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INVESTIGATOR TRAINING GUIDELINES

2nd

Edition

2017

KOMITE NASIONAL KESELAMATAN TRANSPORTASI


INVESTIGATOR TRAINING

GUIDELINES

2nd Edition – 2017




Published in separate Bahasa Indonesia and English by:

Komite Nasional Keselamatan Transportasi

Jalan Medan Merdeka Timur Nomor 5

Jakarta – Indonesia

www.knkt.dephub.go.id/knkt

http://www.knkt.dephub.go.id/knkt



RECORD OF REVISION

Revision No. Date of Revision Affected Pages Remarks/Purpose of Revisions

Original 9 September 2014 All First Edition

1 14 September 2015 Foreword Person in charge changed

0 14 August 2017 All

Second Edition.

Change KNKT Logo and revision to

several chapters to refer ICAO Annex

13 amendment 15

Note:

Each amended page of KNKT guideline shall show the appropriate amendment number and date. A vertical black line on the right margin adjacent to the item that has been changed will indicate all changes. However, in any circumstances, the vertical black line is not necessary when the amendment is more than 50 percent of total pages, therefore new edition will be issued.



FOREWORD

Komite Nasional Keselamatan Transportasi, KNKT (National Transportation Safety Committee, NTSC) is no blame, independent, multimode safety investigation body within the Republic of Indonesia responsible directly to the President of the Republic of Indonesia.

KNKT has the main duty of conducts objective and independent transport safety investigation (investigation) for four modes of transportation which are; aviation, railway, road and marine transportation. KNKT investigation is intended to prevent similar occurrence in the future without implying blame or liability.

KNKT investigation in aviation is to conduct objective and independent investigation of civil aircraft accident and serious incident under the provision of International Civil Aviation Organization (ICAO) Annex 13.

The investigation of an aircraft accident is a task that can be almost unlimited in scope. As an investigator gains experience, he will realize that the need to increase his knowledge and upgrade his skills is a continuing process. While training is essential, the optimization of an investigator’s capabilities generally depends upon a personal commitment to excellence.

KNKT develop common standards for the training of investigators. The Investigator training standards are to be compiled in such a way that they would be adaptable to a variety of cultures and operational requirements. The Investigator training standards is developed based on ICAO guidelines for the training of investigators in the ICAO circular No 928.

Because this guideline deal with both accident and serious incident investigations and, for reasons of brevity, the term “accident”, as used herein, applies equally to “serious incident”. Throughout this guideline, the use of the male gender should be understood to include male and female persons. Although this guideline will be of use by experienced and inexperienced investigators alike, it is not a substitute for investigation training and experience.

This guideline will be amended periodically as new investigation techniques are developed and new information becomes available.

Readers are invited to submit material for possible inclusion in subsequent editions of this guideline. This material should be addressed to: Komite Nasional Keselamatan Transportasi; Gedung Kementerian Perhubungan lantai 3, Jalan Medan Merdeka Timur Nomor 5, Jakarta – Indonesia 10110 or email to [email protected].

Jakarta, 14 August 2017

Dr. Ir. Soerjanto Tjahjono

Chairman

mailto:[email protected]

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TABLE OF CONTENTS

TABLE OF CONTENTS ....................................................................................................... i

GLOSSARY ........................................................................................................................ ii

LIST OF ACRONYMS ......................................................................................................... v

1 BACKGROUND ......................................................................................................... 1-1

2 TRAINING PHASES .................................................................................................. 2-1

2.1 General ........................................................................................................... 2-1

2.2 Training Phase ............................................................................................... 2-1

2.3 Investigator Levels .......................................................................................... 2-3

3 TRAINING SYLABUSS ............................................................................................. 3-1

3.1 Detailed subjects Discussion of the AAIF ........................................................ 3-1

3.2 Safety at Accident Site .................................................................................... 3-6

3.3 On the Job Training ........................................................................................ 3-6

3.4 Advanced Accident Investigation Courses ..................................................... 3-7

3.4.1 Advanced Course Topics ................................................................... 3-7

3.4.2 Additional Training ............................................................................. 3-9

4 APPENDICES............................................................................................................ 4-1

4.1 On the Job Training Syllabus .......................................................................... 4-1

4.2 Criteria of Assessment on the Job Training .................................................... 4-3

4.3 Investigator Training Records ......................................................................... 4-4

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GLOSSARY

When the following terms are used in this guideline, they have the following meanings:

Accident: An occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down, in which:

a) A person is fatally or seriously injured as a result of:

1) being in the aircraft, or

2) direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or

3) direct exposure to jet blast,

except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or

b) The aircraft sustains damage or structural failure which:

1) adversely affects the structural strength, performance or flight characteristics of the aircraft, and

2) would normally require major repair or replacement of the affected component,

except for engine failure or damage, when the damage is limited to a single engine, (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes), or for minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike (including holes in the radome); or

c) the aircraft is missing or is completely inaccessible.

Note 1 – For statistical uniformity only, an injury resulting in death within thirty days of the date of the accident is classified as fatal injury

Note 2 – An aircraft is considered to be missing when the official search has been terminated and the wreckage has not been located

Note 3 – Guidance for the determination of aircraft damage can be found in KNKT Investigation Guideline.

Accident Investigation Authority: The authority designated by a State as responsible for

aircraft accident and incident investigations within the context of this guideline

Accredited representative: A person designated by a State, on the basis of his or her qualifications, for the purpose of participating in an investigation conducted by another State. Where the State has established an accident investigation authority, the designated accredited representative would normally be from that authority.

Adviser: A person appointed by a State, on the basis of his or her qualifications, for the purpose of assisting its accredited representative in an investigation.

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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.

Causes: Actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident. The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

Flight recorder: Any type of recorder installed in the aircraft for the purpose of complementing accident/incident investigation. The flight recorder includes Automatic Deployable Flight Recorder (ADFR), a combination flight recorder installed on the aircraft which is capable of automatically deploying from the aircraft.

Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.

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/or contributing factors and, when appropriate, the making of safety recommendations.

Investigator: A person on the basis of his or her qualification and competency to conduct transport safety investigation. In this guideline the Investigator mean KNKT investigator unless otherwise specified.

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.

Komite Nasional Keselamatan Transportasi (KNKT): Indonesian accident investigation authority that is independent from State aviation authorities and other entities that could interfere with the conduct or objectivity of an investigation.

Major Accident. Investigation into an accident involving a large aircraft and usually involving fatalities. The major accident may potentially increases the complexity of investigation with regards to media interest or political issue, number institution involves, or status of occupants involves as crew or passengers.

Operator: A person, organization or enterprise engaged in or offering to engage in an aircraft operation.

Safety recommendation: A proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident. In addition to safety recommendations arising from accident and incident investigations, safety recommendations may result from diverse sources, including safety studies.

Serious incident: An incident involving circumstances indicating that there was a high probability of an accident and associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down.

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Serious Injury: An injury which is sustained by a person in an accident and which:

a. requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or

b. results in a fracture of any bone (except simple fractures of fingers, toes or nose); or

c. involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage; or

d. involves injury to any internal organ; or

e. involves second or third degree burns, or any burns affecting more than 5 per cent of the body surface; or

f. involves verified exposure to infectious substances or injurious radiation.

State of Design: The State having jurisdiction over the organization responsible for the type design.

State of Manufacture: The State having jurisdiction over the organization responsible for the final assembly of the aircraft, engine, propeller or major components

State of Occurrence: The State in the territory of which an accident or incident occurs.

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.

State of Registry: The State on whose register the aircraft is entered.

Observer: A person permitted to be present in an investigation for the purpose of observing the investigation process

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LIST OF ACRONYMS

The following abbreviations are used throughout this guideline:

AAIF : Aircraft Accident Investigation Fundamental

ADFR : Automatic Deployable Flight Recorder

ATC : Air Traffic Control

CASR : Civil Aviation Safety Regulation

Doc. : Document

EFIS : Electronic Flight Instrument System

EGPWS : Enhanced Ground Proximity Warning Systems

GPS : Global Positioning System

ICAO : International Civil Aviation Organization

IIC : Investigator-in-charge

ISASI : International Society of Air Safety Investigators

kg : Kilogram

KNKT/NTSC : Komite Nasional Keselamatan Transportasi / National Transportation Safety Committee

MoU : Memorandum of Understanding

OJT : On-the-job training

PPE : Personal protective equipment

SARPs : Standards and Recommended Practices

SMS : Safety Management System

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1 BACKGROUND

Aircraft accident investigation is a specialized task which should only be undertaken by qualified investigators. Qualified investigator is a person who has been trained appropriately in the accident investigation techniques required to participate in or to conduct an aircraft accident investigation. When assigned to an accident investigation, such personnel should be relieved of their regular duties for the duration of the investigation.

Potential accident investigators must have considerable practical experience in aviation as a foundation on which to build their investigation skills. This experience can be acquired from civil or military qualification as a pilot, aeronautical engineer or aircraft maintenance engineer. Personnel qualified in flight operations, airworthiness, air traffic management, or aviation related management might also be suitable to be trained as investigator.

Since accident investigations will often involve specialized areas, it is important that those selected for training as investigators understand the aviation infrastructure and are able to relate to the many different areas of aviation.

In addition, the investigators should have a comprehensive understanding of the interrelationship of each of the supporting services that are necessary to operate an aircraft in the aviation environment.

Since the outcome of an accident investigation is largely dependent upon the aviation knowledge, skills and experience of the assigned aircraft accident investigators, they should have:

a. An understanding of the depth of investigation that is necessary in order for the investigation to conform with the legislation, regulations and other requirements of the State for which they are conducting the investigation;

b. A knowledge of aircraft accident investigation techniques;

c. An understanding of aircraft operations and the relevant technical areas of aviation;

d. The ability to obtain and manage the relevant technical assistance and resources required to support the investigation;

e. The ability to collect, document and preserve evidence;

f. The ability to identify and analyze pertinent evidence in order to determine the causes and, if appropriate, make safety recommendations; and

g. The ability to write a final report that meets the requirements of the accident investigation authority of the State conducting the investigation.

In addition to technical skills and experience, an accident investigator requires certain personal attributes. These attributes include integrity and impartiality in the recording of facts; ability to analyze facts in a logical manner; perseverance in pursuing inquiries, often under difficult or trying conditions; and tact in dealing with a wide range of people who have been involved in the traumatic experience of an aircraft accident.

KNKT personnel assigned for duty officer or supporting in investigation should have minimum of the initial training prior to perform their duty.

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The process of improving the technical skill and experience KNKT investigator will used this guideline under the responsibility of the Head of Aviation Accident Investigation Sub Committee and the Head of Human Resource and General Affair.

KNKT Investigator Training Program and Responsibility

The Head of Aviation Accident Investigation Sub Committee

The Head of Human Resource and General Affair

1. Training need assessment 1. Training plan and budget

2. Training syllabus and material 2. Training facility assessment

3. Selection and availability of instructor or training facility

3. Personal data and training record

4. Training quality assessment

This guideline described trainings required for newly hired investigator. The Head of Aviation Accident Investigation Sub Committee should develop training program for improving the technical skill and experience investigator. The Head of Human Resource and General Affair shall arrange the budget according to the training program. The Head of Human Resource and General Affair shall maintain training records form for each investigator, the sample of the investigator training records is described in the Appendix 4.3 of this guideline.

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2 TRAINING PHASES

2.1 General

Investigators require different levels of experience, knowledge and training according to the particular role to which they are assigned. Investigators should receive training commensurate with their responsibilities as an accident investigator, group leader, Investigator in Charge, Accredited Representative, Adviser or Expert. The training guidelines and course syllabi should be planned in such a way that the investigators receive appropriate levels of training that will enable them to perform efficiently in any of the roles assigned to them by the employer.

Training for investigator involves several phases. These phases include initial training, aircraft accident investigation fundamental, on-the-job training, and an advanced accident investigation course supplemented by specialized courses. While on-the-job training is an ongoing process that continues for many years, there should be sufficient time intervals between each formal course to allow the investigator to consolidate the information and the techniques learned.

Formal courses are designed to complement on-the-job training by exposing trainee investigators to a cadre of technical experts who can pass on the details of their specialties to the student. The technical experts may be taken from KNKT investigator or recruited from those with experiences in a particular area of accident investigation. They include experienced investigators, aviation medicine physicians, air traffic controller, pilot, psychologists, aeronautical engineers and manufacturers representatives or technical expert on relevant subject.

The aircraft accident investigation courses are conducted by KNKT, universities, manufacturers, military establishments, other states accident investigation authorities and other institutions.

The selection of the training facility for the aircraft accident investigation course should be evaluated and assessed for the ability and capability of the organization in the aircraft accident investigation training.

2.2 Training Phase

Phase 1 — Initial Training

The objective of the initial training is to familiarize new investigators with the legislation in Indonesia and with the procedures and requirements of the KNKT. The following subjects should be included in the initial training or indoctrination:

a. Administrative arrangements

1) Applicable legislation; (Indonesia Aviation Law number 1 of 2009, Government Regulation number 62 of 2012, Civil Aviation Safety Regulation (CASR) Part 830 and Notification.

2) International agreements (including Annex 13 Aircraft Accident and Incident Investigation);

3) Memoranda of Understanding (MoU) with other organizations;

4) Liaison arrangements with local and national authorities;

5) Structure of the KNKT;

6) KNKT Policies and Procedures Manuals;

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7) Definitions and accident classification;

8) Equipment and tools;

9) Transport arrangements;

10) Ethics and conduct; and

11) Expenditure control.

b. Initial response procedures

1) duty officer procedures;

2) Notification of other national authorities and organizations;

3) Securing of records, recordings and samples;

4) Accident site jurisdiction and security;

5) Investigator safety including psychological stress;

6) Requests for autopsies; and

7) Family assistance.

c. Investigation procedures

1) Authority and responsibility;

2) Size and scope of the investigation;

3) Investigation management;

4) Use of specialists;

5) Parties to the investigation, accredited representatives, advisers and observers; and

6) Release of information to the news media.

Phase 2 — Aircraft Accident Investigation Fundamentals (AAIF)

After completing the initial familiarization training, the investigator who is under training should attend Aircraft Accident Investigation Fundamentals (AAIF) or basic accident investigation course as soon as is practicable, preferably within the first year of employment. A basic course should have a syllabus that includes the subjects discussed in Chapter 3 in this guideline.

Phase 3 — On-the-Job Training

Following the AAIF training, on-the-job training will be provided for a new hire investigator. During this third phase, the new investigator will practice the procedures and tasks covered in the initial training and AAIF, and gain familiarity with investigation techniques. This training will also familiarize him with the investigation tasks at the accident site, the collection of factual information, the analysis of the factual information and the development of the final report.

The conduct of on-the-job training often involves more than one experienced investigators.

Each investigator shall have an on the job training record form (Appendix 4.1) that approved by the assessor or the Head of Aviation Accident Investigation Sub Committee indicated that he or she has qualified to particular task as stated on the approval.

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Phase 4 — Advanced Accident Investigation Courses and Additional Training

a. Advanced accident investigation courses

As a trained investigator gains experience, he should be enrolled for an advanced accident investigation course where he can update his knowledge of the basic techniques and increase his knowledge in special areas relevant to accident investigations.

KNKT has establish advance accident investigation course consist of human factors for transport investigation and investigation analysis course.

b . Additional trainings

Investigators may be called upon to investigate accidents involving a variety of aircraft types. It is impracticable to train an investigator on each of the aircraft types that he may encounter. Nevertheless, investigators should have a basic knowledge of most of the major air transport aircraft types that are operated in Indonesia.

It is therefore recommended that investigators attend additional training such as aircraft type courses or engine type courses on the most common aircraft or engine types used by the airlines in Indonesia. Preferably, such aircraft type courses should include specialized technology transport category aircraft (i.e. aircraft equipped with a glass cockpit, fly-by-wire systems and aircraft which contain composite materials in their structure).

Additional training intended to improve the investigator knowledge or skill base on background specialties. There is no need for investigators to attend all additional trainings. For example, investigators with a pilot background could attend the aircraft type courses for pilots while investigator with ATC background could attend traffic management course.

Investigator also require for training, in order to maintain the investigator with the latest regulation, technology or other necessary knowledge, such as Safety Management System (SMS), new investigation tools or methods, etc.

Other additional training can be obtained by attending conferences and seminars conducted by aircraft accident investigation organizations, such as the International Society of Air Safety Investigators (ISASI); by reading related material such as the Aircraft Accident Digest circulars and aircraft accident reports issued by other States; and by exposure to major investigations as observers at major investigations on site in other States.

2.3 Investigator Levels

The investigator levels are described on Policies and Procedures Manuals. The level of investigator depends of the training that has been attended, experience, and years on service.

a. Level I - Junior Investigator.

An investigator who meets the general qualification requirements and completes the level I of initial and Aircraft Accident Investigation Fundamental (AAIF) courses.

A level I Investigator may be appointed as a member of accident or serious incident investigation team for on-site investigation activities under supervision

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b. Level Il – Middle Investigator.

An investigator who meets qualifications of level I investigator and has completed the minimum one additional training or attend minimum of two relevant safety seminars, and has actively and successfully in a minimum of 3 (three) investigations including minimum of 3 (three) on site investigation, and contributed to the development of the final report.

Investigator level II may be appointed as an IIC for accident involving aircraft with maximum mass 2,250 kg or serious incident involving aircraft with maximum mass 5,700 kg or as a group leader of an accident.

c. Level III - Senior Investigator.

An investigator who meets all qualifications and training requirements for level II investigator, completed the minimum two additional trainings or attend minimum of two relevant international safety seminars, conferences or workshops and has actively and successfully participated in minimum of 5 investigations including minimum of 4 on site investigation and including minimum of 2 accidents. The Level III Investigator shall have acted as group leader of at least 2 accident investigations, and have written the final report and completed the investigation.

An Investigator Level III shall receive training in the international investigation practice, particularly those contained in ICAO Annex 13, in order to prepare the investigator to represent the interests of Indonesia during investigations conducted by other States involving Indonesian registered, operated, designed or manufactured aircraft.

An Investigator level III may be appointed as an IIC for accident or serious incident investigation or as Accredited Representative.

d. Assessor

Is a level III investigator, authorized by the Head of Aviation Accident Investigation Sub Committee, to guide on the job training for new hire investigators and for the assessment of investigators for their qualification as an investigator. The result of the assessment shall be reported to the Head of Aviation Accident Investigation Sub Committee. An Assessor may be appointed as an investigator in charge for major accident investigation.

e. Specialist

A person with specific knowledge required for examination of wreckage, components, documents, or research or other purposes in support of the KNKT investigation may classified as a specialist and may participate in investigation as Seconded Investigator upon requested by the IIC, the Head of Aviation Accident Investigation Sub Committee or Chairman.

In the case of investigation that considered “special”, notwithstanding the investigator levels indicated above, the Head of Aviation Accident Investigation Sub Committee may develop other designations for investigator in charge who deal specifically with a certain specialty area. Such specialties are cabin safety and dangerous goods.

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3 TRAINING SYLABUSS

KNKT has established several trainings such as:

1. Aircraft Accident Investigation Fundamental Training (AAIF);

2. Safety at accident site

3. Human factors for transport investigation;

4. Investigation analysis;

3.1 Detailed subjects Discussion of the AAIF

a. Rules and Regulation

The first phase of a course should introduce the investigator to the history of aircraft accident investigation, the development of the international agreements on the conduct investigations, and the Standards and Recommended Practices (SARPs) adopted by ICAO and its Contracting States in the field of aircraft accident investigation.

This subject also discusses the history of KNKT, the role, function and responsibility including the Indonesia rules and regulations for aircraft accident investigation based on Indonesia Aviation Law number 1 of 2009, Government Regulation number 62 of 2012, Civil Aviation Safety Regulation (CASR) Part 830 and KNKT policies and procedures.

b. Notification Procedures

The investigator should be introduced to the accident notification systems and the appropriate responses to be expected from each State and organization that are notified. This introduction should cover the ways on how the notification of the occurrence of an accident initiates the process of an investigation.

It should also cover the support to be provided to the accident investigation authority in the State of Occurrence when Indonesia as the State of Registry, the State of the Operator, the State of Design, the State of Manufacture, or States that are involved by virtue of the number of their Indonesia citizen involved in the accident or are involved by providing a permanent base for the investigation due to their proximity to an accident site. Accident investigators should be made aware of the requirements of ICAO Annex 13 in relation to this phase of an investigation.

c. Safety at Accident Site

The safety of personnel at an aircraft accident site is of paramount importance and must be understood by participants of an investigation. An investigator is a valuable resource and it is important that he is protected and well equipped to do his work in the field with as little risk as is practicable and with the optimum efficiency. Aircraft accidents frequently occur in adverse weather conditions in areas of inhospitable terrain such as mountainsides, swamps and deserts, or in adverse climatological conditions involving snow and ice or fierce heat. Investigator will be introduced with hazard that may exist in the accident site.

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The need to take appropriate measures to protect those on the site against exposure to the elements, to any hazardous cargo or dangerous materials released from the aircraft, and against injury or infection must be understood. There are medical risks and hazards from the aircraft wreckage itself and they should be explained to the investigators.

Another subject that must be covered is how to deal with psychological stress of investigators and other personnel with exposure at an accident site. Disease is an ever-present risk and inoculations against such risks as hepatitis, malaria and tetanus are essential.

The use of protective equipment against airborne and blood borne pathogens should be demonstrated. Utilities such as gas mains, electricity transmission lines and main transport routes require special consideration.

Finally, a plan for aid and rescue in the event of an accident involving personnel at the site is required by many occupational health and safety organizations and is also dictated by common sense.

d. Investigation Measurement

This subject discusses the activities during the on-site investigation that may require measuring distance to determine wreckage distribution, taking picture as evidence and other activities that require special equipment. The equipment to be used during investigations will be determined not only by availability and cost but also by the means available to transport it to the site.

Information on the use of contemporary aids such as Global Positioning Systems (GPS), satellite telephones, and data links back to base, as well as on the use of basic items such as compasses and inclinometers should be made available. Means of recording in extreme wet or cold conditions should not be overlooked. Instruction on the proper method of taking samples of aircraft fluids and the appropriate containers should also be included.

e. Action at the Accident Site (Initial, Gathering Information and Protection of Evidence)

The investigator should be given a thorough understanding of the numerous considerations that should be taken into account at the accident site. With some exceptions such as accidents involving missing aircraft or resulting in wreckage that is inaccessible, the accident site is the primary area of investigation. The methods of apportioning time effectively, prioritizing the types of information to be gathered, plotting the position of surface marks, and identifying and plotting the position of items of wreckage, as well as the preparation for the removal of any exhibits to a secure site are important considerations that the investigator should become familiar with from the outset.

The investigator under training should be introduced to the methods of gathering and reviewing relevant documentation and procedures. The topics discuss the data required to be collected on the accident site, significant marks, and the review of aerodrome facilities, emergency services responses and meteorological data.

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To establish a suitable environment for a competent examination of the area and the accident debris, wreckage diagram, measures should be taken to protect the wreckage from fires, and meteorological hazards. The need to give priority to recording transient evidence, securing light objects that may be lost in the wind, and recording ground scars and other site markings that may become obliterated should be addressed.

f. Witness Interviews

The range of witnesses varies with physical condition, nature of involvement, and differences in ethnic backgrounds. They will also vary in their value based on their understanding of the required information and their proximity to the scene. They may be a visual witness who saw an event or an aural witness who heard a sound or relevant conversation.

The preparation for interviews, information to be gleaned from body language, the relative positioning of the interviewer and interviewee, preparation of the questions to be asked, the use of open questions, the art of listening and general conduct of the interview, the use of recorders such as video cameras and tape recorders, the value of written statements and signed transcripts should be considered.

The precautions to be taken when interviewing the injured or persons in ill health, the young, the aged and hostile witnesses as well as the use of technical experts in the field of inquiry should be discussed.

g. Recorders and Recording Media

In addition to the flight recorders, there are many other forms of recorders used in the aviation industry, from the security cameras on the aerodrome perimeter fence to the maintenance recorders in the aircraft, each with potential use to an investigator. The value of each form of recorder, the methods of interpreting and downloading the information, and the sources of readout must be in the course syllabus. Equally, the value of manufacturer’s expertise in recovering information from damaged recorders (such as global positioning receivers, solid-state flight recorders and inertial navigation unit components) should be explored. Another aspect of importance is the means of locating the flight recorders and recovering them from locations that are difficult to reach. Recorders at air traffic services facilities, particularly those that record radar returns, should be the subject of a separate study and guidance regarding their potential use to an investigation.

The various media available for communicating to and from an accident site and for recording the evidence at the accident site and throughout the investigation are essential elements of an investigation course. Digital video cameras and digital cameras, standard film photography, laptops and hand-held computers with connections via satellite telephones to sources of information of immediate use at the accident site, and tape recorders are all useful for recording the available information as accurately and rapidly as is practicable. As each type of equipment is evolving rapidly, it is an essential subject in the training of an investigator.

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h. Examination of Relevant Maintenance Documents

The maintenance history of the aircraft is established primarily from the records held by the operator.

The investigator should learn to establish whether the maintenance, inspection procedures and servicing that are recorded as having been completed have in fact been carried out, and he should also learn to determine the adequacy of the specified maintenance procedures.

i. Human Factors

Discuss the area of human factors and basic understanding of human factor investigation of human capabilities.

It also discuss that investigators are also human that may have limitation and may affects with all human capabilities.

j. Crashworthiness and Survival aspects

The chances of occupants surviving an accident can be assessed and the means to do so should be given to the accident investigator. The investigator should know the formula for impact force calculations and the various forms of attenuating impact forces. A discussion on the limits of human tolerance to heat and impact forces is worthwhile, as are the effects of toxic by-products of the accident environment.

The efficiency of the rescue and firefighting services, standard pre-flight passenger briefing spiels, restraint systems, seat anchorages and aids to egress from the aircraft is items that should be studied under this heading. It is also very important to review the factors that affect the occupants’ chances of surviving the accident.

The means of determining the after effects of a fire on the occupants and the fire’s impediment to passenger evacuation must be discussed, as must the availability of such items as smoke hoods and smoke goggles. An understanding of the methods used to protect the aircraft occupants from the impact forces and post-impact effects (such as thermal stress and water immersion) is very important for the accident investigator. He must be able to assess the effectiveness of the methods and make recommendations which will provide better protection for the occupants in the future.

k. Aircraft Structures and Material failure

As the basis for the examination of the wreckage, the study of structures is an area of prime interest to the investigator. The study of structures should comprise metallurgy, fiber reinforced plastics and timber structures, stress analysis and the strength of these materials. It should also include the various modes of failure and the characteristics of such failures in the materials used in aircraft structures. The methods of failure analysis, reconstruction of areas of interest in the airframe, and the evidence of the various modes of failure are important considerations.

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The various types of flight controls and landing gear structures should also be studied under this heading. This section of the syllabus should cover the advanced equipment used in the study of failure mechanisms, the preparation of samples for examination by such equipment, and the methods for comparative testing of similar materials. The study of structures also provides a platform for introducing the means of wreckage trajectory analysis. Every effort should be made to provide examples of the various failure modes in materials used in aircraft construction.

l. Aircraft systems

Aircraft systems vary from mechanical controls that are still found in general aviation aircraft to the fly-by-wire systems already extant in wide-bodied transport aircraft. There are a wide variety of systems that the investigator should become familiar with in general terms. However, the focus should be on the resources available to assist the investigator in the event of an accident involving a complex system and on common causes of system failure that might be experienced.

A lead to system health can often be found in past maintenance records or on-board recorders. It is necessary to discuss, in general terms, fuel, hydraulic, pneumatic, electrical, pressurization, flight control, instruments, navigation, autopilot and instrument systems. Other topics that should be considered include software failures in airborne computers and the adequacy of the protection against catastrophic events ensuing from such failures.

m. Aerodynamics

The common areas of aerodynamics that frequently assume importance in an investigation are those related to performance and in-flight structural failure caused by overload or flutter. A review of basic aerodynamics and the means of detecting failure from aerodynamic factors should be included in the investigator’s basic training. The topics of engine failure recognition speed, V1

and V2, climb gradient, over-speed, engine-out performance, icing and stability

also deserve special attention.

n . Power plants

The detailed analysis of power plants is normally the subject of a separate course and is usually carried out in conjunction with the engine manufacturer’s representatives.

Nevertheless, the explanation of the basic principles of reciprocating and turbine engines has a place in basic and advanced investigation courses. The same is true with regards to the analysis of damage to propellers and helicopter rotors, and a general overview of methods of evaluating damage to determine if further investigation of the particular propeller or engine is warranted. For example, propellers and turbines can give a worthwhile indication of an absence of engine power at the time of impact. This is another subject in which examples of failures and accident damage form an essential part of the course.

o. Rotary wing aircraft

A general introduction to the principles of flight for helicopters and their control systems is relevant. However the subject of investigating helicopter and other rotary wing aircraft accidents is usually the subject of a separate specialty course.

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p. Air Traffic services

A general introduction of air traffic services function and the available data that may support the investigation including how to collect it.

q. Evidence photography

Photography is a method of preserving of evidence. Investigator required to be able to do evidence photograph for improving analysis the investigation. In this training investigator introduce basic photography including camera feature.

r. Report writing

Report writing is an integral responsibility of an accident investigator. KNKT has developed formats for writing reports that leads logically from the history of the flight to the safety recommendations. There is a minimum of duplication and a full consideration of aspects of the flight that are relevant to the improvement of safety. Knowledge of this format and process gives the investigator a sound basis for drafting the final report, including the formulation of appropriate safety recommendations.

3.2 Safety at Accident Site

Investigators should be aware of the potential hazards at an accident site and what precautions to take. For this reason the investigator shall aware of all known and potential hazards and should establish safety practices.

Course should discuss:

a. hazard that may exist in the accident site including natural hazard, mechanical hazard, and bio hazard;

b. standard personal protective equipment (PPE) required including the use and donning the PPE;

c. securing the accident site;

d. the procedure while conducting investigation in the accident site;

After completion of the training and assesses satisfactory, participant will receive a blood-borne pathogen card. Participant conducts first blood-borne pathogen training, the blood-borne pathogen card valid for two years and shall conducts recurrent training. Following the recurrent training, the blood-borne pathogen card will valid for four years.

3.3 On the Job Training

Following the Aircraft Accident Investigation Fundamental (AAIF) training, a new investigator should conducts on-the-job training. The new investigator will practice the procedures and tasks covered in the AAIF and initial training, and gain familiarity with investigation techniques. The on-the-job training familiarize new investigator with the investigation tasks at the accident site, the collection of factual information, the analysis of the factual information and the development of the final report.

During the on-the-job training new investigator will be guided by one or more level III investigators. The experienced investigator guides the new investigator will be assigned by the Head of the Aviation Accident Investigation Sub-Committee.

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The guidance includes the area of:

a. On-site investigation;

1) Include recognizing hazard at the accident site and selection of proper PPE;

2) Coordination with other organization;

3) Identify, collecting and preserving evidence;

4) Interview.

b. Interview (if has not been performed);

c. Analysis;

d. Report writing.

Depend on the opportunity to perform all task, a new investigator may be guided by different experienced investigator for various task. After completion of guidance, the experienced investigator shall fill the assessment form.

The criteria for assessment are described in the Appendix 4.2 in this guideline.

3.4 Advanced Accident Investigation Courses

3.4.1 Advanced Course Topics

In order to improve KNKT investigators knowledge and skill, advance courses are provided. Most topics covered in the AAIF may also apply to advanced courses, but the discussions are expected to more detail of these topics to suit the purpose of the course and the experience level of the investigator.

In general, an advanced course is desirable for preparing an investigator for the responsibilities of group leader or IIC of a major investigation. Such a course should aim to give the investigator an understanding of and some competence in the organization of a major accident investigation.

KNKT has established Human Factor for Transport Investigation and Investigation Analysis course.

a. Human Factors for Transport Investigation

The course provides a general overview of human factor in safety critical system. The training provide the participants awareness of the following items:

1) The key term and consept used in human factors;

2) Basic human performance capabilities and limitations;

3) The factors that influence the human peformance;

4) The importance of human factors in transport safety;

5) How human factors issues can be considered during an investigation; and

6) Where to find expertise on complex human factors issues.

The course discusse following topics:

1) Human information processing

2) Hypoxia and spatial dissorientation

3) Fatigue

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4) Culture

5) Medical and environment condition

6) Workload

7) Situational awareness

8) Ergonomics

9) Stress

10) Dicission making

11) Team resource management

12) Communication

13) Human error

14) Alarm and response

15) Automatic system

16) Organizational influences

17) Investigating safety management system

18) Investigating human factor

b. Investigation Analysis

The course objectives are:

1) to define analysis terms and concepts;

2) conduct investigation analysis using KNKT tecniques.

The course discusse following topics;

1) analysis framework

2) sequence of event

3) evidence table

4) evidence analysis

5) contributing factor

6) developing safety recomendation

In addition investigator may attend training conducted by other institution while the topics discuss topic includes:

a. The provision of family assistance to those involved in an accident;

b. Relations with the media;

c. An introduction to methods for cataloguing a large number of fragments of wreckage;

d. Management of a large accident site for security, safety and protection of the personnel;

e. Preparation of briefings and answers to formal questions for members of government;

f. The methods of undertaking investigations; and

g. Liaison with the law enforcement authorities in accidents involving unlawful

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interference.

3.4.2 Additional Training

Additional training may be introduced to an investigator at any stage after a basic course. The courses would augment the skills and knowledge acquired by the investigator in order to meet the needs of a particular area of accident investigation that is relevant to his assigned duties.

For topics such as helicopter accident investigation, gas turbine engine accident investigation, accident survival aspects, fires and explosions, Human Factor investigation, family assistance and media relations, they are generally extensive enough to warrant a short course of their own with a specialized syllabus.

Description of the systems involving specialized technologies (such as glass cockpit, fly-by-wire systems, GPS, Electronic Flight Instrument System (EFIS) and Enhanced Ground Proximity Warning Systems (EGPWS) is usually provided during aircraft type courses. However, aircraft type courses do not include the investigation aspects nor the investigation techniques of such complex systems. Extensive information can be obtained from memory chips and other solid state electronic circuits used in new technology systems. Increasingly, the investigation techniques for solid state electronic circuits are covered in accident investigation courses. Nevertheless, aircraft accident investigation authorities should contact the manufacturers of such systems for specialty courses, since most manufacturers have accident investigators and support personnel that are familiar with the systems and the investigation techniques required to extract the information stored in the systems

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4 APPENDICES

4.1 On the Job Training Syllabus

Investigator Name :

Title (operations/engineering/ATC/survival factors/etc.):

Transportation mode : Aviation

No Subject Date Remark Assessor

On site investigation

1 Hazard identification

(Name and sign)

2 Safety at accident site

3 Personal Protective Equipment (PPE)

4 Identify, collecting and preserving evidence

5 Liaison with other organization

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No Subject Date Remark Assessor

Further Investigation

6 Witness interview

7 Analysis

8 Report Writing

Acknowledge by:

The Head of Aviation Accident Investigation Sub Committee

Date, name and sign

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4.2 Criteria of Assessment on the Job Training

During the on the job training, the assessor guides and assess the candidate in the following subjects. In general, the criteria to be acceptable are that the candidate shall be able to perform minimum of 75% of the total task of particular subjects.

The details of the tasks for particular subjects are as follows:

a. Hazard Identification

1) Identify the natural hazard such as wildlife, terrain, vegetation, weather, etc.;

2) Identify the mechanical hazard such as sharp object, pressure vessel, carbon fiber, etc.;

3) Identify other hazard such as housing utility, etc.

b. Safety at accident site

The candidate is able to perform good safety behavior during perform the task on the accident site and general safety.

c. Personal Protective Equipment

The candidate able to select properly, don and remove PPE for particular hazardous condition, including disposal of contaminated PPE.

d. Identify, collecting and preserving evidence

The candidate is able to identify scratch marks and required measurement, evidence documents, material evidence (such as metal failure) and other documents, collecting those evidences and preserving including taking photograph and sketch.

e. Liaison with other organizations

The candidate able to coordinate with organizations directly involve to an accident such as air operator, Airport authority, ATS provider, meteorology service provider, ground handling etc. Coordination with other organization such as police, accredited representatives, hospital or other organization not directly involve to the accident does not include in this assessment.

f. Witness interview

The candidate able to prepare list of questions, opening an interview, questioning, maintain good rapport and make record of interview according to the KNKT policies and procedures as stated in the Interview Guidelines.

g. Analysis

The candidate able to collect appropriate data, making the sequence of events, and analysis the data including writing in the investigation report.

h. Report Writing

Refer to KNKT policies and procedures, the candidate able to

1) Collect data for appropriate sub-heading;

2) Writing in plain English according to each Chapter;

3) Clear and concise.

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4.3 Investigator Training Records

TRAINING RECORDS

PHOTO

Investigator Name :

Title (operations/engineering/ATC/survival factors/etc.):

Transportation mode : Aviation

No Name of course Year Remark

(certificate, etc.)

INITIAL

1 KNKT Basic Indoctrination

2 Aviation Law and Regulation

3 Accident Notification Procedure

4 Safety at Accident Site

5 Investigation Measurement

6 Gathering Information at accident site

7 Evidence protection at accident site

8 Witness interview

9 Recording and recording media

10 Examination of relevant document

11 Human factor (general)

12 Crashworthiness and survival aspects

13 Aircraft structure and material failure

14 Aircraft system

15 Aerodynamics

16 Powerplants

17 Rotary wing aircraft

18 Report writing

19 Media Awareness

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No Name of course Year Remark

(certificate, etc.)

ADVANCED

1 Human Factor

2 Fatigue, Stress & Human Error

3 Investigation Analyzing

4 Blood borne Pathogen

5 Photography for Investigation Process

GENERAL

1 Training of Trainer

2 Safety Management System

3 Workplace Safety and Health - K3

4 Dangerous Goods

5 Ground Hazard

6 Microsoft Office

7 Computer Design Graphics

8 Company Aviation Safety Officer

9 English TOEFL/ TOEIC

SPECIFIC TRAINING

1 ECCAIR End User

2 Searching for Under Water Recorder

3 MEDA (Maintenance Error Decision Aid)

KOMITE NASIONAL KESELAMATAN TRANSPORTASI Jl. Medan Merdeka Timur No.5 Jakarta 10110 INDONESIA

Phone: +62 21 351 7606 / 384 7601 Fax: +62 21 351 7606 Call Center: +62 812 12 655 155 Website: knkt.dephub.go.id/knkt Email: [email protected]

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