Accident and Incident Investigation
Overview
Civil Aviation Authority of Sri Lanka is responsible for the investigation of aircraft accidents/ incidents within the territory of Sri Lanka involving both local and foreign commercial aircraft. The administrative functions are carried out by the Accident Investigation Unit. Aviation Safety Monitoring Unit.
Aircraft Accident Investigation Board
The Aircraft Accident Investigation Board (AAIB) will be appointed by the Authority as per the provisions laid down in the Civil Aviation Act No. 14 of 2010 as the case may be. In addition investigators would participate in overseas investigations of accidents / incidents involving aircraft registered in Sri Lanka or aircraft which are operated by an operator of Sri Lanka as appropriate. When carrying out investigations, the appointed AAIB will gather, record and analyze all the available information on the accidents and incidents, determine the causes and/or the contributing factors, identify the possible safety issues and draw up safety recommendations to address these safety issues to rectify them and complete the investigation report.
Objective
The sole objective of an investigation of an accident is the prevention of accidents and incidents due to similar causes in future. It is not to apportion blame or liability.
Definition
List of Serious incident - (Example includes)
The incidents listed below are examples of what may be serious incidents. However, the list is not exhaustive list. and, depending on the context, items on the list may not be classified as serious incidents if effective defences remained between the incident and the credible scenario.
- Near collisions requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when an avoidance action would have been appropriate.
- Collisions not classified as accidents.
- Controlled flight into terrain only marginally avoided.
- Aborted take-offs on a closed or engaged runway, on a taxiway1 or unassigned runway.
- Take-offs from a closed or engaged runway, from a taxiway1 or unassigned runway.
- Landings or attempted landings on a closed or engaged runway, on a taxiway1, on an unassigned runway or on unintended landing locations such as roadways.
- Retraction of a landing gear leg or a wheels-up landing not classified as an accident.
- Dragging during landing of a wing tip, an engine pod or any other part of the aircraft, when not classified as an accident.
- Gross failures to achieve predicted performance during take-off or initial climb.
- Fires and/or smoke in the cockpit, in the passenger compartment, in cargo compartments or engine fires, even though such fires were extinguished by the use of extinguishing agents.
- Events requiring the emergency use of oxygen by the flight crew.
- Aircraft structural failures or engine disintegrations, including uncontained turbine engine failures, not classified as an accident.
- Multiple malfunctions of one or more aircraft systems seriously affecting the operation of the aircraft.
- Flight crew incapacitation in flight: a) for single pilot operations (including remote pilot); or b) for multi-pilot operations for which flight safety was compromised because of a significant increase in workload for the remaining crew.
- Fuel quantity level or distribution situations requiring the declaration of an emergency by the pilot, such as insufficient fuel, fuel exhaustion, fuel starvation, or inability to use all usable fuel on board.
- Runway incursions classified with severity A. The Manual on the Prevention of Runway Incursions (Doc 9870) contains information on the severity classifications.
- Take-off or landing incidents. Incidents such as under-shooting, overrunning or running off the side of runways.
- System failures (including loss of power or thrust), weather phenomena, operations outside the approved flight envelope or other occurrences which caused or could have caused difficulties controlling the aircraft.
- Failures of more than one system in a redundancy system mandatory for flight guidance and navigation.
- The unintentional or, as an emergency measure, the intentional release of a slung load or any other load carried external to the aircraft.
Regulatory Material relating to Aircraft Accident Investigation
- Civil Aviation Act No 14 of 2010
- Aircraft Accident and Incident Investigation Regulations
- AIC – Aircraft Accident or Serious Incident Compliance requirements of Aircraft Operators, Aerodromes Operators & Air Navigation Service Providers
- Aviation Occurrence Reporting System – IS 006
- Arrangement between CAA, Sri Lanka and Transport Safety Investigation Bureau of Singapore
- Declaration of Intent between the Civil Aviation Authority of Sri Lanka (CAA-Sri Lanka) and BEA-France.
Accident Reporting
When;
- An aircraft accident or serious incident occurs in Sri Lanka, regardless of the country that the aircraft is registered in and
- An any aircraft registered in Sri Lanka or an aircraft operated by an operator of Sri Lanka which is involved in an accident or serious incident overseas
- the owner, operator, hirer, lessor, agent or the pilot-in- command of the aircraft at the time the accident or incident as the case may be, occurred;
- where the accident or incident occurs on or adjacent to an aerodrome in Sri Lanka, the owner or operator of such aerodrome or the Air Traffic Service Provider;
- where the accident or incident occurs in Sri Lankan airspace, the ATS provider;
- where the accident or incident occurs during a flying display or festival being held within Sri Lanka, the organizer of such flying display or festival; or
- where the accident or incident occurs during a demonstration flight in Sri Lanka, the handler or organizer of such demonstration flight.
- Police or Security Forces
- Any other Local Authority/ Eyewitness or general public
The notification is required to be passed to this Authority by the quickest means and giving, as far as possible, the required information.
Notifying person should provide whatever information is able to gather as soon as possible without waiting for all the information to become available.
Details omitted from the notification may be provided later, when they become available.
- In the case of an accident the identifying abbreviation "ACCID" or, in the case of a serious incident, the identifying abbreviation "INCID";
- the type, model, nationality and registration marks of the aircraft;
- the names of the owner, operator and hirer (if any) of the aircraft;
- the name of the commander of the aircraft;
- the date and time (UTC) of the accident/ serious incident;
- the last point of departure and the next point of intended landing of the aircraft involved;
- the position of the accident in relation to some easily defined geographical location and the latitude and longitude of such location;
- the number of -
- crew on board and the number killed or seriously injured.
- passengers on board and the number killed or seriously injured.
- other persons killed or seriously injured as a result of the accident.
- the nature of the accident or incident and the extent of damage as far as is known.
- Physical characteristics of the location in which the accident or incident occurred
- Presence and description of dangerous goods, if any that were being carried on board the aircraft
- Identification & contactable details of the notifying person
where the accident or serious incident occurred outside Sri Lanka, the means by which the investigator-in-charge and the Accident Investigation Authority of the State of Occurrence may be contacted at any time;
Subsequently the Aircraft Accident / Serious Incident Report Form shall be completed and submit to this Authority. Click here to download the Form
Incident Reporting
The requirements of mandatory incident reporting is laid down in Implementing Standard 006
Report Forms
- Occurrence Report Form
- ATC Occurrence Report Form
- Air Traffic Incident Report Form
- Air Traffic Incident Report Form ( Pilot Report Over Radio)
- On-ground Occurrence Report Form
- Bird Strike Incident Reporting Form
- ATS Engineering Occurrence Report Form
- Notice of death in an aircraft registered in Sri Lanka
- Birth Occurring in an aircraft registered in Sri Lanka
- Person missing and believed to have died in consequence of an accident to an aircraft registered in Sri Lanka
Voluntary Incident Reporting
Voluntary and Confidential Aviation Incident Reporting (VCAIR) System
The Voluntary and Confidential Aviation Incident Reporting (VCAIR) System is a voluntary, non-punitive, confidential reporting system established by the Civil Aviation Authority of Sri Lanka (CAASL). This System provides a channel for reporting of aviation incidents and safety deficiencies while protecting the reporter’s identity.
The key objective of Voluntary and Confidential Aviation Incident Reporting system is to enhance aviation safety through the collection of reports on actual or potential safety deficiencies that would otherwise not be reported through other channels or that may appear minor, but which nevertheless can allow others to learn from the reporter’s experience and even lead to changes in procedures, practices or design. Such reports may involve occurrences, hazards or threats relevant to aviation safety. This Reporting System focuses on systems, human factors, procedures and equipment, rather than on individuals.
This system does not eliminate the need for mandatory reporting of aircraft accidents and incidents to CAASL under the existing law.
Areas covered by the System
The VCAIR System covers following areas;
- Flight Operations
- Departure/en-route/approach/landing
- Aircraft cabin operations
- Air proximity events
- Weight and balance and performance
- Ground Operations
- Aircraft Ground operations
- Movement on the airport
- Fueling operations
- Airport conditions or services
- Cargo handling
- Air Traffic Management
- ATC Operations
- ATC equipment and navigation aids
- Crew and ATC communications
- Aircraft Maintenance
- Aircraft/engines/ components design or production activities
- Design and manufacturing
- Aircraft / engines/components design or production activities
- Approved training organizations
- Training activities involving flight operations
- Miscellaneous
- Passenger handling operations related to safety
What should not be reported
- Accidents or serious incidents or Criminal activities
- Incidents or events with no aviation safety content
- Personal problems, personality conflicts and industrial relation issues
- Legal/commercial disputes
Who can make a Report
If you belong to any of these groups, you can contribute to safety enhancement through the VCAIR System by reporting on actual or potential occurrences, hazards, threats and deficiencies in aviation operations.
- Flight and cabin crew members;
- Air traffic controllers;
- Licensed aircraft engineers, technicians or mechanics;
- employees of maintenance, design and manufacturing organizations;
- aerodrome ground handling operators;
- airport employees;
Individuals involved in general aviation
When to report
You should make a report when:
- You wish for others to learn and benefit from the incident but are concerned about protecting your identity.
- There is no other appropriate reporting procedure or channel.
- You have tried another reporting procedure or channel but the issue has not been addressed.
Note: It is possible that an incident reported by you is also reported to the other relevant authorities by a third party. The VCAIR System cannot prevent these authorities from taking the action(s) that they deem necessary, even though your identity will be protected by the VCAIR System.
Processing of reports
The CAASL pays particular attention to the need to protect the identity of the reporter when processing of all reports.
Every reports will be read and validated by the administrator. The administrator may contact the reporter to make sure he understand the nature and circumstances of the occurrence / hazard reported and/or to obtain the necessary additional information or clarification.
When the administrator is satisfied that the information obtained is complete and coherent, he will de-identify the information and enter the data into the VCAIR System database. Should there be a need to seek inputs from any third party, only the de-identified data will be used.
The VCAIR form, with the date of return annotated, will eventually be returned to the reporter. The administrator will endeavour to complete the processing within ten (10) working days if additional information is not needed. In cases where the administrator needs to discuss with the reporter or consult a third party, more time may be needed.
If the administrator is away from his office for a prolonged period, the alternate administrator will process the report. Reporters can rest assured that every VCAIR report will be read and followed through by either the administrator or the alternate administrator.
Feedback to the aviation community
Relevant de-identified reports and extracts may be shared with the aviation community through periodic publication so that all can learn from the experiences. Relevant authorities and parties can also review their policy and plan for improvements.
If the content of a VCAIR report suggests a situation or condition that poses an immediate or urgent threat to aviation safety, the report will be handled with priority and referred, after de-identification, to the relevant organizations as soon as possible to enable them to take the necessary safety actions.
Submission of Voluntary Report
Step 01 - By mail - Complete the VCAIR form and mail it to the following address: (Click here to view form)
Attention: VCAIR System
Civil Aviation Authority of Sri Lanka
No: 152/1, Minuwangoda Road
Katunayake
Anonymous reports will not be accepted. This is to ensure that the Administrator can contact you to obtain or clarify information when necessary, and to also advise you on the action taken or outcome arising from your report.
Past Accident & Incident Reports
Nature of Occurrence | Date | Location | Operator | Brief Description | Report Title |
Accident | 04th Dec. 1974 | Maskeliya, Sri Lanka | Martinair | Aircraft collided with rising terrain as the crew descended the aircraft below safe altitude owing to incorrect identification of their position vis-a vis the airport | Report on the Accident in to Martinair DC-8, PH-MBH on 4th December 1974 at Theberton Estate, Maskeliya, SriLanka |
Accident | 15th Nov. 1978 | Vicinity of the Bandaranayake International Airport, Katunayake, Sri Lanka | Loftleider Icelandic Airways | Collision with rising terrain caused an accident into Loftleider Icelandic | Report of Accident into Loftleider Icelandic Airways airraft DC-8-63F, TF-FLA on 15th November 1978 at Katunayake, Sri Lanka |
Incident | 17th April 1998 | Colombo TMA on ATS Route G-465 | A320 and DH-8 | Near Miss incident between Airbus A320 out bound to Maldives on the climb and DH-8 inbound to Colombo descending from flight level 230 | Final Report - ATC near miss incident on 17th April 1998 |
Accident | 24th March 2000 | Kadirana, Negombo, Sri Lanka | Skycabs(Pvt) Ltd | Accident to Sky Cabs flight AN-12 due to fuel exhaustion while attempting to land at the destination | Final report of accident into Sky Cabs AN-12 aircraft, RA-11302 on 24th March 2000 at Kadirana, Negombo, Sri Lanka |
Accident | 11th April 2001 | Bandaranayake International Airport, Katunayake, Sri Lanka | Sri Lankan Airlines | Smoke ingestion into the cabin which resulted emergency evacuation | Final report of Emergency Evacuation on SriLankan Airlines flight UL 557, A330, 4R-ALD on 11th April 2001 at Bandaranayake International Airport, Katunayake, Sri Lanka |
Accident | 08th Sept. 2005 | Bandaranayake International Airport,Katunayake, Sri Lanka | Saudi Arabian Airlines | Emergency evacuation after being alarmed by the bomb threat lead to an accident | Final report on Accident of Saudi Air Flight SV781, Boeing B747-368, registration HZ-AIP on 08th Sept. 2005 at Bandaranayake International Airport, Katunayake, Sri Lanka |
Accident | 16th Oct. 2005 | Bandaranayake International Aircraft, Katunayake, Sri Lanka | Sri Lankan Airlines | Collision between maintenance platform vehicle and stepladder during disembarkation, caused a passenger to fall through the gap created | Final report on Accident of SriLankan Airlines Flight UL316 Airbus A330-243, 4R-ALA on 16th Octomber 2005 at Bandaranayake International Airport Katunayake, Sri Lanka |
Serious Incident | 02nd Dec. 2006 | Colombo Airport, Ratmalana, Sri Lanka | Aero Lanka | Aircraft overran the threshold of runway | Final report on Serious Incident of Aero Lanka flight RNL 106, HS 748 series 2B, registration 4R-SER 02nd Decemper 2006 at Colombo Airport, Ratmalana, Sri Lanka |
Incident | 01st June 2007 | Bandaranayake International Airport, Colombo | SriLankan Airlines | In the pre-departure maintenance check, while replacing deflated nose wheel tyre, the aircraft nose wheel Jack pedestal depressed into the concreted parking floor by shifting the aircraft slightly towards the right hand | Incident of Srilankan Airlines Flight UL163 A320-211, Registration 4R-ABF on 01st June 2007 at Bandaranayake International Airport, Colombo, Sri Lanka |
Incident | 05th June 2007 | Colombo Airport, Ratmalana, Sri Lanka | SriLankan Airlines | Incident due to aircraft landed on runway without extending landing gears | Final report on Incident of SriLankan Airlines flight UL 5302, DHC-3T, Registration 4R-ARB on 05th June 2007 at Colombo Airport, Ratmalana, Sri Lanka |
Serious Incident | 15th October 2007 | London Heathrow Airport, United Kingdom | SriLankan Airlines | A ground collision occurred when Airbus A340-311 attempted to pass the Boeing B 747-436 that was stationary on an adjoining taxiway, at night | Final report on Serious Incident to Boeing 747-436, Airbus A340 4R-ADC, at London Heathrow Airport on 15 October 2007. This investigation conducted & report issued by AAIB, United Kingdom |
Incident | 13th Oct. 2008 | Chennai International Airport, India | SriLankan Airlines | Aircraft port outboard wheels overran the runway edge lights at Chennai International Airport India | Final report on Incident of SriLankan Airlines flight UL121 Airbus A330, 4R-ALC on 13th October 2008 at Chennai International Airport India |
Incident | 21st February 2008 | Colombo Airport, Ratmalana | Expo Aviation | Incident of aircraft return back due to engine fire warning | Final report on Incident of Expo Aviation flight EXV 711, F-27, Registration 4R-MRA on 21st February 2008 at colombo Airport, Ratmalana, Sri Lanka |
Incident | 05th Feb 2012 | London Heathrow Airport | SriLankan Airlines | The aircraft started its takeoff from a runway intersection for which no regulated takeoff weight chart was available in the aircraft. The pilots calculated performance using a chart for a different runway which did not consider obstacles relevant to the runway in use. The takeoff and subsequent flight were completed without further incident | Final Report on SLA incident(very low T/O), A340, 4R-ADG on 05th Feb 2012 at London Heathrow Airport, United Kingdom |
Incident | 14th June 2014 | Paragasthota, Milleniya, Sri Lanka | Detachment of a wheel during flight | Final Report on Incident Millennium Airlines Pvt Ltd, Cessna 152, 4R-DJD on 14th June 2014 | |
Incident | 01st May 2015 | En-route to Colombo(Flight from Sharjah to Colombo) | Mihin Lanka | First Officer failed to enter into the flight deck due to PIC not responding to the door call bell | Incident of Mihin Lanka Flight MJ408 (SHJ-CMB), Airbus A321, bearing registration 4R-MRC on 01st May 2015 |
Incident | 08th Oct 2014 | En-route to Colombo(TRZ to CMB) | Srilankan Airlines | The flight UL 134 returned to base(TRZ) due to a technical reason | Incident of SriLankan Airlines Flight UL134, Airbus Industrie A320-200, bearing registration 4R-ABL at Tiruchirappalli International Airport, India on 08th Oct 2014 |
Accident | 29th September 1998 | Mannar, Sri Lanka | Gomelavia, operated for Lionair Ltd | The act of unlawful conduct on Lionair flight | Re-opened accident investigation report of Lion Air Flight LN 602, EW 464665 |
Serious Incident | 02nd July 2013 | Bandaranaike International Airport,Katunayake,Sri Lanka | SriLankan Airlines | On 02nd July 2013, SriLankan Airlines flight UL266, Airbus A340, registration 4R-ADA departed from RUH to CMB and touched down on VCBI runway 22 at 0215 UTC encountering a hard landing and a tail strike. | Serious Incident of SriLankan Airlines flight UL 266, A340-311, bearing registration 4R-ADA at Bandaranaike International Airport, Colombo, Sri Lanka on 02nd July 2013 |
Aircraft Accident Information
- Useful Aircraft Accident Information - http://www.planecrashinfo.com/cause.htm
- Boeing Statistics on Accidents - http://www.boeing.com/resources/boeingdotcom/company/about_bca/pdf/statsum.pdf
- Air Safety Information - http://www.airsafe.com/events/models/atr.htm