EUROPEAN CIVIL AVIATION CONFERENCE - CONFÉRENCE EUROPÉENNE DE L'AVIATION CIVILE

Air accident and incident investigations

Accident investigation

The investigation of aviation incidents and accidents is today recognised as a fundamentally important element of improving safety, and those responsible for investigations have come to be considered by national and international safety authorities as key partners, both on the policy and technical levels.      

Accident and incident investigation, as defined by ICAO Annex 13 to the Chicago Convention, is carried out within a precise methodological framework informed by objectivity, transparency and international cooperation. Its objective is not to address notions of liability or blame but rather to provide explanations for events, by recording findings, analysing and understanding them and then making proposals and recommendations in order to reduce the risk of a reoccurrence.

Air Accident and Incident Investigation Group of Experts (ACC)

ACC's involvement in the international development of the organisation of accident and incident investigations dates back to ICAO's Accident Investigation Divisional meeting in 1992, and has continued ever since. It both serves as a think-tank for its European members, and contributes to the thinking behind some initiatives planned at the European Community level.

From the very beginning, ACC has adopted a policy of holding each of its meetings in a different ECAC Member State with the objective of promoting familiarity with how the different safety investigation authorities (SIA) are organised, and builds contacts and working relationships between staff at all levels. A key focus of its activities is the exchange of experience in methods of investigation, the evolution of investigation techniques and tools and the challenges encountered during investigations. These exchanges happen formally through meeting presentations and discussions, and can include a host country's briefing on its organisation, reports on recent investigations and updates on latest experiences or developments. Informal exchanges during breaks are just as valuable to participants.

The development of cooperation in Europe was a natural extension of these contacts. In December 2016, ACC released an updated version of its "Code of Conduct on Cooperation in the Field of Accident/Incident Investigation", originally opened for signature by heads of the accident investigation bodies in April 2006. 

ACC Terms of Reference and Rules of Procedure (September 2019)

ACC workshops

ACC also organises workshops on issues of common interest to Europe's accident investigators.

These have included a seminar in Tallinn (Estonia) in 2000 on the needs of victims and their families, a workshop in Nicosia (Cyprus) in 2002 on the organisation of investigation bodies, one in Bucharest (Romania) in 2005 on communication following an accident, and one on the drafting and issuing of safety recommendations, in Athens (Greece).

In 2009, in close cooperation with the Croatian authorities, ECAC and the French Bureau d'Enquêtes et d'Analyses (BEA) organised a three-day workshop in Dubrovnik on the underwater recovery of aircraft wreckage and flight recorders, which included a day at sea practising location and recovery techniques. Given the interest triggered by this workshop, it was followed up the next year with a second one in Larnaca (Cyprus) focusing on underwater recovery operations.

Accident and incident investigation was also on the agenda of a joint ECAC/FAA workshop held in Istanbul (Turkey) in 2013. Focusing on best practices in three key areas of aviation safety, the workshop discussed, inter alia, developments in new oversight systems such as continuous monitoring and regional oversight, collaboration in identifying safety risks and solving them, and the role of incident investigation in aviation safety. 

A workshop was held in May 2014 in Lucerne (Switzerland) on the subject of investigations in extreme and challenging environments. This workshop attracted the support of speakers from several parts of the world, involving experts who had conducted investigations in conditions of snow and ice, jungle, mountains and deserts as well as politically and culturally challenging circumstances. It also led to the issuance of Guidance on the Underwater Location and Recovery of Aircraft Wreckage and Flight Recorders (2015).

In 10 May 2016 in The Hague (Netherlands), ACC organised a workshop on social communication associated with the air accident investigation process. Participants examined issues including the impact of social media on the investigation, best practices for developing communication plans, finding the balance between the need to inform and the need to maintain the integrity of an investigation, communication with the families of the victims and managing media expectations. 

The latest ACC workshop took place in Valletta (Malta) in November 2018 and looked at the investigation of general aviation accidents within the ECAC Member States and observer States. In particular, it focused on the potential for increased cooperation or technical assistance among safety investigation authorities.

Workshop reports

Title  Location Date Download

Report of ECAC/FAA Workshop

Best Practices in Three Key Areas of Aviation Safety: National Safety Oversight, Runway Safety, and Accident & Incident Investigation

Istanbul, Turkey May 2013 download

Report of Workshop on the Treatment of Incidents

Roskilde, Denmark 15-16 May 2012 download

Second ECAC Workshop on Underwater Recovery Operations

Report only (without Annexes)

Larnaca, Cyprus 18-20 October 2010 download

Second ECAC Workshop on Underwater Recovery Operations

Larnaca, Cyprus 18-20 October 2010 download

First ECAC Workshop on Underwater Recovery Operations

Dubrovnik, Croatia June 2009 download

ACC guidance documents

In November 2012, ECAC published Guidance on the Underwater Location and Recovery of Aircraft Wreckage and Flight Recorders. Reflecting on the learning gained from the two workshops mentioned above, this guidance addresses the issues peculiar to underwater location and recovery operations, including the expertise, procedures and equipment needed to mount an effective response to an accident of this kind.

A major outcome of the May 2014 Workshop on the Investigations in Extreme and Challenging Environments was the publication in October 2015 of ECAC Guidance for Investigations in Extreme and Challenging Environments, now available for free on this website.

In 2020, ACC developed the ECAC ACC Guidance Note on Conducting Investigations during a Pandemic, due to the challenges faced for air accident investigations during the COVID-19 pandemic. This proposal was approved by the ACC group in December 2020 and endorsed by Directors General on 29 January 2021, both through a written consultation. The guidance is based on discussions and experiences of ACC members and observers and focuses on air accident investigation-specific issues to minimise the risks of catching or spreading the coronavirus.

ECAC News on safety matters

ECAC News n°66 ECAC News n°61