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Definition

Investigation - A process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety recommendations. [ICAO Annex 13]

  • Regulatory Requirements

According to the provisions laid down in International Civil Aviation Organisation (ICAO) Annex 13 - Aircraft Accident and Incident Investigation, States shall investigate or delegate the investigation of accidents which have occurred in their territory. Serious incidents should be investigated by States or by other organisations, such as dedicated accident/incident investigation bodies or aviation service provider organisations.

According to Regulation (EU) No 996/2010 on the investigation and prevention of accidents and incidents in civil aviation “every accident or serious incident involving aircraft other than those specified in Annex II to Regulation (EC) No 216/2008 shall be the subject of a safety investigation”. The investigation of incidents, other than serious incidents, is also encouraged as this will enable drawing of safety lessons.

The ICAO divisional meeting on Accident Investigation and Prevention held in Montreal in October 2008 proposed a change in Annex 13 to foster a more proactive approach towards the prevention of accidents. It is proposed that States be mandated to investigate serious incidents by upgrading the current ‘recommended practice’ to a ‘standard’ to be applicable to serious incidents involving aircraft with a maximum mass limit of over 2 250 kg.

EUROCONTROL ESARR 2 mandates the investigation of safety occurrences in ATM which occur in the States in which in is applicable.



  • Objective

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability. (ICAO Annex 13)

Occurrence investigations are carried out in order to:



  • Better understand the events leading up to the occurrence;

  • Identify hazards and conduct risk assessments;

  • Make recommendations to reduce or eliminate unacceptable risks; and

  • Communicate the safety messages to the appropriate stakeholders.

  • Scope

According to the EU Council Directive 94/56/EC “The extent of investigations and the procedure to be followed in carrying out such investigations shall be determined by the investigating body, taking into account the principles and the objective of this Directive and depending on the lessons it expects to draw from the accident or serious incident for the improvement of safety”.

The extent of an investigation should depend on the actual or potential consequence or hazard. Incidents that indicate high risk potential should be investigated in greater depth than those with lower risk potential.

Although the investigation should primarily focus on the factors that are most likely to have influenced action, the dividing line between relevance and irrelevance is often blurred. Data that initially may seem to be unrelated could later prove to be relevant once the relationship between the different elements of an occurrence are better understood.

Investigation and analysis of safety occurrences is an essential ingredient of the overall risk management process in aviation. Effective safety management systems largely depend on the quality of the investigation of reported accidents, incidents and safety issues.


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