Ulf Kramer, Chairman of EU Network for Safety Investigation Authorities


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The lecture shows, by means of an example the importance, cooperation in regard to the determination of facts has. It makes clear that all parties involved, judicial authorities and investigation authorities, need to work together form the very beginning. At the same time it clarifies at which point cooperation ends and the authorities investigate further depending on their respective assignment of tasks.
Conclusion: only, if both authorities have the same level of information regarding the determined facts, a more in-depth investigation by the accident investigation authority and determination of causes without blaming someone is possible without interference by the judicial authority or legal representatives.

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Ulf Kramer, Chairman of EU Network for Safety Investigation Authorities

  1. 1. ICAO-COPAC International Safety Seminar Madrid, 24 and 25 March, 2011 <ul><li>Coordination between </li></ul><ul><li>judicial and safety investigation </li></ul><ul><li>authorities </li></ul><ul><li>Ulf Kramer </li></ul><ul><li>Director BFU </li></ul>
  2. 2. Legal Basis for the Safety Investigation Authority <ul><li>REGULATION OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL 996 / 2010 </li></ul><ul><li>ICAO Annex 13 </li></ul><ul><li>National rules </li></ul>
  3. 3. After an Accident Two „Independant“ Investigations have to be Coordinated <ul><li>safety investigation judicial investigation </li></ul><ul><li>Both autorities need to have all relevant facts </li></ul>
  4. 4. First at the Accident Site: Police, Fire Fighters, Rescue Services Documentation?
  5. 5. Accident Site
  6. 6. Article 13 (996/2010) Preservation of evidence <ul><li>Pending the arrival of safety investigators, no person shall modify the state of the site of the accident, take any samples therefrom, undertake any movement of or sampling from the aircraft, its contents or its wreckage, move or remove it, except where such action may be required for safety reasons or to bring assistance to injured persons, </li></ul>
  7. 7. Protection (Annex 13) <ul><li>The State of Occurrence shall take all reasonable measures to protect the evidence and to maintain safe custody of the aircraft and its contents for such a period as may be necessary for the purposes of an investigation . </li></ul>
  8. 8. Protection: by Police
  9. 9. Investigation Team Arrived <ul><li>„ coordination talks“ </li></ul><ul><li>What was done and / or has been documented? </li></ul><ul><li>“ When a judicial investigation is also instituted, the investigator-in-charge shall be notified thereof” (Article 12, 996/2010) </li></ul><ul><li>Further steps and responsibilties </li></ul><ul><li>Press release (content and responsibility) </li></ul><ul><li>Who is allowed to enter the accident site? </li></ul>
  10. 10. The Investigation Team IIC, Acc. Reps, Advisers, Authorities (also Judicial)
  11. 11. Traces (Combined Work Force)
  12. 12. Indentification of Parts (Combined Work Force)
  13. 13. Investigation steps of safety investigation steps of judicial investigation to be coordinated Continuation of safety investigation Duties of police Recovery of persons killed Information
  14. 14. Search for Recorders ( Combined Work Force )
  15. 15. Handling of Recorders <ul><li>Protection of flight recorder evidence requires that the recovery and handling of the recorder and its recordings be assigned only to qualified personnel </li></ul><ul><li>(ICAO) </li></ul><ul><li>Safety investigation authority accompanied by judicial authority (Article 12 (1) 996/2010) </li></ul>
  16. 16. Readout of Recorders investigation authority (and judicial authority under secured procedures)
  17. 17. Reconstruction of Flight (Investigation Authority)
  18. 18. Further Examination of Wreckage
  19. 19. Article 12 996/2010 <ul><li>If examination or analysis of such material may modify, alter or destroy them, without prejudice to national law, prior agreement from the judicial authorities will be required. </li></ul>
  20. 20. What is this?
  21. 21. Lightning
  22. 22. Destroyed Parts (Investigation Authority)
  23. 23. Which Parts were Affected? (Investigation Authority)
  24. 24. Wiring of the Plane (Investigation Authority)
  25. 25. Flight Manual (Investigation Authority)
  26. 26. End of Coordination <ul><li>Important: </li></ul><ul><li>Exchange of all relevant facts </li></ul><ul><li>between the judicial and safety investigation authorities. The investigation conducted from here on, can proceed without interference from either side. </li></ul>
  27. 27. Further Areas to be Investigated by the Authorities e.g.: <ul><li>safety judicial </li></ul><ul><li>Regulations relevant? responsible for? </li></ul><ul><li>Type certification relevant? responsible for? </li></ul><ul><li>Maintenance relevant? responsible for? </li></ul><ul><li>Crew training/licences relevant? responsible for? </li></ul><ul><li>Operator relevant? responsible for? </li></ul><ul><li>Flight Preparation relevant? responsible for? </li></ul><ul><li>Communication/ATC relevant? responsible for? </li></ul>
  28. 28. <ul><li>Article 14 </li></ul><ul><li>Protection of sensitive safety information </li></ul><ul><li>The following records shall not be made available or used for purposes other than safety investigation: </li></ul>
  29. 29. Article 14 996/ 2010 <ul><li>Statements, information collected by the safety investigation, voice and image recordings, notes, etc, etc, </li></ul>
  30. 30. 5.12 Annex 13 <ul><li>The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations: </li></ul>
  31. 31. Outcome without blame <ul><li>Findings </li></ul><ul><li>Causes </li></ul><ul><li>Contributing factors </li></ul><ul><li>Safety recommendations </li></ul>
  32. 32. Safety Recommendation 1 <ul><li>To the regulator </li></ul><ul><li>Requirement change </li></ul><ul><li>Equipment of airplanes with an additional artificial horizon, powered from a source independent of the electric generating system </li></ul>
  33. 33. Safety Recommendation 2 <ul><li>To manufacturer and operators (flight manual) </li></ul><ul><li>Information for pilots </li></ul><ul><li>Procedures for reconnection of the batteries and generators after total failure of the electrical power supply system </li></ul>
  34. 34. Safety Recommendation 3 <ul><li>To manufacturer </li></ul><ul><li>Modification of the battery-bus-relay </li></ul><ul><li>Modification in such a way that a failure is extremly improbable </li></ul>
  35. 35. Benefits <ul><li>The recommendations have contributed to the preventation of 3 possible accidents in Germany in the 20 years after their publication. </li></ul>