The course's last lesson belongs to Annex 13 and its two European companions. Annex 13 defines what counts as an accident, a serious incident and an incident, and prescribes an investigation whose sole purpose is prevention — never blame. Regulation (EU) 996/2010 turns that machinery into binding European law with an independent investigation authority in every Member State, and Regulation (EU) 376/2014 builds the reporting system that feeds tomorrow's prevention with today's occurrences.
The definitions
First the machine itself: an aircraft is 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: the definition that admits balloons and helicopters while excluding hovercraft. Then the occurrence classes. An accident is an occurrence associated with the operation of an aircraft, taking place (for a manned aircraft) between the time any person boards the aircraft with the intention of flight until all such persons have disembarked, in which:
(a) Injury — a person is fatally or seriously injured from being in the aircraft, direct contact with any part of it (including detached parts), or direct exposure to jet blast (excluding natural causes, self-inflicted or inflicted injuries, and stowaways outside the normal passenger and crew areas).
(b) Damage — the aircraft sustains damage or structural failure adversely affecting its structural strength, performance or flight characteristics and normally requiring major repair or replacement, with a carve-out for engine failure limited to a single engine, propellers, wing tips, antennas, tyres, brakes, fairings, small dents and the like.
(c) Missing — the aircraft is missing or completely inaccessible; missing meaning the official search has been terminated and the wreckage not located.
For statistical uniformity, an injury resulting in death within THIRTY DAYS of the accident is classified by ICAO as a fatal injury.
Serious incident — an incident involving circumstances indicating that there was a HIGH PROBABILITY of an accident, in the same boarding-to-disembarkation window. The Annex's own note: the difference between an accident and a serious incident lies ONLY IN THE RESULT.
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 gathering and analysing information, drawing conclusions (including the determination of causes and/or contributing factors) and, when appropriate, making safety recommendations.
Flight recorder — any type of recorder installed in the aircraft for the purpose of COMPLEMENTING accident/incident investigation.
Maximum mass — maximum certificated take-off mass, plain and short.
Operator — a person, organization or enterprise engaged in or offering to engage in an aircraft operation.
The five States — State of Occurrence (where it happened), State of Registry (whose register carries the aircraft), State of the Operator (where the operator's principal place of business, or failing that permanent residence, is), State of Design and State of Manufacture.
Serious injury — among its tests: hospitalisation for more than 48 hours commencing within seven days of the injury; fracture of any bone except simple fractures of fingers, toes or nose; severe haemorrhage or nerve, muscle or tendon damage; injury to any internal organ; and, completing the list, serious burns and verified exposure to infectious substances or injurious radiation.
Accident or serious incident? Reading an occurrence
Classification questions turn on two hinges. First, the RESULT: if the occurrence produced the accident-level outcome (death or serious injury from the aircraft, damage demanding major repair, a missing aircraft) it is an accident; if the outcome stopped short but few or no safety defences remained between the incident and the accident it nearly became, it is a serious incident. Second, the LIST: Annex 13's Attachment C gives the classic serious-incident examples (a list of examples, not an exhaustive catalogue):
Near collisions requiring avoidance.
Controlled flight into terrain only marginally avoided.
Aborted take-offs on, take-offs from, and landings on a closed or engaged runway or a taxiway.
A wheels-up landing, or the dragging of a wing tip, an engine pod or another part of the aircraft during landing, not classified as an accident.
Gross failures to achieve predicted take-off performance.
Fires or smoke even when extinguished.
Events requiring the emergency use of oxygen by the flight crew.
Structural failures or uncontained engine failures below the accident threshold.
Multiple malfunctions seriously affecting the operation.
Flight crew incapacitation in flight (a single pilot, or a multi-pilot operation where flight safety was compromised).
Fuel states requiring an emergency declaration.
The investigation: one objective, one owner
Annex 13's most quoted sentence: 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. The owner is the State of Occurrence: it shall institute an investigation into an accident, and into a serious incident when the aircraft's maximum mass is over 2,250 kg (a recommendation covers serious incidents generally), though it may delegate the whole or any part of the investigation to another State or a regional accident and incident investigation organization by mutual arrangement and consent. When the occurrence is outside the territory of any State, the State of Registry investigates. The investigation is independent, with unrestricted authority over its conduct, and separate from any judicial or administrative proceedings to apportion blame or liability; the States of Registry, the Operator, Design and Manufacture are each entitled to appoint an accredited representative, with advisers to assist.
The paper trail ends in prevention. The Final Report is made publicly available as soon as possible and, if possible, within TWELVE MONTHS — failing which the State conducting the investigation publishes an interim statement on each anniversary of the occurrence, detailing progress and any safety issues raised. Safety recommendations go to whoever can act on them, never creating a presumption of blame, and the ADREP system feeds the investigation's data to ICAO.
Europe: Regulation (EU) 996/2010
Regulation (EU) No 996/2010 is Annex 13 with the force of European law: its aim is efficient, expedient, high-quality civil aviation safety investigations whose sole objective is the prevention of future accidents and incidents, without apportioning blame or liability. It takes its classifications straight from the Annex: an occurrence is an accident, incident or serious incident per the ICAO Annex 13 definitions, so the two instruments can never disagree about what happened. Each Member State maintains a permanent national civil aviation safety investigation authority, functionally independent of the aviation authorities responsible for airworthiness, certification, flight operation, maintenance, licensing, air traffic control and aerodrome operation (and of any party whose interests could conflict with its task), neither seeking nor taking instructions from anybody, with unrestricted authority over the conduct of its investigations. The Regulation adds what the Annex leaves to States: rules on the timely availability of information about persons and dangerous goods on board, and assistance plans for victims and their relatives.
Occurrence reporting: Regulation (EU) 376/2014
Regulation (EU) No 376/2014 covers the layer below the accidents, and the two regulations divide the field cleanly:
996/2010 — owns the INVESTIGATION of accidents and serious incidents.
376/2014 — owns the REPORTING, analysis and follow-up of the wider ocean of occurrences.
They are complementary instruments with the same sole objective, the accidents and serious incidents investigated under 996/2010 flowing into the same European databases as 376/2014's occurrence reports. The subject of 376/2014 is the reporting, collection, storage, protection, exchange, dissemination and analysis of occurrences in civil aviation, with the now-familiar refrain that the sole objective of occurrence reporting is the prevention of accidents and incidents, not to attribute blame or liability. MANDATORY reporting covers occurrences which may represent a significant risk to aviation safety in four categories (the operation of the aircraft; technical conditions, maintenance and repair; air navigation services and facilities; and aerodromes and ground services), reported by the listed persons, the pilot-in-command first among them, within 72 HOURS of becoming aware of the occurrence, through the organisation's reporting system (organisations pass the reports to their competent authority, likewise within 72 hours).
VOLUNTARY reporting catches the rest: occurrences not captured by the mandatory system, and any other safety-related information the reporter perceives as an actual or potential hazard, open to persons not on the mandatory list at all. Everything flows the same way: into the organisation's database, onward to the national database, and into the EUROPEAN CENTRAL REPOSITORY, stored ECCAIRS-compatible and classified with the ICAO ADREP taxonomy so the whole continent's data can be analysed together. And the system runs on JUST CULTURE: employees and contracted personnel shall not be subject to any prejudice on the basis of what they report, except in cases of wilful misconduct, or manifest, severe and serious disregard of an obvious risk — because a reporting system that punishes reporters soon has nothing to read.