Flying is generally a safe and fast method of transportation, but accidents always happen whether through human error, mechanical failure, or criminal activity. Over the last two decades, there have been many fatal aircraft accidents per year worldwide. These, and lesser accidents, have to be investigated scientifically in order to gain important lessons about aircraft performance and safety.
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The International Civil Aviation Organization (ICAO) requires that a civil aircraft accident be investigated by an independent body belonging to the country where the accident took place. Each country has its own organization taking responsibility for this: in the United States, it is theNational Transportation Safety Board(NTSB); in the United Kingdom, it is the Air Accidents Investigation Branch (AAIB) and in Malaysia it is the Department of Civil Aviation. The purpose of the investigation is to find out why the accident happened and how similar events might be avoided in the future, rather than to apportion blame. The police will be involved in the investigation if sabotage or some other form of criminal activity is suspected, and the military generally looks into accidents involving service aircraft.
My research is about the air disaster investigation procedure for Malaysia on the matter of the procedure step, incident statistic, comparison between the Malaysian investigation procedures with other region.
History for aircraft investigation
The procedures for air accident investigations were first laid down in 1928 by the US National Advisory Committee for Aeronautics. They required air accident investigators to consider the immediate and underlying factors of an accident in order to establish and apportion blame for its occurrence. A credit system was put in place that weighted causal factors according to their overall culpability – for example, an accident could be regarded 70% the result of pilot error and 30% the result of environmental factors.( New Zealand Air Line Pilots’ Association, 2009)
In 1944 the Chicago Convention drafted a set of procedures and processes to govern the burgeoning international civil aviation industry. Included in these procedures were rules concerning the responsibilities of contracting states in the event of an aviation accident on their soil. These standards and recommended practices were developed by the Accident Investigation Division between February 1946 and February 1947, and were later designated as Annex 13 of the convention. The convention allowed states to generate their own rules for accident investigation, so as long as the core practices of Annex 13 were incorporated and investigative practices aligned with ICAO Doc 9620, the Manual of Aircraft Accident Investigation.( New Zealand Air Line Pilots’ Association, 2009)
The primary focus of Annex 13 differed from that of the US National Advisory Committee for Aeronautics in 1928: it was no longer to find fault and apportion blame for an aircraft accident, but to provide a mechanism by which participants in the industry – pilots, aircraft manufacturers and regulatory agencies – could learn from their mistakes.( New Zealand Air Line Pilots’ Association, 2009)
Accident Trend
In recent years, progress and development in science and technology have made dramatic contributions to human society. However, these same development have given rise to many new type of dangers, and a massive increase in loses that would have been in conceivable in the past. (Masako Miyagi, 2005)
This trend is by no means an indication of carelessness on the part of the individuals involved: rather, it could be considered an indication that the methods used to implement traditional safety measures in the past have reached a limit of effectiveness. This is because the most basic safety measures taken in the past were limited to reprimands and punishments targeting the person responsible for the accidents, and improvements to mechanical aspects stemming from the result of accident investigations. Such accident investigations placed an emphasis on technical analysis of events in accidents that had already occurred, and for this reason there is no question that they contributed to a sharing of important information regarding the mechanical aspects of these accidents, that this information was put to use in making improvements, and that significant results were archived through this process. (Masako Miyagi, 2005)
Human beings are able to develop and increase their abilities to some extent through education and training. The fact remain, however, that it is extremely difficult to obtain the information on human aspects of accidents that would be required to implement such training, because the people most directly involved may have been killed in the accident, or may be reluctant to come forward for fear of being held responsible. There are definitive limitations to approach described above even if all the relevant information in obtained; namely that when studied are made into accident prevention measures based on accident investigations, the investigations can only begin after the accident has occurred. Furthermore, the improvement measure based on accident investigations will only be of value in preventing the re-occurrence of accidents that are identical to those on which the measures were originally based. (Masako Miyagi, 2005)
Graf below showed that, by years to years, more accident happen because of human carelessness rather than mechanical failure. By times go by the percentage being increasing.
Graft 1.1(Masako Miyagi)
Boeing`s statistical summary
There are several reliable sources of accident data. One of the most easily accessible accident databases is maintained by Boeing, which publishes an annual Statistical Summary of commercial Jet Airplane Accident. Another good sources document is the International Air Transport Association (IATA) Safety Board Record(Jet), also published annually.( Alexander T.Wells and Clarence C.Rodrigues, 2004)
Hull losses were also analyzed according to the phase of flight in which they occurred (Graft 1.2). After the combined approach and lading phases, the next greatest numbers hull-loss accident occurred in the combined phases from landing through initial climb. Cruise, which accounts for about__ of flight time in a 1.5 hour flight, occasioned only 6% of hull-loss accidents.( Alexander T.Wells and Clarence C.Rodrigues, 2005)
The summary also considered primary cause factor for commercial operations hull-loss accidents for the period 1990-1999(Graft1.3). For accidents with known causes, flight crew were considered the primary cause in most 67% over the 10 years periods.( Alexander T.Wells and Clarence C.Rodrigues, 2005)
Graft 1.2 Phase of flight in hull-loss accident, all aircraft, worldwide commercial jet fleet
(1990-1999)
(Boieng commercial airplanes Group)
Graft 1.3 Primary causes factors (as determined by the investigating authority) in hull-loss accidents, all aircraft, worldwide commercial Jet fleet(1990-1999)(Boeing Commercial Airplanes Group)
Chart below showed about accident categorizes by airplane generation for the period 1990-1999 (Table 1.1). Most accidents occurred on landing, with 157 out of 385 for the 10-years period. Interestingly, most landing accident involved current generation aircraft. (Alexander T.Wells and Clarence C.Rodrigues, 2005)
Type of incidentGeneration
First
Second
Early Widebody
Current
total
Controlled flight into terrain
5
17
3
11
36
Loss of control
8
7
2
12
30
Midair Collision
1
1
2
In-Flight fire
1
2
1
1
5
Fuel tank explosion
1
1
2
off end on landing
7
17
3
22
49
Off side on Landing
3
20
3
11
37
hard landing
3
15
5
32
55
Landed short
4
9
1
2
16
Gear collapse/fail/up
8
8
2
13
31
Ice/snow
3
3
6
Fuel management/exhaustion
2
4
1
7
Windshear
1
1
1
3
Takeoff configuration
1
1
1
3
Off side on takeoff
1
1
3
3
8
Runway Incursion vehicle/people
5
1
10
16
Wing strike
2
2
Engine Failure/Separation
3
2
4
1
10
Ground collision
2
2
6
10
Ground Crew injury
3
2
2
7
Boarding/deboarding
2
2
4
Turbulance fatality
1
1
1
3
Miscellaneous
1
2
2
3
8
Fire on ground
1
2
3
2
8
aircraft structure
2
2
2
6
Unknown
1
3
3
7
Refused take-off end
3
6
3
2
14
Total
54
134
49
148
385
Table 1.1 Accident categorizes by airplane generation for the period 1990-1999 (Alexander T.Wells and Clarence C.Rodrigues,2005)
*Miscellaneous Accidents
-Coffee Maker Explosion
-Fuel spill
-Instrument error
-Hypoxia
-Jet blast
-Pilot incapacitated
-Taxied across ditch
-Window fail
-Tailstrike/RTO
-other
(Alexander T.Wells and Clarence C.Rodrigues)
Graft 1.4 Accident categorizes by airplane generation for the period 1990-1999 (Alexander T.Wells and Clarence C.Rodrigues)
Generation
Aircraft Type
First
Comet 4, 707/720,DC-8,CV-880/-990,Caravelle
Second
727,trident VC-10,BAC 1-11,DC-9,737-100/200,F-28
Early widebody
-100/-200/-300/SP, DC-10,L-1011,A300
Current
– MD-80,767,757,A310,Bae 146, A300-600, 737-300/-400/-500,F-100,A320/310/321, 747-400,MD-11,A340,MD-90,777,737NG,717
Table 1.2 Aircraft by generation (Alexander T.Wells and Clarence C.Rodrigues)
Graft 1.5 Accident Categories by airplane generation, all accidents, worldwide commercial jet operations. (1990-1999).(Boeing Commercial Airplanes Group)
1.2 Problem definition
The problem with the current situation is, even thought so many precaution have been make, but air disaster still happen. Is there any way to prevent this disaster to happen? Each country had theirs own investigation team. But after the investigation, still have some aircraft that crash and involve a mass casualty.
This research will study about the limitation of the investigation body if there is an air crash or air disasters occur in or outside of the investigation body region.
1.3 Objectives of research
The main objectives of this thesis are to make a research upon the investigation procedure and type of accident happen in Malaysia and throughout the world. These are several more objectives of the project:
Compare the investigation procedure between America and Malaysia.
To understand the concept of how the air disaster investigation procedure.
To prove that aircraft investigation can reduce air disaster.
Making a survey about the awareness of the investigation procedures.
To know the party that involved in board of investigation rules and regulation in Malaysia
1.4 Research scope
This thesis will go through the ICAO annex 13, Aircraft Investigation Procedure Manual and MCAR Part 12 to study the exact procedure of the Aircraft Investigation Procedures.
Chapter 2: Literature Review
2.1 Introduction
The Chicago Convention on International Civil Aviation established the International Civil Aviation Organization (ICAO) as a specialized aviation department within the United Nations. ICAO Annex 13 defines and directs requirements forAircraft Accident and Incident Investigationprocedures. As a result most nations or consortium of nations have some form of air regulating body which subsequently contains an investigation division.
Unfortunately not all agencies are created equally and national differences exist which influencefactual results in accident investigation. Six areas have been presented as a hindrance to proper investigative techniques in a paper by Dr. Horacio A. Larrosa of the International Society of Air Safety Investigators (ISASI)Accident and Incident procedures in Argentina MO4131.
Expertise and Experience
Investigative Budgets
Political and Religious Influence and Beliefs
Nepotism and Cronyism
Dedication and Desire
National Pride or Prejudice
2.2 Internationally Respected Players
2.2.1 National Transportation Safety Board (NTSB)
The National Transportation Safety Board is an independent federal agency charged with determining the probable cause of transportation accidents and promoting transportation safety, and assisting victims of transportation accidents and their families. The NTSB investigates accidents, conducts safety studies, evaluates the effectiveness of other government agencies’ programs for preventing transportation accidents, and reviews the appeals of enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and the U.S. Coast Guard (USCG), as well as the appeals of civil penalty actions taken by the FAA.(NTSB,2002)
To help prevent accidents, the NTSB develops safety recommendations based on our investigations and studies. These are issued to federal, state, and local government agencies and to industry and other organizations in a position to improve transportation safety. Recommendations are the focal point of the NTSB’s efforts to improve the safety of the nation’s transportation system. (NTSB,2002)
NTSB Mission:
To promote transportation safety by
maintaining our congressionally mandated independence and objectivity;
conducting objective, precise accident investigations and safety studies;
performing fair and objective airman and mariner certification appeals; and
advocating and promoting safety recommendation. And
to assist victims of transportation accidents and their families.
2.2.2 European Aviation Safety Agency (EASA)
European Aviation Safety Agency has been the cornerstone of the European Union’s aviation safety programs for years; however, accident investigation has been the jurisdiction of each individual member state. In 2009 the EU outlinedthe requirementsto establish a “better and more uniform quality of accident investigations across the EU.” It will establish the rules for accident investigation for all states controlled by a central EU body in the near future. (EASA,2011)
The EASA has become the competent Community Aviation Authority for the safety of aviation underBasic Regulation 1592/2002; thus, it may be the recipient of safety recommendations related to the areas of its responsibilities. Furthermore, ICAO Annex 13 provides that the State of Design and the State of Manufacture shall each be entitled to appoint an accredited representative because of the function that have been attributed to each of those States with respect to the airworthiness of aircraft under Annex 8. Therefore, as the EASA is now in charge of the airworthiness, is shall be represented in Safety investigation in order to fulfil its obligation.(EASA,2011)
Under both, international and community law, all safety recommendations must be taken into full consideration by the entity to which they are addressed. In addition, in the preamble of theBasic Regulation 1592/2002it is stated that the results of the accident investigations should be acted upon by the EASA, as a matter of urgency in particular when, they relate to defective aircraft design or operational matters. ( EASA,2011)
To successfully discharge its responsibilities in this area, the EASA has included in its organ gram an Accident Investigation Section. It is responsible for the follow-up of occurrences where the Safety has been endangered. (EASA,2011)
Its main devoted tasks are:
To follow the progress of aircraft accidents and incidents investigations,
To be represented in investigations and collect information related to occurrences,
To achieve the processing of Safety Recommendations addressed to the Agency,
To provide progress reports and statistics on the Safety Recommendations processing,
To maintain a good coordination with European Accident Investigation Bodies,
To identify safety deficiencies and disseminate related information.
2.2.3 The European Three (E3)
The European Three are combination of the safety bureau in Europe, there are the Air Accidents Investigation Branch ( AAIB) of England, French Air Accident Investigation Bureau ( BEA France) and Aircraft Accident Investigation Bureau (AAIB Switzerland) are recognized as world leaders in several accident investigation areas. Not only do they aid nations of the EU in investigations but also non EU nations that have accidents involving aircraft manufactured in Europe, European registered aircraft, accidents occurring in any nation that was a colony of one of the EU member states and any nations requesting help.
2.2.4 Australian Transport Safety Bureau (ATSB)
Australian Transport Safety Bureau has gained a reputation as Oceana and Asia’s air accident investigating body. They are investigators in most of the small island nations of the South and Central Pacific or whenever requested by other nations. Australia’s development as a nation through the twentieth century was closely linked to the development of the aviation industry. This industry has helped us overcome vast internal distances and geographical isolation from the rest of the world.(ATSB, 2011)
The ATSB is responsible for the independent investigation of accidents and incidents involving civil aircraft in Australia. The ATSB’s primary focus for its investigations is fare-paying passenger operations. However, all accidents and incidents related to flight safety in Australia or involving Australian registered aircraft overseas must be reported to the ATSB. While the ATSB does not investigate all of these, it still needs to be notified so that the data can be recorded for possible future safety research and analysis. (ATSB,2011)
2.2.5 Transportation Safety Board of Canada
The Canadian Transportation Accident Investigation and Safety Board (TSB) has emerged as the leader in South and Central America. Similar to Australia the small population nation that is home to ICAO, works in close coordination with the larger NTSB in the USA. However, viewed as an alternative to Washington many Latin American nations work directly with Canada out of desire, security or necessity.(TSB, 2010)
Summaries
Most nations have the required ICAO investigative agencies but the variations between countries are still very strong. The positive factor for international accident investigation is that many investigators within these nations are willing to call upon each other and aid their work. Working together in the vast majority of air accidents, the public has a good chance of obtaining the truth about accidents within their borders.
2.3 Definition:
Before going through a little further, these are some definition that being use in the investigation for any accident or incident that happen. All definition are taken from ICAO , 2001, Annex 13, MCAR part 12 and NTSB 2002, Aircraft accident Investigation Manual.
2.3.1 Aircraft Accident
An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which a person is fatally or seriously injured as a result of being in the aircraft or direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or direct exposure to jet blast.
The aircraft sustains damage or structural failure which is adversely affects the structural strength, performance or flight characteristics of the aircraft, or the aircraft is missing or is completely inaccessible.
2.3.2 Aircraft Incident
An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.
Serious incident – An incident involving circumstances indicating that an accident nearly occurred.
2.3.3 Investigation
A process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety recommendations.
2.3.4 Investigator in charge
A person charged, on the basis of his or her qualifications, with the responsibility for the organization, conduct and control of an investigation.
2.3.5 Chief Inspector
The Chief inspector of Air Accidents and includes any deputy chief inspector;
2.3.6 Inspector
Aperson appointed as an Inspector of Air Accidents
2.3.7 Field Investigation
An investigation which is not intended to be the subject of a report by an Inspector to the Minister.
2.3.8 Formal Investigation
An investigation which is intended tobe the subject of a report by an Inspector to the Minister.
2.3.9 Serious Injury
An injury which is sustained by a person in a reportable accident and which:
Requires his stay in hospital for more than forty-eight hours commencing within seven days from the date on which the injury is received
results in a fracture of any bone except simple fractures of fingers, toes or nose.
involves lacerations which cause severe nerve, muscle or tendon damage
involves injury to any internal organ; or involves second or third degree burns or any burns affecting more than five per centum of the surface of the body.
2.3.10 Aircraft.
Any machine that can derive support in the atmosphere from the reactions of the air other than the reactions of the air against the earth’s surface.
2.3.11 Causes.
Actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident.
2.3.12 Flight recorder.
Any type of recorder installed in the aircraft for the purpose of complementing accident/incident investigation.
2.3.13 Maximum mass.
Maximum certificated take-off mass.
2.3.14 Operator.
A person, organization or enterprise engaged in or offering to engage in an aircraft operation
2.3.15 Preliminary Report.
The communication used for the prompt dissemination of data obtained during the early stages of the investigation.
2.3.16 Safety recommendation.
A proposal of the accident investigation authority of the State conducting the investigation, based on information derived from the investigation, made with the intention of preventing accidents or incidents.
2.3.17 State of Design.
The State having jurisdiction over the organization responsible for the type design
2.3.18 State of Manufacture.
The State having jurisdiction over the organization responsible for the final assembly of the aircraft
2.3.19 State of Occurrence.
The State in the territory of which an accident or incident occurs.
2.3.20 State of the Operator.
The State in which the operator’s principal place of business is located or, if there is no such place of business, the operator’s permanent residence.
2.3.21 State of Registry.
The State on whose register the aircraft is entered.
2.4 Investigation Responsibility for Instituting and Conducting the investigation.( ICAO , 2001)
2.4.1 Accidents or incidents in the territory of a contracting state.
State of Occurrence
The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State by mutual arrangement and
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