Aircraft Accident Investigation Course – Typical Topics

Chapter 1. Regulatory Framework

 ICAO Annex 13 – Aircraft Accident and Incident Investigation

 National regulations (DGCA, FAA, EASA, etc.)

 Roles of Investigator-in-Charge (IIC), accredited representatives, and technical experts

 International cooperation in investigations

Chapter 2. Investigation Process

 Accident notification and initial response

 Securing and managing the crash site

 Evidence collection, preservation, and chain of custody

 Safety of investigators at crash sites (hazards: fire, fuel, biohazards, UXOs)

 Coordination with police, fire services, and emergency response

Chapter 3. Technical Investigation

 Wreckage examination and reconstruction

 Aircraft systems and structures analysis

 Flight data recorder (FDR) and cockpit voice recorder (CVR) recovery & analysis

 Maintenance records and airworthiness documentation review

 Meteorological and ATC data analysis

Chapter 4. Human Factors

 Pilot performance, training, and experience

 Fatigue, stress, and workload

 Crew Resource Management (CRM) & communication issues

 Medical and toxicological examinations

 Organizational factors (management, SOPs, safety culture)

Chapter 5. Accident Causation Models

 SHELL Model (Software–Hardware–Environment–Liveware)

 Reason’s Swiss Cheese Model of accident causation

 Threat & Error Management (TEM)

 HFACS (Human Factors Analysis and Classification System)

Chapter 6. Data & Evidence Handling

 Photography, mapping, and 3D site documentation

 Witness interview techniques

 Use of simulation and re-creation of events

 Laboratory analysis (materials, fire, explosions)

Chapter 7. Report Writing

 ICAO Annex 13 format for Final Reports

 Interim statements and safety recommendations

 Structure of factual information, analysis, conclusions, and safety actions

 Communicating findings to stakeholders and public

Chapter 8. Safety & Prevention

 Link between investigations and Safety Management System (SMS)

 Developing safety recommendations

 Accident prevention strategies

 Feedback loop into airline/ATC training and regulatory improvements

Chapter 9. Case Studies

 Review of major international accidents (e.g., Tenerife, Air France 447, B737 MAX)

 Lessons learned and regulatory changes following accidents

 Application of theory to real-world events

✅ Duration:

 Short course (5 days): Overview of investigation methods, ICAO framework, case

studies.

Chapter- 1
 Regulatory Framework

1. ICAO Annex 13 – Aircraft Accident and Incident Investigation

 Definition of Accident, Serious Incident, and Incident

 Objectives of investigation – not to apportion blame, but to prevent recurrence

 Notification requirements:

o State of Occurrence

o State of Registry

o State of the Operator

o State of Design & Manufacture

 Rights of States during investigations

 Obligations: preservation of evidence, access to wreckage, FDR/CVR handling

 Final Report – ICAO standard format, timelines, safety recommendations

2. National Regulations (DGCA, FAA, EASA, etc.)

 DGCA (India)

o Aircraft (Investigation of Accidents and Incidents) Rules, 2017

o Role of Aircraft Accident Investigation Bureau (AAIB India)

o Mandatory reporting requirements under CAR

 FAA (USA)

o NTSB Part 830 – Notification and reporting of accidents/incidents

o FAA–NTSB coordination

 EASA (Europe)

o Regulation (EU) 996/2010

o European Network of Civil Aviation Safety Investigation Authorities (ENCASIA)

 Comparison of approaches (DGCA vs FAA vs EASA)

3. Roles in an Investigation

 Investigator-in-Charge (IIC):
 o Leads the investigation team

o Coordinates with States, technical experts, laboratories

o Ensures adherence to Annex 13 standards

 Accredited Representative:

o Official appointed by State of Registry, Operator, Design, Manufacture

o Rights to participate in all aspects of the investigation

 Advisers / Technical Experts:

o Aircraft manufacturer, airline, maintenance organization, air traffic services,

meteorology, human factors, medical experts

 Other Stakeholders: Police, fire services, legal authorities, insurance, and families of
victims

4. International Cooperation

 ICAO’s role – ensuring standardization across States

 Mutual assistance agreements between States for complex investigations

 Sharing of data through ADREP (Accident/Incident Data Reporting System)

 BEA (France), NTSB (USA), AAIB (UK) – examples of cooperation in global cases

 Challenges in cross-border investigations:

o Jurisdictional issues

o Language & cultural differences

o Confidentiality vs transparency

Learning Outcomes of this Module

By the end of this session, trainees should be able to:

✅ Explain ICAO Annex 13 framework and objectives
✅ Identify national regulatory bodies and their investigation procedures
✅ Understand the responsibilities of IIC, accredited representatives, and technical experts
✅ Appreciate the importance of international cooperation in accident investigation
 Chapter- 2

Investigation Process

1. Accident Notification and Initial Response

 Notification channels: ATC, airline operator, airport authority, police, or witnesses.

 Mandatory information in notification (Annex 13):

o Aircraft identification, operator, and type

o Place and time of accident

o Number of crew and passengers onboard

o Nature of accident (fire, crash, runway excursion, etc.)

 Initial actions of Investigator-in-Charge (IIC):

o Alert investigation team

o Coordinate with national authorities (DGCA/AAIB)

o Arrange logistics for immediate site access

 Golden Hour principle – rapid mobilization is critical for evidence preservation.

2. Securing and Managing the Crash Site

 Establishing site perimeter and security cordon with local police/airport security.

 Restricting access to authorized personnel only.

 Protecting wreckage from fire, weather, and looting.

 Setting up command post for investigators.

 Mapping wreckage distribution using grid method or GPS coordinates.

 Ensuring safety before entry (hazard survey).

3. Evidence Collection, Preservation, and Chain of Custody

 Physical evidence: wreckage, instruments, controls, flight data recorders.

 Environmental evidence: weather conditions, terrain, obstacles.

 Documentary evidence: maintenance logs, flight plans, ATC recordings, crew training
records.
  Witness statements: passengers, crew, ATC, ground staff, first responders.

 Chain of custody:

o Every piece of evidence must be logged, tagged, photographed, and signed

off.

o Clear documentation ensures admissibility in legal and safety proceedings.

4. Safety of Investigators at Crash Sites

 Common hazards:

o Fire, fuel vapors, toxic smoke

o Sharp wreckage, high-temperature surfaces

o Biohazards from human remains and bloodborne pathogens

o Wildlife and environmental risks (snakes, terrain, weather)

o Unexploded ordnance (UXOs) in conflict zones

 Protective measures:

o PPE: helmets, gloves, boots, reflective vests, respirators, biohazard suits

o Safety briefing before site entry

o Onsite medical support and emergency evacuation plan

5. Coordination with Police, Fire Services, and Emergency Response

 Police: Secure perimeter, manage crowd control, assist with chain of custody.

 Fire services: Fire suppression, hazardous material containment, rescue assistance.

 Emergency Medical Services (EMS): Triage and evacuation of survivors.

 Airport authority: Provide operational support, logistics, and crisis management

center.

 Civil Defense / Military (if required): Support in remote or hostile environments.

 Coordination ensures balance between rescue operations and preservation of

evidence.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:
✅ Explain procedures for accident notification and rapid response
✅ Demonstrate methods of site security and crash site management
✅ Apply correct evidence collection and chain-of-custody principles
✅ Identify hazards and implement investigator safety practices
✅ Coordinate effectively with emergency services and law enforcement

Chapter- 3

Report Writing

1. ICAO Annex 13 Format for Final Reports

  Purpose: To prevent future accidents, not to apportion blame.

 Mandatory sections:

1. Factual Information – aircraft, crew, weather, ATC, flight history, wreckage

info.

2. Analysis – logical examination of facts, human/technical/organizational

factors.

3. Conclusions – direct causes, contributing factors, systemic issues.

4. Safety Recommendations – preventive measures for

industry/regulators/operators.

 Appendices: supporting data, flight recorder traces, witness statements, diagrams.

 Timelines: States must publish final report as soon as possible (ideally within 12
months).

2. Interim Statements and Safety Recommendations

 Interim Statements:

o Issued if final report is delayed beyond 12 months.

o Provide current status of investigation without conclusions.

 Safety Recommendations:

o Can be issued at any stage (even before final report) if urgent safety issues are
identified.

o Sent to regulatory authorities, operators, manufacturers.

o Must be practical, specific, and actionable (e.g., changes in procedures,

design modifications, training requirements).

 Follow-up: Authorities and operators must respond and track implementation.

3. Structure of Factual Information, Analysis, Conclusions, and Safety Actions

 Factual Information: objective, verifiable details (no opinions).

 Analysis: explain why events occurred, linking technical, human, and organizational
factors.

 Conclusions:
 o Probable cause(s).

o Contributing factors.

 Safety Actions Taken:

o Immediate corrective measures by airline/manufacturer/regulator.

o Safety alerts or bulletins already issued.

4. Communicating Findings to Stakeholders and Public

 Internal stakeholders: airline management, regulatory authority, ATC, airport

authority, aircraft manufacturer.

 External stakeholders: families of victims, media, general public.

 Principles of communication:

o Transparency – share essential safety information.

o Sensitivity – respect for victims’ families.

o Accuracy – avoid speculation or premature blame.

o Clarity – use plain language for public communication.

 Tools: press briefings, official reports, ICAO ADREP system, safety databases.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Understand and apply ICAO Annex 13 report format
✅ Prepare interim statements and issue timely safety recommendations
✅ Structure a final report with clear facts, analysis, conclusions, and safety actions
✅ Communicate findings effectively to stakeholders while maintaining professionalism and
sensitivity

Chapter- 4

Technical Investigation

1. Wreckage Examination and Reconstruction

  Site survey methods:

o Mapping wreckage distribution (impact marks, debris scatter pattern).

o Identifying initial point of impact and breakup sequence.

 Wreckage reconstruction:

o Reassembling key sections (cockpit, wings, tail, control surfaces).

o Determining in-flight breakup vs. ground impact damage.

 Structural evidence indicators:

o Burn patterns (post-crash fire vs in-flight fire).

o Metal fatigue, corrosion, or overload failure.

o Deformation signatures (compression, tension, torsion).

 Tools used: drones, 3D scanning, forensic photography.

2. Aircraft Systems and Structures Analysis

 Airframe: fuselage, wings, empennage, landing gear, flight control surfaces.

 Propulsion systems: engines, fuel systems, thrust reversers.

 Avionics and electrical systems: flight instruments, autopilot, navigation,

communication.

 Hydraulic and pneumatic systems: actuators, brakes, flight controls.

 Structural failures: fatigue cracks, maintenance-induced damage, corrosion.

 Objective: determine if mechanical/structural failure contributed to the accident.

3. Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) Recovery & Analysis

 Recovery:

o Location and retrieval from crash site (underwater locator beacons if

required).

o Handling procedures to prevent data loss.

 FDR Analysis:

o Records hundreds of flight parameters (altitude, airspeed, control inputs,

engine performance).
 o Data correlation with ATC radar and wreckage findings.

 CVR Analysis:

o Records last 30–120 minutes of cockpit audio.

o Crew communications, alarms, background sounds (engine noise, stall

warnings, GPWS alerts).

 Synchronization: aligning FDR, CVR, ATC, and radar data to reconstruct the event
timeline.

4. Maintenance Records and Airworthiness Documentation Review

 Aircraft maintenance logs: scheduled inspections, deferred defects, component

replacements.

 Airworthiness Directives (ADs) compliance: ensuring regulatory requirements were

met.

 Operator’s Maintenance Program: conformity with manufacturer’s instructions.

 Previous defect history: recurring technical issues.

 Certification records: airworthiness certificate validity, modifications, repairs.

 Human factors in maintenance: errors, shortcuts, fatigue, documentation gaps.

5. Meteorological and ATC Data Analysis

 Weather data sources: METAR, TAF, radar imagery, satellite observations.

 Factors considered: thunderstorms, turbulence, icing, wind shear, visibility, volcanic

ash.

 ATC recordings & radar data:

o Pilot–controller communications timeline.

o Clearances, deviations, missed communications.

o Surveillance radar track of aircraft’s flight path.

 Coordination with meteorological services: verification of forecast vs. actual

conditions.

 Impact on accident sequence: weather-related decision-making, situational

awareness, ATC instructions.
Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Conduct systematic wreckage examination and basic reconstruction
✅ Analyze aircraft systems and structural integrity for failures
✅ Recover and interpret FDR & CVR data in accident investigations
✅ Review maintenance and airworthiness documentation for compliance issues
✅ Evaluate meteorological and ATC data as contributory factors in accidents

Chapter- 5

Human Factors

1. Pilot Performance, Training, and Experience

  Pilot records review: licensing, training history, recency of experience, type rating,
simulator checks.

 Performance analysis: decision-making, adherence to SOPs, situational awareness,

workload management.

 Experience factors: total flight hours, time on type, experience in similar

weather/terrain/operations.

 Errors vs. violations: unintentional mistakes vs. deliberate non-compliance.

 Case examples: Tenerife disaster (miscommunication + overconfidence), AF447

(automation reliance + loss of manual flying skills).

2. Fatigue, Stress, and Workload

 Fatigue types: acute, cumulative, circadian disruption.

 Stressors: operational pressure, emergencies, family/personal issues, organizational

stress.

 Workload balance: overload (excessive tasks, time pressure) vs underload (low

arousal, boredom).

 Fatigue management: duty time limitations, rest requirements, fatigue risk

management systems (FRMS).

 Impact on accidents: fatigue as a contributing factor in >20% of major aviation

accidents.

3. Crew Resource Management (CRM) & Communication Issues

 CRM Principles: leadership, teamwork, situational awareness, decision-making,

communication.

 Communication breakdowns: misheard ATC clearances, ambiguous language, lack of

cross-checking.

 Cultural factors: high power distance cultures may reduce assertiveness of junior
crew.

 Automation management: overreliance vs underutilization.

 Case examples:

o United 173 (Portland, 1978) – poor communication & workload prioritization.

o Avianca 52 (New York, 1990) – communication breakdown with ATC.

4. Medical and Toxicological Examinations

 Post-mortem toxicology: alcohol, drugs (prescribed/illicit), carbon monoxide, other

toxins.

 Medical history review: existing health conditions (cardiac, neurological, psychiatric).

 Fitness for duty: compliance with medical examinations and aviation medical
standards.

 Impact of incapacitation: sudden illness or impairment during flight.

 Confidentiality and ethical considerations in handling crew medical data.

5. Organizational Factors (Management, SOPs, Safety Culture)

 Role of airline/operator: training quality, supervision, rostering, maintenance

planning.

 SOPs (Standard Operating Procedures): clarity, enforcement, and adherence.

 Safety culture: reporting culture, blame culture vs just culture, organizational

learning.

 Latent conditions (Swiss Cheese Model): organizational weaknesses that combine

with active failures.

 Case examples:

o Colgan Air 3407 (2009) – inadequate training and fatigue.

o Korean Air (1990s) – CRM and cultural hierarchy issues.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Assess pilot training, performance, and experience in accident context
✅ Identify fatigue, stress, and workload impacts on human performance
✅ Evaluate CRM and communication issues contributing to accidents
✅ Interpret findings from medical and toxicological reports
✅ Understand how organizational culture and management decisions affect safety outcomes
 Chapter- 6

Accident Causation Models

1. SHELL Model (Software–Hardware–Environment–Liveware)

 Concept:
 o A human factors model used to analyze the interaction between the human
(Liveware) and other system components.

 Elements:

o S – Software: rules, regulations, SOPs, manuals, checklists.

o H – Hardware: aircraft design, cockpit layout, controls, instruments.

o E – Environment: weather, ATC, operational conditions, work environment.

o L – Liveware: human operator (pilot/ATC/engineer).

 Liveware–Liveware (L–L): teamwork, communication between crew members, ATC–

pilot relations.

 Application in investigations:

o Identifying mismatches at interfaces (e.g., poorly designed cockpit displays

leading to misinterpretation).

2. Reason’s Swiss Cheese Model of Accident Causation

 Concept:

o Accidents occur due to a combination of latent conditions and active failures.

 Layers of defense (the cheese slices):

o Organizational factors (policies, resources).

o Supervisory factors (oversight, training).

o Preconditions for unsafe acts (fatigue, stress, communication gaps).

o Unsafe acts (errors, violations).

 Holes in the cheese: weaknesses that may align to allow an accident to occur.

 Key takeaway: focus on organizational/systemic failures rather than just frontline

human error.

3. Threat & Error Management (TEM)

 Concept:

o A proactive model to understand and manage operational threats and errors

before they lead to accidents.

 Definitions:
 o Threats: external events beyond crew’s control (bad weather, ATC error,
technical failures).

o Errors: crew actions/inactions that deviate from expectations (incorrect

configuration, missed callouts).

o Undesired Aircraft States (UAS): unstable approach, runway excursion, loss of

separation.

 Management strategies:

o Anticipate → Recognize → Recover.

 Use in training:

o Integrated into Crew Resource Management (CRM) programs.

o Line Operations Safety Audits (LOSA) for data collection.

4. HFACS (Human Factors Analysis and Classification System)

 Concept:

o A taxonomy developed from the Swiss Cheese Model to systematically

categorize human errors.

 Levels:

1. Unsafe Acts: Errors (decision, skill-based, perceptual) & violations.

2. Preconditions for Unsafe Acts: Crew fatigue, poor communication, adverse

mental states.

3. Unsafe Supervision: Inadequate training, improper planning, supervisory

violations.

4. Organizational Influences: Safety culture, resource management, operational

processes.

 Benefits:

o Provides structured framework for identifying root causes.

o Used by military, civil aviation authorities, and airlines worldwide.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Apply the SHELL model to identify mismatches between people, equipment, and
environment
✅ Explain how Swiss Cheese Model illustrates latent failures and active errors
✅ Use TEM to understand the management of threats, errors, and undesired states
✅ Categorize human error using the HFACS framework for deeper root cause analysis

Chapter- 7

Data & Evidence Handling

1. Photography, Mapping, and 3D Site Documentation

 Photography Standards:

o Wide-angle overview → mid-range → close-up shots.

 o Use of scales, labels, and evidence tags in images.

o Night/low-light photography techniques.

 Mapping the Site:

o Establish wreckage grid using GPS or total station.

o Document impact marks, debris path, and distribution.

o Create site sketches for reference.

 3D Documentation:

o Use of drones, laser scanners, and photogrammetry.

o Produces accurate 3D crash site models for analysis and courtroom

presentation.

 Preservation of digital evidence (storage devices, phones, EFBs).

2. Witness Interview Techniques

 Types of witnesses: flight crew, ATC, ground staff, first responders, local residents,
passengers.

 Interview environment: neutral, quiet, non-threatening setting.

 Best practices:

o Use open-ended questions first, then specific ones.

o Avoid leading or suggestive questions.

o Cross-check testimony with physical evidence.

 Cognitive Interview Techniques (CIT): encourage detailed recall by reinstating

context.

 Recording: audio/video documentation, signed transcripts.

3. Use of Simulation and Re-creation of Events

 Flight simulators: replicate flight conditions, crew decisions, and aircraft

performance.

 Computer modeling: recreate trajectory, weather effects, collision dynamics.

 Animation tools: used to visually demonstrate accident sequence for investigators,

courts, and training.
  Benefits: test hypotheses, evaluate alternate scenarios, validate FDR/CVR data.

 Limitations: simulations are reconstructions, not exact replicas of events.

4. Laboratory Analysis (Materials, Fire, Explosions)

 Materials Analysis:

o Metallurgical tests for fatigue, corrosion, or overload failure.

o Fractography (microscope examination of fracture surfaces).

 Fire & Explosion Analysis:

o Burn residue analysis (accelerants, fuel sources).

o Fire pattern mapping to distinguish in-flight vs post-impact fire.

o Explosive residue testing (TNT, RDX traces).

 Component Testing:

o Engine teardown, avionics inspection, hydraulic/pneumatic system checks.

 Human factors laboratory tests: blood/tissue analysis for toxins, hypoxia evidence.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Apply professional standards in photographing and mapping accident sites
✅ Conduct structured witness interviews to gather reliable evidence
✅ Use simulation tools for accident re-creation and validation of findings
✅ Understand the role of laboratory analysis in confirming mechanical, chemical, or
explosive causes

Chapter 8
Safety & Prevention
1. Link Between Investigations and Safety Management System (SMS)

 Role of investigations in SMS:

o Provide essential data on hazards, errors, and systemic weaknesses.

 o Feed lessons learned into the four SMS pillars:

1. Safety Policy – evidence-based policies.

2. Safety Risk Management – hazards identified from past

accidents/incidents.

3. Safety Assurance – monitoring effectiveness of safety actions.

4. Safety Promotion – training and awareness using real accident

findings.

 From reactive → proactive → predictive safety using investigation data.

 Integration with ASRs (Accident/Incident Safety Reports) and databases (e.g.,

ECCAIRS, ADREP).

2. Developing Safety Recommendations

 Characteristics of strong recommendations:

o Specific, measurable, achievable, relevant, time-bound (SMART).

o Address root cause, not just symptoms.

o Practical for operators/regulators to implement.

 Types:

o Operational (crew training, SOP revisions).

o Technical (aircraft design changes, equipment upgrades).

o Regulatory (rule amendments, oversight strengthening).

o Organizational (safety culture improvements, resource allocation).

 Prioritization: based on risk severity and likelihood.

3. Accident Prevention Strategies

 Reactive strategies: learning from past accidents (classic investigations).

 Proactive strategies: identifying hazards through audits, inspections, voluntary

reporting.

 Predictive strategies: using big data, flight data monitoring (FDM/FOQA), AI-based
trend analysis.

 Examples of prevention initiatives:

 o Runway Safety Teams (ICAO).

o LOSA (Line Operations Safety Audit).

o CFIT/LOC-I prevention programs.

o Fatigue Risk Management Systems (FRMS).

4. Feedback Loop into Airline/ATC Training and Regulatory Improvements

 Airlines:

o Use investigation reports in crew recurrent training, CRM case studies, and
simulator sessions.

o Update SOPs and checklists based on real-world accident lessons.

 Air Traffic Control (ATC):

o Enhance phraseology, conflict alert training, and human factors awareness.

o Case-based workshops for controllers on ATC-related accidents.

 Regulators:

o Amend regulations (e.g., post-Tenerife disaster: standard phraseology).

o Strengthen surveillance and enforcement mechanisms.

 Manufacturers & Industry Bodies:

o Feed accident lessons into design improvements, certification standards, ICAO

SARPs.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Understand how accident investigation outcomes strengthen the SMS framework
✅ Formulate effective safety recommendations to prevent recurrence
✅ Apply accident prevention strategies (reactive, proactive, predictive)
✅ Implement a feedback loop into airline/ATC training and regulatory practices
 Chapter 9
Case Studies

1. Review of Major International Accidents

Tenerife Disaster (1977, KLM 747 & Pan Am 747)

 Cause(s): Miscommunication, non-standard phraseology, poor visibility, and human

factors.

 Lessons:

o Standardized ATC phraseology (e.g., “takeoff clearance”).

 o Emphasis on Crew Resource Management (CRM).

o Clearer cockpit authority gradient and decision-making protocols.

Air France Flight 447 (2009, Airbus A330)

 Cause(s): Pitot tube icing, unreliable airspeed indications, automation reliance, loss
of situational awareness, stall mismanagement.

 Lessons:

o Training on manual flying skills & high-altitude stall recovery.

o Improved pitot tube design standards.

o Greater emphasis on automation-human interface training.

Boeing 737 MAX (2018 Lion Air JT610 & 2019 Ethiopian ET302)

 Cause(s): MCAS software malfunction, inadequate pilot information, certification

oversight failures.

 Lessons:

o Strengthened regulatory oversight and certification processes.

o Enhanced pilot training on new aircraft systems.

o Transparency in manufacturer-regulator relationships.

2. Lessons Learned and Regulatory Changes

 ICAO & Regulators (FAA, EASA, DGCA, etc.):

o Adopted mandatory CRM training post-Tenerife.

o Introduced upset prevention & recovery training (UPRT) after AF447.

o Reformed aircraft certification and software oversight post-B737 MAX crisis.

 Airlines:

o Incorporated real accident scenarios into simulator training.

o Implemented stricter SOPs and communication standards.

 Industry Impact:

o Strengthened focus on safety culture.

o Integration of Flight Data Monitoring (FDM/FOQA).

o Global sharing of safety lessons through ICAO ADREP & ECCAIRS databases.
3. Application of Theory to Real-World Events

 Accident Causation Models:

o Tenerife: Swiss Cheese Model (multiple layers breached).

o AF447: TEM (threat & error mismanagement, loss of manual flying skills).

o B737 MAX: HFACS (organizational & regulatory failures, latent conditions).

 Investigation Principles Applied:

o Evidence collection (FDR, CVR, wreckage).

o Human factors analysis (stress, communication, training gaps).

o Safety recommendations leading to systemic improvements.

Learning Outcomes of this Module

By the end of this session, trainees will be able to:

✅ Analyze major accidents using investigation techniques.
✅ Apply accident causation models to real cases.
✅ Understand how investigation findings drive regulatory changes.
✅ Translate lessons learned into practical safety improvements for airlines, ATC, and
regulators.