An introduction to the AAIB and the accident reporting process

The UK AAIB was initially established in 1915 when Captain G. B. Cockburn was appointed as Inspector of Accidents for the Royal Flying Corps, but has been under the jurisdiction of the Department of Transport (now the Department for Transport) since 1983 and its name changed to the current title in November 1987 (AAIB, N.D). Its purpose is to determine causes of aviation accidents and make recommendations as necessary with a view to preserving life and avoiding future occurrences; it is not to apportion blame (AAIB, 2010).

The processes involved from an accident taking place to the report being published are straightforward in principle. On notification of an accident, normal procedure is to dispatch an Operations and an Engineering Inspector to examine particulars such as procedures, human factors, weather, aircraft systems and engines, maintenance records and so on (AAIB, 2010). The investigation will include inspection of the wreckage, interviews with witnesses (including the pilot if they are able), obtaining records relating to the pilot’s training and experience and other data as appropriate, following which the Chief Inspector of Air Accidents decides how to proceed (AAIB, 2010).

The report can take several months or more to produce, depending on the nature of the accident and any unforeseen complications. For most minor events, the pilot involved is requested to fill in a standard form and provide details of their own experience and ideas as to the causal factors. This is then checked by an Inspector who will produce the formal document. Where a report is produced

through a field investigation, a draft copy is sent to the pilot (or their representative), as well as persons whose reputations may be adversely affected by publication of the report and are given 28 days to make representations before the report is finalised (AAIB, 2010).

A report generally contains three main sections consisting of preliminary accident/pilot details, narrative and analysis/conclusions but this may vary depending on the accident severity, unusual circumstances, evidence available and other variables associated with accident investigation.

The first section contains details of the aircraft involved, the date and location of the accident, injuries and damage sustained, type of flight (training or private) and details concerning the pilot, including their age, level of license and experience.

The second part discusses the events leading up to the accident, the accident itself according to witnesses and evidence and determines probable causal factors. The amount of detail given varies, depending on the severity of the event and the author of the report. Common sections include a synopsis and where appropriate, a more in-depth appraisal of the aircraft, pilot, airfield and the weather. If necessary, commentary is given on topics specific to the accident and may include medical/pathological information, aircraft performance calculations, operational information, engineering analysis, wreckage details, radar track recordings and eyewitness accounts.

Analysis is often, but not always included. It serves to interpret the information given in the preceding part of the report and offer both causal and contributory factors of the accident without apportioning blame. Similarly, conclusions are not always presented as a separate section, but are contained within the analysis. Only where they are deemed to be beneficial to the future safety of aviation and practical enough for implementation will recommendations be given by the AAIB, but as the AAIB is not a regulatory authority, it has no power to enforce any that are made (AAIB, 2010). The final section can be presented either as a summary or a conclusion. Preliminary details are presented as shown in Table 8 and are common to all reports, regardless of severity.

Table 8: Initial accident details as presented on an AAIB accident report or bulletin AAIB Bulletin: Designated title code for the bulletin/report

INCIDENT (or ACCIDENT as determined by the AAIB) Aircraft Type and Registration: G-AAIB

No & Type of Engines: 2 Generic 01-01-AA piston engines Year of Manufacture: (of aircraft)

Date & Time (UTC): (of event) Location: (of event)

Type of Flight: (private, training)

Persons on Board: Crew – ‘X’ Passengers – ‘X’ Injuries: Crew – ‘X’ Passengers – ‘X’

Nature of Damage: (Brief summary) Commander’s Licence: (PPL, CPL, ATPL…etc) Commander’s Age: (years)

Commander’s Flying Experience: ‘X’ hours (of which ‘X’ were on type)

Last 90 days – ‘X’ hours Last 28 days – ‘X’ hours

Information Source: (one or more from: )

 AAIB field investigation

 Aircraft Accident Report Form submitted by the pilot

 ATC reports

 Airport operator reports

Due to their factual nature, reports do not allow for any inference concerning issues such as individual pilot skill level, attitudes towards safety, pilot mental or physical condition, the quality and/or duration of training received, or levels of situational awareness at the time of the event. Whilst these variances may influence accident causation or outcome, they cannot be included in any analysis being merely supposition and conjecture.

Variations between reports may occur due to them being written by different accident investigators who have different styles in the way they present their findings. Reports are also tailored to each accident, different accidents producing different information and conclusions, thus not always necessitating the same format. Disparity in reports will also occur for less serious accidents where the information was presented by the pilot. Despite being reviewed, edited and published by the AAIB, individual opinion, personal ideology and human uniqueness will result in a varying amount and type of information.