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AviationAccidentInvestigationTemplate

General

This template is designed to serve as a checklist for the writer of the report. Delete portions that
do not apply to the accident under investigation. Review chapter 6 of the Accident Investigation
Guide.

Do not identify involved personnel by name in the narrative. Identify involved personnel by their
position. Involved personnel are individuals:

Who had an active role in the accident


Who were injured in the accident
Whose actions or inactions initiated or sustained the accident sequence
______________________________________________________________________________

Photographs, maps, illustrations, exhibits, and so forth, will be referenced in the section where
applicable and properly identified as figure 1, figure 2, and so on.

Photographs should be taken before the accident scene (wreckage) is disturbed. General views of
the scene from several different directions is recommended. The location and direction of each
photo should be recorded. The following kinds of items should be photographed.

Aircraft site Control surface positions Ground impact marks


Instruments Suspicious bends or breaks Seats and seat belts
Controls in cockpit Vegetation strike points Approach
paths
Radio settings Propeller blades showing pitch positions Terrain and obstacles, if relevant

Fuel valve setting Engine control positions in cockpit and


engine Photographic documentation of crash sequence
Switch locations Fire damage Aerial pictures
documenting the site and wreckage
orientation

Location maps (include as appropriate)


General location map Suppression plan and initial action
plan
Profile of flight/probable path of flight Shelter deployment location
diagram
Diagram/sketches of the airport layout/helibase Fire progress maps
Accident scene or aerial photo identifying important features
Physical Evidence
Analysis reports from any aircraft components

Records
Factual data and documents used to substantiate facts involving the accident. Witness statements
and interviews shall be signed. If telephone and transcribed statements cannot be signed due to
witness condition, timing, or availability, insert a statement by the investigator or interviewer
attesting to the time and date of the interview, followed by the investigators or interviewers
signature. These records should not be part of the factual section or the management evaluation
section. These records shall reside in an official case file. They may be used by the ARB for their
deliberations. Examples of records are witness statements and interviews, training records,
licenses, and aircraft and pilot cards.

You must delete these general pages and the checklist items as you fill in the sections and
proceed through the report. Do not address items that do not apply.

United States Department of Agriculture


Forest Service

THIS DOCUMENT CONTAINS MATERIALS FOR INTERNAL AGENCY USE ONLY


AND MAY NOT BE RELEASED UNDER THE FREEDOM OF INFORMATION ACT
WITHOUT OFFICE OF GENERAL COUNSEL REVIEW

Draft Preliminary Aircraft Accident


Investigation Report

(Type of accident)
(Unit, location)
(Region/station/area/institute)
(City, State)
(Date of accident or incident)
Mount 4- by 6-inch photo here

DRAFT FOR OFFICIAL USE ONLY Copy_____of_____


This report will remain preliminary until the NTSB releases the final report.

Preliminary Aircraft Accident Investigation Report

Accident: (Aircraft tail number, make, and model, and accident type)
___________________________________________________________________________________
___________________________________________________________________________________

Location: (Unit and location where accident occurred)


___________________________________________________________________________________

Date: (Date of accident)________________________________________________________________

Signatures:
___________________________________________________________________________________
Investigation team leader: (Name, title, and location of home unit)

___________________________________________________________________________________
Qualified technical investigator: (Name, title, and location of home unit)

Investigation team members: (Names, titles, and locations of home units)


___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Investigation technical consultants: (Names, titles, and locations of home units)


___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Table of Contents

Preliminary Factual Section___________________________x

Executive Summary________________________________x

Narrative____________________________________________x
Findings_____________________________________________x

Causal and Contributing Factors__________________x

Appendixes_________________________________________x
A. xxxxxxx__________________________________________x
B. xxxxxxx__________________________________________x
C. xxxxxxx__________________________________________x

Preliminary Management Evaluation Section_________x

Preliminary Recommendations_______________________x

Preliminary Factual Section


Executive Summary 12.Indicate who communicated with and/or
observed the
mission including those who witnessed the
Briefly describe the mission being performed
accident.
and the event that occurred to initiate the
accident investigation. It normally should not
Crash Sequence/Accident Response
exceed one page.

13.Describe the flight regime of the aircraft


during the final
Narrative
moments of flight, detailing each evolution,
until the
Mission
aircraft comes to a complete and final
resting position
1. Describe the mission events leading up to the
and all personnel have exited the aircraft.
accident.
2. Include brief statement describing the
14.Include all external factors involved in the
weather, terrain,
accident
obstacles, and other operational information
scenario such as fire, blade strikes, seat
concerning
belt integrity,
the mission.
component separation, and wreckage
movement.
3. Indicate who communicated with and/or
observed the
15.Provide a disintegration sequence from the
mission, including those who witnessed the
first point of
accident.
impact, or inflight separation.

4. List the personnel involved.


16.Describe briefly the actions taken
A. Describe the seating location in the
concerning:
aircraft.
A. Crash rescue efforts/body removal, and so
B. List the capacity of each crewmember or
forth.
passenger.
B. Accident plan availability and utilization.

5. Identify the make, model, and serial number


17. Describe briefly the problems encountered
of each
concerning:
aircraft.
A. Communication.
B. Availability of personnel/equipment.
6. Describe the aircraft configuration and
C. Transportation and other resources.
loading.
D. Interagency cooperation.
7. Identify who authorized (ordered) the flight.

Injury and Damage Descriptions


8. Identify who dispatched and provided flight
following
18.Personnel.
for the aircraft.
A. Briefly describe all personnel injuries.
B. List expected time of
9. Identify who provided operation control of
hospitalization/treatment.
the aircraft
other than the pilot. (For example; the forest 19. Aircraft.
or district A. Describe essential damage to the
dispatcher, the Incident Commander, the aircraft.
District Ranger, B. State whether damage was minor,
or the regional office). substantial,
demolished or burned.
Accident Chronology/Sequence of Events C. State whether the accident was
survivable and
10.Using a timeline, describe each significant whether the cabin retained structural
event prior integrity.
to the accident, including discovery, rescue, D. Photographic documentation.
and E. Other.
recovery.
20. Accident site
11. Include a brief statement describing the A. Describe accident site and damage.
weather, terrain,
obstacles, and other operational information 21. Omit details or circumstances that are
concerning unrelated to the
the mission. accident.

Preliminary Factual Section

Operational History A. Discuss the communications involved in


the mission.
22. Operation Base. When was the mission ordered?
A. Briefly describe the operation base How was it controlled?
supporting the Was there a flight plan?
mission. Were communications recorded?
B. Include only information that is related to Timely?
the mission B. Discuss accident response.
and accident. Timeliness.
C. Describe the appearance, accessibility, Availability of personnel and equipment.
location, C. Discuss use of checklists (crash/rescue,
suitability, organization, and management risk analysis,
of the pilot and aircraft, and so forth).
facility, including deficiencies. D. Does the forest aviation plan address
D. Describe communication between the these issues?
facility and Is it adequate? Current? Utilized?
dispatch including aircraft
communications. 26. Operational inspections and followup.
E. Describe the safety measures for the base, A. List the contract inspections performed
including on the pilot
the condition and suitability of equipment. and aircraft since award.
F. Equipment inspection currency. B. Document and discuss operations
G. Accident planning and response. inspections
performed on mission personnel.
23. Aircraft and pilot.
A. Discuss the following concerning the 27.Physical environment.
aircraft. A. Discuss the effects of altitude,
Maintenance history. temperature, terrain,
Inspections and approval. weather, and turbulence on the accident
Mission loading. mission.
B. Discuss contractor performance. B. Discuss the accident mission in relation
C. Discuss the following items concerning to other
the pilot. missions performed by the pilot or unit.
Performance and habits. Was the mission more difficult than
Manifesting and records management. normal?
Establish a 24-hour history (longer if Were environmental factors
necessary). considered ? By pilot,
Inspection and approval. crew, or dispatching?
Document last days off and flight and Was management involved in the decision
duty process?
limitations compliance. C. What was the workload on the pilot and
crew?
24. Organizational structure and management Was this taken into consideration by
relationships. managers and
A. Prepare an organizational structure chart at what levels?
for the D. Was the departure and arrival base or site
personnel involved in the accident and suitable
identify for the mission undertaken?
relationships to the mission flown. Discuss
super- Compliance With Directives
vision and staffing levels if relevant.
B. Identify the agency person who was in 28. Operational procedures.
operational A. Were standard procedures followed?
command of the mission. Establish why Pilot proficiency/currency.
and how Weight and balance/manifests.
this individual was selected. Load calculations/manifest.
C. Identify the individuals both inside and Aircraft and preflight checklists.
outside the Power trend checks.
organization who were in a position to Go/no-go checklists.
exercise some Personal protective equipment, PPE,
form of control over the mission, including (worn/used).
accident Pilot and aircraft approvals.
prevention (i.e., dispatcher, district ranger, Flight following.
helicopter Passenger controls (exposure to
manager, forest aviation officer, and so hazards).
forth).
D. Discuss the relationships as they are
relevant to the
investigation.

25. Aircraft dispatching and aircraft


management.
Preliminary Factual Section

Flight and duty limitations. B. Who reviews these documents on the unit?
Contracting. What is
Airport guides. done about problems identified? Determine
Minimum altitudes. timeliness
Safety briefings. of submission including review.
Other. C. Were other unit incident reports reviewed
B. Identify and discuss special mission and dis-
procedures as cussed by the individuals involved in the
they are related to the accident. accident? Is
a file available?
29. Training and Qualifications D. Are other unit reports or safety alerts
A. The purpose of this section is to evaluate available and
the training used?
and qualifications of personnel including
supervisors 33. Mission risk factors.
involved or directly associated with the A. Determine whether a risk analysis has been
accident. performed
B. Identify and discuss specific violations of and by whom. Is it current and applicable
established to the
policy. accident mission? Who was involved;
management,
30. Records management. pilot, crew, incident commander?
A. Identify and discuss whether directives, B. Determine whether risk determination is a
operational guides, contracts, manifest, and so consider-
forth, were readily available and properly ation in mission planning. How frequent?
utilized by personnel associated with the Supervision
accident. Were they current? and oversight?
B. Other records to consider: C. Establish what part the risk analysis
Timesheets and overtime records. played in the
Dispatching logs and communications accident mission.
records.
Forest aviation plan, fire plan, and so 34. Safety emphasis. The objective of this
forth. section is to determine the safety emphasis at
Daily diaries. each level of the organi-zation as it applies to
Other ICS forms, and so forth. this accident.
A. Who provides emphasis on safety?
31. Accident prevention opportunities. B. How is it provided? Accountability?
A. Attitudes and performance C. What is the frequency of briefings?
Discuss attitudes of personnel involved D. When was the last safety briefing held?
in the E. Do the district ranger, fire management
accident and their peers concerning: officer, forest
Use of PPE. fire staff, forest aviation officer, and others
Records management. participate?
Training guide and handbook
compliance.
Pilot and contractor performance.
Past operational practices. Findings
Weather, terrain, and fire behavior
predictions.
35. Develop findings from supporting data.
Safety practices and standard orders.
Findings are the conclusions of the accident
Management oversight.
investigation team based on the facts, weight of
evidence, professional knowledge, and good
32. Incident reports. The purpose of this
judgment. Each finding should, where possible, be
section is to
supported by two or more facts from the
determine whether 570014s, SAFECOMs,
investigation.
safety
A. Divide the listing of findings into sections
documents, and other operational information
by subject matter. For example:
is routinely
People
completed and submitted. Establish the
Pilot
following:
Personnel
A. History of submission by the
Management
unit/individual. Deter-
Equipment
mine whether any are related to the
Aircraft
accident being
Fuel Truck
investigated. If relevant include a listing of
reports and
actions taken to correct at the field and
Forest level.

Preliminary Factual Section


Environment Causal and Contributing Factors
Weather
Terrain
36. Causal factor definition:
A. Any behavior, acts, or omission that starts
Sample findings:
or sustains
an accident/incident occurrence. These
The accident/incident was partially survivable
can occur
due to the limited cabin structural damage and
individually or in combination. An event(s)
absence of fire following the accident (page
which
xxx).
sustain the occurrence sequence but were
normal to
The flight crewmembers were properly
the situation as it developed are not
certified and inspected (page xxx).
causal factors.
B. Base the causal factor(s) on the findings.
The load calculation and passenger manifest
Although
were properly completed and accurately
all the findings are significant, not all of
depicted conditions at the destination helispot
them relate to
(page xxx).
the cause of the accident.
C. Reference which findings were used to
Dispatch had not received a position report or
determine
contact for more than 30 minutes, and no attempt
each causal factor.
had been made during this period to contact the
aircraft or firefighters (page xxx).
37.Contributing factor definition:
A. Any behavior, act, or omission, which
The Forest Aviation Officer (or FMO) position
contributes to
had been vacant for 6 months, and no
but does not directly causean
assignments had been made to another
accident/incident
individual to perform this task (page xxx).
occurrence.
B. Management actions, failures, and behavior
Three 5700-14s, SAFECOMs reports had been
frequently
prepared on the pilot in the 12 days prior to the
contribute to an accident scenario, but by
accident (page xxx-xxx).
themselves
do not cause the accident to happen.
The last entry in the suppression
These actions
crewmembers training record was dated 21
meet this definition of contributing factor.
months prior to the accident. No helicopter
C. Reference which findings were used to
training was provided in 2000 (page xxx).
determine
each contributing factor.

Appendixes

38. Appendixes. Appendixes can be used as


reference information in the report. They should
not be part of the case file. Examples of
appendixes are:
A. Weather reports/summaries.
B. Aviation Human Factors Classification
Analysis
(HFACS).
C. PPE analysis.
D. Teardown analysis.
E. Equipment analysis.
F. NTSB Form 6120 1/2.

Preliminary Management Evaluation Section

Preliminary Recommendations forwarded to the Washington Office, Office of


Safety and
Occupational Health.
Recommendations

Case files will be maintained for the time period


Recommendations suggest measures that
required by Forest Service records management
management may take to prevent similar
rules or FOIA rules as appropriate and then
accidents. They must be reasonable, feasible,
destroyed, except one copy of the accident
and relate to the causal factors of the accident.
investigation report that will be kept
All recommendations must allow for a definite
permanently.
solution to the problem. Every causal factor
should have recommendations for future
Examples of records that would go in the case
prevention or mitigation, although exceptions
file are:
may occur. Upon completion of the report,
preliminary recommen-dations will be developed.
1. Witness statements and interviews.
This last step culminates in the investigation
report and represents the purpose for which the 2. Contract and equipment records.
investigation was conducted. Considerable effort A. Applicable portions of contracts and
should be expended to ensure that the Accident equipment
Review Board (ARB) develops quality records. Include contract number and
recommendations for further review and action. date signed.
Number the recommendations consecutively. Identify the contracting officer and
contraction
Recommendation number 01: officers representative (COR).
Recommendation number 02: B. COR diary or records.
Recommendation number 03: C. Rental equipment (as necessary and
relevant).
Case File
3. Aircraft records.
The accident investigation case file consists of A. FS aircraft inspection records.
two components: the accident investigation B. Discrepancy sheets and FS data cards.
report (factual section and management C. Aircraft log sheets relevant to the
evaluation section), and the supporting accident.
documentation and equipment that are not in the D. Power check forms.
investigation report. Cassette tapes, photos not E. Load calculation forms.
used or unfit for distribution, witness F. Load manifests and weight and balance
statements, and documents that may be too forms.
large, should not be included in the investigation
report. They should be kept in the case file and 4. Pilot records.
only referenced in the accident investigation A. Federal Aviation Administration (FAA)
report to support the teams findings. certificates.
B. Medical certificates.
The Washington Office, Office of Safety and C. Electrocardiogram (EKG).
Occupational Health is the office of record for all D. FS application and check-ride forms.
Chiefs level investigations. The office of record E. Pilot approval card and date.
for delegated Chiefs level investigations is the F. Pilot training and flight time records.
safety office of the Region or Station delegated G. Medical injury report.
responsibility to conduct the investigation. H. Autopsy (relevant portions only).
However, a copy of the accident investigation I. Death certificates.
report will be J. Previous 24-hour history.
K. Pilot safety briefing and contract briefing.

Preliminary Management Evaluation Section


5. Personnel records. 7. Communications record.
A. Aircraft crewmembers, helitack, and A. Radio and dispatch logs.
suppression B. Tapes and other communication records.
personnel.
Training and qualification records 8. NTSB Records.
Medical records of injured personnel A. Letter of transmittal.
Other related records B. Preliminary Accident Report.
Pay records (as needed)
9. Other:
6. Weather and terrain description.
A. Accident site.
B. Flight service station, FS fire weather,
lookout reports,
and so forth.
C. Fire behavior, predicted and actual.
D. Other.

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