COMMISSION OF THE EUROPEAN COMMUNITIES 
C0MC93) 406 final 
Brussels» 1 Sspteiaber 1993 
Proposal for a 
fflWNH1 HIRECTIVE 
ESTABLISHING THE FUNDAMENTAL PRINCIPLES GOVERNING THE 
INVESTIGATION OF CIVIL AVIATION ACCIDENTS AND INCIDENTS 
(presented by the Commission) 
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EXPLANATORY MEMORANDUM 
I. Introduction 
In November 1987 the Commission organised an Air Safety Symposium 
aiming at providing the forum for an exchange of information and 
Ideas on aviation safety and identifying priority areas for such 
action as may be appropriate at Community level. 
One of the three broad themes discussed during this symposium was 
the investigation of aircraft accidents. The conclusions drawn 
from the discussions*1* showed clearly that although the situation 
was generally satisfactory in Europe, Community actions in the 
fields of accident investigations was needed in a number of areas. 
In order to obtain more detailed information, the services of the 
Commission launched two specific studies which were completed in 
1989: 
"Cooperation and shared utilisation of available resources in 
aircraft accident investigation" by Geoffrey Wilkinson, former 
Chief Inspector of Accidents of the United Kingdom Accident 
Investigation Branch; and 
"Problems raised by the double enquiry into air 
Lucien Rapp, Professor at the Faculty of Law. accidents" by 
The results and conclusions of these studies were carefully 
assessed by experts from governments and Industry in a number of 
meetings organised by the services of the Commission in 1990. 
(1) Proceedings of the Air Safety Symposium, Office for 
Pub I I cat ions of the European Communities, Luxembourg, 1988 Off icial 
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In 1991, the Commission, taking into account the comments of the 
experts and the discussions taking place in the international 
organisations, in particular ICAO and ECAC, issued a "Communication 
to the Council on Community initiatives concerning civil aviation 
incidents and accidents. 
This communication included a working programme which foresees, 
amongst others, legislative measures in the field of accident 
invest igat ion. 
Consequently the proposed measure is intended to lay down strong 
and common foundations for the investigations carried out by the 
Member States at national level. 
In 1992, a number of meetings with experts took place enabling the 
services of the Commission to draft the present proposal based on 
identified needs derived from shortcomings in the system. 
II. Shortcomings In the present system 
The present system of aircraft accident investigation is governed 
by the international standards and recommended practices contained 
in the current edition of Annex 13 to the Convention on 
International Civil Aviation published by ICAO. 
While the process described above was taking place in the services 
of the Commission, a parallel evolution of thoughts was initiated 
in the aviation circles and in particular in ICAO. 
For this reason, ICAO organised in February 1992 a very large 
Accident Investigation Divisional Meeting (AIG 92) attended by more 
than 200 delegates from more than 70 countries and organisations. 
A large number of proposals to modify and update Annex 13 and other 
relevant ICAO documents were adopted in order to try to overcome 
the shortcomings identified by all those experts. 
The present proposal takes into account the work carried out at AIG 
92 and is therefore in line with latest and foreseen ICAO 
requirements, turning into Community legislation a number of 
measures to correct shortcomings. 
First of all, the objective of the investigation must be clearly 
expressed: namely prevention of future accidents and incidents. 
Experience has shown when investigating several recent accidents in 
Europe that difficulties can arise from national legislations which 
do not provide for a clear separation between the technical 
investigation only interested in accident prevention and the 
Judicial inquiry seeking for faults or liability. The existence of 
this double inquiry creates a very complex problem that could 
hamper the investigation of the accident and is aggravated by the 
fact that Judicial traditions vary from State to State. 
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The potential conflict of interest could be avoided by defining 
very clearly the status of the technical investigation and 
recognising a number of basic rights of the investigators to enable 
them to achieve their mission while respecting the legal procedures 
in force. The investigators and their work has also to be 
protected from misuse which could be counter productive by 
deterring the parties in an accident from cooperating by fear of 
subsequent legal action. Only factual information arising from the 
technical investigation should be available for use by the Judicial 
authorities, analysis or conclusions should remain limited to 
accident prevention use. 
The findings of the investigation are usually published in some 
form of report. The dissemination of the report including the 
safety recommendations derived from the investigation is of utmost 
importance in the interest of accident prevention. As an example, 
last year an accident happened in the USA with the same aircraft 
and in similar conditions as a Canadian accident three years 
earlier. The Canadian investigation report had not been officially 
sent to the US authorities. 
Although safety recommendations are sent to the relevant parties, 
very often there is no follow-up procedure to check if any action 
has been taken to correct the deficiencies. Such a procedure 
should be sufficiently flexible to allow the interested parties to 
either apply strictly the recommendations, apply other corrective 
action deemed more appropriate or reject the recommendations 
providing a reasonable Justification is given. 
In the Community, accident investigations are carried out by 
national bodies, the organisation of which differs greatly both 
with regard to the extent of their resources (human and material) 
and to independence vis-à-vis the national aviation authorities. 
The low probability of a major accident occurring in a small state 
does not Justify a large organisation but, should such accident 
happen, the possibility should exist to obtain at short notice the 
needed resources. Expertise could be brought from other Community 
accident investigation bodies according to the 1980 Directive on 
future cooperation and mutual assistance between the Member States 
in the field of air accident investigation*1) but this cooperation 
could be improved if all those bodies were working according to a 
number of common basic principles. 
In order to avoid possible conflict of interests, the investigating 
body should be independent of any party which could directly or 
indirectly have a responsibility in the cause of an accident. 
(1) OJ no. 375, 31.12.1980 
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Finally, an important modification proposed is to extend to serious 
incidents the investigation process applied to accidents. The 
investigation of accidents is a reactive activity and therefore not 
the best means of prevention. In addition, there is fortunately a 
very limited number of accidents. For this reason, investigation 
of serious incidents to the standards employed for accidents will 
provide a greater source of accident prevention data than is 
available through the investigation of accidents alone. 
III. Application of the subsidiarity principle 
Due to the international nature of aviation and, in particular in 
the community where the liberalisation measures of air transport 
and the realisation of the single market will lead to more 
multinational operations, accident investigations will very often 
involve several Member States. 
The small number of aviation accidents does not Justify large 
investigation units and cooperation between units is therefore 
needed. 
New international standards and recommended practices are 
definitely needed and the Community has the legal instruments to 
ensure a quick and efficient implementation of those standards in 
all the Member States. 
The present proposal could be considered as a framework directive, 
a number of articles setting goals leaving to the Member States 
freedom as to the way to reach these goals. However, due to the 
technical nature of this subject, it has been necessary sometimes 
to look into some matters in more detail. 
The burden for the majority of the Member States will be limited 
due to the fact that they already apply standards at least 
equivalent to those contained in Annex 13. However, some Member 
States and in particular the smaller ones, will have to change 
their legislation and invest in independent investigation units. 
The consultations carried out by the services of the Commission 
during the last five years have shown that usually in these Member 
States the technical authorities have recognised the need to 
proceed with those required changes and would welcome such a 
Community initiative as a support to give air safety the priority 
ranking it deserves. 
In addition, the Commission does not claim for any additional 
competence in this field, but by establishing fundamental 
principles, it will encourage a better mutual cooperation between 
responsible bodies. As a consequence, the adoption of the present 
proposal could also permit to repeal the 1980 Directive on future 
cooperation and mutual assistance between Member States in the 
field of air accident investigation. 
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IVt Conclusions 
The present proposal is the outcome of a long process, started in 
1987 during which a wide consultation was organised at each stage. 
It should help the Member States to bring their accident 
investigation methods and legislations up-to-date and encourage 
them to cooperate. 
Such an improvement should lead to a better understanding of 
accidents and incidents and therefore contribute to a more 
efficient safety policy and prevention of accidents. 
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COMMENTS ON INDIVIDUAL ARTICLES 
Article \ 
This article defines the general objective of the Directive which is 
the improvement of air safety. 
Article Z 
This article defines the scope of the Directive. It covers not only 
the investigations of accidents but also incidents. This is in 
accordance with recent ICAO proposals. 
In paragraph 1, the scope is limited to the Community while in 
paragraph 2, the scope can be extended outside of the Community when an 
incident occurs to a Community aircraft and no investigation is carried 
out by the State where the incident occurred. This is due to the fact 
that very often, it is the State of registry of the aircraft which is 
better placed to carry out an investigation of an incident. 
Article 3 
This article defines the terms used in the Directive. These 
definitions are those used by ICAO except h) which is a definition used 
in other Community legislation on air transport^1). 
Article 4 
This article sets out the principle of the mandatory investigation of 
every accident and also every serious incident. This last provision is 
new but complies with ICAO guidelines. This article also do not 
prevent the investigation body to investigate any other incident if it 
could be beneficial to air safety. In addition, it is the 
responsibility of the investigation body to determine the type of 
investigation and the efforts to invest into it according to the 
knowledge that could be expected from an accident prevention point of 
view. 
(1) Council Regulation (EEC) no. 2407/92 of 23 July 1992 on licensing 
of air carriers; OJ no. L240 of 24.8.92. 
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Article 5 
The purpose of this article is to draw a clear dividing line between 
the technical investigation and the Judicial enquiry. It establishes 
the status of the technical investigation in order to reach the 
objective of this Directive. 
Paragraph 1 sets the general principle while paragraph 2 lists a number 
of minimum rights necessary for the investigators to carry out their 
mission. 
Art|ç|e $ 
This article deals with the body responsible for carrying out the 
technical investigation of aviation accidents. 
Paragraph 1 gives the general principles: permanence and independence 
in order to avoid possible conflict of interest or any direct or 
indirect involvement in the causes of any investigated accident or 
incident. 
Paragraph 2 enables small Member States which consider that even a 
limited permanent structure dealing only with investigations would not 
be justified, to use also this structure as a safety data collection 
and analysis unit running for example incident reporting system, 
occurrences data bases etc. 
Paragraph 3 deals with the minimum means necessary for such a structure 
to be operat ional. 
Paragraph 4 contains some of the provisions of Council Directive 
80/1266/EEC therefore enabling it to be repealed in the present 
proposal. 
Article 7 
This article obliges the investigation body to publish a report to 
ensure the widest possible dissemination of safety related information 
in the event of an accident. 
Paragraph 2 sets a goal of 12 months for the completion of the report. 
Setting a firm deadline could be counter productive by preventing long 
and sophisticated research which could be needed to reach important 
conclusions but setting a goal is necessary to avoid complacency. 
Paragraph 3 introduces a provision to enable interested parties to 
comment and give them an opportunity to request a revision of the 
report. 
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Article 8 
This article deals with the report in the case of an incident. Due to 
the special nature of incidents, their greater frequency and the fact 
that they usually are not published, it could be counter productive to 
use the same procedure as in the case of accidents. It is therefore 
important to protect the parties involved and to limit the circulation 
of the report to professionals, dealing with accidents prevention or 
aviat ion safety. 
Article 9 
This article addresses the important issue of safety recommendations. 
Paragraph 1 ensures that the dissemination of safety recommendations is 
achieved by addressing them to all parties concerned and sending a copy 
to the Commission. By receiving the safety recommendations from ail 
the Member States it will be able to distribute them to all the 
investigation bodies and aeronautical authorities of the Community. 
This could also lay the groundwork for a future central data base of 
safety recommendations. 
Paragraph 2 creates an obligation to follow-up at national level the 
measures taken by the addressees when receiving a safety 
recommendation: compliance or justified rejection or alternative 
action. It also ensures that the corrective measures will not affect 
Community law such as, for example, the free movement of aircraft. 
Article 10 
This article reinforces the protection of the technical investigation 
by measures to avoid its use for purposes other than its exclusive 
objective which is prevention of future accidents or incidents. 
Paragraph 1 limits the use of the report for other purposes to the 
factual part of it, therefore excluding the analysis and conclusions 
part. 
Paragraph 2 enables the investigating body to draft safety 
recommendations concerning shortcomings discovered during the 
investigation but which could be unrelated to the causes of the 
accident or incident without risk of these recommendations being used 
for purposes other than prevention. 
Paragraph 3 prevents the use of the report for disciplinary action. 
Paragraph 4 reinforces the protection of the investigators by 
preventing them to be placed in a situation where there would be a 
confIict of interest. 
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Article 11 
As the provisions of this proposal go further than those contained in 
Council Directive 80/1266/EEC, there is no reason to maintain this 
Directive anymore. 
Article 12 8. 13 
Procedural articles. 
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PROPOSAL FOR A COUNCIL DIRECTIVE 
ESTABLISHING THE FUNDAMENTAL PRINCIPLES GOVERNING 
THE INVESTIGATION OF CIVIL AVIATION ACCIDENTS AND INCIDENTS 
THE COUNCIL OF THE EUROPEAN COMMUNITIES, 
Having regard to the Treaty establishing the European Economic 
Community, and in particular Article 84§2 thereof, 
Having regard to the proposal from the Commission*1>, 
Having regard to the Opinion of the European Par Iiament*2), 
Having regard to the Opinion of the Economic and Social Committee^) t 
Whereas the opening of the internal market and the liberalisation of 
air transport will increase the air traffic operations, in particular 
these involving crew, aircraft and undertakings from different Member 
States; 
Whereas a high general level of safety in the single market requires 
harmonised procedures to the extent that there will be less direct 
links between individual Member States and individual operators-, 
whereas operations in the Community will involve more multilateral 
contacts between Member States and operators and therefore there will 
be a need for general principles to enable Member States to apply the 
same high level of accident prevention measures; 
Whereas a high general level of safety in civil aviation in Europe 
should be maintained and ail efforts should be made to reduce the 
already limited number of accidents and serious incidents; 
(1) O.J. N* C.. 
(2) O.J. N- C. 
(3) O.J. NT C.. 
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Whereas account should be taken of the Convention on International 
Civil Aviation, signed in Chicago on 7 December 1944, which provides 
for implementation of the measures necessary to ensure the safe 
operation of aircraft; whereas account should also be taken in 
particular of the Annex 13 to the said Convention which provides 
international standards and recommended practices for aircraft accident 
investigation; 
i Whereas the expeditious realisation of technical investigations of 
civil aviation accidents and incidents would improve air safety in 
helping to prevent the occurrence of such accidents and incidents; 
Whereas international standards provide for the investigation of 
accidents to be carried out under the responsibility of the State where 
the accident occurs, if investigation of incidents is not carried out 
by the State where the incident occurs, this investigation should be 
carried out by the State of registry-, 
Whereas investigation of serious incidents should be carried out in a 
similar way to investigation of accidents; 
Whereas air safety requires accident investigations to be carried out 
in the shortest possible time, investigators should be able to proceed 
to their tasks with the greatest freedom allowed by the legal system; 
Whereas investigation of civil aviation accidents and incidents should 
be carried out by an independent body to avoid any conflict of interest 
and any possible involvement in the causes of the occurrence being 
investigated; whereas this body should be suitably equipped and its 
tasks could include other prevention activities; 
Whereas it is important for accident prevention to publish the findings 
of accident investigations in the shortest time possible while giving 
opportunity to interested parties to comment on these findings; 
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Whereas the particular nature of incidents should be taken into account 
when circulating the findings of incident investigation; 
Whereas the safety recommendations resulting from an accident or 
Incident investigation should be duty taken into account; 
Whereas the technical investigation should only be used for prevention 
purposes» only factual information collected during the investigation 
should be allowed to be used to apportion blame or liability; 
HAS ADOPTED THIS DIRECTIVE: 
Article 1 - Objective 
This Directive aims at improving air safety by facilitating the 
expeditious realization of investigations, the exclusive objective of 
which is prevention of future accidents or incidents. 
Article 2 - Scope 
1. This Directive shall apply to investigations of civil aviation 
accidents and incidents occurring in the territory of the European 
Community taking into account the international obligations of the 
Member States. 
2. This Directive shall also apply outside the territory of the 
European Community to investigations of serious incidents involving 
aircraft registered in a Member state or operated by an undertaking 
established in a Member State, when such an investigation is not 
carried out by another State. 
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Article 3 - Definitions 
For the purposes of this Directive 
a) 'Accident' means an occurrence associated with the operation of an 
aircraft which takes place between the time any person boards the 
aircraft with the intention of flight until such time as all such 
persons have disembarked, in which: 
1) a person is fatally or seriously injured as a result of: 
being in the aircraft, or 
direct contact with any part of the aircraft, including 
parts which have become detached from the aircraft, or 
direct exposure to Jet blast, 
except when the injuries are from natural causes, self-
inflicted or inflicted by other persons, or when the injuries 
are to stowaways hiding outside the areas normally available to 
the passengers and crew; or 
2) the aircraft sustains damage or structural failure which: 
adversely affects the structural strength, performance or 
flight characteristics of the aircraft, and 
would normally require major repair or replacement of the 
affected component, 
except for engine failure or damage, when the damage is limited 
to the engine, its cowlings or accessories; or for damage 
limited to propellers, wing tips, antennas, tires, brakes, 
fairings, small dents or puncture holes in the aircraft skin; 
or 
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3) the aircraft is missing or is completely inaccessible; 
b) 'Serious injury' means an injury which is sustained by a person in 
an accident and which: 
1) requires hospitalisation for more than 48 hours, commencing 
within seven days from the date the injury was received; or 
2) results In a fracture of any bone (except simple fractures of 
fingers, toes, or nose); or 
3) involves lacerations which cause severe haemorrhage, nerve, 
muscle or tendon damage: or 
4) involves injury to any internal organ; or 
5) involves second or third degree burns, or any burns affecting 
more than 5 per cent of the body surface-, or 
6) involves verified exposure to infectious substances or 
injur ious radiât ion; 
c) 'Fatal injury' means an injury which is sustained by a person in an 
accident and which results in death within 30 days of the date of 
the accident -, 
d) 'Causes' means action(s), omission(s), event(s), condition(s), or a 
combination thereof, which led to the accident or incident; 
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e) 'Investigation' means a process conducted for the purpose of 
accident and incident prevention which includes the gathering and 
analysis of information, the drawing of conclusions, including the 
determination of cause(s) and, when appropriate, the making of 
safety recommendations; 
f) 'Invest Igator-ln-charge' means a person charged, on the basis of 
his qualifications, with the responsibility for the organisation, 
conduct and control of an investigation; 
g) 'Flight recorder' means any type of recorder installed in the 
aircraft for the purpose of complementing accident/incident 
investigation; 
h) 'Undertaking' means any natural person, any legal person, whether 
profit-making or not, or any official body whether having its own 
legal personality or not; 
i) 'Incident' means an occurrence, other than an accident, associated 
with the operation of an aircraft which affects or could affect the 
safety of operation-, 
J) 'Serious incident' means an incident involving circumstances 
indicating that an accident nearly occurred. 
A list of examples of serious incidents can be found in the Annex 
to this Direct ive; 
k) 'Safety recommendation' means a proposal of the investigation body 
of the State conducting the investigation, based on information 
derived from the investigation, made with the intention of 
preventing accidents or incidents. 
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Article 4 - Mandatory investigation 
1. Every civil aviation accident or serious incident shall be 
subjected to an investigation, the scope of which shall be 
determined by the investigation body taking into account the 
objective of this directive. 
2. This does not prevent Member States to take measures to enable the 
investigation of other incidents when the investigation body may 
expect to draw air safety lessons from it. 
Article S - Status of the investigation 
1. The Member States shall define, in the framework of their 
respective internal legal systems, a legal status of the 
investigation that shall enable the investigators-in-charge to 
achieve their mission, in the most efficient way and within the 
shortest time. 
2. Without prejudice to the internal legal procedures in force and in 
cooperation with other authorities of the Member States responsible 
for the Judicial enquiry, the provisions of paragraph 1 shall allow 
in part icular: 
unimpaired access to the site of the accident or incident as 
well as to the aircraft or its wreckage; 
immediate controlled removal of debris, bodies or components 
for examination or analysis purposes; 
immediate access to and use of the contents of the flight 
recorders and any other recordings; 
immediate examination of, or taking of samples from, the bodies 
of victims or persons involved; 
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examining witnesses; 
full access to any relevant information or records held by the 
owner, the operator, the maintenance organisation or the 
manufacturer of the aircraft and by the authorities responsible 
for civil aviation or airport operation. 
Article 6 - investigation body 
1. The Member States shall ensure that the conduct of investigations 
is entrusted to a permanent civil aeronautical body. This body 
shall be functionally independent in particular of the national 
aeronautical authorities responsible for airworthiness, 
certification, flight operation, maintenance, licensing, air 
traffic control or airport operation. 
2. Notwithstanding paragraph 1, the activities entrusted to this body 
can be extended to the gathering and analysis of air safety 
related data in as far as these activities do not affect its 
independence and entail no regulatory , normative or administrative 
responsibiIity. 
3. The body referred to in paragraph 1 above shall be given the means 
required to carry out its responsibilities independent from the 
authorities referred to above and should be able to obtain 
sufficient resources to do it. Its personnel shall benefit from a 
statute giving the necessary protection and guarantees of 
independence. It shall comprise at least a suitably trained 
investigator to exercise the function of investigator-in-charge in 
the event of a civil aviation accident or serious incident. 
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4. If necessary, the body conducting an investigation may request the 
assistance of bodies from other Member States to supply: 
a) installations, facilities and equipment for: 
the technical investigation of wreckage and aircraft 
equipment and other objects relevant to the investigation. 
the evaluation of information from flight recorders. 
and the computer storage and evaluation of air accident 
data. 
b) accident investigation experts to undertake specific tasks but 
only where an investigation is opened following a major 
accident. 
When available, such assistance should be given, as far as possible 
free of charge. 
Article 7 - Accident report 
1. Any investigation of a civil aviation accident shall be the subject 
of a report in a form appropriate to the accident. This report 
shall point out the exclusive objective of the investigation 
mentioned in article 1 of this Directive and contain, where 
appropriate, safety recommendations. 
2. The investigation body shall publish the report in the shortest 
possible time while endeavouring not to exceed 12 months after the 
accident date. 
3. The draft report is submitted for comments to any party which the 
investigation body considers the investigation to be of particular 
importance and it shall give a deadline for the submission of 
comments. 
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Article 8 - Incident report 
1. Any investigation about an incident involving civil aviation shall 
be the subject of a report in a form appropriate to the type and 
to the gravity of the incident, and shall contain where 
appropriate relevant safety recommendations. This report shall , 
as far as possible, protect the anonymity of the parties involved 
in the incident. 
2. This report shall be the subject of as wide a circulation as 
possible to the parties likely to benefit from the findings of 
the aforementioned report. 
Article 9 - Safety recommendations 
1. The reports and the safety recommendations referred to in Article 
7.1 and 8.1 shall be addressed to persons, undertakings or national 
aeronautical authorities concerned and copied to the Commission. 
2. The Member States shall take the necessary measures in order to 
ensure that the safety recommendations from the investigation body 
are duly taken into consideration and acted upon where appropriate 
without prejudice to the Community law and in particular that 
concerning the functioning of the internal market. 
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Article 10 - Liability 
1. The analysis and conclusions drawn from the investigation or 
arising from it shall not be used to apportion blame or within the 
context of proceedings to determine liability. 
2. A safety recommendation does not by itself create a presumption of 
blame or liability for an accident or incident. 
3. Investigation reports shall not be used for disciplinary action. 
4. The Member States shall, in the context of Articles 5 and 6, take 
the necessary measures to protect investigators from involvement in 
I itigation proceedings intended to apportion blame or liability 
arising from an accident or incident. 
Article 11 
The Council Directive 80/1266/EEC of 16 December 1980 is repealed. 
Article n 
1. The Member States shall bring into force the laws, regulations and 
administrative provisions necessary to comply with this Directive 
not later than 1 January 1996. They shall forthwith inform the 
Commission thereof. 
2. When the Member States adopt these provisions their texts shall 
refer to this Directive or shall be accompanied by such a reference 
when officially published. The Member States shall decide what 
method to use to make this reference. 
Article 13. 
This Directive is addressed to the Member States. 
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Annex 
List of examples of serious Incidents 
The incidents listed are typical examples of serious incidents. The 
list is not exhaustive and only serves as guidance to the definition of 
"Serious Incident". 
A near collision requiring an avoidance manoeuvre or when an 
avoiding manoeuver would have been appropriate to avoid a collision 
or an unsafe situation. 
Controlled flight into terrain (CFIT) only marginally avoided. 
An aborted take-off on a closed or engaged runway, or a take-off 
from such runway with marginal separation from obstacle(s). 
A landing or attempted landing on a closed or engaged runway. 
Gross failure to achieve predicted performance during take-off or 
initial climb. 
All fires and smoke in the passenger compartment, in cargo 
compartments or engine fires, even though such fires are 
extinguished by the use of extinguishing agents. 
Any events which required the emergency use of oxygen by the flight 
crew. 
Aircraft structural failure or engine disintegration which is not 
classified as an accident. 
Multiple malfunctions of one or more aircraft systems that 
seriously affects the operation of the aircraft. 
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Any case of flight crew incapacitation in flight. 
Any fuel state which would require the declaration of an emergency 
by the pi lot. 
Take-off or landing incidents. Incidents such as undershooting, 
overrunning or running off the side of runways. 
System failures, weather phenomena, operation outside the approved 
flight envelope or other occurrences which could have caused 
difficulties controlling the aircraft. 
Failure of more than one system in a redundancy system which is 
mandatory for flight guidance and navigation. 
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ISSN 0254-1475 
COM (93) 406 final 
DOCUMENTS 
EN 07 
Catalogue number : CB-CO-93-444-EN-C 
ISBN 92-77-58958-2 
Office for Official Publications of the European Communities 
L-2985 Luxembourg