Establishing an Accident Investigation Office

A credible investigation authority is defined less by its equipment than by its independence and its procedures. We help States stand one up from the ground, or restructure an existing office to meet international expectations.

Legal and institutional framework

Enabling legislation and regulations establishing the authority, its powers, and its independence from the regulator, operators, and any party whose interests could be affected by a finding.

Organizational design

Mandate, structure, reporting lines, staffing model, position descriptions, and funding approach.

Procedures and documentation

Investigation manual, standard operating procedures, notification and activation protocols, evidence custody and control, records management, and report review and publication workflow.

Coordination agreements

Memoranda of understanding with police and prosecutors, military, search and rescue, airport and ANSP operators, and the State’s regulator, so that roles at an accident site are settled before there is an accident site.

International interfaces

Procedures for notification, for participation as a State of Occurrence, Registry, Operator, Design, or Manufacture, and for hosting and appointing accredited representatives and advisers.

Capability and readiness

Go-team composition and call-out, equipment and personal protective gear, laboratory and recorder-readout arrangements, an occurrence database, and the initial and recurrent training pipeline that keeps investigators current.

Quality assurance

Internal review, competency management, and a means of tracking safety recommendations through to response and implementation.

IASA Audit Preparation

The FAA’s International Aviation Safety Assessment program evaluates whether a State’s civil aviation authority provides safety oversight consistent with ICAO standards — principally Annex 1 (Personnel Licensing), Annex 6 (Operation of Aircraft), and Annex 8 (Airworthiness of Aircraft). The rating a State holds directly affects its carriers’ access to the U.S. market, which makes preparation a matter of both safety and commerce.

We prepare authorities for assessment through:

• Gap assessment against ICAO’s critical elements of a State safety oversight system — primary legislation, operating regulations, State structure and functions, technical personnel qualification and training, technical guidance and tools, licensing and certification obligations, surveillance obligations, and resolution of safety concerns.
• Documentation and records readiness — regulations, inspector handbooks, checklists, certification and surveillance records, and the evidence trail that shows oversight actually happened rather than merely being written down.
• Inspector qualification and training review — credentials, currency, delegation authority, and training records.
• Mock assessment — a full-rehearsal review conducted the way the assessment team will conduct it, including interviews with the staff who will be interviewed.
• Finding closure — resolving open items from previous ICAO or FAA activity before the team arrives.
• Engagement strategy — preparing authority leadership and technical staff for productive, well-documented dialogue with FAA teams.

Technical Assistance

Some gaps close with a plan; others close only with people. We embed subject-matter experts alongside authority staff to do the work and to leave the capability behind.

• Drafting and revising civil aviation regulations aligned to ICAO Standards and Recommended Practices.
• Developing inspector handbooks, job aids, checklists, and surveillance planning tools.
• Building certification, licensing, airworthiness, and continuing-oversight procedures.
• Establishing surveillance programs, including planning, execution, and finding management.
• Structured knowledge transfer and mentoring, so that the authority’s own staff can sustain the function after we leave.

Corrective Action Plans

A corrective action plan is only as good as its evidence. Plans fail assessment for predictable reasons: they address symptoms rather than causes, they lack owners and dates, they are not resourced, or the State cannot demonstrate that the action was actually completed and had effect.

We develop and execute corrective action plans that hold up:

• Root cause analysis of each finding, so the action addresses the cause rather than the observation.
• Specific, measurable, resourced actions with named owners, milestones, and realistic completion dates.
• Evidence packages assembled as the work is done, not reconstructed afterward.
• Tracking to closure with periodic status reporting and escalation for at-risk items.
• Verification that the action was implemented and is working as intended.
• Sustainability planning so that closed findings stay closed through the next assessment cycle.

Aircraft Accident Investigation Support

When an accident or serious incident occurs, capability is needed immediately and often exceeds what an authority holds in-house. Aertron provides surge support to State investigation authorities, operators, manufacturers, and insurers.

• Go-team augmentation and on-scene investigator support.
• Site and wreckage documentation, examination, and evidence management.
• Flight data and cockpit voice recorder readout coordination and analysis.
• Systems, powerplant, structures, and maintenance records investigation.
• Operations, air traffic services, and meteorological factors.
• Human factors and human performance analysis.
• Survival factors and, where applicable, family assistance coordination.
• Analysis, findings, and drafting of the final report and safety recommendations.
• Support to accredited representatives and technical advisers participating in another State’s investigation.

The Aircraft Accident Investigation Process

A typical investigation moves through these phases:

1. Notification and activationThe occurrence is reported, the authority is notified, other States and ICAO are notified as required, and the go-team is activated.
2. Site security and preservation of evidenceThe site is secured and perishable evidence protected, in coordination with police, rescue, and airport authorities.
3. Team formation and coordinationAn investigator-in-charge is appointed, working groups are formed, and accredited representatives and their advisers are received.
4. On-scene fact gatheringWreckage documentation and mapping, component recovery, witness interviews, and collection of operational, maintenance, ATC, and weather records.
5. Laboratory and technical examinationRecorder readout, component teardown, materials and metallurgical analysis, and performance and simulation work.
6. AnalysisThe facts are tested against candidate explanations; hypotheses are examined and eliminated on the evidence.
7. Findings, causes, and contributing factorsConclusions are drawn and stated in terms of what happened and why.
8. Draft report and consultationThe draft is circulated to States and parties entitled to comment, and comments are considered and addressed.
9. Final report and safety recommendationsThe report is published and recommendations are issued to the organizations able to act on them.
10. Follow-upRecommendation responses are tracked, implementation is monitored, and safety data feeds back into oversight and safety management systems.

Individual investigations vary by State law, occurrence type, and the participation of other States. The above describes the general Annex 13 framework.

Technical Training

Investigative capability is a competency, not a document. We build training programs that create investigators and keep them current — delivered in person, online, or through AR and VR simulation that puts trainees at a site without one.

Course areas include:

• Fundamentals of aircraft accident investigation and the Annex 13 framework.
• On-scene safety, hazard awareness, and evidence preservation.
• Wreckage documentation, mapping, and examination technique.
• Witness interviewing.
• Flight recorder fundamentals and data interpretation.
• Human factors in investigation.
• Analysis, report writing, and drafting effective safety recommendations.
• The interface between investigation findings, State safety programs, and operator safety management systems.
• Tabletop and field exercises with realistic scenarios.

Programs are tailored to the authority’s mandate, fleet, and existing staff experience, and can be sequenced as an initial qualification pathway with recurrent training built in.