Safety investigations

A safety investigation, formerly known as a “technical investigation”, is «a process conducted by a safety investigation authority for the purpose of accident and incident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of cause(s) and/or contributing factors and, when appropriate, the making of safety recommendations» (art. 2 regulation EU 996/2010).

The purpose of safety investigations is therefore solely to prevent future accidents/incidents; consequently, it is not the role of safety investigations to apportion blame or liability.

The extent of safety investigations and the procedure to be followed in conducting such safety investigations shall be determined by the safety investigation authority, taking into account the lessons it expects to draw from such investigations for the improvement of aviation safety.

They are conducted independently and separately from any judicial or administrative proceedings aimed at establishing fault or liability.

In Italy, safety investigations are under the responsibility of the Agenzia nazionale per la sicurezza del volo (ANSV), which is the civil aviation safety investigation authority of the Italian State.

The modus operandi of the ANSV follows international law (the Annex 13 to the Convention on International Civil Aviation) and European Union law (regulation EU 996/2010). Regulation EU No 996/2010 transposes many of the principles and provisions of ICAO Annex 13 to the Convention on International Civil Aviation.

Following the notification of an accident/serious incident occurred to a civil aircraft, the ANSV opens a safety investigation under the provisions of art. 5 of Regulation (EU) n. 996/2010.

For some specific accidents/serious incident there is no obligation to investigate.

Accidents and serious incidents are defined in art. 2 of regulation (EU) n. 996/2010 and in Chapter I “Definitions” of the above mentioned ICAO Annex 13.

The conduct of the investigation is entrusted to an investigator, called “investigator in charge” (or IIC), who, consequently, is in charge of the organization, conduct and control of the investigation itself. Depending on the seriousness and complexity of the event, other investigators may support the IIC, thus forming an investigation team.

In the event of an accident/serious incident occurred abroad to an aircraft of Italian interest (a civil aircraft registered in Italy, designed/built by Italian manufacturers or operated by an Italian operator), an ANSV investigator may be appointed as “accredited representative” in the foreign safety investigation. The accredited representative is entitled, based on the above-mentioned legislation, to participate in the most salient phases of the investigation and to view the main evidence (evidence) acquired.

There are essentially three phases in safety investigations: collection of evidence; analysis of gathered evidence; conclusions.

Phase 1: evidence collection

The first phase of the safety investigation is fundamental since it is during this phase evidence are collected. The following in-depth analysis will make possible to identify the causes of the event.

In this phase of the investigation, the site survey is carried out, many information and documents are acquired (e.g. documentation relative to the aircraft involved and the pilots, witnesses, radar traces, ground-to-ground radio communications, etc.) and various types of technical tests are carried out (e.g. on the fuel, the aircraft engine, etc.). In this phase, if flight recorders are available, they are collected in this phase for data readout.

When an investigation is instituted also by the Judicial Authority, then coordination between the Judicial and the Civil Aviation Safety Investigation Authority (ANSV) is required by law, without prejudice to the separation of the two investigations.

Phase 2: Analysis of evidence

In the second phase, the IIC fully analyses (with the investigation team if available) the evidence collected in phase 1. If the review of all the information in the IIC’s possession reveals the need for other information (e.g. flight simulator tests) or for additional documentation, the evidence collection will continue.

The analysis will take into consideration all the factors that may have contributed to the occurrence of the event such as human factor, organizational factor, technical factor and environmental factor. This phase will also identify the shortcomings in terms of flight safety that emerged during the investigation.

Phase 3: Conclusions

In this phase of the investigation, the IIC will draw conclusions from the evidence acquired and the analysis carried out in phase 2, determining the cause of the event and contributing factors.

In this phase, safety recommendations, if there are any, are issued to address the flight safety concerns identified during the investigation.