civil aircraft accident and incident investigation...

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CIVIL AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION UNIT

Decision of the Head of the Civil Aircraft Accident and Incident Investigation Unit

Number (1) for the year 2018

The Head of the Civil Aircraft Accident and Incident Investigation Unit in consideration of Law No. 15 of 2002 on civil aviation as amended by Law No.15 of 2018 and;

Amiri Decision No. 67 of 2018 on the establishment of the Civil Aircraft Accident and Incident Investigation Unit

Has decided as follows;

Article (1)

The Regulations (QAAI-R 001 initial issue 2018) annexed to this Decision shall be enforced with regard to the Formal Requirements and Standards, relating to: Aircraft Accident and Incident Investigation.

Article (2)

The Regulations (QAAI-R 001 initial issue 2018) annexed to this Decision shall be applicable from November 7th, 2018.

Article (3)

All competent authorities, each within their own jurisdiction, shall implement this Decision, which shall take effect from November 7th, 2018.

HERMANUS J. KLUMPER HEAD OF UNIT Issued on: November 7th, 2018

QAAI-R 001 Initial Issue

Qatar Air Accident Investigation Regulation

CIVIL AIRCRAFT ACCIDENTS AND INCIDENTS INVESTIGATION UNIT


Version: 001/2018

Initial Issue



FOREWORD

The State of Qatar is required under Article 26 of the Convention on International Civil Aviation of 1944, to establish an independent authority for the purpose of investigation of air accidents and serious incidents in the state of Qatar and air accidents and serious incidents involving Qatar registered aircraft wherever they occur.

Pursuant to the General Provisions of Amiri Decision No. 67 of 2018 on establishing the Civil Aircraft Accidents and Incidents Investigation Unit as the Accident Investigation Authority (hereinafter referred to as the Qatar Air Accident Investigation) and Law No. 15 of 2002 as amended by Law 15 of 2018 on the Civil Aviation in the State of Qatar (hereinafter referred to as ‘the Civil Aviation Law’).

This Regulation is governing Air Accident Investigations conducted by the Qatar Air Accident Investigation Unit (QAAI). The promulgation of this Regulation is based on the authority granted by Law 15 article 61.9 and the Amiri Decision 67 article 3.2 and is issued under the authority of the Head of the Unit.

The QAAI as the accident investigation authority having exclusive jurisdiction over the investigation of Air Accidents and Serious Incidents, and being empowered to prescribe and promulgate rules, regulations and orders for the discharge of its functions.

The QAAI shall in the public interest, maintain transparency as regards its obligations, roles and responsibilities.

The information contained in this publication is subject to constant review in the light of the changing regulations and requirements. And shall give effect to the standards and recommended practices of Annex 13 to the Convention on International Civil Aviation of 1944.

This Regulation is in accordance with ICAO Annex 13 - Aircraft Accident and Incident Investigation, its related documents and ICAO Annex 19 - Safety Management.

Regulations issued by the Qatar Air Accident Investigation shall be referred to as Qatar Air Accident Investigation Regulation.



Table of Contents

CONTENT RULES ....................................................................................................................................... 6

Rules of Constructions: .............................................................................................................................. 6 AMENDMENT PROCEDURE ...................................................................................................................... 7

CHAPTER 1 - DEFINITIONS ..................................................................................................................... 8 1.1 Definitions .................................................................................................................................. 8 1.2 Abbreviations ........................................................................................................................... 13 1.3 Serious Incidents ..................................................................................................................... 14 Attachment A Guidance for the determination of aircraft damage ........................................................... 18 CHAPTER 2 - APPLICABILITY ............................................................................................................... 19 2.1 Applicability .............................................................................................................................. 19 2.2 Failure to Comply ..................................................................................................................... 19 CHAPTER 3 - AUTHORITY AND OBLIGATIONS OF THE QAAI ........................................................... 20 3.1 Objective of the QAAI .............................................................................................................. 20 3.2 Authority for Investigations ...................................................................................................... 20 3.3 Intermittent Services ................................................................................................................ 20 3.4 Annual Report .......................................................................................................................... 21 3.5 Equipment ................................................................................................................................ 21 3.6 Investigator Safety Measures .................................................................................................. 21 3.7 Funding .................................................................................................................................... 21 3.8 Investigators Qualifications. ..................................................................................................... 21 3.9 Notification ............................................................................................................................... 21 3.10 Conduct of Investigations ........................................................................................................ 22 3.11 Participation in Investigations conducted by Other States ....................................................... 22 3.12 Reporting ................................................................................................................................. 22 3.13 Safety Recommendations ....................................................................................................... 22 3.14 ICAO Accident/Incident Reporting ........................................................................................... 23 3.15 Incident Reporting Systems and Occurrence Database ......................................................... 23 CHAPTER 4 - NOTIFICATION ................................................................................................................ 24 4.1 Notification Requirements ........................................................................................................ 24 4.2 Reportable Aviation Occurrences ............................................................................................ 24 4.3 Responsibility of Notification .................................................................................................... 24 4.4 Notification to the QAAI ........................................................................................................... 24 4.5 Information to be Included in a Notification ............................................................................. 24 4.6 Information to be provided to the QAAI following the Notification ........................................... 25 4.7 Notification of an Aviation Occurrence involving Civil and Military Aircraft .............................. 25 4.8 QAAI Notification to States and ICAO ..................................................................................... 25 Accidents or Serious Incidents in the State of Qatar to Aircraft of another Contracting State ................. 25 Attachment A Format and Content used for Notification to other States ................................................. 27 CHAPTER 5 - INVESTIGATION .............................................................................................................. 28 5.1 Responsibility of the QAAI ....................................................................................................... 28 5.1.1 Investigation on Qatar Registered and Operated Aircraft ........................................................ 28 5.2 Purpose of an Investigation ..................................................................................................... 28 5.3 QAAI Authority to Order an Investigation ................................................................................ 29 5.3.1 Role and Authority of the Investigator-in-Charge .................................................................... 29 5.3.2 Role of the Investigative Groups.............................................................................................. 29 5.4 Civil and Military Aviation Occurrences ................................................................................... 29 5.5 Criminal Act.............................................................................................................................. 30 5.6 Discontinuation of Investigation ............................................................................................... 30 5.7 Participation of the QAAI in Foreign Investigations ................................................................. 30 5.7.1 Participation of QAAI ............................................................................................................... 30 5.8 Authority of a QAAI Investigator .............................................................................................. 30 5.9 Preservation of Evidence ......................................................................................................... 32 5.9.1 Protection and Custody of Evidence ....................................................................................... 32

5.9.1.1 Protection of Evidence ............................................................................................................. 32 5.9.1.2 Requests from State of Registry, State of the Operator, State of Design or State of Manufacture ........................................................................................................................................ 33 5.9.2 Custody of the Aviation Occurrence Site ................................................................................. 33



5.10 Responsibilities of the Airport Authority ................................................................................... 33 5.11 Responsibilities of Rescue and Fire Fighting Services (RFFS) ............................................... 33 5.12 Responsibilities of Air Traffic Services (ATS) .......................................................................... 33 5.13 Responsibilities of Weather Observation Station .................................................................... 34 5.14 Responsibilities of the Operator............................................................................................... 34 5.15 Access to Site, Aircraft Wreckage, Records and Examinations .............................................. 35 5.16 Participation in QAAI Investigations ........................................................................................ 35 5.16.1 The Right to Participation as an Expert ................................................................................... 35 5.16.2 Participants in the Investigation ............................................................................................... 35 5.16.3 Accredited Representatives Entitlements ................................................................................ 35 5.16.3.1 Participation by Other States. ............................................................................................. 36 5.16.3.2 Participation in the Investigation ......................................................................................... 36 5.16.4 Observers ................................................................................................................................ 37 5.16.5 Obligations of Accredited Representatives and their Advisers ................................................ 37 5.16.6 Presence at Tests .................................................................................................................... 37 5.17 Non-disclosure of Records ...................................................................................................... 37 5.18 Right of Representation ........................................................................................................... 37 5.19 Autopsies and Toxicological Examinations ............................................................................. 38 5.20 Medical Examinations .............................................................................................................. 38 5.21 Flight Recorder Read-Out and Analysis .................................................................................. 38 5.21.1 Authority of the QAAI ............................................................................................................... 38 5.21.2 Initial response ......................................................................................................................... 38 5.21.3 Choice of Facility ..................................................................................................................... 38 5.21.4 Recommended Procedures ..................................................................................................... 39 5.22 Release from Custody ............................................................................................................. 39 5.23 Transportation and Communication ........................................................................................ 40 5.24 Investigative Equipment Requirements ................................................................................... 40 5.24.1 Policy ............................................................................................................................................ 40 5.25 Serious Incident Investigation .................................................................................................. 40 5.26 Facilities, Equipment and Additional Manpower ...................................................................... 41 5.26.1 Water Recovery Plan ............................................................................................................... 41 Attachment A Rights and obligations of the State of the Operator in respect of accidents and incidents

involving Leased, Chartered or Interchanged aircraft .............................................................................. 42 Participation by the State of Manufacture (or Design) and the State of the Operator ............................. 42 CHAPTER 6 - REPORTING .................................................................................................................... 43 6.1 Release of Information/Consent .............................................................................................. 43 6.2 Release of the Preliminary Report ........................................................................................... 43 6.3 Accident/ Incident Data Report ................................................................................................ 44 6.3.1 ICAO Obligation ....................................................................................................................... 44 6.4 Stand-Alone Recommendation ................................................................................................ 44 6.5 Inquiries ................................................................................................................................... 44 6.6 The QAAI Aviation Occurrence Report .................................................................................... 44 6.7 Release of the Final Report ..................................................................................................... 45 6.8 Re-opening of case/investigation ............................................................................................ 45 6.9 Occurrences Investigated by other entities ............................................................................. 46 ATTACHMENT A. -FORMAT of the Final Report .................................................................................... 47 1. FACTUAL INFORMATION ....................................................................................................... 47 2. ANALYSIS ............................................................................................................................... 49 3. CONCLUSIONS ...................................................................................................................... 50 4. SAFETY RECOMMENDATIONS ............................................................................................ 50 APPENDICES .......................................................................................................................................... 50 CHAPTER 7 - DATA REPORTING .......................................................................................................... 51 7.1 Release of the ICAO Data Report ........................................................................................... 51 7.2 Accident and Incident Database .............................................................................................. 51 7.3 Data Sharing ............................................................................................................................ 51 CHAPTER 8 - PREVENTION ................................................................................................................... 52 8.1 Safety Reports ......................................................................................................................... 52 8.2 Safety Recommendations ........................................................................................................ 52 8.2.1 Policies on Safety Recommendations ..................................................................................... 52 8.3 Responding/ Follow-up to Safety Recommendations.............................................................. 53 8.4 Safety Recommendations from Other States .......................................................................... 53 8.5 Participation ............................................................................................................................. 53 8.6 State Safety Program (SSP) .................................................................................................... 53



CHAPTER 9 – POST ACCIDENT ............................................................................................................ 54 9 Post Accident and Incident Communications .......................................................................... 54 9.1 Good Rapport with the Media .................................................................................................. 54 9.2 Release of information .............................................................................................................. 54

CHAPTER 10 – ASSISTANCE TO SURVIVORS AND FAMILIES ......................................................... 55



November 2018 Page 6 of 55

CONTENT RULES

Rules of Constructions:

(1) To avoid any misunderstanding within this Regulation, certain words are to be interpreted as having specific meanings unless the context requires otherwise:

(a) Words importing the singular include the plural;

(b) Words importing the plural include the singular; and

(c) Words importing the masculine gender include the feminine.

(2) In this Regulation, the following protocol is used:

(a) The words "shall" and "must" indicate that compliance is compulsory;

(b) The word "should" indicates a recommendation. It does not mean that compliance is optional but rather that, where insurmountable difficulties exist, the QAAI may accept an alternative means of compliance, provided that an acceptable safety assurance shows that the safety requirements will not be reduced below that intended by the requirement;

(c) The word " can " or "may" is used in a permissive sense to state authority or permission to do the act prescribed, and the words "no person may * * *" or "a person may not * * *" mean that no person is required, authorized, or permitted to do the act prescribed;

(d) The word "will" is used to express the future; and

(e) The word "includes" means "includes but not limited to".




AMENDMENT PROCEDURE

The QAAI Regulations will be periodically reviewed to reflect the latest updates to ICAO Annexes 13 and 19, as well as to ICAO Documents 9962 and 9756. It may also be amended to reflect the latest aviation safety provisions issued by other regional and international aviation entities. A complete revised edition incorporating all amendments will be published every three (3) years from the original effective date of this Regulation. The amendment procedure shall be as follows:

(1) When an amendment to any relevant ICAO Annex and Document or any other safety provisions

issued by relevant Safety Organizations that can affect the provisions of this Regulation is received, the QAAI will assess the impact of that information and if required develop a “Notice of Proposed Amendment” (NPA) for this Regulation;

(2) The NPA will be distributed and made available to concerned parties which will be invited to provide comments within a timeframe which is considered suitable.

(3) Based on the received comments QAAI will prepare and distribute the amendment to this

regulation;

(4) The Amendment effective date will take into account the time required for distribution to and implementation by all concerned parties;

(5) All concerned parties will be provided access to a copy of the new amendment and will be requested to update their copy of the QAAI Regulations accordingly;

(6) It is the responsibility of all concerned parties to use the latest copy of the QAAI Regulation as published on the website; and

(7) Differences between the QAAI Regulation and applicable ICAO Annexes will be published through ICAO and the Qatar Aeronautical Information Publication Q-AIP as per applicable procedures.




CHAPTER 1 - DEFINITIONS

1.1 Definitions

When the following terms are used in this Regulation, they shall have the following meaning:

Accident

An accident is an aviation occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time it comes to rest at the end of the flight and the primary propulsion system is shut down, in which:

(1) A person is fatally or seriously injured as a result of:

(a) being in the aircraft; or

(b) being in direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or direct exposure to jet blast, except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or

(2) The aircraft sustains substantial damage or structural failure which

(a) adversely affects the structural strength, performance or flight characteristics of the aircraft, and

(b) would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to a single engine(including) its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin ( e.g. small dents or puncture holes), or for minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike( including holes in the radome);or

(3) The aircraft is missing or is completely inaccessible; or

(4) A forced landing off an airport, irrespective of injuries or damage.

Note 1: An aircraft is considered missing when the official search has been terminated and the wreckage has not been located.

Note 2: In case of an investigation of an unmanned aircraft system, only aircraft with a design and/or operational approval are to be considered

Note 3: Please refer to Guidance for the determination of aircraft damage in Attachment A of this Chapter

Accident Investigators

Designated individuals responsible for conducting investigations into accidents and serious incidents or assist in making general enquiries with investigations that the Accident Investigation Unit has chosen to inquire into.




Accredited Representative (ACCREP) A person designated by a State, on the basis of his/her qualifications, for the purpose of participating in an investigation conducted by another State. Where the State has established an accident investigation authority, the designated Accredited Representative would normally be from that authority. Adviser

A person appointed by a State, on the basis of his/her qualifications, for the purpose of assisting its Accredited Representative in an investigation.

Aircraft

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.

Aviation Occurrence

(1) Any accident or incident associated with the operation of an aircraft; or (2) Any situation or condition that could, if left unattended, could induce an accident or incident.

Unit

Qatar Air Accident Investigation (QAAI)- The accident investigation authority designated by the State as responsible for air accident and incident investigations within the context of Annex 13.

Causes

Actions, omissions, events, conditions, findings, or a combination thereof, which led to the aviation occurrence. The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

Civil Aircraft

An aircraft registered on a civil registry without regard to its owner or operator.

Collision

An impact between two aircraft or an impact between an aircraft and another object.

Communication Record

The whole or any part of any record, recording, copy, transcript or substantial summary of any type of communications that take place between any of the following persons: air traffic controllers, aircraft crew members, airport vehicle operators, and persons who relay messages respecting air traffic control or related matters.

Contributing Factors

Actions, omissions, events, conditions, or a combination thereof, which if eliminated, avoided or absent, would have reduced the probability of accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The identification of contributing factors does not imply the assignment of fault or the determination of administrative, civil, or criminal liability.




Fatal Injury

Any injury that results in death within 30 days of the aviation occurrence.

Flight Recorder

Any type of recording device installed in an aircraft which could complement an investigation into an aviation occurrence.

Incident

An occurrence, other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations.

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/findings/contributing factors, and when appropriate, the making of safety recommendations.

Investigator-In-Charge (IIC)

A person designated, on the basis of his or her qualifications, with the responsibility for the organisation, conduct and control of an investigation.

Loss of separation

A situation where the distance separating two or more aircraft is less than the minimum established in the Air Traffic Services Procedures.

Mandatory Reporting

All reportable aviation occurrences, all accidents and incidents that shall be reported according to the applicable regulations.

Maximum Mass

Maximum certificated take-off mass.

Notification

Any form of reporting an aviation occurrence.

Observer

A person who attends an QAAI investigation for training or other valid purposes other than participation.

Operator

A person, organization or enterprise authorizing, engaging or offering to engage in an aircraft operation.




Participant

Subject to any conditions that the Head of the QAAI may impose, a person may attend as a Participant at an investigation of an aviation occurrence conducted by the QAAI, if the person:

(1) is an Accredited Representative or an Adviser to an Accredited Representative, pursuant to an

international agreement or convention relating to aviation to which the State of Qatar is a party; or

(2) is invited by the QAAI to attend as a Participant because, in the opinion of the QAAI, the person has a direct interest in the subject-matter of the investigation and/or will contribute to achieving the QAAI’s objective

Preliminary Report

The communication used for prompt dissemination of factual data obtained during the early stages of the investigation.

Reportable Aviation Occurrences

All aircraft accidents and incidents, as defined in this Regulation, shall be reported to the QAAI.

Risk of Collision

An incident associated with the operation of an aircraft in which a possibility of a collision occurs as a result of a separation of less than 500 feet to another aircraft or where a report is received from a pilot or other flight crew member stating that a collision hazard existed between two or more aircraft.

Safety Recommendation

A proposal by an investigation authority based on information derived from an investigation made with the intention of preventing aviation occurrences and which in no case has the purpose of creating a presumption of blame or liability for an aviation occurrence. In addition to safety recommendations arising from aviation occurrence investigations, safety recommendations may result from various sources, including safety studies.

Serious Incident

An incident involving circumstances indicating that there was a high probability of an accident and associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down.

Note. The differences between an accident and a serious incident lie only in the result

Serious Injury

An injury sustained by a person in an accident and which:

(1) Requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or

(2) Results in a fracture of any bone (except simple fractures of fingers, toes, or nose); or




(3) Involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage; or

(4) Involves injury to any internal organ; or

(5) Involves second or third degree burns or any burns affecting more than 5 per cent of the body surface; or

(6) Involves verified exposure to infectious substances or injurious radiation. State of Design

The State having jurisdiction over the organization responsible for the type design.

State of Manufacture

The State having jurisdiction over the organization responsible for the final assembly of the aircraft, engine or propeller.

State of Occurrence

The State in the territory of which an accident or incident occurs.

State of the Operator

The State in which the operator’s principle place of business is located or if there is no such place of business, the operator’s permanent residence.

State of Registry

The State in whose register the aircraft is entered.

State Safety Program (SSP)

An integrated set of regulations and activities aimed at improving safety.

Statement

(1) The whole or any part of an oral, written, or recorded statement relating to an aviation occurrence and given to the QAAI, an investigator or any person acting on behalf of the QAAI or on behalf of an investigator;

(2) A statement is privileged and no person, including any person to whom access is provided under this Regulation, shall knowingly communicate it or permit it to be communicated to any person except as provided by this Regulation or as authorized in writing by the person who made the statement; and

(3) The QAAI may make such use of any statement as it considers necessary in the interest of aviation safety.

Substantial damage

Damage or failure which:

(1) Adversely affects the structural strength, performance, or flight characteristics of an aircraft, and would normally require major repair or replacement of the affected component.




(2) except for: engine failure or damage limited to a single engine of a multi-engine aircraft (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes), or for minor damage to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike (including holes in the radome).

1.2 Abbreviations

When the following abbreviations are used in this Regulation, they shall have the following meaning:

QAAI Aviation Investigation Unit of the State of Qatar (the Unit or QAAI) / Qatar Air Accident Investigation (QAAI)

ANS Air Navigation Services

ATS Air Traffic Services

FDR Flight Data Recorder

ICAO International Civil Aviation Organisation

IIC Investigator-In-Charge

QCAA Qatar Civil Aviation Authority

OEM Original Equipment Manufacturer

UTC Universal Coordinated Time




1.3 Serious Incidents

This article applies to all aircraft and contains examples of incidents that are likely to be serious enough for investigation. The list only serves as guidance and is not exhaustive. The decision to investigate a serious incident incorporates factors like the number of remaining defences, and the existence of a credible scenario by which the incident could have escalated into an accident.

(1) Air Traffic Control Incidents

(a) Loss of separation, risk of collision, and other hazardous air traffic control incidents

including faulty procedures or equipment failures; and

(b) All Traffic Collision Avoidance System Resolution Advisories (TCAS RAs)

(2) Bird Strike

The indication of a bird strike regardless of residual evidence.

(3) Crew Incapacitation

Any crew member whose duties is directly related to the safe operation of an aircraft, and is unable to perform its duties as a result of a physical or psychological incapacitation that poses a threat to the safety of any person, property or the environment.

(4) Depressurization

Depressurization resulting in an emergency descent.

(5) Door/Window/Hatch

Total failure or loss of a door, a window or a hatch.

(6) Emergency Oxygen Use

Events requiring the emergency use of oxygen by the flight and cabin crew.

(7) Engine Failures

(a) Single Engine aircraft/rotorcraft: all failures;

(b) Multi-Engine aircraft/rotorcraft;

(i) An engine fails or is shut down as a precautionary measure; or

(ii) Failures which are not contained within the power-plant case (i.e. turbine disk burst, chunk failure, serration failure); or

(iii) Failure of structural components of a turbine engine, excluding compressor blades and turbine blades and vanes; or

(iv) Sustained loss of power or thrust by two or more engines.

(8) Evacuation

The evacuation of an aircraft in which an emergency egress system is utilized.

(9) External Load Release




The unintentional or as an emergency measure, the intentional release of a slung load or other load carried to the aircraft.

(10) Fire and Explosion

A fire, explosion, or smoke occurring on the ground or in flight and within the cockpit, the passenger compartment, in cargo compartments or engine fires, even though such fires were extinguished by the use of extinguishing agents.

(11) Flight Control Malfunction, Failure, or Stability Problems

An Occurrence of any nature which can cause difficulties in controlling the aircraft such as aircraft system failures, malfunctions, weather phenomena, and operation outside the approved flight envelope.

(12) Flight crew incapacitation in flight

(a) For single pilot operations (including remote pilot) (b) For multi-pilot operations for which flight safety was compromised because of a

significant increase in workload for the remaining crew.

(13) Foreign Object Damage

Any damage resulting in an engine change or other significant structural damage. (Please see Attachment A in this Chapter)

(14) Fuel Inadequacy

A fuel quantity requiring the declaration of an emergency by the pilot or a fuel shortage that necessitates a diversion or requires approach and landing priority at the destination, or the aircraft lands with less than the minimum fuel required, or with a fuel imbalance/fuel starvation, or the incorrect quantity, or type of fuel is loaded and inability to use all usable fuel on board due to another reason

(15) Ground Collision

Contact made between aircraft and loading bridges, fuel trucks, mobile lounges, service trucks or other equipment including damage caused by jet blast.

(16) Lightning Strike

The observation of the phenomenon or indication of resulting damage

(17) Loading

Significant load sheet discrepancy, load insecurity, fumes, container leakage, and aircraft damage caused by cargo or baggage.

(18) Loss of Aircraft Parts

Detachment of any aircraft part during taxi, take-off, cruise, approach or landing.

(19) Propeller Failure/Malfunction

Failure or malfunction of a propeller blade, hub, or related part, including the separation or over-




speeding of a propeller, or the failure of a propeller system.

(20) Rotor Failure/Malfunction

Failure or malfunction of a rotor blade, hub, or related part, including the separation, or over-speeding of a rotor or failure of the rotor drive system, or a transmission gearbox malfunction occurs.

(21) System Failures

(a) Failures of more than one system in a redundancy system mandatory for flight, flight guidance or navigation

(b) In-flight failure of electrical systems which requires the sustained use of an emergency bus powered by a back-up source such as a battery, auxiliary power unit, or air-driven generator to retain flight control or essential instruments; or

(c) In-flight failure of hydraulic systems that results in sustained reliance on the sole remaining hydraulic system or mechanical system for movement of the flight control surfaces.

(22) Take-off and Landing Events

(a) Undershooting, overrunning, or running off the side of runways, wheels-up landing, landing at the wrong airport, hard landing, overweight landing, landing gear collapse, tail strike, dragging a wingtip; or

(b) Aborted take-off after take-off thrust has been set; or

(c) Take-off or aborted take-off from a closed or engaged runway on a taxiway or unassigned runway; or

(d) Landing or attempted landing on a closed or engaged runway, on a taxiway, or unassigned runway or unintended landing locations such as roadways

(e) Retraction of a landing gear leg or wheels-up landing not classified as an accident (f) Dragging during landing of a wingtip, an engine pod or any other part of the aircraft,

when not classified as an accident.

(g) Gross failure to achieve predicted performance during take-off or initial climb; or

(h) All runway incursions and excursions.

(23) TCAS RAs

All Traffic Collision Avoidance System Resolution Advisories

(24) Terrain and Obstacle Clearance

Controlled flight into terrain (CFIT) only marginally avoided.

(25) Unapproved Part

A part, component, or material that has not been manufactured or repaired in accordance with the relevant Regulations, does not conform to an approved type design or does not conform to established industry or manufacturers specifications (OEM). Includes, but is not limited to:

(a) Counterfeit or fraudulently marked parts, components or materials; or




(b) Parts shipped directly to users by a manufacturer, supplier, or distributor who does not hold or operate under the authority of a production approval for the part; or

(c) Parts that have been maintained or repaired and returned to service by persons or facilities not authorized under QCAA Regulation.




Attachment A Guidance for the determination of aircraft damage (1) If an engine separates from an aircraft, the event is categorized as an accident even if damage is

confined to the engine. (2) A loss of engine cowls (fan or core) or reverser components which does not result in further damage

to the aircraft is not considered an accident. (3) Occurrences where compressor or turbine blades or other engine internal components are ejected

through the engine tail pipe are not considered accidents. (4) A collapsed or missing radome is not considered an accident unless there is related substantial

damage in other structures or systems. (5) Occurrences of missing flaps, slats and other lift augmenting devices, winglets, etc., that are permitted

for dispatch under the configuration deviation list (CDL) are not considered accidents. (6) Retraction of a landing gear leg or wheels-up landing, resulting in skin abrasion only, when the aircraft

can be safely dispatched after minor repairs or patching, and Chapter subsequently undergoes more extensive work to affect a permanent repair, would not be classified as an accident.

(7) If the structural damage is such that the aircraft depressurises, or cannot be pressurised, the occurrence is categorized as an accident.

(8) The removal of components for inspection following an occurrence, such as the precautionary removal of an undercarriage leg following a low-speed runway excursion, while involving considerable work, is not considered an accident unless significant damage is found.

(9) Occurrences that involve an emergency evacuation are not counted as accidents unless someone receives serious injuries or the aircraft has sustained significant damage.

Note 1.- Regarding aircraft damage which adversely affects the structural strength, performance or flight characteristics, the aircraft may have landed safely, but cannot be safely dispatched on a further sector without repair.

Note 2.- If the aircraft can be safely dispatched after minor repairs and subsequently undergoes more extensive work to affect a permanent repair, then the occurrence would not be classified as an accident. Likewise, if the aircraft can be dispatched under the CDL with the affected component removed, missing or inoperative, the repair would not be considered as a major repair and consequently the occurrence would not be considered an accident.

Note 3.- The cost of repairs, or estimated loss, such as provided by insurance companies may provide an indication of the damage sustained but should not be used as the sole guide as to whether the damage is sufficient to count the occurrence as an accident. Likewise, an aircraft may be considered a “hull loss” because it is uneconomic to repair, without it having incurred sufficient damage to be classified as an accident.




CHAPTER 2 - APPLICABILITY

2.1 Applicability

This Regulation applies to aviation occurrences:

(1) Within the territory of the State

(2) Outside the territory of the State when associated with an aircraft registered in the State or is operated by an AOC holder in the State, provided that the incident or accident occur in a non-contracting State that does not intend to investigate the accident or incident in accordance with the Chicago Convention Annex13.

(3) In another ICAO contracting State when the investigation is delegated to the State by mutual agreement, provided that the requesting State will assume all the costs and expenses arising out of the investigation.

(4) In the high seas or over territories not belonging to a State when applicable.

2.2 Failure to Comply

Any person, who resists or intentionally obstructs a representative of the QAAI in the execution of his/her powers and duties under this Regulation, or who knowingly gives false or misleading evidence at an investigation, or who intentionally fails to comply with the provisions of this Regulation and applicable Law shall be subject to the penalties in accordance with applicable articles of Law 15 of 2002 as amended by Law 15 of 2018. The same penalties will apply to a person who knowingly mutilates, obliterates, destroys or attempts to do so; or, without authority takes and carries away, removes, conceals or withholds any records or part of, or property related to a civil aircraft involved in an aviation occurrence.




CHAPTER 3 - AUTHORITY AND OBLIGATIONS OF THE QAAI

3.1 Objective of the QAAI

The sole objective of the QAAI is to improve aviation safety of civil aviation activities within the State of Qatar by conducting independent investigations into aviation occurrences, by monitoring the implementation of safety recommendations and by identifying and correcting systemic errors through a continuous/ predictive data-based accident prevention program encompassing all elements of the civil aviation environment.

This chapter applies to the following activities:

(1) Accidents and serious incidents involving a Qatar registered civil aircraft wherever they occur;

(2) Accidents and serious incidents involving a foreign aircraft if occurred in the territory of the State of Qatar

All investigations of aviation occurrences will be conducted in a manner consistent with the highest international safety standards; as such, the Standards and Recommended Practices contained in ICAO Annex 13.

3.2 Authority for Investigations

(1) The QAAI is the sole entity within the State of Qatar authorized to investigate air accidents and serious incidents;

(2) The QAAI may delegate, in writing, to any entity the gathering of factual information related to an aviation occurrence;

(3) All aviation occurrence investigations conducted by the QAAI have priority over any type of fact gathering/investigation conducted by any other Entity;

(4) The QAAI may authorize other entities to participate in its investigations; When experts from the QCAA or other entities are assigned to an investigation, such personnel should be relieved of their duties and responsibilities for the duration of their task in the investigation;

(5) Under no circumstances is an aviation occurrence investigation, in which a portion of the investigation is delegated to another entity, considered to be a joint investigation in the sense of sharing responsibility. Those investigations remain strictly the QAAI investigations.

(6) Other entities participating in investigations of the QAAI, shall ensure that information which is related to the investigation is exchanged in a timely manner with all participants;

(7) Where conflicting interests arise between the QAAI and any other entity, the requirements and interests of the QAAI shall take precedence.

3.3 Intermittent Services

The QAAI may:

(1) Procure temporary or intermittent services of experts;

(2) Make agreements and other transactions to carry out this Regulation.




3.4 Annual Report

The QAAI shall submit an annual report to the Minister of Transport and Communications encompassing all its related activities during the previous calendar year. The report shall include, but is not limited to:

(1) A resume of the general activities of the QAAI

(2) A statistical and analytical summary of all aviation occurrences reported to the QAAI;

(3) A statistical and analytical summary of the aviation occurrence investigations and safety studies conducted by the QAAI;

(4) A survey and summary of all the recommendations made by the QAAI with the response to each recommendation; and

(5) A list of on-going investigations and safety studies and an estimate for their completion date.

3.5 Equipment

The QAAI shall provide its personnel with the appropriate equipment required for investigations and, the required training to use the equipment necessary for the proper performance of their duties.

3.6 Investigator Safety Measures

QAAI shall make every effort to identify and mitigate or eliminate hazards at accident sites. The QAAI will ensure that personnel involved in the conduct of the investigation will have personal protective equipment (PPE) readily available for use when they are present at such sites.

3.7 Funding

The financial resources of the Unit consist of:

(1) Funds allocated by the State and;

(2) Other funds approved by the Council of Ministers, by the recommendations of the Minister of Transport and Communications.

The Head may request extra financial allocation, when deemed necessary, in cases of a major accident or unexpected circumstances.

3.8 Investigators Qualifications.

(1) A key element in the effectiveness of aircraft accident and incident investigations is the qualification of the investigators.

(2) QAAI has documented qualifications that must be met by investigators as well as personnel involved in the QAAI operations.

3.9 Notification

(1) The QAAI has taken measures to ensure its prompt receipt of, on a 24 hour a day basis

notification of accidents and serious incidents when they occur in the State of Qatar or elsewhere when Qatar is the State of the Operator or the State of Registry.

(2) Upon its receipt of notifications, the QAAI will notify all parties as per the specification of this regulation.




(3) When receiving a notification from the State of Occurrence, QAAI, as the State of the Operator and/or the State of the Registry, will promptly respond to the State of Occurrence in the prescribed manner concerning matters such as:

(a) Appointment of Accredited Representative when applicable

(b) The provision of information regarding the aircraft, flight crew, passengers and;

(c) Dangerous goods on board the aircraft

3.10 Conduct of Investigations

(1) The QAAI will conduct the investigations of aircraft accidents and incidents in accordance with the standard procedures.

(2) The State of Qatar, through the QAAI, will fulfil its obligations, particularly with regard to the required separation of investigative activities and any judicial proceedings, and respect the participatory rights of other ICAO Contracting member States and identified industry parties

(3) When an investigator is appointed as the Investigator-in-Charge (IIC) for a particular investigation, he shall be responsible for the organization, conduct and control of the investigation.

3.11 Participation in Investigations conducted by Other States

(1) The State of Qatar, through the QAAI, upon request or invitation will participate, through the

appointment of an accredited representative and any needed experts and/or advisers, in investigations conducted by other States in situations in which Qatar is:

(a) The State of the Operator, or (b) The State of the Registry, or (c) As a State whose citizens suffered fatalities or serious injuries

(2) The QAAI will fully cooperate in such investigations by facilitating within its scope and authority access to flight recorders data, the recorders, and providing information related to the operation of the aircraft.

3.12 Reporting

In its preparation of the final report of an investigation, the QAAI will:

(1) Follow the format prescribed in Annex 13, coordinate the draft with the appropriate States for their comments, and

(2) Disseminate the final version to ICAO when applicable, and the States with which the draft was coordinated or any relevant States.

3.13 Safety Recommendations

(1) At any stage in the conduct of its investigations, the QAAI will, when necessary, make safety

recommendations addressed to the investigation authorities of other States and to ICAO, particularly in situations when immediate or near-term action is needed to prevent the likelihood of recurrences.

(2) QAAI will also exercise due diligence in responding to safety recommendations directed to the State of Qatar by indicating preventive or remedial actions planned or taken or explaining why no action will be taken within 90 days of the issuing date.




3.14 ICAO Accident/Incident Reporting

As an ICAO Contracting State, the State of Qatar, through the QAAI, will meet its obligation to prepare and submit Preliminary Reports, Accident Data Reports, and Incident Data Reports to ICAO in the aftermath of aircraft accidents and serious incidents within the applicable periods.

3.15 Incident Reporting Systems and Occurrence Database

(1) Several parts of the QCAA established mandatory incident reporting requirements as well as sanctioning the voluntary reporting of incidents by affording appropriate protection to reporters, as stipulated in relevant Laws and regulations, thus created the foundation for Qatar's' mandatory and voluntary incident reporting systems.

(2) QCAA’s creation and use of an Occurrence Reporting System (ORS) database, in connection with the ICAO ADREP and European Coordination Centre ECCAIRS for Accident and Incident Reporting, is used to capture and store data from accident and incident reports as well as providing the means for continuous safety analysis by QCAA and QAAI.




CHAPTER 4 - NOTIFICATION

4.1 Notification Requirements

This chapter contains the requirements for notification of reportable aviation occurrences within the State of Qatar as well as any similar events involving Qatar registered civil aircraft occurring outside the State of Qatar.

Immediate notification of accidents and incidents to the QAAI is essential as the proper conduct of investigation requires the prompt arrival of investigators at the accident site.

Furthermore, any delay in notification may well result in the deterioration or disappearance of essential evidence due to theft, displacement or improper handling of the wreckage, adverse weather, corrosion of the wreckage, obliteration of ground scars or contamination of information from witnesses.

4.2 Reportable Aviation Occurrences

Aviation occurrences that require notification are all accidents and serious incidents as defined in 1.3, Attachment A in Chapter 1 of this Regulation.

4.3 Responsibility of Notification

When a reportable aviation occurrence takes place, the owner, operator, pilot-in-command, or any crew member of any civil aircraft, or any public aircraft, or any foreign aircraft and; where the reportable occurrence involves an Air Traffic Services Unit, any air traffic controller having direct knowledge of the reportable occurrence shall notify the QAAI. Any other person aware of a reportable aviation occurrence shall notify the QAAI. In all cases, all reportable aviation occurrences shall be reported immediately to the QAAI.

The QAAI contact information will be available to all Air Traffic services facilities, airport authorities, MOI and other relevant entities.

4.4 Notification to the QAAI

The QAAI is on standby 24/7 to react on any notification that requires immediate attention QAAI can be

contacted as follows:

Telephone: +974 44571313

Web Site: www.qaai.gov.qa (under construction)

Email: [email protected]

FAX: +974 44571314

The information outlined in Article 4.5 of this Chapter should be provided.

Having information that is incomplete or unverified does not justify delaying the notification. Corrected and additional information can be provided at any time it becomes available or, as specified in Article 4.6 of this Chapter.

4.5 Information to be Included in a Notification

Notifications are preferably in English and contain as much of the following information as is readily available. Dispatch of the notification shall not be delayed due to lack of complete information.

(1) Aircraft make, model, type, serial number, nationality, and registration markings of the aircraft;

(2) Name of registered owner, name of the operator of the aircraft and hirer, if any

(3) Qualification of the pilot-in-command, nationality of crew and passengers

http://www.qaai.gov.qa/

mailto:[email protected]




(4) Date and time (Local time or UTC) of the accident or incident;

(5) Last point of departure and point of intended landing; (6) Vertical and horizontal position of the aircraft with reference to some easily defined geographical

point at the time of the event;

(7) Total number of persons aboard, number of fatalities, number seriously injured and number of minor injuries;

(8) Type of accident or incident; and indicate identifying abbreviation ACCID for accident and INCID for serious incidents

(9) Prevailing weather conditions at the accident or incident site;

(10) Description of the occurrence and the Extent of damage to the aircraft, so far as is known;

(11) Damage to objects or structures on the ground, if any; and

(12) A description of any explosives, radioactive materials, or other dangerous articles carried on board the aircraft if applicable

(13) An indication to what extent the investigation will be conducted or is proposed to be delegated by QAAI as State of Occurrence

(14) Physical characteristics of occurrence area, as well as indication of access difficulties to the occurrence site

(15) Identification of the QAAI as the originating authority and provide the contact details of the IIC and QAAI at any time

4.6 Information to be provided to the QAAI following the Notification

(1) In addition to the notification, a written report detailing the aviation occurrence shall be submitted

to the QAAI within seven (7) calendar days of the aviation occurrence. This report is required for all reportable aviation occurrences even when a notification has already been made; and

(2) Each crew member, if physically able at the time of the notification is submitted, shall attach a statement setting forth the facts, conditions, and circumstances relating to the reportable aviation occurrence. If the crew member is incapacitated, he shall submit the statement as soon as he is physically able.

4.7 Notification of an Aviation Occurrence involving Civil and Military Aircraft

(1) For an aviation occurrence involving civil and military aircraft, the military commander having first

knowledge should notify the appropriate military service in accordance with applicable Service Directives. The military Headquarters shall immediately relay pertinent information to the QAAI; and

(2) The QAAI shall immediately notify the appropriate military Services Headquarters when it has first knowledge of an aviation occurrence involving civil and military aircraft.

4.8 QAAI Notification to States and ICAO

Accidents or Serious Incidents in the State of Qatar to Aircraft of another Contracting State

(1) Responsibility of the QAAI as the competent authority of the State of Occurrence




The QAAI shall forward a notification of an accident or serious incident with a minimum of delay and by the most suitable and quickest means available to the involved States such as the State of Registry, State of the Operator, State of Design, State of the Manufacture and to ICAO when the aircraft involved is of a maximum mass of over 2 250 kg or is a turbojet-powered aircraft. The QAAI will also send notification to other States whose citizens suffered fatalities and serious injuries and to States which may be requested to provide information. The QAAI will send details of information following format and contents as specified in 4.5 of this chapter and Annex 13 - 4.2; 4.3 and 4.4 (Please see Attachment A in this chapter)

(2) Responsibility of the QAAI as the State of Registry, State of the Operator State of Design, or State of the Manufacture.

The QAAI should acknowledge receipt of the notification of an accident or serious incident. Upon receipt of the notification, the QAAI shall, as soon as possible provide the State of Occurrence all relevant information available to it regarding the aircraft and flight crew involved in the occurrence. Further, it shall, with a minimum of delay and by the most proper and immediate means available provide the said State the details of dangerous goods carried on board the aircraft, if applicable. The QAAI shall also inform the State of Occurrence or the State conducting the investigation, when specifically requested, whether it intends to appoint an accredited representative and if such is appointed, the name, contact and travel details shall be provided.

(3) Notification to State of Occurrence on unknown serious incident When the State of Occurrence is not aware of a serious incident, the QAAI as the State of Registry or State of Operator as appropriate, shall forward a notification of such incident to the State of Occurrence, State of Manufacture and State of Design.

4.8.2 Accidents or Serious Incidents in the State of Qatar as a State of Registry in a Non-Contracting State or outside the State of Qatar

(1) Responsibility of QAAI as the State of Registry.

When the QAAI, as the State of Registry, institutes the investigation of an accident or serious incident , the QAAI shall forward a notification of the occurrence in accordance with the format and content specified in Annex 13 - 4,2 and 4.3 with a minimum of delay and by the most suitable and quickest means available to the State of the Operator, State of Design, State of Manufacture and ICAO when aircraft involved is of a minimum mass of over 2,250 kg or a turbo-jet powered aircraft. (Please see Attachment A in this chapter)

(2) Responsibility of QAAI as the State of the Operator and/or State of the Registry: (a) Upon receipt of the notification, the QAAI, as the State of the Operator/State of the

Registry should acknowledge receipt of the notification. and shall, upon request, provide the State instituting the investigation with any relevant information available to them regarding the flight crew and the aircraft involved in the occurrence, The QAAI shall also inform the said State whether it intends to appoint an accredited representative and if such an accredited representative is appointed, the name, contact details and travel details are provided.

(b) The QAAI as a State of the Operator with a minimum of delay and by the most suitable and quickest means available, shall also provide the State of Registry with details of dangerous goods on board the aircraft, if applicable.




Attachment A Format and Content used for Notification to other States

The notification shall be in plain language and contain as much of the following information as is readily available, but its dispatch shall not be delayed due to the lack of complete information:

(1) for accidents the identifying abbreviation ACCID, for serious incidents INCID;

(2) manufacturer, model, nationality and registration marks, and serial number of the aircraft;

(3) name of owner, operator and hirer, if any, of the aircraft;

(4) qualification of the pilot-in-command, and nationality of crew and passengers;

(5) date and time (local time or UTC) of the accident or serious incident;

(6) last point of departure and point of intended landing of the aircraft;

(7) position of the aircraft with reference to some easily defined geographical point and latitude and longitude;

(8) number of crew and passengers; aboard, killed and seriously injured; others, killed and seriously injured;

(9) description of the accident or serious incident and the extent of damage to the aircraft so far as is known;

(10) an indication to what extent the investigation will be conducted or is proposed to be delegated by the State of

Occurrence;

(11) physical characteristics of the accident or serious incident area, as well as an indication of access difficulties or special requirements to reach the site;

(12) identification of the originating authority and means to contact the investigator-in-charge and the accident investigation authority of the State of Occurrence at any time; and

(13) presence and description of dangerous goods on board the aircraft.

Language

The notification shall be prepared in one of the working languages of ICAO, taking into account the language of the recipient(s), whenever it is possible to do so without causing undue delay.




CHAPTER 5 - INVESTIGATION

5.1 Responsibility of the QAAI

The QAAI is the investigation authority that has been established directly under the Minister of Transport and Communications to be responsible for the investigation of all aviation occurrences involving civil registered aircraft within the sovereign area and territorial waters of the State of Qatar.

Accordingly, Qatar as a State of Occurrence shall also institute an investigation into situations of a serious incident when the aircraft is of a maximum mass of 2250 kg and for investigation of unmanned aircraft system, only aircraft with a design and /or operational approval are considered. The QAAI shall have independence in the conduct of the investigation and have unrestricted authority over its conduct consistent with the provisions of ICAO Annex 13. Except as provided for by the latter.

The QAAI is responsible for the following:

(1) The gathering, recording and analysis of all relevant information on the occurrence;

(2) The protection of certain occurrence investigation records in accordance with applicable Laws and procedures.

(3) If applicable, the issuance of safety recommendations;

(4) If feasible, the determination of the causes and /or contributing factors and

(5) Completion of final report and ADREP reporting

Where possible, the QAAI shall visit the occurrence site, examine the wreckage and take statements from the witnesses. The extent of the investigation and procedures to be followed shall be determined by the QAAI depending on the results it expects to draw from the investigation for the improvement of safety.

5.1.1 Investigation on Qatar Registered and Operated Aircraft

(1) With regard to accidents or serious incidents of Qatar registered / operated aircraft that occur in non- Contracting ICAO member States that do not intend to conduct an investigation, the State of Qatar, through the QAAI, will institute and conduct an investigation in cooperation with the State of Occurrence, if possible.

(2) With regard to accidents or serious incidents of Qatar registered/ operated aircraft that occur in undetermined locations but likely outside the territory of any State, the State of Qatar, through the QAAI will institute and conduct any necessary investigation in cooperation with the State of occurrence, while reserving the option to delegate the whole or any part of the investigation to another State by mutual arrangement and consent.

5.2 Purpose of an Investigation

The purpose of an investigation is to determine the facts, conditions, and circumstances in order to arrive at findings that will identify causal factors. The sole objective of the investigation of an aviation occurrence shall be the prevention of aviation occurrences. It is not the purpose of this activity to apportion blame or liability.

Any judicial or administrative proceedings to apportion blame or liability will not be conducted under the provisions of this Regulation. The QAAI recognizes the need for coordination between the investigator-in- charge (IIC) and the judicial authorities. Further, any report issued under this Regulation or any evidence collected by the QAAI during an investigation is expressly inadmissible as evidence and may not be used or referred to in any related judicial proceedings. Particular attention will be given to evidence which requires prompt recording and analysis for the investigation to be successful, such as the examination and identification of victims and read-outs of flight recorder recordings. Possible conflicts between the QAAI and the judicial authorities regarding the custody of flight recorders and their recordings may be




resolved by an official of the judicial authority carrying the recordings to the read-out facility, thus maintaining custody.

For any investigation conducted under this Regulation, the QAAI will have unrestricted access to all evidence without delay and will not be impeded by administrative or judicial investigations or proceedings.

The QAAI will develop documented policies and procedures detailing its investigation duties. These will include organization, planning, investigation, reporting, and prevention.

5.3 QAAI Authority to Order an Investigation

(1) Upon receipt of a notification of an aviation occurrence, the QAAI is authorized to order an immediate investigation;

(2) The Head of QAAI shall appoint an IIC and the Chief Investigator shall appoint all other required investigators;

(3) The QAAI will, upon receiving a notification from a foreign authority, as required, assign an Accredited Representative and/or Advisers.

5.3.1 Role and Authority of the Investigator-in-Charge

(1) The IIC will be assigned/appointed by the Head of the QAAI or deputy to conduct an investigation. (2) The IIC has unhampered access to the wreckage and all relevant material, including flight

recorders and ATS records, as well as unrestricted control over it to ensure that a detailed examination can be made without delay by authorized personnel participating in the investigation.

(3) In this role, the IIC is responsible to the Head of the QAAI to organize, conduct and manage the investigation. The main objective is to gather and analyse factual information related to the occurrence and identify those deficiencies that may have contributed to the severity of the occurrence. and shall report findings, causes and contributing factors related to the occurrence, and submit recommendations designed to reduce or eliminate any related safety deficiencies.

5.3.2 Role of the Investigative Groups

(1) An accident investigation involving a large or complex aircraft requires a large team of investigators in order to conduct the investigation in the most effective and expeditious way.

(2) The effective utilization of the available investigators in a major investigation can be achieved by dividing the investigation activities into functional areas, each of which can be assigned to a group within the overall investigation team.

(3) Each investigative group will have as many members as necessary to examine the particular circumstances of the accident.

(4) Members of the investigative groups and supporting experts are from the QAAI and other QCAA departments or seconded from national and international aviation entities.

(5) Since the outcome of an accident investigation is largely dependent on the skill and experience of the assigned investigators, at least one experienced investigator should be assigned to each investigative group to ensure an adequate level of experience.

(6) Members of an investigative group should normally have access to all information uncovered in the course of the investigation and are usually required to participate in the investigation until the group report is completed.

(7) The circumstances and complexity of the accident will determine the number and types of groups required. In most investigations, a coordinator provided by the aircraft operator is appointed for liaison duties.

5.4 Civil and Military Aviation Occurrences

If an accident or a serious incident involving a military aircraft and one or more civil aircraft occurs, an




investigating committee shall be formed of representatives from the Accident Investigation Unit and the Military Aviation Authority.

5.5 Criminal Act

During an QAAI investigation, if the investigator in charge suspects that the accident or incident constitutes a criminal act, the Accident Investigation Unit shall refer the subject to the appropriate Authority of the State to take the necessary legal proceedings.

5.6 Discontinuation of Investigation

The IIC, may determine that any investigation being conducted into a serious incident or incident is to be discontinued. In the event of a formal investigation being discontinued, no final report shall be published. However, public notice should be given by the IIC in such a case.

Additionally, the IIC shall submit to the QAAI information as he considers recommendable in the interest of subsequent future analysis.

5.7 Participation of the QAAI in Foreign Investigations

5.7.1 Participation of QAAI

This section is applicable to investigations conducted by other States into Qatar registered aircraft accidents or serious incidents that occur outside the territory of the State of Qatar as well as investigations by the said States where the State of Qatar has an interest or in a position that requires the fulfilment of international obligations.

(1) When a State conducting an investigation into an accident or serious incident to an aircraft of a maximum mass of over 2,250 kg specifically requests participation of the QAAI, as the competent authority of the State of Registry, the State of the Operator, the State of Design or the State of the Manufacture, the QAAI shall appoint an accredited representative. The name, contact details as well as the date of expected arrival of the ACCREP will be provided.

(2) In the event of an aviation occurrence in a foreign territory involving an aircraft registered in the State of Qatar, a State of Qatar certified operator, or fatalities or serious injuries to citizens of the State of Qatar, the QAAI will coordinate with the State having jurisdiction over the investigation and designate an accredited representative or expert with appropriate advisers to participate in the investigation. This accredited representative will meet the QAAI specified requirements of a qualified IIC;

(3) An accredited representative may, at his discretion, select advisers to participate and assist him in the course of a foreign investigation. The accredited representative may or may not travel to the scene of an investigation or to any follow-up activities. If he does not travel, his advisers will still be granted access to the investigation as though he was present. The latter's entitlement and obligations must be made in writing;

(4) The QAAI may disclose records and information only when authorized to do so by the State conducting the investigation;

(5) Nothing in this Regulation shall restraint the QAAI from referring to foreign aviation occurrence information in making safety recommendations;

(6) The QAAI, as the State of Registry and State of Operator, on request from the State conducting the investigation, shall provide pertinent organizational information on any organization whose activities may have directly or indirectly influenced the operation of the aircraft and;

(7) The QAAI will provide the State conducting the investigation relevant information regarding any facilities or services of which have been utilized or would normally have been utilized by the aircraft prior to the accident or serious incident, and which has information pertinent to the investigation.

5.8 Authority of a QAAI Investigator

For the purpose of conducting an investigation under this Regulation, the QAAI, as the responsible authority for an aircraft accident investigation, shall issue applicable credentials to its investigators to enable them to perform their functions. Thus, the QAAI IIC and investigators upon presenting their




credentials, shall be allowed free and direct access to wreckage, material, records and persons involved, without hindrance by organizational hierarchy and shall be granted suitable statutory powers: These powers should however be used only when necessary and utmost discretion is undertaken when gathering information. (Ref. Law 15 of 2002 as amended by Law 15 of 2018 Article 62)

(1) To enter any aircraft, place or property the entry of which the investigator believes is requisite for the purposes of the investigation;

(2) To inspect any aircraft, place, or property, including any equipment, stock, cargo, baggage, records, documents, freight, or other goods or any part thereof found therein, the inspection of which the investigator believes, is requisite for the purposes of the investigation, to make copies of or take extracts from any such records or documents as well as make photos, video recordings and sound recordings;

(3) To seize, detain, remove, preserve, protect and to test to destruction if necessary as long as it is practical, safe and will not unreasonably impede the progress of investigation any aircraft, equipment, stock, cargo, baggage, records, documents, freight, other goods or any part thereof that the investigator believes on reasonable grounds is involved in, or relates to, any aviation occurrence that is being investigated under this regulation. In case of conducting test to destruction of a material that was seized for the purpose of investigation, the investigator may take all reasonable measures to invite the owner of such material, and any person who appears on reasonable grounds to be entitled to it to be present at any such test.

(4) To protect the site of any aviation occurrence that is being investigated under this Regulation and for that purpose, to preclude or limit access to property at the site for a reasonable period of time;

(5) To require a physician or other health practitioner to provide information concerning any of his patients that the investigator believes on reasonable grounds is relevant to the investigation. In such cases, the notice for medical information shall be made in writing and signed by the investigator;

(6) To require such medical examinations of aircraft crew members as the investigator believes on reasonable grounds are requisite for the purposes of the investigation with the provision that no medical examination shall be made that involves surgery, perforation of skin or external tissue, or the entry into the body of any drug or other foreign substance except for the purposes of obtaining blood samples. In such cases, the notice for medical examinations shall be made in writing and signed by the investigator;

(7) To require the performance of such autopsies on deceased aircraft flight and cabin crew members and passengers and such other medical examinations of human remains as the investigator believes on reasonable grounds are requisite for the purposes of the investigation. In such cases, the notice for medical information shall be made in writing and signed by the investigator;

(8) To take custody of all aircraft recorders and to ensure all recovered data is analysed without delay;

(9) To have unrestricted and unhampered access to and physical control over all relevant material/evidence, flight records including Air Traffic Service (ATS) forms, records, tapes, and recordings;

(10) To perform detailed examination of all relevant materials/evidence without delay; (11) To take full and detailed statements from all witnesses or any person, prior to those witnesses

or persons being made available for interviews from any other person, group, or organization and to record the interviews by any means (tape, video, etc…);

(12) To operate equipment on the premises in order to access evident material; (13) Remove evident material from the premises with the consent of the owner or any person in

charge unless locating such owner or person in charge is not feasible; (14) In the case of evident material that is equipment, operate the said evident material; (15) QAAI may secure an evident material pending a warrant to seize the latter; (16) To take equipment and material onto the premises and use it for any of the above purposes;




(17) In such cases, the investigator shall not exercise the authority in relation to a particular place or premises without the consent of the person responsible for such place except when this authorization is exercised under a warrant, or by reason of exigent circumstances where it will not be applicable for the investigator to obtain the said warrant. Hence, the investigator shall then take reasonable steps to give the owner of the premises a written notice on the context of its rights and obligations;

(18) Seek assistance from the competent authorities or other authorized persons to ensure protection of the accident site, including the aircraft and its contents, until such time the IIC is able to take custody as well as coordinate for security of the aircraft and its contents;

(19) The QAAI may appoint additional experts from other national or international source to assist the IIC in a particular investigation and such person(s) shall, for the said purpose will have the authority to participate in the investigation on the condition that such authority is documented and;

(20) The IIC, at any given time, may publish information relating to an accident subject to an investigation or going through re-opening of the original investigation and;

(21) QAAI may serve notices or documents as required. It may be delivered personally to the concerned person, or leaving it at the last known address of the person, or by post mail, or sending it thru fax ensuring that the latter has been received, thus, is considered served.

5.9 Preservation of Evidence

5.9.1 Protection and Custody of Evidence

At the direction of the QAAI, the appropriate government entity available at the site of an aviation occurrence shall take all reasonable measures to protect the evidence and to maintain safe custody of the aircraft and its contents for such a period as may be necessary for the purposes of an investigation. Protection of evidence particularly those of a transitory nature shall include the preservation by photographic or other means of any evidence which might be removed, affected, lost, or destroyed. Safe custody shall include protection against further damage, access by unauthorized persons, pilfering and deterioration. The protection of evidence does not prevent any person from taking necessary measures to ensure the safety of any person, property, or the environment.

5.9.1.1 Protection of Evidence (1) No person shall have access to the site(s) unless authorized by the QAAI: (2) Neither the aircraft involved in an accident or serious incident and with its contents shall be

removed or otherwise interfered with, except when authorized by the QAAI. (3) The aircraft may not be removed or interfered with unless required for the purpose of extricating

persons or animals, removing any mails, valuables and dangerous goods carried by the aircraft, preventing destruction by fire or other cause, or preventing any danger or obstruction to the public or to air navigation or to other transport or, under the supervision of the IIC, or his representative, for the purpose of removing any other property from the aircraft.

(4) Should the aircraft be wrecked on water, the aircraft or any of its contents may be removed to such extent as may be necessary to transfer the latter to a safe place.

(5) The operator of an aircraft involved in an accident or serious incident, for which notification is mandatory, shall be responsible for preserving, to the extent possible, any aircraft wreckage and cargo aboard the aircraft as well as all records, including recording mediums of flight, maintenance, and voice recorders pertaining to the operation and maintenance of the aircraft and to the airmen, until such time the QAAI takes custody thereof and release is granted.

(6) Where it is necessary to move aircraft wreckage or cargo; sketches, descriptive notes, and photographs shall be made, if possible, of the original position and condition of the wreckage and any significant impact marks.

(7) The operator of an aircraft involved in an accident or serious incident shall retain all evidence relevant to the occurrence until authorized by the QAAI.




5.9.1.2 Requests from State of Registry, State of the Operator, State of Design or State of Manufacture (1) If a request is received from the State of Registry, the State of the Operator, the State of Design

or the State of Manufacture that the aircraft, its contents, or any other evidence remain undisturbed pending inspection by an accredited representative of the requesting State, the QAAI, as the competent authority of the State of Occurrence, shall consider such request. Hence, the QAAI shall consider request reasonably practicable and compatible with the proper conduct of the investigation on the condition that the aircraft may be moved to the extent necessary to extricate persons, animals, mails and valuables, to prevent destruction by fire or other causes, or to eliminate any danger or obstruction to air navigation, to other transport or to the public, and provided that it does not result in undue delay in returning the aircraft to service where this is practicable.

(2) Upon receiving a request under 5.9.1.2 (1), the accredited representatives and technical advisers shall have the rights to exercise their activities under the participation privileges as detailed in 5.16 of this regulation and shall be led by the IIC or a representative.

5.9.2 Custody of the Aviation Occurrence Site (1) The QAAI is responsible for preserving the accident or incident site for investigation purposes for

all civil registered aircraft, regardless of its nationality, when occur in or over the sovereign area or territorial waters of the State of Qatar;

(2) preserving of an accident or incident site does not end the responsibility of the local authority having the jurisdiction over the area and the activities involved from fulfilling their responsibilities and providing uninterrupted site security. The local authority shall coordinate with the QAAI IIC for specific security requirements until the on-site investigation is completed and the disposition of the aircraft has been concluded;

(3) The movement or recovery of evidence, including aircraft recorders, shall be performed only by personnel authorized by the QAAI.

5.10 Responsibilities of the Airport Authority

For aviation occurrences at or near an airport, the airport authority shall: (1) Preserve to the extent possible any aircraft wreckage, cargo, mail, and all records aboard the

aircraft by providing appropriate security personnel; (2) Not to disturb any aircraft wreckage, mail, or cargo except to the extent necessary to:

(a) Remove persons injured or trapped; (b) Protect the wreckage from further damage; or (c) Protect the public from injury.

(3) Make sketches, descriptive notes, and take photographs of the accident location including original position and condition of the wreckage and any significant impact marks if it was necessary to disturb or move aircraft wreckage, mail, cargo, and records; and

(4) Coordinate with competent authorities for the implementation of the Emergency Plan for aviation occurrences outside the airport boundaries.

5.11 Responsibilities of Rescue and Fire Fighting Services (RFFS)

The main responsibility of the Rescue and Fire Fighting Services (RFFS) is to assure the safety of persons and property as well as to undertake aircraft fire fighting and rescue duties during an emergency. The RFFS shall be present at the site of an aviation occurrence from the initial response until released by the QAAI IIC. The presence of at least one (1) RFFS manned unit will be required throughout the whole presence of the QAAI personnel at the aviation occurrence site.

The RFFS shall prepare a report describing their response to the aviation occurrence. They shall ensure preservation of the RFFS communication tapes for review and analysis by the QAAI.

5.12 Responsibilities of Air Traffic Services (ATS)

Any Air Traffic Services Unit that was involved in control or communication with an aircraft shall as soon




as possible after becoming aware of an aviation occurrence: (1) Remove and preserve all recordings and documents relating thereto and provide them only to

the QAAI IIC or his representative; (2) Provide immediate recording play back capability and access to ATS personnel for interviews by

the QAAI IIC or his representative; and (3) Upon demand by the QAAI, ATS shall provide a suitable recorded copy of all pertinent recordings

to include a synchronized voice/radar tracking recording, together with a certified verbatim transcript, as well as copies of statements from the controllers involved and copies of all related documentation.

5.13 Responsibilities of Weather Observation Station (1) When weather observation station personnel become aware of an aviation occurrence, they shall

make a special observation as close to the time of the occurrence as possible. They shall also contact the QCAA Meteorological Department to retain all forecast and analysis documentation as well as defence satellite weather photographs taken during the 24 hours preceding the aviation occurrence;

(2) The QCAA Meteorological Department will ensure that copies of all documentation provided to the flight crew involved by the Meteorology Department of the Qatar Civil Aviation in the State of Qatar are retained. If there is weather watch radar in the vicinity of the aviation occurrence, the weather observation personnel involved should instruct the radar station to make special radar observations. These observations should commence immediately and continue for a period of two hours at a minimum of ten minutes interval. Photographed radar displays from these observations shall be retained; and

(3) All documents and records pertaining to the weather for the 24 hours preceding the aviation occurrence, and observations taken thereafter shall be retained and provided to the QAAI IIC or his representative.

5.14 Responsibilities of the Operator

The operator of an aircraft involved in an aviation occurrence, after accomplishing the required notification detailed in Chapter 4 of this Regulation, is responsible to:

(1) Coordinate with the airport authorities/MOI at or near the aviation occurrence site to preserve to the extent possible any aircraft wreckage, cargo, and mail aboard the aircraft, all records and equipment pertaining to the operation and maintenance of the aircraft, including flight recorders, until the QAAI IIC takes custody thereof or a release is granted in accordance with Article 5.21 of this Regulation;

(2) Prior to the QAAI IIC or his authorized representative taking custody of the aircraft wreckage, mail, or cargo; such wreckage, mail, or cargo may not be disturbed or moved except to the extent necessary to:

(a) Remove persons injured or trapped;

(b) Protect the wreckage from further damage; and

(c) Protect the public from injury. (3) Take the necessary precautions when it is necessary to move aircraft wreckage, mail, or cargo

and make sketches and take descriptive notes. Photographs shall be taken, if possible, of the original positions and condition of the wreckage and, of any significant impact marks;

(4) Retain all records and reports, including all internal documents and memorandum dealing with the aircraft and crew involved in the aviation occurrence and release them to the QAAI IIC or his representative;

(5) Provide the QAAI IIC or his representative, free and direct access to facilities, buildings or offices as well as records, documents or personnel that are deemed to be required by the QAAI; and

(6) Provide completed reports as specified in Article 4.6 of this Regulation.




5.15 Access to Site, Aircraft Wreckage, Records and Examinations

The QAAI shall have unhampered access as well as to personnel authorized in writing by the Director of QAAI, the QAAI IIC or his representative to the aviation occurrence site, aircraft wreckage, records, mail, cargo, examinations and testing.

5.16 Participation in QAAI Investigations

5.16.1 The Right to Participation as an Expert

Any State which on request provides information, facilities of experts to the QAAI as the State conducting the investigation shall be entitled to appoint an accredited representative (ACCREP) to participate in the investigation. (See Attachment A in this chapter.)

Note: Any State involved in the following may also appoint an ACCREP to participate in the QAAI investigation:

(1) State that provides an operational base for field investigations; (2) State that has code-share or alliance partner with the operator and (3) State involved in the search and rescue or wreckage recovery operations

If a State which has a special interest in an aviation occurrence by virtue of fatalities or serious injuries to its citizens, the QAAI IIC upon receiving a request shall allow the State with a special interest to appoint an expert who shall be entitled to:

(1) Visit the site of the aviation occurrence; (2) Have access to the relevant factual information; (3) Participate in the identification of the victims; (4) Assist in questioning surviving passengers who are citizens of the expert’s State; and (5) Receive a copy of the Final Report.

5.16.2 Participants in the Investigation

(1) Participants shall be limited to those persons or representatives of government entities, companies, and associations whose employees, functions, activities, or products were involved in the aviation occurrence and who can provide suitable qualified technical assistance in the investigation;

(2) An accredited representative or an adviser to an accredited representative, pursuant to an international agreement or convention relating to aviation to which, the State of Qatar is a party may participate in investigations;

(3) Participants in the investigation shall be responsible to the QAAI IIC or his representative and shall act in accordance with their directives. Participants may lose their Participant status if they do not comply with their assigned duties or instructions, or if they conduct themselves in a manner prejudicial to the investigation; and

(4) No person or lawyer who represents any media, claimants, insurers, nor consultants will be allowed to participate into or observe any portion of an investigation conducted by the QAAI unless the IIC or Head of QAAI decides otherwise if this could be beneficial for the investigation results.

5.16.3 Accredited Representatives Entitlements (1) The QAAI shall entitle the State of Operator, the State of Registry, the State of Manufacture and

the State of Design to designate an Accredited Representative, (ACCREP) to participate in its investigations.

(2) The QAAI shall entitle the State of Design and the State of Manufacture to designate one or more advisers recommended by the organization responsible for the type design and final assembly




of the aircraft to assist its ACCREP. When neither of these States designates an ACCREP, the QAAI as the State conducting the investigation, shall invite the type design organization and aircraft manufacturer to participate in its investigation.

(3) The QAAI shall entitle the State of the Operator and the State of the Registry to designate one or more advisers to assist its ACCREP. When neither of these States designates an ACCREP, the QAAI, as the State conducting the investigation, shall invite the operator to participate in its investigation.

(4) The QAAI, as the State conducting the investigation, shall entitle any State, which on request provides information, facilities or experts to the QAAI, to designate an ACCREP to participate in its investigation.

(5) Advisers assisting the ACCREP shall be authorized and will be under the guidance of the latter to participate in the investigation as needed to enable the ACCREP to make their participation effective.

(6) The QAAI may also entitle the regional or international body as required to enable the IIC to carry out his tasks effectively when the former does not have appropriate qualified investigators to address some aspects of the investigation. Arrangements in place such as Memorandum of Understanding (MOU) will apply to secure such services.

5.16.3.1 Participation by Other States.

The State of Manufacture or Design has airworthiness responsibilities and the expertise normally required to read and analyse flight recorder information. Since flight recorder information can often reveal airworthiness problems, the State of Manufacture or Design should have a representative present when the flight recorder read-out and analysis are being conducted. The State of the Operator has regulatory responsibilities regarding the flight operation and can provide insights into operational issues which may be specific to the operator. Since flight recorder information can reveal operational problems, the State of the Operator should have a representative present when the flight recorder read-out and analysis are being conducted.

Except for the investigation purposes, and as the QAAI determines that it is necessary for the accident investigation purposes, victim's family members, friends or their representatives, shall not listen or have access to any flight or ATC recorded information nor transcripts.

5.16.3.2 Participation in the Investigation

Participants in the QAAI investigation are entitled to participate in all aspects of the investigation as determined by and under the control of the QAAI IIC or his representative, in particular to:

(1) Visit the site of the aviation occurrence; (2) Examine the wreckage; (3) Obtain witness information and suggest areas of questioning; (4) Have access to all relevant evidence; (5) Receive copies of all pertinent documents- pertinent documents include documents such as

reports on examinations of components or studies performed within the framework of the investigation.

(6) Participate in readouts of recorders; (7) Participate in off-site investigation activities such as component examinations, technical

briefings, tests and simulations; (8) Participate in investigation progress meetings including deliberations related to analysis,

findings, causes and safety recommendations; and (9) Make submissions in respect of the various elements of the investigation.

Note 1: Participation of States that provide facilities or experts may be limited to the extent those matters relate to each aspect of the investigation.

Note 2: The QAAI IIC has the authority to restrict the access and participation of any participant.




5.16.4 Observers

For training purposes, Observers representing a State, a registered owner/operator or a military organization may attend an investigation conducted by the QAAI upon approval of a request to do so. The conditions set in Articles 5.16.2 (3) and 5.16.2 (4) of this regulation shall apply.

Note: The QAAI IIC has the authority to Allow/restrict the access of any Observer.

5.16.5 Obligations of Accredited Representatives and their Advisers

The ACCREP and their Advisers are obligated to accomplish the following: (1) Shall provide the QAAI IIC or his representative with all relevant information available to them;

and (2) Shall not divulge any information on the progress and the findings of the investigation without the

express consent of the QAAI IIC.

5.16.6 Presence at Tests

Where a person is invited to be present at a test, that person may be represented by a person having technical knowledge and expertise in the subject-matter of the test; and record or cause to be recorded the condition of the object being tested prior to, during, and after the test. Persons mentioned at Article 5.16.2 (5) of this Regulation shall not participate to tests.

5.17 Non-disclosure of Records

Records used or retained for the purpose of an aviation occurrence investigation shall not be disclosed to any person or organization outside the QAAI unless specifically approved by the Director of the QAAI and the judicial authorities, for the purpose of administration of justice, determines that the disclosure outweighs the adverse or could have a negative effect on the progress of the investigation or future investigations, both locally and internationally. The following records shall not be disclosed:

(1) Statements taken during the investigation; (2) Communications, verbal, or written, between personnel involved in aircraft operations; (3) Communications between persons having been involved in the operation of the aircraft; (4) Recordings and transcripts of recordings from air traffic control units; (5) Cockpit Voice Recorders (CVR) recordings or transcripts of the same; (6) Cockpit image recordings and any part of transcript from such recordings; (7) Opinions formed during the analysis portion of the investigation including Flight Data Recording

(FDR) analysis or copies of the same; (8) Medical information or personal information regarding personnel involved in the aviation

occurrence; and (9) The names of the persons involved in the aviation occurrence.

Note. 1 Only portions of these records which are pertinent to the analysis may be included in the Draft/Final Report. Portions of the records not relevant to the analysis shall not be disclosed.

Note. 2 A communication record obtained under this Regulation shall not be used against any person in any legal or disciplinary proceedings.

Note. 3 Information contained in the records listed above which may include information given voluntarily by persons interviewed during the investigation of an aviation occurrence, could be utilized inappropriately for subsequent disciplinary, civil, administrative and criminal proceedings. If such information is distributed, it may, in the future, no longer be openly disclosed to investigators. Lack of access to such information would impede the investigation process and seriously affect aviation safety.

5.18 Right of Representation

Any person interviewed by an authorized representative of the QAAI during an investigation will be accorded the right to be accompanied by an adviser. This adviser will be approved by the QAAI representative conducting the interview. If a disagreement exists, the QAAI IIC shall hold the final decision




in the matter. At no time will a person or lawyer who represents any media, claimants, insurers, or consultants be allowed to attend an interview.

5.19 Autopsies and Toxicological Examinations (1) QAAI, if conducting an investigation shall arrange for complete autopsy or seek other tests of

fatally injured flight crew and, subject to the particular circumstances, of fatally injured persons and cabin crew. Such persons as may be necessary to the investigation provided that to the extent consistent with the needs of the investigation, the provisions of laws protecting religious beliefs with respect to autopsies shall be observed.

(2) The QAAI IIC is authorized to obtain a copy of the report of an autopsy performed by officials on any person who dies as a result of having been involved in an aviation occurrence within the jurisdiction of the QAAI.

(3) it is the responsibility of the QAAI IIC or his representative to provide a toxicological sample kit to the involved medical personnel (i.e. pathologist or coroner). Once obtained, the QAAI IIC or his representative should ensure that the samples are shipped as directed using the instructions contained in the kit, to the named laboratory and by the most expeditious means possible. The QAAI will bear the costs of such tests.

5.20 Medical Examinations

When appropriate, the QAAI IIC or his representative should arrange for medical examination of the crew, passengers, and other involved aviation personnel by a qualified medical representative experienced in aviation occurrence investigation. These examinations should be conducted and completed in an expeditious manner.

5.21 Flight Recorder Read-Out and Analysis

5.21.1 Authority of the QAAI

The QAAI is the sole entity authorized to retrieve flight recorders from aircraft for the purpose of aviation occurrence investigations. No other party shall retrieve flight recorders from an aircraft involved into an aviation occurrence being investigated by the QAAI. The QAAI, as the State conducting the investigation of the occurrence shall arrange for the read-out of the flight recorders without delay giving consideration to the following:

(1) The capabilities of the facility; (2) The timeliness of the read-out and; (3) The location of the read-out facility.

The IIC shall ensure that only parties relevant to the Flight Recorder Group are invited. These parties may include the QCAA, manufacturer, and operator/owner. Involved flight crew cannot participate as group members.

5.21.2 Initial response

It is essential that the flight recorders be read out as early as possible after an aviation occurrence. Early identification of problem areas can affect the investigation at the aviation occurrence site where evidence is sometimes transient. Early identification of problem areas may also result in urgent safety recommendations necessary to prevent a similar occurrence.

The QAAI IIC shall make timely arrangements to read out the flight recorders at a suitable readout facility if it does not have an adequate facility.

5.21.3 Choice of Facility

The QAAI may request assistance from any State that can best serve the investigation. The manufacturer ’s standard replay equipment and playback software, which is typically used by operators and maintenance facilities, is not considered adequate for investigation purposes.

Facilities for the read-out of flight recorders should have the following capabilities: (1) The ability to disassemble and read out recorders that have substantial damage;




(2) The ability to play back the original recording/memory module without the need for the use of a manufacturer’s copy device or the recorder housing that was involved in the aviation occurrence;

(3) The ability to manually analyse the raw binary waveform from digital tape flight data recorders; (4) The ability to enhance and filter voice recordings digitally by means of suitable software; and (5) The capability to graphically analyse data, to derive additional parameters not explicitly recorded,

to validate the data by cross-checking, and other analytical methods to determine data accuracy and limitations.

5.21.4 Recommended Procedures (1) Flight data recorder and the cockpit voice recorder should be read out by the same facility

because they contain complementary data which can help validate each recording and aid in determining timing and synchronization.

(2) Flight recorders should not be opened or powered up and original recordings should not be copied, particularly not by high-speed devices, prior to the read-out because of possible damage caused to the recordings.

(3) The facility at which the flight recorders are read out for another State should be given an opportunity to comment on the Draft Final Report in order to ensure that the characteristics of the flight recorder analysis have been taken into account.

(4) The facility at which the flight recorders are read out may require the expertise of the aircraft manufacturer and operator in order to verify the calibration data and validate the recorded information.

When conducting the investigation, the QAAI may leave the original recordings or a copy of them, with the read- out facility until the investigation is completed in order to facilitate the timely resolution of additional requests or clarifications, providing that the facility has adequate security procedures to safeguard the recordings.

5.22 Release from Custody

5.22.1 Subject to the provisions of this Regulation, the QAAI IIC is the sole person authorized to release custody of the aircraft, its contents or any parts thereof or any record, which are no longer required in the investigation. The release shall be done in writing to any person or persons duly designated. For this purpose, the QAAI shall facilitate access to the aircraft, its contents, or any parts thereof.

5.22.2 Custody of the material shall be retained by the QAAI if any of the following exists: (1) When the pre-impact position, status or operation of an aircraft component or wreckage piece is

likely to be a matter of controversy. (2) When the material is assessed to have either failed prior to impact, or otherwise involved in the

circumstances leading up to the occurrence; or (3) When political implications, public interest or other circumstances are such that either

controversy or news coverage is likely

5.22.3 For the return of any material taken or seized during an investigation, the following shall be taken prior to release of any material:

(1) All examinations and analysis shall be completed with documentations and findings results. (2) Prior to release of any wreckage, the owner of such evidence or party having interest in the

wreckage shall be advised. (3) The applicable national legislation shall be applied for the said purpose. (4) The IIC shall document all actions taken in accordance with the Qatar Environmental legislation

when disposing wreckage and hazardous materials. 5.22.4 The release of wreckage and seized property shall be documented and signed by the IIC. The owner or other responsible authority will acknowledge the receipt of the said wreckage or property.

5.22.5 The QAAI shall return the material when it is no longer required for the purpose of investigation to the owner or his representative. However, if the IIC is unable to dispose despite making reasonable efforts in determining the owner’s whereabouts, the QAAI may dispose the said items in an appropriate manner.




5.22.6 The QAAI shall have at its disposal, either directly or by means of alliance with another party, or through agreements with other national authorities or entities, qualified personnel and acceptable facilities, the latter of which will include the hangars, to enable the storage and examination of the aircraft, its contents and wreckage.

5.23 Transportation and Communication (1) The QAAI must arrange for appropriate lodging and transportation for the QAAI investigation

team in the area of the accident site. As a contingency measure, the QAAI will make prior arrangements for the expeditious issuance of tickets on commercial flights for the QAAI team members. All other participants shall coordinate their transportation plans or requests with the QAAI. For other State’s accredited representatives, experts as well as advisers’ facilitation of entry into the State Annex 9 is applicable.

(2) Upon presenting his credentials as an QAAI Investigator/Representative to the desk/gate representative of any domestic scheduled operator and requesting transportation to an accident or serious incident site that operator will be obligated to fulfil his request by providing free of charge transportation irrespective of prior seating arrangements that have already been made on board the aircraft. If the cabin is fully occupied, the QAAI Investigator/Representative will occupy the cockpit jump seat. If more than one Investigator/Representative is traveling and the cockpit and cabin are fully occupied, an equal number of ticketed passengers will be deplaned to allow the seating of the additional QAAI Investigators /Representatives.

(3) During the return travel from an investigation site, the operator will be required to provide free of charge transportation to any QAAI Investigator /Representative to include access to unoccupied cockpit jump seat(s). Revenue passengers will not be deplaned to allow the boarding of QAAI Investigators/Representatives during the return travel.

(4) Although the operator is required to provide transportation under the conditions stated above in Article 5.23 2 and 3, the final determination as to which seats will be occupied by the QAAI Investigators/Representatives is at the discretion of the Captain of the flight/aircraft.

(5) The QAAI has a communication plan/policy and procedures for notification of an occurrence and coordination with other involved States, government authorities such as Judicial and MOI, departments, media and other parties that have interest in the investigation. The QAAI has its website and 24/7 contact numbers for notification purposes.

(6) The QAAI will provide investigators, and when applicable accredited representatives and other participants to an investigation, portable radios and/or mobile phones for ease of communication during the conduct of the investigation. Telephone lines will also be installed at the accident site if applicable.

5.24 Investigative Equipment Requirements

Correct planning and preparedness are vital in facilitating the prompt arrival of investigators at an occurrence site. On this point, accident investigators should have their investigation field kits and important personal items prepared so that they can immediately be transported to the occurrence site.

5.24.1 Policy

It is the responsibility of the QAAI to acquire and store this equipment for investigator use when needed.

5.25 Serious Incident Investigation (1) The QAAI, shall institute a preliminary investigation into the circumstances of Serious Incidents

to determine the seriousness. (2) The QAAI may also, as warranted by the circumstances, delegate the whole or part of the

conduct of any investigation to another State by mutual agreement and consent.




(3) The incidents listed in Sec. 1.3 and Attachment B in Chapter 1 are typical examples of serious incidents. The QAAI will determine the classification of an occurrence as per the internal procedures.

5.26 Facilities, Equipment and Additional Manpower

(1) The QAAI may have to rely on assistance from other Qatar civil and foreign organizations to provide facilities, equipment and additional manpower such as:

(1) Helicopters (2) Heavy lifting and moving gear (3) Metal detectors (4) Geiger counters (5) Communication equipment (6) Divers (7) professional surveyors for requirement of extensive wreckage plot

5.26.1 Water Recovery Plan

The QAAI shall establish appropriate arrangements with Marine authorities, private marine salvage services or other States to provide assistance in water wreckage recovery.




Attachment A Rights and obligations of the State of the Operator in respect of accidents and incidents involving Leased, Chartered or Interchanged aircraft

The Standards and Recommended Practices of Annex 13 - Aircraft Accident and Incident Investigation were developed when the State of Registry and the State of the Operator normally were the same. In recent years, however, international aircraft leasing and interchanging arrangements have developed so that in many instances the State of the Operator is different from the State of Registry.

Leasing or interchange arrangements sometimes include the provision of flight crews from the State of Registry. However, more often, flight crews are provided by the State of the Operator and the aircraft operated under national legislation of the State of the Operator. Similarly, a variety of arrangements for airworthiness can emerge from these arrangements. Airworthiness responsibility may rest, wholly or partly, with the State of the Operator or State of Registry. Sometimes the operator, in conformity with an airworthiness control system specified by the State of Registry, carries out maintenance and keeps records.

In the event of an accident or incident, it is important that any State which has assumed responsibility for the safety of an aircraft has the right to participate in an investigation, at least in respect of that responsibility. It is also important that the State conducting the investigation should have speedy access to all documents and other information relevant to that investigation.

When the location of an accident or an incident cannot definitely be established as being in the territory of another State, the State of the Operator, after consultation with the State of Registry, should accept full or partial responsibility for the conduct of the investigation.

Participation by the State of Manufacture (or Design) and the State of the Operator

The State of Manufacture (or Design) has airworthiness responsibilities and the expertise normally required to read out and analyse flight recorder information. Since flight recorder information can often reveal airworthiness problems, the State of Manufacture (or Design) should have a representative present when the flight recorder read-out and analysis are being conducted in a State other than the State of Manufacture (or Design).

The State of the Operator has regulatory responsibilities regarding the flight operation and can provide insights into operational issues which may be specific to the operator. Since flight recorder information can reveal operational problems, the State of the Operator should also have a representative present when the flight recorder read-out and analysis are being conducted.




CHAPTER 6 - REPORTING

6.1 Release of Information/Consent

The QAAI shall not disseminate, publish or give access to a draft report or any part thereof, or any document obtained during an investigation of an occurrence without its consent or consent from the State which conducted the investigation unless such reports or documents have already been published or release by the latter State. (1) Release of information during the investigation, particularly at the aviation occurrence site, shall

be limited to factual information and shall be made only by the Manager of Communications of the QAAI or its Media Representative. For this purpose, the Media Representative of the QAAI shall coordinate all information to be released with the QAAI IIC.

(2) The QAAI, in coordination with the QAAI IIC, will ensure that relevant and timely information on the progress of the investigation will be provided to the families and accident survivors until the Final Report has been completed and approved;

(3) All information concerning the aviation occurrence obtained by any personnel participating in the investigation shall be passed to the QAAI IIC through appropriate organizational channels. Upon approval by the QAAI IIC, Participants to the investigation may relay to their respective organizations information which is necessary for purposes of prevention or remedial action. Under no circumstances shall aviation occurrence information be released to anyone not participating in the investigation, or discussed with any unauthorized persons; and

(4) Information concerning an aviation occurrence involving both civil and military aircraft should be exchanged among the military service and the other parties involved, promptly and completely.

6.2 Release of the Preliminary Report

The QAAI as the State conducting the investigation, shall send a copy of the preliminary report to the State which instituted the investigation, to all States that participated in the investigation and to ICAO, if applicable, for the purpose of obtaining significant and justifying comments on the on the report. (1) If an aircraft involved in an accident is of a maximum mass of over 2 250 kg, the QAAI shall send

a Preliminary Report to:

(a) the State of Registry or the State of Occurrence, as appropriate;

(b) the State of the Operator;

(c) the State of Design;

(d) the State of Manufacture;

(e) any State that provided relevant information, significant facilities or experts; and

(f) ICAO (2) When an aircraft involved in an accident has a maximum mass of less than 2,250 kg and, when

airworthiness or other matters are considered to be of interest to the other States involved, the QAAI shall forward a Preliminary Report to:

(a) the State of Registry or the State of Occurrence, as appropriate;

(b) the State of the Operator;

(c) the State of Design;

(d) the State of Manufacture; and

(e) any State that provided relevant information, significant facilities or experts. (3) The Preliminary Report shall be submitted to the appropriate States and to the International Civil




Aviation Organization in English. (4) The QAAI shall send the Preliminary Report by facsimile, email, or airmail normally within thirty

(30) days of the date of the aviation occurrence unless the Accident/Incident Data Report (ADREP) or the European Coordination Centre for Accident and Incident Reporting Systems (ECCAIRS) has already been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most expeditious means available.

6.3 Accident/ Incident Data Report

6.3.1 ICAO Obligation

This obligation applies to QAAI as the State conducting the investigation of accidents and serious incidents to aircraft over 5700 kg.

Following completion of the investigation and release of the final report, the QAAI will send Accident Data Report to ICAO as soon as practicable after an investigation. If the completion of the investigation indicates that some of the data in the Preliminary Report is inaccurate or incomplete, this information should also be reflected in the Accident Data Report.

QAAI Responsibilities as the State conducting the investigation: (1) Accidents to aircraft over 2250 kg. When an aircraft involved is of a maximum mass of over 2,250 kg., the QAAI shall send, as soon as practicable following the investigation, an Accident Data Report to the ICAO (2) Serious incidents to aircraft over 5,700 kg. When an aircraft involved is of a maximum mass over 5,700 kg, the QAAI shall send, as soon as practicable following the investigation, the Incident Report to ICAO (3) Additional information

The QAAI shall, upon request, provide other States with pertinent information additional to that made available in the Accident/Incident Data Report

6.4 Stand-Alone Recommendation

Any safety deficiency that becomes known during the course of the investigation for which prompt preventative action is required, shall be disclosed immediately through a Stand-Alone Recommendation to all concerned parties including appropriate authorities in other States and ICAO whenever any ICAO documents are involved. This action shall be coordinated through the QAAI IIC.

6.5 Inquiries

Responses to inquiries regarding investigations received from any source will be coordinated with the QAAI IIC prior to release.

6.6 The QAAI Aviation Occurrence Report (1) Upon completion of all phases of the investigation and receipt of all Group Reports, the QAAI IIC

will be responsible for preparing the report in the format defined in this regulation and in accordance with the report standards found in the ICAO Publication. The QAAI IIC may adapt the format of the report to the circumstances of a particular aviation occurrence. The report will be processed in two steps; the Draft Final Report and the Final Report. The Final Report will be completed in English. During the entire report writing and review phases, specified individuals within the QAAI will review the report for accuracy, completeness, logical construction and analysis, appropriate findings and recommendations. In addition to the latter, when applicable any intended safety recommendations are to be included in the draft Final.

(2) The QAAI shall send a copy of the Draft Final Report to all the States that participated in the

investigation, inviting their significant and substantiated comments. The Draft Final Report shall be sent for comments to the:

(a) State that instituted the investigation;




(b) State of Registry; (c) State of the Operator; (d) State of Design; (e) State of Manufacture; and (f) Any State that participated in the investigation

(3) The QAAI shall send, through the States mentioned in Article 6.6(2), a copy of the Draft Final Report to enable them to submit comments on the latter.

(4) No State, nor other Participants to the QAAI investigation shall circulate, publish, or give access to a Draft Final Report or any part thereof, or any documents obtained during an investigation of an aviation occurrence, without the express written consent of the QAAI IIC who conducted the investigation, unless such reports or documents have already been published or released by the QAAI.

(5) If comments are received within sixty (60) days of the date of the transmittal letter, the QAAI IIC should either amend the Draft Final Report to include the substance of the comments received or if desired by the State that provided comments, append the comments to the Final Report. If the QAAI receives no comments within sixty (60) days of the date of the first transmittal letter related to the presentation of the Draft Final Report, it shall issue the Final Report in accordance with this Regulation, unless an extension of that period has been agreed upon with the States concerned.

(6) The Final Report will be prepared by the QAAI IIC and submitted to the Chief Investigator and to the Head of the QAAI for review. The Head of the QAAI will submit the Final Report to the Ministry of Transportation and Communications.

6.7 Release of the Final Report

Upon approval by the Director of QAAI, the Final Report with all the required changes, if applicable, will be processed by the QAAI for final editing, reproduction and official release. After completion, a copy of the Final Report shall be provided to:

(1) The State that instituted the investigation;

(2) The State of Registry;

(3) The State of the Operator;

(4) The State of Design;

(5) The State of Manufacture;

(6) Any State having suffered fatalities or serious injuries to its citizens;

(7) Any State that provided relevant information, significant facilities or experts;

(8) Any State that participated in the investigation and;

(9) ICAO- when it has investigated an accident or incident to an aircraft of a maximum mass of over 5700 kg.

In the interest of averting an accident, the QAAI shall make the Final Report publicly available as soon as possible, if practicable, within twelve (12) months.

Note: The Final Report shall be made publicly available as soon as possible and, if feasible, within one (1) year from the date of the aviation occurrence unless factors beyond the control of the QAAI preclude meeting this deadline. If the one-year deadline cannot be achieved, a Transitional Report or an interim statement shall be issued detailing the progress, identifying any outstanding safety issues along with an estimate of the additional time required to complete the Final Report.

Making the Final Report publicly available will be achieved by posting the Final Report on the QAAI Website. A hard copy of the Final Report will be available only by a written request.

6.8 Re-opening of case/investigation




In case, new and significant evidence becomes available during the course of an investigation and even after the Final Report has been released, the QAAI, if it conducted the investigation, shall re-open the investigation. Reconsideration and modification will be entertained only, if based on the submission of evidence not previously known or available such as; statements of prospective witnesses, authenticated documents on the discovery of pertinent new evidence or by a showing that the findings as to the facts, conditions and circumstances of the aviation occurrence are substantially in error. An explanation shall be provided indicating why such substantiation was not available prior to the QAAI determination of the findings. Such requests shall be made in writing. Requests which are repetitious or based on positions previously advanced will not be entertained.

If the QAAI conducted the investigation but did not originally institute it, the QAAI shall first obtain the consent of the State which first instituted the investigation before re-opening the investigation.

Further, any re-opened investigation shall be subject to and conducted in accordance with this regulation.

6.9 Occurrences Investigated by other entities

When the QAAI does not conduct an investigation of an aviation occurrence, the QAAI may obtain any relative information and documentation related an aviation occurrence from any department, or operator. The information shall be provided in a format that is consistent with the report outlined in ICAO Annex 13 or any other format agreeable to the QAAI. The department or the operator may not arbitrarily delay investigating an event or providing the results of an investigation to the QAAI. Any delays must be justified and appropriately documented.




ATTACHMENT A. -FORMAT of the Final Report 1) Title. The Final Report begins with a title comprising:

(a) name of the operator;

(b) manufacturer, model,

(c) nationality and registration marks of the aircraft; and

(d) place and date of the accident or incident.

2) Synopsis. Following the title is a synopsis describing briefly all relevant information regarding:

(a) notification of accident to national and foreign authorities;

(b) identification of the accident investigation authority and accredited representation;

(c) organization of the investigation;

(d) authority releasing the report and

(e) date of publication and concluding with a brief resume of the circumstances leading to the accident

3) Body. The body of the Final Report comprises the following main headings:

(a) Factual information

(b) Analysis

(c) Conclusions

(d) Safety recommendations

Note: Each heading consisting of a number of subheadings as outlined in the following.

4) Appendices. Include as appropriate.

Note. - In preparing a Final Report, using this format, ensure that:

a) all information relevant to an understanding of the factual information, analysis and conclusions is included under each appropriate heading;

b) where information in respect of any of the items in 1.- Factual information is not available, or is irrelevant to the circumstances leading to the accident, a note to this effect is included under the appropriate subheadings.

1. FACTUAL INFORMATION

1.1 History of the flight. A brief narrative giving the following information:

- Flight number, type of operation, last point of departure, time of departure (local time or UTC), point of intended landing.

- Flight preparation, description of the flight and events leading to the accident, including




reconstruction of the significant portion of the flight path, if appropriate.

- Location (latitude, longitude, elevation), time of the accident (local time or UTC), whether day or night.

1.2 Injuries to persons. Completion of the following (in numbers):

Note. - Fatal injuries include all deaths determined to be a direct result of injuries sustained in

the accident. Serious injury is defined in Chap 1 of Annex 13

1.3 Damage to aircraft. Brief statement of the damage sustained by aircraft in the accident (destroyed, substantially damaged, slightly damaged, no damage).

1.4 Other damage. Brief description of damage sustained by objects other than the aircraft.

1.5 Personnel information:

a) Pertinent information concerning each of the flight crew members including: age, validity of licences, ratings, mandatory checks, flying experience (total and on type) and relevant information on duty time.

b) Brief statement of qualifications and experience of other crew members.

c) Pertinent information regarding other personnel, such as air traffic services, maintenance, etc., when relevant.

1.6 Aircraft information:

a) Brief statement on airworthiness and maintenance of the aircraft (indication of deficiencies known prior to and during the flight to be included, if having any bearing on the accident).

b) Brief statement on performance, if relevant, and whether the mass and centre of gravity

were within the prescribed limits during the phase of operation related to the accident. (If not and if of any bearing on the accident give details.)

c) Type of fuel used. 1.7 Meteorological information:

a) Brief statement on the meteorological conditions appropriate to the circumstances including

both forecast and actual conditions, and the availability of meteorological information to the crew.

b) Natural light conditions at the time of the accident (sunlight, moonlight, twilight, etc.).

Injuries Crew Passengers Others

Fatal

Serious

Minor/None




1.8 Aids to navigation. Pertinent information on navigation aids available, including landing aids such as ILS, MLS, NDB, PAR, VOR, visual ground aids, etc., and their effectiveness at the time.

1.9 Communications. Pertinent information on aeronautical mobile and fixed service communications and their effectiveness.

1.10 Aerodrome information. Pertinent information associated with the aerodrome, its facilities and condition, or with the take-off or landing area if other than an aerodrome.

1.11 Flight recorders. Location of the flight recorder installations in the aircraft, their condition on recovery and pertinent data available therefrom.

1.12 Wreckage and impact information. General information on the site of the accident and the distribution pattern of the wreckage, detected material failures or component malfunctions. Details concerning the location and state of the different pieces of the wreckage are not normally required unless it is necessary to indicate a break-up of the aircraft prior to impact. Diagrams, charts and photographs may be included in this section or attached in the appendices.

1.13 Medical and pathological information. Brief description of the results of the investigation undertaken and pertinent data available therefrom.

Note. - Medical information related to flight crew licences should be included in 1.5 - Personnel information.

1.14 Fire. If fire occurred, information on the nature of the occurrence, and of the firefighting equipment used and its effectiveness.

1.15 Survival aspects. Brief description of search, evacuation and rescue, location of crew and passengers in relation to injuries sustained, and failure of structures such as seats and seat-belt attachments.

1.16 Tests and research. Brief statements regarding the results of tests and research.

1.17 Organizational and management information. Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example: the operator; the air traffic services; airway, aerodrome and weather service centres; and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices, and regulatory framework.

1.18 Additional information. Relevant information not already included in 1.1 to 1.17.

1.19 Useful or effective investigation techniques. When useful or effective investigation techniques have been used during the investigation, briefly indicate the reason for using these techniques and refer here to the main features as well as describing the results under the appropriate subheadings 1.1 to 1.18.

2. ANALYSIS




Analyse, as appropriate, only the information documented in 1. - Factual information and which is relevant to the determination of conclusions and causes and/or contributing factors.

3. CONCLUSIONS

List the findings, causes and/or contributing factors established in the investigation. The list of causes and/or contributing factors should include both the immediate and the deeper systemic causes and/or contributing factors.

Note. - As stated in Chapter 6, 6.1, the Final Report format presented in this Appendix may be adapted to the circumstances of the accident or incident. Thus, States may use either “causes” or “contributing factors”, or both, in the Conclusions.

4. SAFETY RECOMMENDATIONS

As appropriate, briefly state any recommendations made for the purpose of accident prevention and identify safety actions already implemented.

APPENDICES

Include, as appropriate, any other pertinent information considered necessary for the understanding of the Final Report.




CHAPTER 7 - DATA REPORTING

7.1 Release of the ICAO Data Report

When the aircraft involved in an aviation occurrence has a maximum mass of over 2,250 kg; (1) The QAAI shall send, as soon as practicable after the investigation, a completed ADREP /

ECCAIRS Report to the International Civil Aviation Organization. (2) The QAAI should, upon request, provide other States with pertinent information additional to that

made available in the Accident/Incident Data Report (ADREP)/ECCAIRS.

7.2 Accident and Incident Database

All accidents and incidents reported under the requirements of this Regulation shall be electronically stored as a standardized descriptive database. The data retrieval will display frequencies over time to identify adverse trends. The database will include the following information:

(1) Type, nationality, registration marks of the aircraft and flight number for scheduled flights;

(2) Position of the aircraft with reference to some easily defined geographical point;

(3) Airport, if applicable;

(4) Name of the operator of the aircraft;

(5) Date and time of the occurrence;

(6) Number of persons aboard, number killed, and number seriously injured;

(7) Description of the occurrence;

(8) Name of the IIC;

(9) The extent of damage to the aircraft;

(10) Classification of the occurrence;

(11) Category;

(12) Sub-category;

(13) Written summary; and

(14) Contributing factors

7.3 Data Sharing

The QAAI is authorized to share aviation occurrence data with ICAO member States and regional and international flight safety organizations for the sole purpose of improving aviation safety. Additional guidance is also included in Annex 19, Safety Management.




CHAPTER 8 - PREVENTION

8.1 Safety Reports

(1) The QAAI shall provide periodic analytical reports to the Minister of Ministry of Transportation and Communications

The reports shall:

(a) Advocate meaningful responses to reduce the likelihood of aviation occurrences similar to those investigated by the QAAI; and

(b) Propose corrective action to make air transportation as safe and free from risk of injury, including action to minimize personal injuries that occur in aircraft accidents.

(2) Studies, Investigations, and Other Reports. The QAAI will also:

(a) Carry out special studies and investigations about aviation safety; (b) Evaluate the adequacy of safeguards in the transportation of hazardous material by air and

the performance of other government authority responsible for the safe transportation of hazardous material; and

(3) Other organizations involved or affected by the accident, such as airlines, airports, emergency

services and aircraft manufacturers, may release information to the media on their related fields.

(4) Make safety recommendations resulting from studies or investigations.

8.2 Safety Recommendations

8.2.1 Policies on Safety Recommendations

(1) The sole objective of investigations is prevention of recurrences, the determination of appropriate safety recommendations and addressing them to the appropriate authority is of utmost importance.

(2) Such recommendations should describe the safety problem and provide justification for safety actions.

(3) Care should be taken to avoid prescribing specific solutions, deferring instead to the recipient authority to determine how the objective of the recommendation can best be achieved.

(4) The QAAI shall be responsible for recommending corrective or remedial actions as a result of investigations or safety studies for the purpose of preventing further aviation occurrences. The recommendations should be broad in application to allow the addressees of the recommendations to have some discretion in implementing specific remedial actions.

(5) At any stage of the investigation of an aviation occurrence, the QAAI shall recommend in a dated transmittal correspondence to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

(6) The QAAI, if conducting an investigation, shall address, when applicable, any safety recommendations arising from its investigations to an occurrence to the concerned State(s), other parties as appropriate, and to ICAO, when ICAO documents are involved. Safety concerns identified which did not contribute to an accident but which, nonetheless, are safety deficiencies.




These safety deficiencies should be addressed in the Final Report.

(7) It is the policy of the QAAI that safety-related information provided in confidentiality and not in the context of particular aviation occurrence investigations will not be disclosed. Reference to such information for the purpose of safety recommendations will be undertaken with consideration for its confidentiality.

(8) The safety recommendation shall in no case create an assumption of blame or liability for an accident, serious incident or incident.

(9) When Final reports contain safety recommendations addressed to ICAO, it will send such reports to ICAO with a letter outlining the specific action proposed.

8.3 Responding/ Follow-up to Safety Recommendations

So that action may be taken on any recommendation issued by the QAAI and to receive timely feedback regarding the implementation of any recommendation, the following will apply:

(1) The receiving State of a safety recommendation shall give the QAAI a formal written response to each safety recommendation no later than 90 days after receiving the safety recommendation;

(2) The written response shall indicate what action was taken to adopt the safety recommendation or part of it;

(3) If the safety recommendation was rejected, the State shall explain the reasons for its refusal to implement the safety recommendation; and

(4) The QAAI may make available to the public all responses to all safety recommendations through the QAAI Website.

8.4 Safety Recommendations from Other States

When the QAAI receives safety recommendations as the result of a foreign investigation, the QAAI shall inform the proposing State no less than ninety (90) days after receiving the safety recommendation the preventive action taken or under consideration, or the reasons why no action will be taken.

Further, QAAI shall also implement procedures to record and track the responses to the safety recommendations it has issued or receives from foreign States as well as progress of the action taken in response to each safety recommendation.

All safety responses will be publicly available or posted on the website of the State that has issued the safety recommendation.

8.5 Participation

The QAAI should participate in all appropriate non- governmental organizations that have as their primary function, the advancement of aviation safety through active exchanges of safety-related information.

8.6 State Safety Program (SSP)

The SSP is mainly the responsibility of the regulatory authority (QCAA) within the State of Qatar. The participation of the QAAI to the SSP will be to provide the QCAA with the required safety data in accordance with Annex 19.




CHAPTER 9 – POST ACCIDENT 9 Post Accident and Incident Communications

The QAAI shall establish a system to promote dissemination, on regular basis, of factual information of an accident or serious incident and the progress of its investigation to the media. The system shall ensure that speculation and rumours about the occurrence are minimized and that the released facts do not cause partiality to the investigation and that the needs of the media do not interfere with the proper conduct of the investigation.

9.1 Good Rapport with the Media (1) Since most major accidents generate a high degree of interest from both the public and the

media, the QAAI will strive to establish good rapport with the media. (2) To promote dissemination of factual information and to minimize speculations and rumours about

the accident, the QAAI or the IIC or any designee, serves as the single point of contact for providing the media, on a regular basis, with all facts that can be released without prejudice to the investigation.

(3) Such media contact, in consultation with the accredited representatives, should provide non-prejudicial facts and circumstances to the media. Nonetheless, the QAAI will ensure that the needs of the media do not interfere with the proper conduct of investigation.

9.2 Release of information (1) No one other than the person designated by the Head of Air Accident Investigation Unit, may

release, or cause to be released, any information to the media/public about the progress of the investigation, on any findings or causes thereof.

(2) The QAAI and the accredited representatives as well the latter' advisers participating in the investigation shall not provide the media or the public access to any documents obtained during the investigation without the express consent of the Head of the QAAI as this would undermine the mutual confidence and cooperation among the States involved and therefore must be avoided.

(3) Other organizations involved or affected by the accident, such as airlines, airports, emergency services and aircraft manufacturers, may release information to the media on their related fields.




CHAPTER 10 – ASSISTANCE TO SURVIVORS AND FAMILIES (1) Since the IIC must remain focused on the investigation, the provision of family assistance should

be separate from the investigation. (2) Nonetheless, the QAAI has a responsibility to provide relevant and timely information to the

families and the accident survivors, information of immediate concern such as the release of human remains and personal effects held as part of the investigation, information on the progress of the investigation in determining the causes of the accident, and safety recommendations being contemplated to prevent similar accidents.

(3) To fulfil this responsibility, the Head of the QAAI will shield the IIC from the customary large number of direct inquiries by appointing a liaison person as the focal point of the families.