Each year, we receive thousands of reports about aviation occurrences. All of them are analysed and classified and then some of them (accidents, serious incidents and some incidents) are selected for investigation.
Depending on the type of aircraft, victims status, damage to the aircraft, etc., we send a Go Team or , PKBWL expert to an occurrence site. In a case of minor occurrences, we obtain the necessary information from the police, fire brigade or other services that are present on the site.
In any case, the goal of PKBWL at this stage is to obtain available information, ensure the protection of the site, make an initial inspection, collect evidence, make photographic documentation, interview witnesses or at least obtain their contact details.
What should be remembered, PKBWL members or authorized experts have immediate and unlimited access to the: occurrence site, the aircraft, its parts, contents and documents, as well as the results of expertise that are conducted by other organizations.
Parallel to the activities on the occurrence site, organizational activities are carried out, such as notifying the concerned services and/or organizations, notifying the safety investigation authorities of the concerned States, such as the State of Registry, Operator, Designer and/or Manufacturer (in accordance with ICAO Annex 13 – Chapter 4).
Following the decision to investigate the occurrence, Investigator-In-Charge (IIC) and, if necessary, members of an Investigation Team are appointed. In case of a major accident, when on-site activities are continued for an extended period of time, additional infrastructure and equipment are needed, such as tents, helicopters and heavy lifting and handling equipment, metal detectors and communication equipment. In such a case, PKBWL will be supported by other organizations including private enterprises with which appropriate agreements have been concluded.
PKBWL also has an option to be supported by Accredited Representatives or to request assistance from a safety investigation authority of another EU state.
PKBWL investigation is a technical process which involves the collection and analysis of evidence to determine the causes of investigated occurrence and, where appropriate, to make safety recommendations. PKBWL has developed a number of detailed procedures and checklists covering various phases of the investigation, from organization and planning, through on-site activities, analyses, writing and disseminating reports, issuing safety recommendations and monitoring their implementation.
Activities at the scene of the occurrence are only the beginning of the investigation process. Further activities include: collecting and securing aircraft and crew records, records of actions taken by air traffic control services, weather conditions,, search and rescue operations, evacuation, firefighting, etc.
If there are on-board recorders or other recording devices, PKBWL immediately acts to recover these devices and read out their recordings.
In addition, specialized tests are carried out on parts and systems of the aircraft involved in the investigated occurrence.
PKBWL may request assistance from other countries as well as local authorities and organizations, including the police and judicial authorities.
In justified cases, PKBWL uses expert opinions and tests contracted with specialized entities.
The collected evidence and the results of tests and expert opinions are analyzed by the investigation team in order to determine the causes of the accident or incident.
Where appropriate, within 30 days from the date of receiving notification on the occurrence, PKBWL elaborates and publishes a preliminary report.
The evidence analysis phase can last from several months to several years depending on the complexity of the investigation. At any stage of the investigation, PKBWL may issue safety recommendations to appropriate parties which should take preventive measures to avoid similar occurrences in the future.
After analysis of the collected evidence, the investigation team develops a draft final report that includes facts, analysis and conclusions, as well as, if possible, the causes of the occurrence and contributing factors.
The draft final report goes through several stages of internal verification within PKBWL. Then, it is forwarded to the interested domestic and foreign entities with a request for their substantive comments, which should be sent within 60 days, unless an extension of that deadline has been agreed.
If the comments are accepted, the draft final report is amended accordingly. If PKBWL does not agree with the comments, they are attached to the occurrence records or to the final report, depending on their source.
When a final report is completed, it is sent to interested entities, organizations and states and then it is published on the PKBWL website. If victims of an accident or their families have expressed such a wish, PKBWL sends them the final report prior to publication.
If it is not possible to publish the final report within twelve months from the date of an occurrence, PKBWL issues an interim statement on each anniversary of the event, informing about the progress of the investigation and any significant safety issues.
Final reports are published and available free of charge on our website in the Occurence database bookmark.
As it was mentioned above, at any stage of the investigation PKBWL may issue safety recommendations, addressing safety concerns and proposing preventive measures to avoid similar occurrences in the future. A safety recommendation shall in no case create a presumption of blame or liability for an accident, serious incident or incident.
The addressee of a safety recommendation shall acknowledge receipt of the transmittal letter and within 90 days inform PKBWL of the actions taken or under consideration, and where appropriate, of the time necessary for their completion and where no action is taken, the reasons therefor.
PKBWL records all safety recommendations into the SRIS (Safety Recommendations Information System) database https://sris.aviationreporting.eu/safety-recommendations. The system contains safety recommendations and actions taken to implement them.
Explanation of all terms contained in the text is under Definitions headline.