Doc 10062. Edition 2
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Manual on the Investigation of Cabin Safety Aspects in Accidents and Incidents
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Approved by and published under the authority of the Secretary GeneralINTERNATIONAL CIVIL AVIATION ORGANIZATIONDoc 10062Manual on the Investigation of Cabin SafetyAspects in Accidents and IncidentsSecond Edition, 2022
Approved by and published under the authority of the Secretary GeneralINTERNATIONAL CIVIL AVIATION ORGANIZATIONDoc 10062Manual on the Investigation of Cabin SafetyAspects in Accidents and IncidentsSecond Edition, 2022
Published in separate English, Arabic, Chinese, French, Russian and Spanish editions by the INTERNATIONAL CIVIL AVIATION ORGANIZATION 999 Robert-Bourassa Boulevard, Montral, Quebec, Canada H3C 5H7 For ordering information and for a complete listing of sales agents and booksellers, please go to the ICAO website at www.icao.int First edition 2017 Second edition 2022 Doc 10062, Manual on the Investigation of Cabin Safety Aspects in Accidents and Incidents Order Number 10062 ISBN 978-92-9265-674-4 print version ICAO 2022 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without prior permission in writing from the International Civil Aviation Organization.
iii AMENDMENTS Amendments are announced in the supplements to the Products and Services Catalogue the Catalogue and its supplements are available on the ICAO website at www.icao.int. The space below is provided to keep a record of such amendments. RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS CORRIGENDA No. Date Entered by No. Date Entered by
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Doc 10062. Edition 1. Manual on the Investigation of Cabin Safety Aspects in Accidents and IncidentsAnnex 6. Part 1. Edition 12. Operation of Aircraft. Part I. International Commercial Air Transport. AeroplanesAnnex 13. Edition 12. Aircraft Accident and Incident InvestigationAnnex 18. Edition 4. The Safe Transport of Dangerous Goods by AirDoc 9868. Edition 3. Procedures For Air Navigation Services. TrainingDoc 9284. Edition 20212022. Technical Instructions for the Safe Transport of Dangerous Goods by AirDoc 9587. Edition 4. Policy and Guidance Material on the Economic Regulation of International Air TransportDoc 9756. Part 4. Edition 3. Manual of Aircraft Accident and Incident Investigation. Part IV. ReportingDoc 9946. Edition 1. Manual on Regional Accident and Incident Investigation OrganizationDoc 9962. Edition 2. Manual on Accident and Incident Investigation Policies and ProceduresDoc 9973. Manual on Assistance to Aircraft Accident Victims and their FamiliesDoc 9998. Edition 1. ICAO Policy on Assistance to Aircraft Accident Victims and their FamiliesDoc 10002. Edition 2. Cabin Crew Safety Training ManualDoc 10072. Edition 1. Manual on the Establishment of Minimum Cabin Crew RequirementsDoc 10086. Edition 1. Manual on Information and Instructions for Passenger SafetyDoc 9734. Part 1. Edition 3. Safety Oversight Manual. Part A. The Establishment and Management of a State Safety Oversight SystemDoc 10004. Edition 2019. 2017-2019 Global Aviation Safety PlanDoc 10004. Edition 20202022. 2020-2022 Global Aviation Safety PlanDoc 10117. Edition 1. Manual on the Legal Aspects of Unruly and Disruptive PassengersDoc 10158. Edition 1. Manual on Safety Management in Cabin OperationsВСЕ ДОКУМЕНТЫALL DOCUMENTSDoc 10062
Table Of Contents
COVER PAGE
AMENDMENTS
FOREWORD
CONTENTS
GLOSSARY
PUBLICATIONS
Chapter 1. INTRODUCTION
1.1 ACCIDENT INVESTIGATION
1.2 INCIDENT INVESTIGATION
1.3 PURPOSE
1.4 SCOPE
Chapter 2. OVERVIEW OF ICAO SARPs AND GUIDANCE MATERIAL
2.1 ICAO STANDARDS AND RECOMMENDED PRACTICES
2.2 ICAO GUIDANCE MATERIAL
2.3 ADDITIONAL GUIDANCE MATERIAL
Chapter 3. ACCIDENT INVESTIGATION AND CABIN SAFETY IMPROVEMENTS
3.1 GENERAL
3.2 IN-FLIGHT FIRE
3.3 FIRE AND EVACUATION AFTER REJECTED TAKE-OFF
3.4 ENGINE FAILURE AND EMERGENCY LANDING (OCCURRENCE 1)
3.5 LOSS OF CONTROL AFTER TAKE-OFF
3.6 ENGINE FAILURE AND EMERGENCY LANDING (OCCURRENCE 2)
3.7 RUNWAY COLLISION
3.8 IN-FLIGHT FIRE AND IMPACT WITH TERRAIN
3.9 IN-FLIGHT FIRE AND IMPACT WITH WATER
3.10 RUNWAY OVERRUN AND FIRE
3.11 FLIGHT CREW INCAPACITATION
3.12 DITCHING
3.13 TAIL STRIKE DURING LANDING
3.14 RUNWAY EXCURSION DURING LANDING
3.15 COLLISION WITH TERRAIN
3.16 RUNWAY IMPACT DURING ATTEMPTED GO-AROUND
3.17 UNCONTAINED ENGINE FAILURE AND SUBSEQUENT FIRE
3.18 GROUND COLLISION AND EVACUATION
3.19 CABIN SAFETY IMPROVEMENTS
3.20 16G SEATS
3.21 FIRE RETARDANT MATERIALS
3.22 FLOOR PROXIMITY EMERGENCY ESCAPE PATH MARKING
3.23 LAVATORY SMOKE DETECTORS AND FIRE EXTINGUISHERS
3.24 LOW HEAT/SMOKE RELEASE TESTS
3.25 RADIANT HEAT RESISTANT EVACUATION SLIDE
3.26 EXIT DESIGN
3.27 DISTANCES BETWEEN EMERGENCY EXITS
3.28 CARGO COMPARTMENT FIRE DETECTION/SUPPRESSION
3.29 THERMAL/ACOUSTIC INSULATION
Chapter 4. CABIN INVESTIGATOR
4.1 CABIN INVESTIGATOR QUALIFICATIONS AND RESPONSIBILITIES
4.2 CI TRAINING
4.3 AREA 1 — PREPARE FOR THE INVESTIGATION
4.4 AREA 2 — COLLECT DATA
4.5 AREA 3 — ANALYSE DATA
4.6 AREA 4 — PRESENT FINDINGS AND RECOMMENDATIONS
Appendix A to Chapter 4. CABIN INVESTIGATOR TASKS
Appendix B to Chapter 4. ICAO COMPETENCY FRAMEWORK FOR CABIN INVESTIGATORS
Appendix C to Chapter 4. INVESTIGATION FIELD KIT
Appendix D to Chapter 4. QUICK REFERENCE CHECKLIST
Chapter 5. ACCIDENT INVESTIGATION
5.1 CABIN SAFETY ASPECTS IN ACCIDENT INVESTIGATION
5.2 ANALYSIS OF INFORMATION SPECIFIC TO CABIN SAFETY
5.3 GENERAL INFORMATION
5.4 DOCUMENTATION
5.5 AIRCRAFT (CABIN SPECIFIC) INFORMATION
5.6 HUMAN PERFORMANCE
5.7 ADDITIONAL INFORMATION
5.8 INTERVIEWS
5.9 TYPES OF OCCURRENCES
5.10 EVACUATION
5.11 DITCHING OR INADVERTENT WATER CONTACT
5.12 FIRE/SMOKE/FUMES
5.13 TURBULENCE
5.14 DECOMPRESSION
5.15 AIRCRAFT DAMAGE
5.16 FATAL OR SERIOUS INJURIES (MISCELLANEOUS)
Appendix A to Chapter 5. OCCURRENCE SUMMARY
Appendix B to Chapter 5. GUIDANCE ON CABIN CREW MEMBERAND PASSENGER INTERVIEWS
Appendix C to Chapter 5. GUIDANCE FOR INVESTIGATING AN EVACUATION
Appendix D to Chapter 5. GUIDANCE FOR INVESTIGATING A DITCHING OR INADVERTENT WATER CONTACT
Appendix E to Chapter 5. GUIDANCE FOR INVESTIGATING ON-BOARD FIRE/SMOKE/FUMES
Appendix F to Chapter 5. GUIDANCE FOR INVESTIGATING A TURBULENCE ENCOUNTER
Appendix G to Chapter 5. GUIDANCE FOR INVESTIGATING A DECOMPRESSION
Appendix H to Chapter 5. EXAMPLE OF PASSENGER QUESTIONNAIRE ON BRACE POSITIONS AND INJURIES
Chapter 6. INCIDENT INVESTIGATION
6.1 GENERAL
6.2 MANDATORY OCCURRENCE REPORTING
6.3 TYPES OF OCCURRENCES
6.4 INCIDENT REPORT AND INFORMATION SPECIFIC TO CABIN SAFETY
6.5 EXAMPLES OF INCIDENT INVESTIGATIONS
6.6 INADVERTENT SLIDE DEPLOYMENT
6.7 MEDICAL EVENT
6.8 UNRULY PASSENGER EVENT
Appendix A to Chapter 6. GUIDANCE FOR INVESTIGATING AN INADVERTENT SLIDE DEPLOYMENT
Appendix B to Chapter 6. GUIDANCE FOR INVESTIGATING A MEDICAL EVENT
Appendix C to Chapter 6. GUIDANCE FOR INVESTIGATING AN UNRULY PASSENGER EVENT
Chapter 7. REPORTS ON SURVIVAL FACTORS
7.1 SURVIVAL FACTORS GROUP FACTUAL REPORT
7.2 AIRCRAFT CONFIGURATION
7.3 CABIN CREW INFORMATION AND TRAINING
7.4 SUMMARY OF THE OCCURRENCE
7.5 PASSENGER INFORMATION
7.6 ON-SCENE DOCUMENTATION
7.7 ADDITIONAL DOCUMENTATION AND TESTING
7.8 EMERGENCY RESPONSE
7.9 MEDICAL AND PATHOLOGICAL INFORMATION
7.10 AERODROME INFORMATION
7.11 CRASH SITE INFORMATION
7.12 FINAL REPORT
7.13 CONCLUSIONS AND RECOMMENDATIONS