

The Investigator submits the report to the Commissioner for Civil Aviation (CCA), and, if appropriate, the report is to be distributed by the CCA to interested parties after the report was reviewed on an Internal Review Committee meeting.

1.2.2 Statutory Provisions

Statutory provisions, relating to the investigation of an aircraft occurrence are:

Civil Aviation Regulations

The Civil Aviation Regulations published in the Government Gazette No. 18286 of 28 September 1997 came into force on 1 January 1998. Part 12 of these regulations deal with procedures relating to aviation accidents and incidents.

Note: The SA-CATS-ACCID and INCID document should be kept in mind whenever these regulations are read.

Aviation Act No. 74

Aviation Act No. 74 as amended allow officers who have been appointed as investigators under the Act (Investigators) to enter premises with the consent of the occupier of the premises.

Additionally, Investigators may obtain a warrant under Section 5 (6) authorising entry and search of premises and aircraft.

1.3 CAA Responsibility and Participation

CAA officers may be involved in aircraft occurrence investigation in one of two ways:

1.3.1 Obliged by Aviation Legislation

The investigator has a primary obligation to investigate aircraft occurrences as described in the Aviation Act, No. 74 (refer to 1.1 above).

The accident investigator has a secondary obligation when employed in this way. That is, to keep CAA managers informed of the progress of an investigation and to advise them immediately of information, which indicates a need to take urgent safety-related action.

In exercising this obligation the investigator must not divulge any specific information which has been gained in confidence as part of the investigation. Similarly, the official must not release occurrence-related data or information to unauthorised persons.

1.3.2 Participation under the provisions of Annex 13

Where an occurrence has taken place involving a South African registered aircraft in an ICAO contracting state or non contracting state different from the state of registry of the aircraft, the officials of CAA could obtain participation status in the investigation of the occurrence. This participation status would be obtained under the provisions of ICAO Annex 13.

Annex 13 (5.18) indicate under the title "rights" that the state of registry and the state of the operator shall be entitled to appoint an accredited representative to participate in the investigation. When neither the State of Registry, nor the State of the Operator appoint an accredited representative, the State conducting the investigation should invite the operator to participate, subject to the procedure of the State conducting the investigation.

Investigators participating in an investigation of a different state must operate in harmony with the investigator-in-charge and observe any reasonable requests and directions of the investigator-in-charge. The investigator must not release occurrence-related data or information to unauthorised persons.

1.4 Interaction and Co-operation with other Services

In most cases aerodrome officials, local inhabitants and/or police will probably be the first persons to arrive at the scene of an aircraft accident. It is, therefore, extremely important to enlist the co-operation of the police and aerodrome officials to ensure the security of the wreckage. This prevents vital evidence being lost by unnecessary interference with the wreckage before the arrival of the investigation team.

If it is suspected that the aircraft may have carried dangerous cargo such as radio-active material, explosives, ammunition, corrosive liquids, gaseous-, liquid-and solid poisons or even bacterial cultures special precautions should be taken in placing security personnel at a safe distance from the wreckage. This is particularly important if a fire has occurred.

All licensed aerodromes are required to have an Airport Emergency Response Manual that contains documented procedures detailing the responsibilities and actions of the relevant emergency response agencies in the event of an aircraft occurrence.

Accidents that occur away from licensed aerodromes, however, come under the direct control of the local police who are responsible for the initial coordination of the emergency response services.

1.5 Responsibilities of Key Personnel

The following information is provided to enable CAA officers to have an understanding of the procedures generally followed by local authorities when notification is received of an aircraft accident or incident. An appreciation of the procedures may enable the investigator/s to establish greater co-operation in the initial investigative phase, however the investigator/s could not be held responsible if these role players do not meet their obligations.

1.5.1 Aerodrome Operator

Airport officials from The Airports Company of South Africa (ACSA) are obliged by their Memorandum of Understanding (paragraph 3) with the CAA to notify the Commissioner as soon as practicable of an aircraft occurrence

Assess the serviceability of the aerodrome and if needed advise for a NOTAM to be issued by the appropriate ATS unit

If first on the scene, establishes a command post until the arrival of the police

Assist the police, including, as appropriate, the safe passage of emergency vehicles to the command post and collection of crash kit.

1.5.2 Local Police

Proceed to the crash scene and establish a command post, generally at least 1OO meter from the crash site. Isolate the crash site, admitting only essential fire-fighting personnel and equipment

Ascertains from the senior fire officer on the scene when the area is safe for other emergency services to enter

Directs appropriate support, as required, into the area

Establish contact with the aircraft operator's representative

Accounts for all persons on board

After authority has been obtained from the investigator-in-charge, photograph and mark the positions of the deceased prior to removal

Guards the wreckage until the CAA investigation team relieves them of their responsibility

Liaise with the aerodrome operator if needed

Notify the state pathologist and next of kin

Establish a media link.

1.5.3 Fire Service

Proceeds to the scene of the occurrence

Establish a liaison officer at the command post

Establish fire control

Secures a 'Safe Area' around the crash site.

1.5.4 Medical and Rescue Service

Reports to the crash site command post

Establish an ambulance/medical control post adjacent to the command post

Handle casualties

Notify hospital services of requirements.

1.5.5 Airline/Operator Company

Dispatches an officer to the command post

Advise the police of the number of persons on board and of any dangerous cargo

Liaise with investigation personnel prior to any action

Arrange for the removal of the aircraft when advised by the investigator-in-charge

Provide transport for passengers.

1.5.6 Air Traffic and Navigation Services

By agreement with ATNS, they provide CAA with pertinent information regarding aircraft involved in accidents or incidents.

Additionally, ATNS Search and Rescue is the organisation with the prime responsibility to assist civil aircraft in distress, and to provide priority emergency response.

1.5.7 Relations with Media

During investigations, all inquiries from the media regarding the occurrence are to be directed to the investigator-in-charge.

If required an official media release will be issued by the communication section of the CAA.

1.5.8 Insurance Representative

May have an interest in the salvage or recovery of the aircraft after the investigator-in-charge released the wreck to be removed from the site.

1.5.9 State Pathologist

May choose to visit the occurrence site and carry out the autopsy according to the set standards.