BGA POST-ACCIDENT GUIDE BGA Post-Accident Guide 1 INTRODUCTION .......................................................................................................2 2 DEFINITIONS ............................................................................................................2 3 XXXXXXXXXXXXX GLIDING CLUB – LOCAL INFORMATION ...............................3 3.1 Map of Area ................................................................................................................................4 4 MAJOR ACIDENTS...................................................................................................5 4.1 Major Accidents – Immediate Actions.................................K...E...Y....A..C...T...I.O...N...S...........................5 4.2 Major Accidents – Immediate Follow-Up Actions ..............K...E...Y....A..C...T...I.O...N...S...........................6 4.3 Major Accidents – Witness Report Form ................................................................................7 4.4 Major Accidents – Event Log ...................................................................................................8 4.5 Major Accidents – Press Statement ........................................................................................9 4.6 Major Accidents – Further Actions ........................................................................................10 5 MINOR ACCIDENT / INCIDENT..............................................................................12 6 ACCIDENT REPORTING ........................................................................................13 6.1 What accidents should be reported to the BGA? ................................................................13 6.2 The BGA Accident Report Form. ...........................................................................................13 6.3 BGA Requirements..................................................................................................................13 6.4 The Law and How It Affects BGA Club Officers ...................................................................14 7 ACCIDENT INVESTIGATION..................................................................................18 7.1 Introduction..............................................................................................................................18 7.2 Format.......................................................................................................................................18 December 2009 Page 1 of 22 BGA Post-Accident Guide 1 Introduction This document provides the people in charge in the immediate aftermath of a serious accident with information on how to handle the immediate tasks - calling the emergency services and police, taking care of the injured, avoiding a secondary accident, informing the AAIB, club officers, and the BGA, and preparing for the investigation that will follow. Clubs should use this as a template for their own guide. Items in italics are either explanatory items (which should be removed from the club’s own final version) or are items that should be personalised. The completed, personalised guide should be kept in a readily available place – in the club house, at the launch point and at the winch are suggested locations. This document combines the existing Post Accident Guide and Accident Investigation Handbook and replaces both documents. 2 Definitions Major Accident: Occurrence associated with the flying operations of BGA gliding clubs resulting in death or serious injury, or substantial damage to an aircraft. Serious Injury: An injury which satisfies any of the following: requiring stay in hospital of more than 48 hours. fracture (except simple fracture of fingers, toes or nose). lacerations causing nerve, muscle or tendon damage or severe haemorrhage. injury to internal organ. Substantial Damage: Damage that adversely affects the structural strength, performance or flight characteristics of the aircraft and which would normally require major repair or replacement of the affected component. Minor Accident/Incident: Occurrence not falling under the definition of major accident/ incident, but where an accident has taken place or a potential hazard has been identified. December 2009 Page 2 of 22 BGA Post-Accident Guide 3 XXXXXXXXXXXXX Gliding Club – Local Information 1. Airfield Address 2. Airfield Telephone Number 3. Latitude and Longitude 4. Directions to Airfield Write here a concise but clear set of directions which can be read out over the phone to the emergency services. Include the position of the airfield in relation to easily identifiable local landmarks. 5. Hazards to Air Ambulance Include here a description of any hazards likely to affect an air ambulance with particular reference to power or telephone cables. 6. Other information December 2009 Page 3 of 22 BGA Post-Accident Guide 3.1 Map of Area December 2009 Page 4 of 22 BGA Post-Accident Guide 4 MAJOR ACIDENTS 4.1 Major Accidents – Immediate Actions KEY ACTIONS   Firmly take control and ensure no further accidents occur.  Direct a responsible person to telephone the emergency services and advise: Name and contact telephone (use a number you can keep free) Exact accident location Number of casualties and whether apparently fatal or serious injury Are any dangerous substances or power cables involved?  See to injured people - cautiously! Do not move injured occupants unless necessary to save life because of other threats e.g. fire. Ensure someone stays with the injured person until professional help arrives.  Detail a responsible person to manage the recovery of airborne aircraft.  Send a responsible person to the airfield gate to direct the Emergency Services and to control entry. If there are multiple gates, you need someone at each gate. Notify the following ASAP, passing essential details:  Air Accident Investigation Branch (AAIB)* tel 01252 512299  Local Police (even if 999 call already made), tel  Club Chairman tel  Club Safety Officer tel  Club CFI tel  BGA Office tel 0116 289 2956  Detail a responsible person to redirect any media enquiries to the chairman or the most senior club official who knows of the accident.  Appoint a person to maintain a detailed event log. *It is only necessary to report an accident to the AAIB if it occurred between embarkation of an aircraft with the intention of flight, and disembarkation. For fatal accidents the AAIB should allocate an investigator immediately. If you are not quickly contacted by an investigator you should seek assistance from the BGA Senior Accident Advisor, Chris Heames, tel 01780 482593 (Home); 07850 744927(Mobile); 01400 266156 (Office)). December 2009 Page 5 of 22 BGA Post-Accident Guide KEY ACTIONS 4.2 Major Accidents – Immediate Follow-Up Actions (see page 7 for a witness form; page 8 for a log form)   Secure the accident scene. Unless it is necessary to attend to injured persons or to prevent further accidents, do not move any wreckage until authorised by the AAIB or the BGA accident investigator.  Note the names and contact details of all witnesses and ask them to make written statements. Brief a person to photograph the accident scene.  Brief the Chairman, CFI, and Safety Officer.  If an investigator is expected, consider arranging for lighting at the scene.  For fatal and serious injury accidents obtain and secure the glider C of A / ARC and log book and the pilots’ medical certificate, flying licence or certificate, and log book, and obtain details of the next of kin. Review  Review the actions taken and ensure nothing essential has been omitted.  Gather all paperwork and hand to Safety Officer. December 2009 Page 6 of 22 BGA Post-Accident Guide 4.3 Major Accidents – Witness Report Form Name: Profession or Club Position Held: Address: Telephone: Email: Flying Experience: Statement: (Please print or type) December 2009 Page 7 of 22 BGA Post-Accident Guide 4.4 Major Accidents – Event Log Date: Message No: Message From / To: Message Content: Page: Action Taken: Signed: Date: Message No: Message From / To: Message Content: Name: Action Taken: Signed: Name: December 2009 Page 8 of 22 BGA Post-Accident Guide 4.5 Major Accidents – Press Statement The information below can reasonably be released to the Media in the event of a serious accident, with a view to establishing or maintaining a good relationship with representatives of the Press and other Media, and ensuring, so far as is possible, accurate reporting of accidents. In the event of a serious accident, a "Press Officer'" should be appointed by the Club, who will deal with enquiries and conduct any interviews. Interviewing of Club Members by reporters should be actively discouraged, politely but firmly. If reporters do interview members or witnesses, it should be emphasised that their opinions are not necessarily the opinions of the Club Officials, the British Gliding Association, the BGA Accident Investigators, or the AAIB. Sample Statement On < accident date>.at approximately < time>, a .glider crashed whilst on a flight. The who club members sustained , <(optional)the extent of which are presently unknown>. been taken to a local Hospital for medical checks, The incident is currently under investigation by Air Accident Investigation Branch of the Department for Transport, and the Police, in conjunction with the British Gliding Association. Our club is cooperating fully with these bodies. At the present time there is no indication as to the cause of the accident. . Ends. December 2009 Page 9 of 22 BGA Post-Accident Guide 4.6 Major Accidents – Further Actions 1. Control will initially be handled by the person in charge of operations at the time until the Club member who will finally handle the investigation takes over. He may eventually be replaced by the AAIB or BGA accident Investigator if they are ordered or requested to attend. There are several actions that must be initiated; the following are perhaps the most important but not necessarily in the order of action. 2. Diary of Events. A log of events must be commenced and maintained. This should start at the time of the accident and contain details of actions taken, communications made, arrival of key organisations or personnel, witnesses statements taken (with addresses and contact numbers) and any other information which may have the slightest bearing on the accident and its aftermath. 3. Relatives of those involved. Early consideration must be given to informing relatives of any persons involved in the accident. This is particularly important in the event of serious or fatal injuries and would normally be a police responsibility. 4. Accident Scene. Secure the accident area and its immediate surrounds. The Emergency Services will obviously need complete access, but do try to prevent onlookers trampling all over the impact marks and picking up bits of scattered wreckage (if any). Do not yourself move any wreckage (except as necessary to release occupants and this under supervision of Medics, Ambulance Service or Police) or authorise its movement until cleared by the AAIB or BGA Investigator - if attending. 5. Witness statements. Start getting witness statements as soon as possible. Statements from any injured pilots, pupils, passengers or third parties must of course be left until they are fit, but do talk to them as soon as is reasonable. 6. Documents. In the event of a Serious or Fatal accident the glider C of A/ ARC documents and log-book should be obtained and secured. It is also advisable to do the same for the pilot’s medical certificates, licences (Certificates) and log-book. 7. Lighting. If you are anticipating the arrival of an investigator, consider the provision of lighting. The Investigator will want to see the site at his earliest opportunity and it may be dark when he arrives. Your local police should be able to assist and if they prove less than fully co-operative, talk to the AAIB or the BGA investigator again. 8. BGA Accident/Incident Report Form. Get this under way as soon as you can. The preliminary report form should be submitted on the day of the accident and in any case with 24 hours. The full report form should follow within 28 days. Try to make the report comprehensive but do not delay its transmission if awaiting certain statements. Forward these as soon as possible after the BGA Report Form has been submitted. 9. Wreckage Storage. When the Investigator or yourself needs the wreckage moved, there may be the problem of secure storage. Start thinking about this as you will need a flatbed truck or similar, and a container or hangar for storage plus manpower. 10. Assistance. You are not alone. The BGA Accident Investigation Team and your RSO are there to assist. Contact details for the BGA chief accident investigator are included in this document. They may decide to visit you if circumstances dictate, but even if they do not wish to and you do not require their physical presence a sympathetic ear is very helpful. December 2009 Page 10 of 22 BGA Post-Accident Guide 11. Safety Officers/Investigators Report. In many cases, once the investigation has been completed, a final and separate report (described on the form as ‘The Safety Officers/Investigators Report, analysis and comment) must be submitted. All AAIB reports are to an ICAO defined standard and the BGA Fatal Accident Investigation team follow their format. Pages 18-21 of this document contain a simplified version of this format for the use of Safety Officers or Investigators who complete the final report. It is however not necessary to complete one of these reports for every accident at your club. The following guidelines are offered to help you decide if a full final report is necessary or not: Mandatory Fatal and Serious Injury Accidents to any crew, passengers or third parties. These will be investigated by and reported on by the AAIB, possibly with the assistance of the BGA Accident investigation team. Advisory An accident involving minor injury to crew, passengers or third parties or substantial damage to an aircraft. December 2009 Page 11 of 22 BGA Post-Accident Guide 5 MINOR ACCIDENT / INCIDENT How many of the following items apply will depend on the severity of the accident.  Initial Actions  Firmly control the situation and take all necessary action to prevent a further accident.  In the event of injury, seek medical advice  Ensure the safe recovery of airborne aircraft.  Make notes of the essential details of the accident. Notify the following:  Club Chairman  Club Safety Officer  Club CFI tel tel tel Follow-Up Actions  Note the names and contact details of all witnesses and ask them to make written statements. Brief a person to photograph the accident scene.  Provide the material that the Safety Officer requires for the accident report. December 2009 Page 12 of 22 BGA Post-Accident Guide 6 ACCIDENT REPORTING 6.1 What accidents should be reported to the BGA? All accidents and incidents involving gliders, motor gliders or tugs normally based at a BGA club or resulting from the flying operations of BGA gliding clubs. ‘All accidents and incidents’ includes accidents anywhere in the world resulting in personal injury, and/or damage to gliders, motor gliders, tugs, other aircraft, and 3rd party property. Injury or damage unconnected with gliding operations is excluded, for example a fall in the club restaurant. These definitions and a summary of what should be reported to whom and when are available on the BGA website at http://www.gliding.co.uk/bgainfo/safety/forms/accidentreportingguidance.pdf 6.2 The BGA Accident Report Form. The BGA accident form is the vehicle to use for initial reporting of all accidents and incidents and for final reporting of many of the less severe accidents and incidents. The following notes offer guidance for completing the BGA accident form. Often it is appropriate to complement the report on the form by a full report. Guidance on the structure and preparation of a full report is included in Section 7 of this document Two versions of the form are available from the BGA Website at www.gliding.co.uk/bgainfo/safety/forms.htm. One version is intended for electronic completion and transmission and the other for manual printing and completion. The electronic version contains fields which can be filled in on-screen. The completed form should be saved and Emailed as directed to the BGA office (office@gliding.co.uk), the AAIB (investigations@aaib.gov.uk) and your club’s Regional Safety Officer. The manual version should be printed (pages 2 & 3 back to back), completed, photocopied and sent by fax or surface mail as directed. Please use the electronic form if possible. If the manual form has to be used, please complete it legibly. Completion of the form is relatively self-explanatory, however, in paragraph 8 (ADDITIONAL P1 FLYING EXPERIENCE), it is only necessary to fill out the starred items if relevant,. i.e. a winching accident will require launch failure details, a field landing accident will require field landing practice details, etc. 6.3 BGA Requirements 1. All accidents must be reported by telephone to the BGA Office immediately and an Accident/ Incident Report Form, with as much information as possible sent to the BGA Office within 24 hours. Fully completed forms, short Incident report forms and any other paperwork must be delivered within 28 days. N.B. An ‘Incident’ is defined by the BGA as an occurrence not falling within the definition of an ‘Accident’ (see below). e.g. ground handling, mis-rigging, etc, or where an actual or potential hazard arising from gliding operations is identified. December 2009 Page 13 of 22 BGA Post-Accident Guide 2. Confusion often exists over what is minor or substantial damage. Within the BGA, substantial damage may be considered as that which requires workshop rectification before the glider is subsequently allowed to fly. (NB See the AAIB definition below). 3. Accidents/Incidents to aircraft other than gliders (i.e. motor gliders or tugs) are subject to the regulations (‘Law’) below. The form to be completed is CAA Form CA1673 (Occurrence Report). A copy of this form or a BGA Accident /Incident report should also be sent to the BGA. 4. Whilst the legal responsibility for reporting an accident rests with the pilot of the aircraft, the BGA requires that the club from whose site the glider was launched should offer full support and take responsibility for ensuring correct and prompt action is taken. 5. The Club responsibility rests with the Safety Officer or CFI to initiate Accident/ Incident Form action. In their absence the senior instructor or club member present at the time should assume the responsibility. 6. The rating of an instructor who has an accident, whilst flying gliders or motor gliders or whilst instructing in gliders or motor gliders, will automatically be suspended. For details of the BGA Instructor Suspension and Reinstatement Process see: http://www.gliding.co.uk/bgainfo/instructors/documents/instructorsuspension.pdf 6.4 The Law and How It Affects BGA Club Officers (NB: the law applies to gliders, motor gliders, and tugs.) 1. An ‘Accident’ is an occurrence associated with the operation of an aircraft which takes place between the time when any person boards the aircraft with the intention of flight and such time as all persons have disembarked therefrom in which:- (a) any person suffers death or injury while in or upon the aircraft or by direct contact with any part of the aircraft (including any part which has become detached from the aircraft): or (b) the aircraft incurs damage or structural failure. 2. Reportable Accidents. The Civil Aviation (Investigation of Air Accidents) Regulations require the notification of accidents direct to the Chief Inspector of Air Accidents, Air Accidents Investigation Branch and the local police when there has been death or serious injury or an aircraft receives substantial damage. 3. Responsibility to the AAIB. The permission of the AAIB must be obtained before the aircraft is moved or otherwise interfered with except for the purpose of rescue. A copy of the Accident/ Incident Report Form must be sent, within 24 hours, either electronically by post or fax, to: investigations@aaib.gov.uk The Department for Transport Chief Inspector of Air Accidents Air Accidents Investigation Branch Farnborough House Berkshire Copse Road ALDERSHOT GU11 2HH Fax: 01252 376999 December 2009 Page 14 of 22 BGA Post-Accident Guide 4. ‘Serious Injury’ means an injury which is sustained by a person in an accident which either: (a) requires a stay in hospital for more than 48 hours commencing within seven days from the date of the accident on which the injury was received: or (b) results in a fracture of any bone (except simple fractures of fingers, toes or nose): or (c) involves lacerations which cause nerve, muscle or tendon damage or severe haemorrhage. or (d) involves injury to any internal organ. 5. ‘Substantial Damage.’ Damage or structural failure that adversely affects the structural strength, performance, or flight characteristics of the aircraft that requires major repair or replacement of the affected component(s), and/or if the damage or failure(s) renders the aircraft un-flyable and requires more than 48 hours to repair. December 2009 Page 15 of 22 BGA Post-Accident Guide Date/Time Received by BGA BGA Ref. No BRITISH GLIDING ASSOCIATION - ACCIDENT/INCIDENT REPORT (ELECTRONIC) N.B. 1. This version of the document can be completed on a computer and sent e-mail to recipients. A printable version is separately available for manual completion. N.B. 2. * After an accident involving fatal or serious injury, substantial damage to a glider, or if a powered aircraft is involved, (including a self-launching glider), it is a legal requirement that, as a matter of urgency, the Air Accidents Investigation Branch (01252 512299) are informed. They will contact BGA investigators if necessary. You are also required to inform the local police. * N.B. 3 The Club Safety Officer or his nominee must make a telephone report to the BGA Office Manager, (0116 289 2956) (leaving a message if out of working hours) on the day of the occurrence. The completed form must be sent within 24 hours to bga@gliding.co.uk. and to the AAIB at investigations@aaib.gov.uk. A copy must also be sent to the club Regional Safety Officer. N.B.4. This page must be sent off within 24 hrs of Accident. Page 3 within 28 days. 1. ACCIDENT/INCIDENT/FLIGHT INFORMATION (N.B. 1 For Incidents – only this page essential, 28 days to return.) Date: - Time: - Location of Acc/Inc.: - Reported By Name: - Club Responsibility (CFI, S/O etc): - Tel No. & e-mail address: - Launch Type: - Launch Site: - Object of Flight: - Club Making Report: - Description of occurrence: - 2. PILOT/PASSENGER/THIRD PARTY (Capacity:- P.1, P.2, Passenger etc.) Name Age Capacity Home Club Injuries None Minor Description of injuries: - Instructor? Yes No Serious* Fatal* Name Home Club Description of injuries: - Age Capacity Injuries None Minor Instructor? Yes No Serious* Fatal* 3. AIRCRAFT Type BGA No Fin Ident Description of Damage: - Damage:- Owner None Minor Substantial* Destroyed* 4. INITIAL REPORT CIRCULATION (ACTION TO BE TAKEN BY REPORTING CLUB) AAIB(01252-512299) BGA Office (0116 289 2956) Regional Safety Officer Time Date Other 5. CLUB SAFETY OFFICER - Details Name Tel/Fax Nos. E-mail Address N.B.5. If you are merely reporting an incident, further information is only required if relevant. 6. SITE CONDITIONS AT TIME OF OCCURRENCE - WHERE APPLICABLE Actual wind direction and speed (º/Kt): Gusts? (max/min): Visibility (NM or KM): Cloud type, amount (8ths), base AGL(ft): T/O /Landing Dir. Precipitation? December 2009 Page 16 of 22 BGA Post-Accident Guide 7. FLYING EXPERIENCE (Flying Hours – except where stated as launches (L)) 1st Pilot P.1 P.1 (L) P.2 P.2 (L) On Type 2nd Pilot Last 6 Months Instructing 8. ADDITIONAL P.1. FLYING EXPERIENCE. (If relevant to accident.*) Date of previous solo flight: Gliding Certificates held: Date of last dual check: Bronze/X-c/Silver Completion Dates: Date of last launch failure real or practice: * Instructors Only Date of last field landing check: * Rating held: Number of types flown: Last renewed: Number of field landings: * By whom: Where trained: Last instructors course: (site): Main dual glider types: Last instructors course: (date): Main solo types: Last instructors course: (run by): Launches to solo: * Completion course date: Date of first solo: Medical type & date: 9. MISCELLANEOUS – COMPLETE AS NECESSARY (Yes/No) a) Was an instructor in charge? N Y e) Any possible technical aspects? b) Instructor at the launch point? N Y f) Were any BGA Op. Regulations broken? c) Was a briefing given? N Y g) Has the pilot had a previous accident? d) Any possible medical factors? Y N h) Were energy-absorbing seat cushions in use? If any RED answer in this section is confirmed, give details below and identify. e.g. a) b) etc. Y Y Y N N N N Y 10. ADDITIONAL STATEMENTS/DOCUMENTS/EVIDENCE REQUIRED Pilots & Duty Instructor Statements:- Enclosed / To Maps, Diagrams, Photos:- Enclosed / To Follow Follow Photocopy last page of pilot’s logbook(s):- Enclosed Eye Witness Statements:- Enclosed / To Follow / To Follow CSO/Investigator/CFI’s report, analysis, conclusions or comments:- Enclosed /To Follow . / N/A 11. Summary of Action taken to reduce the risk of a re-occurrence. Use the experience to help others prevent similar incidents/accidents. 12. Any operational or technical implications requiring immediate Instructor or Technical Committee action. BGA SENIOR ACCIDENT ADVISOR Sqn.Ldr.Chris Heames 10, The Hermitage, Stamford, Lincs PE9 2RF 01780-482593 (Home) 07850-744927(Mobile) 01400-266156 (Office) e-ml:- chris-heames@fsmail.net December 2009 Page 17 of 22 BGA Post-Accident Guide 7 ACCIDENT INVESTIGATION 7.1 Introduction As indicated on page 11 item 11, it may be necessary to prepare a full accident report to amplify and supplement the details provided in the BGA accident form and its appendices. Ideally, one person should complete the entire final report. This will usually be the Club safety officer. He/she will be responsible for the whole process which will include conducting any necessary investigations and interviews, liaising with the BGA as necessary, gathering together all supporting documents and other material, completing the report form and forwarding it to the BGA, writing the investigator’s report, and sending that to the BGA. The following are essential points to be observed during this process:  If possible, walk the ground yourself and try to determine exactly what happened  As soon as possible speak to everyone who can usefully contribute to the report and its conclusions in any way, and make sure they understand what it is you want from them. Obtain oral statements initially, followed as soon as possible by written ones.  Before starting to complete the form: o Gather all available and applicable material together (reports, witness statements, photographs etc) o Examine all material. If necessary, conduct follow-up interviews to clarify discrepancies and provide supplementary written information. 7.2 Format NB 1: Some of this information will already be recorded on the BGA Accident/Incident Report Form. However, it helps to have all the information pertinent to the investigation in one document. NB 2: Please use all numbered paragraphs, but if not applicable mark as N/A. NB 3: This report must not contain the names of any persons involved except members of the investigating team. Title. The final report should begin with a title comprising:  Manufacturer  Model  BGA number  Fin number  Place and date of the accident. Synopsis. Following the title should be a synopsis describing briefly all the relevant information regarding:  Identification of the authority and composition of the team investigating the accident  Organisation of the investigation  The authority releasing the report  The date of publication. December 2009 Page 18 of 22 BGA Post-Accident Guide Body of the Report. The body of the final report consists of the following main headings: 1. Factual Information. i. History of the Flight.  A brief narrative giving the following information: i. Intention of flight, point and time of departure. ii. Flight preparation, description of the flight and events leading to the accident iii. including reconstruction of the significant portion of the flight path, if appropriate. iv. Location and time of the accident, whether full daylight or otherwise if relevant. ii. Injuries to Persons  Degree of injury to P1, P2 or others. iii. Damage to Aircraft  Brief statement of the damage sustained by the aircraft in the accident (destroyed, substantially damaged, slightly damaged, no damage). iv. Other Damage  Brief description of damage sustained by objects other than the aircraft. v. Personnel Information  Pertinent information concerning pilots and pupils including; age, validity of licences/certificates, medicals pertaining thereto, instructor ratings, recent checks and flying experience (total, on type, and instructing - if pertinent).  Pertinent information regarding other involved personnel such as passengers,  winch operators, tug pilots, maintenance etc.  N.B. No Names. vi. Aircraft Information  Brief statement on airworthiness and maintenance of the aircraft (indication of any deficiencies known prior or during the flight to be included if having any bearing on the accident).  Brief statement on performance, if relevant, and whether mass and centre of gravity were within prescribed limits at the time of the accident. (If not, and if of any bearing on the accident - give details.) vii. Meteorological Information  Brief statement of any meteorological conditions, which may have a bearing on the accident. viii. Aids to Navigation  Probably not applicable, but if relevant - to be included. ix. Communications  Probably not applicable, but if relevant - to be included. x. Site Information  Pertinent information associated with the gliding site or field where the accident occurred. December 2009 Page 19 of 22 BGA Post-Accident Guide xi. Flight Recorders  Loggers and hand-held GPS receivers can contain information useful to investigators, even if quite badly damaged. Include here any information gleaned from such sources. xii. Wreckage and Impact Information  General information on the site of the accident and the distribution pattern of the wreckage, detected material failures or component malfunctions. Details concerning the location and state of the different pieces of the wreckage are not normally required unless it is necessary to indicate a break-up of the aircraft prior to impact. Diagrams, charts, photographs and videos may be included in this section, but are preferably attached as appendices. xiii. Medical and Pathological Information  Brief description of the results of the investigation undertaken and pertinent data available therefrom. NB If a full medical report is available then this should be attached as an appendix. xiv. Fire  If fire occurred, information on the nature of the occurrence, and of the firefighting equipment used and its effectiveness. xv. Survival Aspects  Brief description of search, evacuation and rescue, location of crew in relation to injuries sustained, availability of parachutes (and operation if used), and failure of structures such as seats or seat belt attachments. xvi. Tests and Research  Brief statements regarding the results of tests and research. xvii. Organisational and Management Information  Pertinent information regarding the organisations and their management involved in influencing the operation of the aircraft. e.g. Flight line organisation, tug management, maintenance etc. xviii. Additional Information  Relevant information not already included in i to xvii above. xix. Useful or Effective Investigation Techniques  When useful or effective investigation techniques have been used during the investigation, briefly indicate the reason for using them and refer here to the main features as well as describing the results under the appropriate headings i to xviii. 2. Analysis i. Analyse, as appropriate, only the information documented in the Factual Information section above and which is relevant to the determination of conclusions and causes. 3. Conclusions i. Findings  List the findings of the investigation in a logical and flowing sequence.  It is normal to start with an assessment of the pilot, e.g. ‘the pilot was medically fit and qualified to carry out the flight.’ December 2009 Page 20 of 22 BGA Post-Accident Guide  Then the glider, e.g. ‘the glider was below maximum permissible weight and within centre of gravity limits.’  Proceed to list what you found out during the conduct of the investigation. Do not be afraid if this list is long and detailed, but avoid making any individual finding too long and complicated. ii. Causes  List the causal factors as you have found them again in a logical and flowing sequence.  The list of causes should include both the immediate and the deeper systemic causes.  NB Good examples of the content of ‘findings and causes’ can be found in any of the A.A.I.B. ‘Yellow’ accident reports. 4. Safety Recommendations i. As appropriate, briefly state any recommendations made for the purpose of accident prevention and any resultant corrective action. 5. Appendices. i. Include, as appropriate, any pertinent information considered necessary for the understanding of the report. December 2009 Page 21 of 22