Aircraft Accident and Incident Investigation — Page 492, Lesson 660

Let's start with the core purpose of all of this. The objective of an accident or incident investigation is prevention — plain and simple. We investigate so we can stop future accidents and incidents from happening. And I want you to hold onto this next part tightly, because it shapes everything a professional investigator does: it is not the purpose of this activity to apportion blame or liability. That's a legal matter, not an investigative one. The investigator's job is to find out what happened and why, so the industry can learn and improve. Now, who actually starts the investigation? That depends on where the event happened. If an accident or serious incident occurs in the territory of a contracting state — that is, a state that is a party to the Chicago Convention — then the State of Occurrence is the one that must instigate the investigation. That's the state on whose soil it happened. But what if it happened in a non-contracting state? Then the State of Registry — the state in which the aircraft is registered — should endeavour to instigate the investigation. Notice the word "endeavour" — it's an effort, a best attempt, not an absolute duty. Now here's a tricky case. What if the accident or incident happened outside the territory of any state at all — say, over the high seas — or the location simply cannot be determined? In that situation, the State of Registry is the one that must instigate the investigation. That's a firm obligation, not just an endeavour. And there's one more scenario. If the State of Occurrence declines to investigate the incident, then the State of Registry — or alternatively the State of the Operator, the state where the airline or operator is based — may step in and investigate. So you can see the hierarchy: State of Occurrence first, then the State of Registry, with the State of the Operator as a fallback. Next, participation. Who gets a seat at the table? The State of Registry, the State of the Operator, the State of Design — that's the state where the aircraft type was designed — and the State of Manufacture, where it was actually built. All four are entitled to be represented at any investigation. But it doesn't stop there. Any state that, when requested, provides information, facilities, or experts to the state conducting the investigation is also entitled to be represented. So cooperation earns a voice. And then there's a special category: states whose citizens have suffered fatalities or serious injuries. If such a state makes a request, it will be permitted to appoint an expert. And that expert has specific rights. Let me walk you through them. They may visit the scene of the accident. They may have access to the relevant factual information. They may participate in the identification of the victims. They may assist in questioning survivors who are citizens of that state. And they may receive a copy of the final report. Those five rights are the full package for that expert. Now, the final report itself. Once the investigation is complete, the state conducting the investigation must send the final report with the minimum delay — meaning as quickly as possible — to a specific list of recipients. That list includes: the state that instigated the investigation; the State of Registry; the State of the Operator; the State of Design; the State of Manufacture; any state whose citizens have suffered fatalities or injuries; and any state that provided relevant information, significant facilities, or experts. So the report flows back to everyone who had a legitimate stake in the process. Finally, ICAO. The International Civil Aviation Organization must be notified of any accident or serious incident involving an aircraft with a maximum mass of over 2250 kilograms. That's the notification threshold. But there's a higher bar for the final report itself. A final report must be sent to ICAO for an aircraft with a maximum mass of more than 5700 kilograms. So remember those two numbers — 2250 kg triggers notification, 5700 kg triggers the full final report to ICAO. Let me tie it all together. The purpose is prevention, never blame. The State of Occurrence leads, with the State of Registry as the fallback, and the State of the Operator as an alternative. Four states are entitled to participate, plus any state that contributed resources, plus states whose citizens were harmed — with a defined set of expert rights. And the final report goes out to a defined list, with ICAO notified at 2250 kg and receiving the full report above 5700 kg. That's the complete framework.