
April 2020  |  www.sayer.com
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ACCIDENT INVESTIGATION
ICAO  Annex  13  prescribes  that  every  member state  must have 
an aviation accident investigation authority.  The Annex emphasises 
that, “The accident investigation authority shall have independence in 
the conduct and have unrestricted authority over its conduct...” in the 
gathering, recording and analysis of evidence, the issuance of safety 
recommendations,  the  determination  of  causes  and  the  completion 
of a nal report.
In  the  United  States,  accident  investigations  are  conducted  by 
the NTSB, the National Transportation Safety Board, which is entirely 
independent from the FAA or other bodies.  In the United Kingdom, 
there is a similarly independent AAIB, or Air Accidents Investigation 
Branch.    Other  ICAO  member  states  have  independent  accident 
investigation  authorities,  or  less  developed  nations  may  use  the 
services of an authority from another state in order to give effect to 
Annex 13.
South Africa’s 2009 Civil Aviation Act devotes an entire chapter 
to the establishment of an independent Aviation Safety Investigation 
Board  (ASIB).    Chapter  4  of  the  Act  is  devoted  to  the  strict 
independence of an ASIB, its jurisdiction, powers, public nominations 
of  board  members  and  their  own  independence  from  political  and 
commercial vested interests.  Accident reports must be published to 
the public, since unbiased accident ndings are of crucial interest to 
the industry and regulator in improving and correcting safety issues, 
as well as to passengers and personnel.
Several  years  ago,  the  Minister  of  Transport  gazetted  a  call 
for  nominations  for  members  of  the  ASIB,  and  AOPA  submitted 
nominations  of  three  eminently  suitable,  qualied  and  experienced 
candidates.    However,  the  Minister  never  established  an  ASIB  as 
prescribed by the Act, leaving accident investigations to a department 
of the CAA, whose investigators are employed and remunerated by 
CAA.
More than a year ago, there were two tragic accidents involving 
Boeing  737  Max  aircraft  which  were  operated  by  Indonesian  and 
Ethiopian  airlines,  both  countries  are  considered  to  be  “developing 
nations”  within  the  purview  of  ICAO’s  NCLB  campaign.    Indeed, 
questions  have  been  raised,  particularly  regarding  Ethiopia’s 
preliminary  accident  report  which  appears  to  lay  the  blame  for  its 
accident  solely  at  Boeing’s  doorstep,  while  underplaying  probable 
deciencies in the airline’s training, procedures and crew skills.  This 
has  been  extremely  damaging  to  Boeing,  with  the  entire  737  Max 
worldwide  eet  having  been  grounded  for  over  a  year.  Further, the 
Ethiopian  accident  report’s  assessment  of  the  Ethiopian  Airlines 
Flight 409 Boeing 737 crash after takeoff from Beirut has been widely 
contested by other aviation authorities.
More recently, SACAA’s Cessna Citation C550 calibration aircraft 
crashed into mountains near George in the Western Cape.  All three 
crew, employees of CAA, perished in the accident.  CAA nevertheless 
proceeded  to  investigate  the  accident  themselves,  notwithstanding 
an outcry from industry and the media that it was wholly inappropriate 
for  CAA  to  investigate  an  accident  involving  an  aircraft  owned  and 
operated by itself and crewed by its own employees.
ICAO published the audit results of member states on its website.  
The global average of implementation of ICAO standards for accident 
investigations stands at a dismal 57.31%.  Indonesia’s implementation 
is  little  better  at  65%.    Ethiopia  manages  an  implementation  of 
accident investigation at 66.67%. This is contrasted with ICAO’s 2017 
audit of South Africa’s CAA implementation of accident investigation 
standards,  placing  it  at  an  astonishing  90.91%.    To  put  this  into 
perspective, ICAO  rates  the  USA’s ASIB  implementation  at  81.32% 
and the United Kingdom at a mere 82.95%.
It  appears  from  their  own  data  that  ICAO  rates  South  Africa’s 
accident  investigation  capabilities  way  above  the  most  advanced 
aviating  nations  in  the  world,  even  though  our  CAA  accident 
investigation  division  cannot be  considered  to  be independent,  and 
most  certainly  not  when  investigating  accidents  involving  its  own 
aircraft,  operations  and  crew.    To  top  it  off,  although  South  Africa 
has  legislation  that  scrupulously  gives  effect  to  Annex  13,  this  has 
never  been  implemented, the Minister  and  CAA  having  made  lame 
excuses  for  not  observing  legislation  enacted  by  Parliament  more 
than a decade ago.
So  how could ICAO  have  given  the SACAA  and for  that  matter 
the Ethiopian Accident investigation capabilities such a high rating?
QUESTIONS:
This state of affairs begs several questions:
Does ICAO implement its NCLB campaign by simply overlooking 
deciencies in developing countries?  
Or  did  CAA  somehow  hoodwink  ICAO  into  believing  that 
SA’s  accident  investigation  deserves  a  stellar  90.91%  gold  star  of 
compliance – better than the USA, Russia, Austria, New Zealand and 
most other European and Asian countries?
Or did they work together to mislead the rest of the world?
Does this explain the almost rabid hostility towards AOPA and our 
criticisms which got a little too close to the bone?
And does this place ICAO’s audit of CAA into question on aspects 
other than just accident investigation?
I have my own conclusions.  You make up your own mind.
AOPA BRIEFING
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The objectives of the accident investigation safety board.