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co-ordinated and supervised by qualified personnel. It is essential that the magnitude and scope of the task
is assessed at an early stage so that the size of the investigation team may be planned, the appropriate skills
marshalled and individuals allotted their various tasks.
The Investigator-in-Charge, or in certain countries a Board of Inquiry, is appointed to be responsible for
the organization, conduct and control of the investigation and for co-ordinating the activities of all
personnel associated with it. It is the responsibility of the Investigator-in-Charge to review the evidence as
it is developed and from this initial evidence, make decisions that will determine the extent and depth of the
investigation. It should be recognized that the precise extent and depth of a particular investigation will be
contingent upon the nature of the accident, and possibly also upon the availability of investigative
resources.
The Investigator-in-Charge should establish working groups as required to cover various aspects of the
investigation. The Group System as described in the AIG Manual is an excellent method of conducting an
extensive investigation into major accidents. The decision to employ such an organization does depend,
however, on the size and complexity of the task, the nature of the accident and the investigative skills
available. The location of the accident may also be a deciding factor. The primary purpose of the Group
System is to establish the facts pertinent to an accident by making use of the specialized knowledge and
practical experience of the participating individuals with respect to construction and operation of the
aircraft involved in the accident and of the facilities and services that provided service to the aircraft prior
to the accident. It also ensures that undue emphasis is not placed on any single aspect of the accident to the
neglect of other aspects that might be significant to the investigation and that, whenever it is possible to
verify a particular point by means of several methods, all those methods have been employed and the
ICAO Preliminary Unedited Version — October 2008 IV-1-2
co-ordination of results has been ensured. Thus the investigation effort may require participation of some
or all of the following groups: operations; meteorology; air traffic services; witness statements; flight
recorders; maintenance records; and specialists in structures, power plants, systems, aviation medicine,
human factors, evacuation, search and rescue or fire fighting, as detailed in the AIG Manual. It is
emphasized that the medical and human factors contributions to the investigation are as important as the
efforts of the other investigative groups in the team. Therefore it can be expected that the participating
aviation medicine and psychology specialists will be supervised and controlled by an
Investigator-in-Charge in the same manner.
GENERAL
The Human Factors Group is responsible for the aeromedical, crash injury and survival aspects of the
investigation with regard to the events and the cause of the accident. The Human Factors (or Medical)
Group will be concerned with:
a) establishing the presence of any physical or psychological disorder which may have contributed to
impaired function of the flight deck crew;
b) discovering any specific environmental factors which may have similarly affected the crew;
c) searching for items in the medical, paramedical and psychological background of the flight crew
which might indicate or explain a decrement in its function or efficiency;
d) identifying the flight crew, and cabin crew, if relevant, their location at the time of the accident by
review of their injuries and activities at the time of the impact.
Bio-engineering aspects will include, among other things, an attempt to establish the relationship of
damage received by cockpit or cabin structures, seat orientation, harness restraint and so on; and to identify
factors that may have affected evacuation of the aircraft and escape. The efficiency of survival aids will
come under scrutiny. The pattern of injuries may provide sound evidence as to the sequence of events or
even the cause of the accident.
The concept that the pilot-in-command or other flight crew members might precipitate an accident by
being less than usually efficient (though suffering neither from organic disease nor impairment due to drugs)
and that this could influence or cause an accident is rather intangible and is likely to be difficult to prove. It
will normally be least difficult in the investigation of a non-fatal accident when the crew can be interviewed
and medically examined, or when cockpit voice and flight data recordings are available. Regarding
bio-engineering aspects, the non-fatal accident is also easier to investigate in that injuries will be fewer and
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Manual of Civil Aviation Medicine 2(124)
