EN    EN EN 
EN    EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Brussels, 29.10.2009 
SEC(2009) 1477 final 
  
COMMISSION STAFF WORKING DOCUMENT 
accompanying the 
 
Proposal for a  
 
 
REGULATION OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL 
 
on investigation and prevention of a ccidents and incidents in civil aviation 
 
IMPACT ASSESSMENT 
{COM(2009) 611 final} 
{SEC(2009) 1478} 
EN 2   EN TABLE OF CONTENTS 
1. Procedural issues and consulta tion of interested parties.............................................. 4 
1.1. Context of the Impact Assessment............................................................................... 4 1.2. Ex-Ante Evaluation...................................................................................................... 4 1.3. Public consultations ..................................................................................................... 5  
1.4. Impact Assessment Board............................................................................................ 6 2. Background – Air Safety and Accident Investigation.................................................. 6 2.1. Air Safety in the EU..................................................................................................... 6  
2.1.1. Social and economic costs of air accidents.................................................................. 8 2.2. The need for independent accident inve stigation and occurr ence reporting................ 8 
2.2.1. Organisation of accident investigation and the parties involved ................................. 9 2.2.2. Role of occurrence repor ting in civil aviation............................................................ 10 
2.3. Current regulatory framework for accident  investigation and occurrence reporting in 
the EU......................................................................................................................... 11 
2.3.1. Civil aviation accide nt investigation.......................................................................... 11 
2.3.2. Occurrence reporting in  civil aviation........................................................................ 13 
3. Problem Definition - The need for change................................................................. 13 3.2. Lack of a uniform investigating capacity in the EU .................................................. 14 3.3. Tensions between safety invest igations and other proceedings................................. 16 
3.3.1.1. Cooperation between the authorities i nvolved in accident investigation................... 18 
3.3.1.2. Protection of sensitive safety information.................................................................. 19 3.4. Unclear role of the Community  in safety investigations............................................ 21 
3.5. Weaknesses in implementation of safety recommendations...................................... 26 3.6. Protection of the rights of air crash victims and their families .................................. 28 3.7. Who is affected, in what ways, and to what extent? .................................................. 30 3.8. Does the EU have the right to act?............................................................................. 31 3.8.1. The added value of Community Action..................................................................... 32 3.8.2. The proportionality of the Community action ........................................................... 32 4. Objectives.................................................................................................................. . 33 
5. Policy options............................................................................................................. 3 6 
6. Analysis of impacts.................................................................................................... 51 6.1. Introduction and rating of impacts ............................................................................. 51 6.2. Safety impacts related to identified problem areas .................................................... 51 6.3. Economic, social and environmental impacts............................................................ 52 6.4. Impacts on fundamental rights................................................................................... 53 
EN 3   EN 6.5. Geographical scope of impacts incl uding on international relations ......................... 53 
6.6. Risk analysis............................................................................................................. .. 54 
7. Cost-efficiency and administrative burden ................................................................ 55 8. Comparing the options ............................................................................................... 58 8.1. Which method was applied and how impacts have been weighted? ......................... 58 
8.2. Results of the weighting between the policy options................................................. 59 
8.3. Which of the policy options ha s the biggest added value? ........................................ 59 
9. Monitoring and evaluation ......................................................................................... 60 9.1. Indicators and methods for the monito ring of the preferred policy option................ 60 
 Annexes...................................................................................................................... 6 4 
EN 4   EN 1. PROCEDURAL ISSUES AND CONSULTATION OF INTERESTED PARTIES  
1.1. Context of the Impact Assessment 
Lead DG : Directorate-General for Energy and Transport 
Agenda planning : This proposal is listed in the Commission’s Legislative Work 
Programme under reference 2009/TREN/004. Prep aration of this Impact Assessment 
(IA) report was assisted by an inter-service steering group created in April 2009 to 
which all the interested Directorates-Gen eral of the Commission were invited to 
participate. The European Aviation Safety Agency was also regularly consulted in the course of the drafting of this proposal. 
This IA analyses different policy options for better efficiency in civil aviation 
accident investigation and prevention in the European Union (EU).
1 It was prepared 
to assist the Commission in taking a policy decision as to the need and direction of 
the revision of Council Directive 94/56/ EC of 21 November 1994 establishing the 
fundamental principles governing the invest igation of civil aviation accidents and 
incidents2 (Directive 94/56/EC) and Direc tive 2003/42/EC of the European 
Parliament and of the Council of 13 J une 2003 on occurrence reporting in civil 
aviation3 (Directive 2003/42/EC), as envisage d in the Commission Legislative and 
Work Programme for 2008.4 
This IA results from the recommendations of the "Group of Experts to advise the 
Commission on a strategy to d eal with accidents in the transport sector" (Group of 
Experts), which is attached as Annex I,5 expert studies and reports, consultations 
with Member States (MS) and interested stakeholders, as well as recommendations addressed to the Commission within the context of the Commission's "Action Programme for Reducing Ad ministrative Burdens".
6 A list of studies, documents and 
literature used for the purpose of th is IA is attached as Annex II. 
Data gathered for the purpose of this IA is considered as constituting a good basis for 
assessing different policy options for th e revision of Directive 94/56/EC and 
Directive 2003/42/EC. 
1.2. Ex-Ante Evaluation 
The preferred policy option identified in this IA involves mobilisation of certain 
Community resources. In this respect, this IA meets all the requirements as set out in 
Article 21(1) of the implementing rules to the Financial Regulation applicable to the 
general budget of the European Communities, and in accordance with the principle 
                                                 
1 This IA deals with investigation of accidents in civil aviation only. In vestigation of accidents of State 
aircraft is usually conducted by separate State se rvices, outside the scope of  the EU common transport 
policy. 
2 OJ L 319 of 12.12.1994, p.14. 
3 OJ L 167 of 4.7.2003, p.23. 
4 COM(2007)640 final 
5 Final report of the Group of expert s to advise the Commission on a stra tegy to deal with accidents in the 
transport sector, Brussels 3.7.2006; The Group of experts was established on the basis of the Commission Decision EC/425/2003, OJ L 144 12.06.2003, pp. 10-11 
6 The programme was launched in January 2007 as part of the Better Regulation Strategy of the 
Commission. 
EN 5   EN of the sound financial management serves as an ex-ante  evaluation within the 
meaning of that Article.7 
1.3. Public consultations 
This IA was preceded by consultations with the interested stakeholders, authorities of 
the MS and the general public. The general principles and minimum standards for consultation of the interested part ies by the Commission were respected.
8 The public 
consultations were opened on the 5th of January 2007 on the "Y our Voice in Europe" 
internet website and closed after 8 weeks, on 2nd March 2007.  
The Commission also relied on the results of  an external impact assessment study 
finalised in July 2007 by ECORYS Nederland BV and National Aerospace Laboratory NLR.
9 The study took into account the resu lts of the public consultations 
on the internet as well as the input from: 
(1) A detailed questionnaire dist ributed directly by the external consultant to a 
large number of interested stakeholders; 
(2) A number of interviews conducted by the external consultant with a limited 
number of interested stakeholders constituting a representative sample; 
The results of the public  consultations on the internet a nd conclusions of  the external 
IA study were presented by the Commission on 31st January and 1st February 2008, 
during a meeting with the MS authorities  and the interested  stakeholders.  
The input received in the course of the public consultations and the results of the 
external IA study were taken into account in  the analysis of the different policy 
options presented in this IA. 
In total 22 replies were submitted in re sponse to the public consultations on the 
internet. In addition, 87 replies were subm itted in response to the questionnaire sent 
out by the external consultant. The list of stakeholders and authorities consulted for 
the purpose of this IA, as we ll as the summary of responses  received are attached as 
Annexs III and IV. The results of the consultations are also available on the 
internet.10 The results of the pubic consultati ons can be summarised as follows: 
(1) All respondents either fu lly or partially agreed that there are currently 
shortcomings in civil aviation accident investigation and occurrence reporting 
in Europe; 
(3) A limited number of respondents were of the opinion th at no additional 
legislative action should be taken at  the EU level for the time being; 
(4) Majority of the respondents argued that it is too early to consider a 
comprehensive revision of Directive 2003/ 42/EC and the that focus should be 
                                                 
7 Commission Regulation (EC, Euratom)  No 2342/2002 of 23 December 2002 laying down detailed rules 
for the implementation of Council Regulation (EC, Euratom) No 1605/2002 on the Financial Regulation applicable to the general budget of the European Communities (OJ L 248 16.9.2002, p.1.)  
8 Communication from the Commission Towards a reinforced culture of consultation and dialogue - 
General principles and minimum standards for consultation of interested parties by the Commission, 
Brussels 11.12.2002, COM(2002)704 
9 Impact Assessment on the modification of Directives 94/56/EC and 2003/42/EC (Framework Contract 
for Ex-ante evaluations and Impact Assessments, TREN/A1/46-2005), Final Report, Rotterdam 20 July 
2007 (not available on the internet); 
10 http://ec.europa.eu/transport/air/consultations/2007_03_02_directive_1994_56_en.htm 
EN 6   EN on improving the efficiency of the re gulatory framework for civil aviation 
accident investigation; 
(5) Majority of all groups of respondents,  with the exception of the National 
Safety Investigation Authorities (NSIAs), favoured a policy option whereby a common regulatory framework and a set of central functi ons for accident 
investigation would be esta blished at the EU level; 
(6) NSIAs favoured a revision of the curr ent regulatory framework for civil 
aviation accident investig ation, while at the same time being of the opinion 
that improved efficiency could be achieved through better coordination and 
promotion of voluntary cooperation; 
(7) Opinions varied considerably as to the added value of a single European 
safety investigation authority. Most  of the respondents representing MS 
authorities indicated that this policy option is not feasible in the current 
situation, whereby some argued that it could be a good option for the future. 
On the other side, majority of the re spondents representing the manufacturing 
industry favored this policy option; 
1.4. Impact Assessment Board 
The draft of this IA was submitted to the Impact Assessment Board (the Board) for 
its opinion on 24 June 2009. The Board reque sted resubmission of the report and 
made a number of recommendations for im provement. A revised version of the IA 
report was submitted to the Board on 20 Ju ly. The Board issued its second opinion 
on the 26 August 2009.  
This IA takes into account the recommendations of the Board expressed in both its 
opinions. In particular, following re-assessmen t of the costs and benefits involved in 
the implementation of all the policy options  originally propose d, as well as the 
analysis of the legal status  and functions of the various  organisational structures 
considered, this IA advocates the establ ishment of a “European Network of Civil 
Aviation Safety Investigation Authorities”. This policy option reli es on promotion of 
voluntary cooperation and does not envisage  establishment of any new Community 
bodies. It allows meeting the envisaged polic y objectives in a proportionate and cost-
efficient manner. 
2. B
ACKGROUND – AIR SAFETY AND ACCIDENT INVESTIGATION  
2.1. Air Safety in the EU 
Air transport in the EU can be considered as  one of the safest fo rms of travel. Thanks 
to the concerted efforts of the regulators and the industry, the average rate of fatal 
accidents between 2001 and 2008 and involving tr ansport category aircraft registered 
in the EU MS (plus Norway, Icel and, Liechtenstein and Switzerland11) decreased to 
3.6 per 10  million flights.12 This is a good level of safe ty in global terms but still 
inferior when compared to regions su ch as North America or East Asia. 
In 2008 there were about 1220 accidents reported to the European Aviation Safety 
Agency (EASA) and involving civil airc raft registered in the EU/EEA/EFTA 
Member States – vast majority of them accidents of small gene ral aviation aircraft 
                                                 
11 Hereinafter referred to as EEA/EFTA MS (European Economic Area/European Free Trade Association) 
12 EASA, Annual Safety Review 2008, http://www.easa.eu.int/ws_ prod/g/g_sir_review.php   
EN 7   EN below 2.250 kg MTOM.13 If only bigger aircraft of  MTOM above 2.250 kg are taken 
into account, the average annual numbe r of accidents involving civil aircraft 
registered in the EU/EEA/EFTA Member States in the period 1997 – 2008 could be 
estimated at 72. 
Figure I: Accidents of EU/EEA/EFTA registered aircraft of MTOM over 2.250 kg 
 CAT 
Aeroplanes CAT 
Helicopters GA/AW 
 Aeroplanes GA/AW 
Helicopters Total 
1997–2006 (avg) 32 (avg)  8 (avg)  22 (avg)  10 (avg)  72 (avg)  
2007 37 7 18 12 74 
2008 35 8 24 8 75 
Source: European Aviation Safety Agency, Annual Safety Review 2008 
However, in the context of the increasing complexity of the European aviation 
market and constant traffic growth, which is expected to doubl e by 2030 compared to 
2007 figures,14 there are concerns that the number of accidents may increase.15 
Also, beyond the challenges that we are f acing in the EU, Community operators are 
exposed to increased safety risks when operating to regions with underdeveloped 
aviation infrastructure or deficient regulatory frameworks. Reports of the 
International Civil Aviatio n Organisation (ICAO) i ndicate that the average 
worldwide level of implementation of intern ational safety standards in civil aviation 
is estimated at only 57%.16 The EU considers that at least 12 non-EU countries do 
not have the capacity necessary to ensure proper safety oversight in accordance with 
their obligations under the Conventi on on International Civil Aviation17 (Chicago 
Convention).18 
Safety therefore can never be taken for granted and constant effort is needed to 
maintain its high level in the constantly  changing operational and economic context 
of the global air transport industry. In th is respect the Singe European Sky II was 
launched by the Commission and the remit of  EASA and of Community legislation 
was recently extended to safety aspects of aerodrome operations and provision of air navigation services and air tr affic management (ANS/ATM)
19. By 2012, the EU will 
also adopt a comprehensive set of impleme nting rules on licensing of flight crews 
and safety of air operations.20 The EU is also activel y engaged in strengthening 
                                                 
13 Maximum Take Off Mass (the heaviest weight at which the aircraft has been shown to meet all the 
airworthiness requirements applicable to it) 
14 Challenges of Growth 2008, Eurocontro l, Air Traffic Statistics and Forecasts 
http://www.eurocontrol.int/statfor/p ublic/subsite_homepage/homepage.html  
15 Report of the High Level Group for the Future European Aviation Regulatory Framework, Brussels, 
July 2007 (http://ec.europa.eu/transport/air/doc/hlg_2007_07_03_report.pdf) 
16 Commission's analysis of the ICAO Universal Safe ty Oversight Audit Programme (USOAP) reports 
(10.08.2009); 
17 Convention on International Civil Aviation, signed in Chicago on 7 December 1944, ICAO Doc. 7300/8 
18 List of airlines subject to operating restrictio ns: http://ec.europa.eu/transport/air-ban/list_en.htm 
19 Communication from the Commission to the European Parliament, the Council, the European 
Economic and Social Committee and the Committee of the Regions - Single European sky II: towards 
more sustainable and better performing aviation, Brussels, 25.6.2008, COM(2008) 389 final 
20 Regulation (EC) 216/2008 of the European Parliament and of the Council of 20 February 2008 on 
common rules in the field of civil aviation and establishing a European Aviation Safety Agency, and 
EN 8   EN aviation safety oversight at an internationa l level, notably through a regular dialogue 
with ICAO and technical cooperation projects with third countries. 
2.1.1.  Social and economic costs of air accidents 
No matter what transport mode, accidents al ways reduce confidence in the safety of 
the transport system. They can lead to de ath or injury, cause environmental damage, 
and likely to have serious commercial and financial consequences. They can also lead to civil or criminal litigatio ns and affect professional careers. 
It is difficult to precisely quantify the cost  of air accidents in the EU due to lack of 
comprehensive studies in this respect.  A study conducted in 2006 by the Australian 
Department of Transport and Regional Servic es concluded that the estimated cost of 
each fatality occurred in civil aviation in 2004 in Australia was in the magnitude of 
$2.17 million (€1,56 million).
21 Research undertaken in  the past in the EU22 resulted 
in similar values of €1–2 million for the Value of Statistical Life (VOSL23). Thus, the 
order of magnitude for the VOSL lost in ai r accidents in Europe  in the period 1997 – 
2008 (accidents of civil aircraft register ed in the EU/EEA/EFTA MS with a MTOM 
above 2.250kg) can be estimated at €276 million per annum (Figure II). 
Figure II: Number of fatalities involved in accidents of EU/EEA/EFTA registered 
aircraft with MTOM above 2.250 kg. 
 CAT 
Aeroplanes CAT 
Helicopters GA/AW 
 Aeroplanes GA/AW 
Helicopters Total 
1997–2006 (avg) 106 (avg)  12 (avg)  17 (avg)  6 (avg)  141 (avg)  
2007 26 7 8 11 52 
2008 162 4 22 5 193 
Source: European Aviation Safety Agency, Annual Safety Review 2008 
2.2. The need for independent accident investigation and occurrence reporting 
Independent investigations of accidents are e ssential in the drive to improve transport 
safety. Analysis of the circumstances of  accidents leads to recommendations being 
made to prevent these dramatic events from re-occurring. 
Accidents rarely result from a single failure  but rather from a combination of events - 
for example, an error in maintenance that cau ses a failure in flight that a member of 
the flight crew then responds to incorrectl y. In other words, accidents result from a 
chain of events that make them difficult to analyze but also provide multiple 
                                                                                                                                                         
repealing Council Directive 91/670/EEC, Regulation (EC) No 1592/2002 and Directive 2004/36/EC 
(OJ L 79, 19.03.2008, p. 1.)  
21 Cost of Aviation Accidents and Incidents, Bureau of Transport and Regional Economics report 113, 
Commonwealth of Australia 2006. 
22 Impact Assessment Guidelines, European Commission 
23 The VOSL research method does not measure the value of life per se, which is priceless and cannot be 
monetised. Instead it puts a monetary value on the willin gness of individuals to accept slightly higher or 
lower level of risk. 
EN 9   EN opportunities to prevent them. If any link in the fatal chain is removed than the 
accident can be avoided.24  
Thus, beyond accident investigation, the crucia l element in prevention of accidents is 
open reporting and careful analysis of even the smallest incidents, failures and other 
occurrences in daily operations which may indicate the existence of serious safety 
hazards, and which if not corrected may lead to subsequent accidents. 
2.2.1.  Organisation of accident investig ation and the parties involved 
Due to international characte r of civil aviation, involve ment of many States in 
accident investigation is a common situati on, and the success of the process depends 
on the ability of all the States c oncerned to cooperate efficiently. 
Unless the conduct of the investigation was delegated, the State of Occurrence25 will 
institute the investigation and its NSIA will appoint the investigator-in-charge (IIC), 
responsible for the overall supe rvision of the investigati on. The IIC will rely on the 
teams of experts in various areas of expertis e. Each team will collect data related to 
its domain under the supervis ion of the IIC. The representatives from foreign 
countries (in particular the State of Design26, Registry27, Manufacture28 and 
Operator29) will also participate in the inve stigation by appointi ng their "accredited 
representatives" who may be accompanied by technical advisors, in particular from 
the airline, design organisation, manufactur er or a foreign aviation authority as 
appropriate (Figure III).30 Other States having an intere st in the investigation may 
also participate on a case by case basis.31 
Although organisation of accident investigatio n may vary in detail from State to 
State, the process is usually structured al ong the three main phases. In the first phase 
the investigation team conduc ts examinations at the crash site. After the on-scene 
examination of the wreckage is completed further studies and examinations may be 
undertaken, including the read-outs of the flight recorders ("black boxes"), 
reconstruction of a part of the wreckage, autopsies, simu lations and the overview of 
                                                 
24 One of the best known concepts of accident causatio n in complex organisations as employed in civil 
aviation (or any other complex system) accident investigation was developed in 1997 by Professor 
James T. Reason. According to this model, accide nts require the coming toge ther of a number of 
enabling factors — each one necessary, but in itself not  sufficient to breach system defences. Because 
complex systems such as aviation are extremely we ll-defended, single-point failures are rarely 
consequential in aviation (Reason, J.T. Managing th e risks of organizational accidents, Aldershot 1997; 
Safety Management Manual (SMM), ICAO Doc.  9859, Second Edition 2009 Montreal). 
25 The State in the territory of which an accident or incident occurs (Annex 13 to the Chicago Convention) 
26 The State having jurisdiction over the organisation responsible for the type design (Annex 13 to the 
Chicago Convention) 
27 The State on whose registry the aircraft is entered (Annex 13 to the Chicago Convention) 
28 The State having jurisdiction over the organisation responsible for the final assembly of the aircraft 
(Annex 13 to the Chicago Convention) 
29 The State in which the operator's principal place of bu siness is located or, if there is no such place of 
business, the operators permanent residence (Annex 13 to the Chicago Convention) 
30 According to Annex 13 to the Ch icago Convention, "an accredited repr esentative is a person designated 
by a State, on the basis of his or her qualifications, for the purpose of participating in an investigation 
conducted by another State". 
31 Annex 13 to the Chicago Convention stipulates that any State which on request provides information, 
facilities or experts to the State conducting the investigat ion shall be entitled to appoint an accredited 
representative to participate in the investigation. The Annex also envisages that any State which has a 
special interest in an accident by virtue of fatalities or serious injuries to its citizens shall, upon making 
a request to do so, be permitted by the State conducting the investigation to appoint an expert.  
EN 10   EN the overall context of the event. Once all th e data is gathered, di fferent scenarios are 
built and analysed to determine the probable cause of the accident. If needed, further studies and examinations are undertaken to collect supplementary data or verify the 
probability of alternative scenarios. 
Figure III: Principal actors in the accident investigation process  
 
Briefings and updates will be given by the I CC as the investigation unfolds. Interim 
reports may also be published or immediat e safety recommendations issued. The 
investigation is concluded with the publica tion of the final report, determining the 
probable cause of the accide nt and specifying safety r ecommendations to be acted 
upon to prevent re-occurrence of si milar events in the future. 
2.2.2.  Role of occurrence repo rting in civil aviation 
While the role of accident investigation is improvement of safety through analysis of 
serious events, occurrence reporting aims to  improve safety by timely detection of 
operational hazards and system deficiencies , which if not properly addressed could 
escalate into much more seri ous catastrophes in the future. 
In practical terms, occurren ce reporting are sophisticated systems which call aviation 
professionals to report, in a protected envi ronment, errors, abnormal events and other 
irregular circumstances, and which allow to analyse the data collected in order to 
draw and disseminate safety lessons and identify safety risks. 
Occurrence reporting is an essential tool in promotion of organisational safety culture 
(“Just Culture"), understood as a working environment where "front line operators 
or others are not punished for actions, omissions or decision s taken by them that are 
commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated".
32 
                                                 
32 "Just Culture" (JC) Definition and Implementation of a JC Concept, Working Paper (AIG/08-WP/33), 
presented by France on behalf of the European Community and its Member States by the other Member States of the European Civil Aviation Conferen ce and by EYROCONTROL), Accident Investigation 
and Prevention (AIG) Divisional Meeting, International Civil Aviation Organisation, Montreal 13 – 18 
October 2008. 
EN 11   EN "Just Culture" in general and occurrence repor ting in particular ta ke a system wide 
approach to accident prevention and recogni se that moving beyond blame is essential 
in enhancing safety in a proactive way – notions which have been confirmed through 
decades of safety and human factors research.33 
2.3. Current regulatory framework for acci dent investigation and occurrence 
reporting in the EU 
2.3.1.  Civil aviation accident investigation 
Civil aviation, although in existence for a relatively short period of time, when 
compared to other modes of transport, has well established traditions in accident investigation and occurrence reporting. The obligation to inves tigate accidents in 
civil aviation is enshrined in the Chica go Convention, to which all MS are Parties. 
Detailed standards and recommended practices in this respect, also for occurrence reporting, are defined in Annex 13 to the Convention
34 and the related guidance 
material.35 
Recognising the importance of accident investigati on, the EU already in 1980 
adopted a Directive 80/1266/EEC on cooperatio n and mutual assistance between the 
Member States in the field of  air accident investigation36 (which was the first piece 
of air safety legislatio n adopted in the Community). The 1980 Directive was 
subsequently replaced by Directive 94/56/ EC. In addition Dir ective 2003/42/EC on 
occurrence reporting in civil aviation was adopted in 2003. 
By transposing into the Community legisl ation a number of funda mental principles 
contained in Annex 13, Directive 94/56/EC  significantly contributed to the 
harmonisation of civil aviation acc ident investigation in the EU. 
Under Directive 94/56/EC MS are obliged to ensure that every accident or serious 
incident37 in civil aviation is s ubject to an investigatio n by an independent body and 
that the only purpose of the investigation is  to prevent future accidents and not to 
apportion blame or liability. Investigators ha ve been given additional rights enabling 
them to carry out their tasks in a more efficient manner and the basic principles concerning publication of reports and dissemi nation of safety recommendations were 
established. Summary comparison of Anne x 13 and Directive 94/56/EC can be found 
in Table I below. 
Table I: Summary comparison of Annex 13 and Directive 94/56/EC 
Issue addressed Annex 13 Directive 94/56/EC 
Scope  Responsibilities of the State 
leading the investigation and of 
States participating in the Focused on situations where a MS is 
leading the investigation (either as a State 
of Occurrence, or a State of Registry or 
                                                 
33 For an overview of the "Just Culture " concept see for example: S. Dekker, Just Culture: Balancing 
Safety and Accountability, Ashgate 2008. 
34 Aircraft Accident and Incident Investigation", 9th edition, July 2001 
35 In particular "ICAO Manual of Aircraft Accident and Incident Investigation" (Doc 9756) 
36 Council Directive 80/1266/EEC of 16 December 1 980 on future cooperation and mutual assistance 
between the Member States in the filed of air acci dent investigation (OJ L 375, 31.12.1980, p.32) 
37 For editorial reasons, this IA re port refers to investigation of accidents only (unless justified by a 
specific context). However, the cons iderations presented are valid also for the investigation of serious 
incidents and any other incidents if safety lessons are expected to be drawn form the investigation, as 
defined in Directive 94/56/EC. 
EN 12   EN investigation through accredited 
representatives. Operator). 
Objective of safety 
investigations Sole objective - prevention of 
future accidents and incidents 
and not to apportion blame or establish liability. 
Judicial or administrative 
proceedings to be separate from the safety investigation.  
Sole objective – prevention of future 
accidents and incidents and not to apportion blame or establish liability. 
Status of the NSIA NSIA to have independence in 
the conduct of the investigation. MS to ensure the investigation to be 
carried out by a permanent and 
independent NSIA. NSIA to be 
adequately resourced and staffed. 
Status of the investigation NSIA to have unrestricted 
authority over the conduct of the investigation. IIC to have 
unhampered access to the 
wreckage and relevant material.  
State of Occurrence to recognise 
the need for coordination 
between the IIC and judicial authorities. 
Right of the State participating 
in the investigation to request protection of evidence pending 
arrival of its accredited 
representative. 
State of Occurrence to protect 
the evidence and maintain 
custody of the aircraft and its content for the purpose of the 
investigation. Details to be defined by MS in their 
national legislation. Minimum rights of investigators defined in the Directive 
(free access to the accident site, wreckage 
and recorders, right to examine witness etc).  
Investigators to cooperate with the 
judicial authorities where appropriate. 
Cooperation between the NSIAs State may delegate the conduct 
of the investigation (or part of 
it), to another State by mutual 
consent. 
States to cooperate and provide 
mutual assistance in the 
investigation. NSIA allowed requesting assistance from 
other NSIAs. Assistance to be provided as 
far as possible free of charge. MS may 
delegate the carrying out of an investigation to other MS. 
Final report Draft report and other pertinent 
documentation to be protected 
by States from unauthorised 
disclosure. 
Every state participating in the 
investigation has the right to 
comment on the report and to have its comments appended if 
not taken into account. 
Report to be issued as soon as 
possible and preferably within 
12 months.  Every investigation subject to a report 
appropriate to the type of the event. 
Report to be issued in the shortest 
possible time and if possible within 12 months. 
EN 13   EN Safety Recommendations Safety recommendations to be 
issued at any stage of the 
investigation. ICAO should be 
informed if ICAO documents are involved. 
States shall inform the issuing 
NSIA of the preventive action taken (or why no action is taken) Where appropriate, report should contain 
safety recommendations. MS to take 
safety recommendations duly into 
consideration, and wh ere appropriate act 
upon them. 
Safety recommendations should not 
create presumption of blame or liability. 
Protection of safety 
information Sensitive safety information to 
be protected from un-authorised 
disclosure or use for non-safety 
related purposes. Not addressed specifically within the 
Community context. 
Qualifications of 
investigators Addressed through guidance 
material to Annex 13. Not addressed specifically within the 
Community context. 
Standardisation of NSIAs Addressed at the general level 
through the ICAO USOAP 
programme. Not addressed specifically within the 
Community context. 
2.3.2.  Occurrence reporting in civil aviation 
Directive 2003/42/EC, by supporting the cr eation of safety occurrence reporting 
systems, significantly contributed to the promotion of "Just Culture" in European 
civil aviation. Aviation profe ssionals are now obliged to report occurrences in their 
daily work and provisions have been made to ensure that the information reported 
can be exchanged and disseminated, so th at safety lessons can be learned. The 
Directive obliges MS to ensure confidentia lity of the information, in particular in 
relation to the identity of the reporter. The Directive also supports and encourages 
the MS to promote the establishment of  voluntary occurrence reporting systems. 
Directive 2003/42/EC was supplemented w ith implementing rules establishing a 
central repository of information on ci vil aviation occurren ces exchanged in 
accordance with the Directive38 and dissemination of the information stored in the 
occurrence databases39. In 2008, over 41 thousands occurr ences were stored in the 
central repository. 
3. PROBLEM DEFINITION - THE NEED FOR CHANGE  
The Community system for civil aviation accident investigation and occurrence 
reporting as currently established, functions  below optimum efficiency. The current 
regulatory framework dealing with this s ubject, i.e. Directive 94/56/EC, which is 
now already 15 years old, no longer meets the requirements of the Community and 
the Member States. In particular: 
                                                 
38 Commission Regulation (EC) 1321/2007 of 12 November 2007 laying down implementing rules for the 
integration into a central repository of inform ation in civil aviation occurrences exchanged in 
accordance with Directive 2003/42/EC of the European and of the Coun cil (OJ L 249, 13.11.2007, p.3). 
39 Commission Regulation (EC) 1330/2007 of 24 September 2007 laying down implementing rules for the 
dissemination to interested parties of information on  civil aviation occurrences referred to in Article 
7(2) of Directive 2003/42/EC of the European Parliament and of the Council (OJ L 295, 14.11.2007, p. 
7.) 
EN 14   EN (1) There is much more divergence in the investigating capacity of the Member 
States comparing to the situation in 1994. Especially after the recent 
enlargements of the EU in 2004 a nd 2007, the investigating capacity is 
concentrated in a few Member States only; 
(2) Aircraft and their systems are beco ming increasingly complex, which also 
means that investigation of aviation accidents requires substantially more 
diversified expertise and re sources than a decade ago; 
(3) The EU common aviation market grew substantially both in size (now 
covering 27 Member States) and complexity  in the last decade (emergence of 
multi-based operators, increasing reliance on outsourcing of maintenance, multinational design and manufacturing), which creates new challenges in 
safety oversight; 
(4) The increase in the size and complexity of the internal aviation market also 
called for increased responsibility of the Community for aviation safety. The EU institutional and legal framework changed significantly since the adoption of Directive 94/56/EC. Safety standard s are now almost exclusively defined 
at the EU level and the European Aviation Safety Agency, which on behalf of the Member States is responsible for certification of aircraft in the Community, was established in 2002; 
(5) The EU and its Member States gained  significant practical experiences in 
application of Directive 94/56/EC. These lessons should be used to strengthen 
the efficiency of the current regulatory system; 
The specific problem areas resulting from the above considerations, and which will 
be further analysed in this IA report, include: 
(1) Lack of a uniform investigating capacity in the EU; 
(2) Tensions between safety invest igations and other proceedings; 
(3) Unclear role of the Community in safety investigations; 
(4) Weaknesses in implementation of safety recommendations; 
(5) Lack of common standards concerning management of passenger manifests 
and support to the victims of ai r accidents and their families; 
3.1. To what extent are these problems related  to the implementati on of the current 
regulatory framework? 
The problems analysed in this IA only to a certain extent derive from the 
inefficiencies in the implementation of the current regulatory framework. As indicated above, the problem drivers are more of an institutional and structural nature 
and relate to the fact that major changes in the organisation of  the single aviation 
market took place since the adoption of Directive 94/56/EC. The severity of the problems identified also vary across the EU , as for example some MS may be more 
affected by lacks in their investigating capacity, while others by tensions between 
safety investigations and other proceedings. 
3.2. Lack of a uniform investi gating capacity in the EU 
Although the EU as a whole has enough investigating cap acity to deal with any 
major accident in the Community or beyond, the resources available are not used 
efficiently. Especially the smaller MS lack appropriate means to deal with 
EN 15   EN investigation of complex accidents. Th e experience and qualifications of 
investigators and of the NSIAs is also not uniform across the EU. 
Inefficiencies in the use of resources cont ribute to the difficulty of the NSIAs in 
meeting the recommended deadlines for clos ing investigations and publication of 
final reports. Diverging level in experience and training of investigators also prevents 
the EU from having a more uniform level of  expertise in accide nt investigation and 
impacts on the overall quality of safety i nvestigations in some  MS. The sharing of 
resources between the NSIAs, despite some recent improvements in this respect, is 
still mainly organised on an ad hoc  basis, which may not be sufficient when a 
number of accidents occur in the same pe riod of time and necessitate extended 
simultaneous engagement of a few NSIAs. 
From the EU perspective the issue of capacity  of NSIA and quality  of investigations 
is important not only to ensure high standard s at the level of indi vidual MS but also 
consistency in the way investigations are conducted across the EU. This is due to the 
fact that, with the adoption of the comm on safety standards and establishment of 
EASA, any deficiencies in Community re gulations, certifica tion procedures or 
oversight practices may have EU-wide consequences. 
3.2.1.  Problem drivers and evidence 
At the time of the adoption of Directive 94/56/EC, the investigating capacity of the 
EU as a whole used to be mu ch more uniform than it is  now. Currently  however and 
especially after the recent enla rgements of the EU, the situation is much more diverse 
and the investigating capacity is essentially concentrated in a few MS only. 
The number of investigators in MS varies substantially (from 1 to over 60 depending 
on the MS40). Also, only a very limited number of MS dispose of facilities and 
equipment for complex technica l investigations such as th e readouts of "black boxes" 
or conduct of complex simulations.41 Especially for smaller MS it is difficult to 
mobilise the necessary expertise for more complex investigations and to be on par 
with large manufacturers or operators wh ich can often muster more substantial 
resources than the local NSIA. 
In practice, only MS with big manufacturing industry can  justify budgets necessary 
to maintain a properly staffed and equippe d NSIA. For others, it is increasingly 
difficult to justify any incr ease in the budget, especial ly taking into account a 
relatively limited number of  accidents in Europe. A survey conducted by the 
Commission in 2006 showed that a large number of MS experience difficulties in 
meeting the recommended deadlines of twelve months for closing a safety investigation.
42 
Although there have been some important improvements in the recent years in this 
respect, the sharing of resources between the NSIAs is still organised mainly on an 
ad hoc basis. This, combined with a varying exposure of MS to accidents, prevents 
the EU from building up uniform expe rience in accident investigation.  
                                                 
40 Council of European Aviation Safety Investig ation Authorities (CIRCA based information bank) 
41 idem  
42 Replies to the questionnaire on the application of Council Directive 94/56/EC of 21 November 1994 
establishing the fundamental prin ciples governing the investigatio n of civil aviation accidents and 
incidents (presented by the Commissi on at the meeting of th e group of experts on civil aviation accident 
investigation, Brussels, 8 February 2006) 
EN 16   EN At the same time, the ongoing technological progress means that aircraft and their 
systems are becoming increasingly complex, which makes accident  investigation an 
activity requiring much more diversified a nd specialised skills and equipment than a 
decade ago. 
It has to be also recognised that, with  the exception of the ICAO guidance material43, 
there are currently no uniform standa rds in the EU con cerning training and 
qualification of the investigat ors. This problem was highli ghted in the final report of 
the "Group of Experts", which indicated that "in particular smalle r Member States 
identify a need for European Union based training for investigators, both on the 
coordination of training and in  relation to training standards".44  
Likewise, the methodology for technical in vestigations, alth ough based on common 
principles of Annex 13, is not fully ha rmonised in the EU . Neither Directive 
94/56/EC nor Annex 13 are directly applicable  and need to be tr ansposed into the 
national legal orders of the MS, who are also entitled not to implement certain 
standards of Annex 13 (not covered by Directive 94/56/EC) and to notify the 
differences to ICAO accordingly. Last but not least, with the exception of ICAO 
USOAP audits, there is currently no standardisation program allowing for verification of consistency in implemen tation of Directive 94/56/EC and Annex 13 
by the MS. 
The issue of under-optimal use of resources  is partially addre ssed through voluntary 
cooperation between NSIAs envisa ged in the Directive 94/56/EC,
45 and was recently 
strengthened with the establishment of the Council of European Aviation Safety Investigation Authorities
46 and other dedica ted initiatives.47 
3.3. Tensions between safety investigations and other proceedings 
The sole objective of accident investig ation and occurrence reporting should be 
prevention of accidents and incidents. Their purpose should not be to attribute blame 
or liability and the process should be independent from any other proceedings 
(criminal, administrative, ci vil) whose objectives could c onflict with this purpose. 
At the same time, safety investigations or occurrence reporting should not interfere 
with the proper administration of justi ce either and nothing should prevent the 
judicial or other authorities from carryi ng out their own investigations, under their 
own procedural rules and to collect evid ence that could serve as a basis for 
establishing the eventual liability of th e persons involved the event. Through these 
parallel but independent procedures the common objective of protecting human life 
and delivering justice ma y be served jointly. 
More specifically, independent safety invest igations are necessar y in particular to: 
                                                 
43 Training Guidelines for Aircraft Accident Investigators, ICAO Circular 298, June 2003 
44 Final report of the Group of expert s to advise the Commission on a stra tegy to deal with accidents in the 
transport sector, Brussels 3.7.2006; The Group of experts was established on the basis of the Commission Decision EC/425/2003, OJ L 144, 12.06.2003, p. 10-11. 
45 Article 6.4 and 6.5 of the Directive  
46 The Council constitutes a body coordinating, on a voluntary basis, the activities of the NSIAs of the EU 
Member States. It is composed of heads of EU NS IAs and chaired by the representative of the Member 
States currently holding Presidency of the EU. 
47 Such as establishment of the "Code of Conduct for civil aviation accident inves tigation" and the "check-
list on assistance", both developed within the framework of the Group of Experts on accident 
investigation of the European Civil Aviation Conference (ECAC/ACC Group). 
EN 17   EN – Promote transparency and avoid potential c onflict of interests which could affect 
the findings resulting from the safety inve stigation (this would be for example the 
case if a safety investigation authority w ould be at the same time responsible for 
rulemaking or certification); 
– Identify not only a direct cause of an accident, which will be usually a focus of 
proceedings that aim to attribute blame or liability, but most importantly the 
underlying and latent causes which might ha ve contributed to th e accident. Safety 
lessons can only be learned and corrective measures put  in place, if all the 
underlying causes are identified; 
– Help families of the victims or the victim s themselves to come to terms with the 
suffering by answering the quest ion "what really happened?" 
Although the fundamental principle of indepe ndent safety investigations is widely 
accepted and recognised by both international48 and Community49 law, certain 
aspects of this principle are far from be ing implemented in the EU in a uniform 
manner. There are tensions between the NS IAs and judicial authorities across the 
Community and the independent status of  accident investigation and especially 
protection of sensitive safety information co llected in the course of the investigation 
cannot be guaranteed in all MS. Although some of the MS managed to develop 
legislation or certain arrangements to deal with this issue50, due to international 
character of safety investigation, their NS IA may be nevertheless affected by such 
tensions when participati ng in investigation in other MS thr ough their accredited 
representatives. 
3.3.1.  Problem drivers and evidence 
The drivers concerning this particular issu e are complex and concern both legal and 
cultural aspects. This IA focuses on the drivers related to the transposition of Annex 13 into Community law, and the way provisions of Annex 13 and Directive 
94/56/EC are applied in pract ice by the MS authorities.  Coordination between the 
authorities involved in accident investiga tion, gathering and sharing of evidence and 
protection of sensitive safety information co llected in the course of an investigation 
or through occurrence reporting systems, need to be mentioned in particular in this 
context. 
Whenever a serious accident occurs, at least two separate investigations will 
normally have to be carried out, one to dete rmine the direct and underlying causes of 
the accident, the other to determine whethe r there is sufficient evidence to justify 
criminal proceedings against any of the parties involved
51. Although objectives of 
these proceedings will be different and they will be carried out by separate 
                                                 
48 Standard 3.1 and 5.4 of Annex 13 
49 Article 1, 4(3) and 6(1) of Directive 94/56/EC  
50 In the UK for example a memorandum of understanding between the Crown Prosecution Service (CPS) 
and the Air Accidents Investigation Branch (AAIB), the Marine Accident Investigation Branch (MAIB) 
and the Rail Accident Investigation Branch (RAIB), se ts out the principles for liaison between the CPS 
and the AIBs. The aim is to ensure effective investigation and decision making processes while 
maintaining the independence of all parties and rein forcing the role of the AI Bs as the guardians of 
public safety when investigati ng transport accidents and incidents 
(http://www.aaib.gov.uk/cms_resources/MOU%20AIB-CPS.pdf) 
51 Increasingly in recent years, this may be paralleled by investigations to suppo rt civil proceedings to 
apportion liability. 
EN 18   EN authorities, it is in practice very difficult to ensure a full separation between them and 
these two proceedings will have to interact  with each other to a certain extent. 
The experience of the Community shows that these interactions may be a source of 
tensions that can negatively affect th e efficiency of safety investigations. 
3.3.1.1.  Cooperation between the authorities invo lved in accident investigation 
Various authorities involved  in accident investigation, although conducting separate 
inquires and pursuing different objectives  will always need, while retaining 
independence within their respective areas of  responsibility, cooperate to a certain 
extent in order to efficiently discharge thei r obligations. In partic ular, all authorities 
will need to gather evidence, including f actual information and statements from the 
parties involved in the accident. They w ill also need to store and analyse the 
evidence gathered to draw the necessary conclusions. 
Although Directive 94/56/EC defines the broad principles of the status of a safety 
investigation,52 including the rights of the investigators to access to the crash site and 
the relevant evidence, the practical experiences in the application of Directive 94/56/EC show that the uniform implementati on of these principles in the EU is far 
from being satisfactory and may affect safet y. Judicial authorities often argue that the 
obligation to sanction illegal activities supers edes any safety considerations, and that 
any evidence may and should be used for the purposes of exam ining liability, in 
accordance with the principle of the open a ssessment of evidence. In practice this 
means that access of the NSIA investigators to the crash site may be hampered or crucial safety evidence seized and not made  available or its availability delayed. 
The investigation into the crash of Air France Concorde F-BTSC at Gonesse on 25th 
July 2000 can be given as an example here. The investigation was led by the NSIA of France and the UK NSIA also participated  as a joint State of Manufacture. In 
addition to the technical inve stigation led by the NSIA, an immediate judicial inquiry 
was launched, and the French transport minister also convened his own panel of 
experts to advise him personally. Thus in total three inquiry teams were competing 
for access to physical evidence, resulting in delays and restrictions in the access to 
the crash site and material evidence by the safety experts.
53 As another illustration of 
a potential impact of the lack of proper c oordination between the authorities involved 
in the investigation, the case of the collision at the Milano- Linate Airport in October 
2001 can be given (see Case I below). 
The safety consequences of the delay in i nvestigations or of l ack of access by NSIAs 
to important evidence may be serious: not co mplete findings, delays in publication of 
the final report, inadequa te safety recommendations. 
Lack of coordination and tensions between  the authorities participating in the 
investigation is recognised by the experts. Th e "Group of Experts" in particular in its 
final report recommends addressing " difficulties and tensions between the safety 
investigation and judici al investigations ". 
On the other side, it ha s to be recognised that the inte rests of judicial  authorities can 
be also negatively affected by the lack of appropriate coordi nation and by giving 
priority in all the cases to the tech nical investigation. For example factual 
                                                 
52 Article 5 "Status of the Investigation" of Directive 94/56/EC 
53 Accident on 25 July 2000 at La Patte d’Oie in Gonesse to the Concorde registered F-BTSC operated by 
Air France, Report by Bureau Enquetes-Accidents, f-sc000725a 
EN 19   EN information deriving from examinations  which cannot be repeated, such as 
destructive testing of parts of equipment may be in cont radiction with the statutory 
obligation of the judicial investigator to secure and present to the court the best 
evidence possible. Other examples may i nvolve evidence, which from a technical 
point of view can be produced only by a NSIA, such as analysis of factual 
information extracted from a flight data recorder (FDR). 
Currently, Directive 95/56/EC does not c ontain any provisions similar to the ones 
which can be found in Annex 13 (in partic ular standard 3.2 and 3.3), which oblige 
the State of Occurrence to maintain appropriate custody of the evidence and of the 
accident site. 
Case I: Tensions between safety in vestigations and judicial procedures 
On the 8th of October 2001 a Boeing MD-87, registration marks SE-DMA operated by SAS, while on 
takeoff run on runway 36R of Milano Linate Airp ort, collided with a Cessna 525-A, registration 
marks D-IEVX which taxied into the active runway. After the collision the MD-87 hit a baggage 
handling building. All occupants of the two aircraft  as well as four member s of the ground staff 
personnel suffered fatal injuries.  
Both safety and judicial inquires were initiated. In the course of the safety investigation the NSIA in 
charge of the investiga tion could not receive testimonies fr om the ground (GND) and tower (TWR) 
controllers as well as TWR supervisor, as they made themselves unavailable pending the judicial 
procedure. Transcripts of radio and telephone communications pertaining the incident were obtained 
from the Magistrate office (audio files on CD), while the original tape was not made available. The 
NSIA could not test the efficiency of the Cessn a ARTEX equipment the transmission of which were 
not present on the tapes recorded. The equipment ha s been seized by the Magistrate for the purpose 
of the criminal inquiry and not made available.54 
3.3.1.2.  Protection of sensitive safety information 
Evidence gathered in the course of a safety  investigation may be  of various nature. 
Some information will be purely factual, and should be freely shared between all the authorities involved in the i nvestigation in orde r to avoid duplica tion of costs and 
ensure efficient closure of all relevant i nvestigations - be it technical, judicial or 
administrative. 
Some information however will be of much  more sensitive nature and its protection 
from unauthorised disclosure or inappropria te use is of utmost importance. This 
applies in particular to evidence such as  witness testimonies or other statements, 
accounts and notes taken or received by the NI SAs. Availability of such information 
is crucial in the disclosure of all circumstances of the event and of its causes. Inappropriate use of such evidence may compromise its future availability, as pilots or other aviation professionals may be relu ctant to share it with the investigators 
without having certainty that it will not be late r used to blame them. This is a 
sensitive issue, linked not only with sa fety considerations but also with the 
fundamental right of every citizen to a fair  trail and prohibition of  self-incrimination.  
Similar philosophy underpins occurren ce reporting systems under Directive 
2003/42/EC, which sole objective is to detect  at the earliest possible stage existence 
of safety hazards and prevent them from escalating into accidents. The underlying 
principle here is that public safety is best served by sharing and analysing safety 
                                                
 
54 Final Report of the Agenzia Nazionale per la Si curezza del Volo of 20 January 2004, Accident 
involving Aircraft: Boeing MD-87 registration SE-DMA and Cessna 525-A, registration D-IEVX, 
Milano Linate Airport October 8, 2001. 
EN 20   EN information and using it for accident prev ention purposes only and not for punishing 
or prosecuting those who, in good faith, wish to share their mistakes. 
The consequences of such inappropriate use of sensitive safety information in the 
context of accident investigation were i llustrated in an example given above (see 
Case I above). The considerations presente d are however valid al so, and maybe most 
importantly, in respect of statements made by aviation professionals in the 
framework of occurrence reporting system s (see Case II below as an example). 
Case II: Managing safety and account ability – impact on occurrence reporting 
On December 10th 1998 an incident occurred at Schiphol (Amsterdam) Airport in which a Delta 
Airlines Boeing 767 aborted its take-off roll when the pilots observed a towed Boeing 747 crossing 
the runway in front of them. The incident investigation report concluded that the incident happened, 
inter alia , as a result of a misinterpretation by the A ssistant Controller of the actual position of the 
tow-combination when radio-contact was first established.  
In December 2000, almost two years after the date of the incident, the Dutch aviation prosecutor 
decided to formally charge the Co ach/Supervisor, the Trainee and th e Assistant Controller with "the 
provision of Air Traffic Control in a dangerous manner, or a manner that could be dangerous, to persons or properties”. The judge ruled that the assistant controller was not guilty, but that both the 
trainee and the coach/supervisor were. More than a year later, the case appeared before a higher 
court. The court found all three suspects guilty of their crime, it did not, however, impose a sentence. 
The judge had found legal room fo r what seemed to be a compromise, by treating the case as an 
infringement of the law, as opposed to an offence.  
Over the years that the legal proceedings went on, the number of incident reports submitted by 
controllers dropped by 50%.
55 
What are the drivers of the issue? The dive rgence of judicial cultures and regulatory 
frameworks of the MS definitely plays a role  in this respect. However, this IA report 
argues that the problem is amplified by the lack of common princi ples established in 
this respect in Community law.  
Contrary to the requireme nts of Annex 13 (Standard 5.12), Directive 94/56/EC does 
not contain any provisions c oncerning protection of evidence  gathered in the course 
of the investigation, in part icular of witness evidence an d other statements, accounts 
and notes taken or received by the NISAs from use for non-safety related purposes. 
Annex 13 is also far from being implemented in a uniform manner in the EU in this respect. Most of the differences filled by the MS with ICAO in respect of Annex 13 concern implementation of Standard 5.12 deal ing with protection of sensitive safety 
information.
56 FDR and CVR are to certain extent protected on the basis of specific 
provisions contained in the "EU-OPS regulation".57  
Similarly to the previous point, there s eems to be a consensus amongst the experts 
that this is an issue requiring a closer  attention of the Community. The "Group of 
Experts" in its final report recommends: "to introduce legislative protection from 
                                                 
55 Case analysis on the basis of: “Just Culture Ma terial for Interfacing with the Judicial System, 
Eurocontrol 2008” 
56 In accordance with Article 38 of the Chicago Convention, Member Stat es can decide not to implement 
certain standards of Annex 13 and to notify differences to ICAO (the differences notified cannot be in 
contradiction with the provisions of the Directive 94 /56/EC, as this would constitute a violation of the 
Community law) 
57 Council Regulation (EEC) No 39 22/91 of 16 December 1991 on the harmonization of technical 
requirements and administrative procedures in the field of civil aviation (as amended), OJ L 373, 
31.12.1991, p. 4 (the “EU-OPS” regulation) 
EN 21   EN disclosure for confidential documents li sted in Chapter 5.12 of Annex 13 to the 
Chicago Convention".  
Similarly, the obligation to report o ccurrences establis hed under Directive 
2003/42/EC is not sufficiently balanced  by the protection of the information 
contained in the reports from use in non-safety related proceedings.58 In particular 
Directive 2003/42/EC does not establish cl ear principles or guidance defining under 
which conditions such information could be disclosed to the judicial authorities.59 
This may discourage aviation professiona ls from open reporting of occurrences 
(which may constitute potentially self-i ncriminating information), and thus reduce 
the opportunities for the EU  aviation community to collectively learn from 
mistakes.60 
Last but not least, there has been an im portant precedent recen tly in the Community 
law as far as protection of sensitive sa fety information gathered through accident 
investigation is concerned. The newly adopt ed Directive 2009/18/ EC establishing the 
fundamental principles governing the inve stigation of accidents in the maritime 
transport sector61, envisages common provisions c oncerning protection of sensitive 
safety information, largely inspired by th e language of Standa rd 5.12 of Annex 13. 
As this is an issue of a horizontal nature , similar principles s hould apply to safety 
investigations in al l transport modes. 
3.4. Unclear role of the Community  in safety investigations 
An issue of fundamental importance to be a ddressed in this IA c oncerns the role of 
the Community in accident investiga tion. This question goes beyond problems 
related to the uniform implementation of Directive 94/56/EC and derives from the 
fact that major institutional and regula tory changes took place in the Community 
since the adoption of Directive 94/56/EC. 
A common set of directly applicable safe ty legislation was established by the EU, 
covering initial and continuous airworthiness, pilot licensing, flight operations (of 
both Community and thir d country operators)62, and was recently extended to Air 
Traffic Management/Air Navigation Servic es and safety aspects of aerodrome 
operations.63 In addition EASA, which carries out on behalf of the MS the functions 
and tasks of the State of Design, Manufactur e and Registry when related to design 
approval, as specified in th e Chicago Convention and its A nnexes, was established in 
                                                 
58 c.f. 15 ("The level of incident re porting, analysis and transparency of the safety system varies widely 
across Europe. As a result, in some places, it is difficult to assess the overallsafety performance 
achieved and to propose actions toimprove safety. One impediment is that the judicial codes of some states discourage or inhibit open reporting of incidents"), p.31 
59 Directive 2003/42/EC in Article 8(5)  only stipulates that its provisions shall apply without prejudice to 
the national rules related to access to information by judicial authorities. 
60 Legal and Cultural Issues in relation to ATM Safety Occurrence Reporting in Europe, Report 
Commissioned by the Performance Review Commission, Eurocontrol, September 2006; Similarly 
“Report of the High Level Group for the future European Aviation Regulatory Framework ( c.f. 15 ) 
61 Directive 2009/18/EC of the European Parliament and of the Council of 23 April 2009 establishing the 
fundamental principles governing the investigation of  accidents in the maritime transport sector and 
amending Directives 1999/35/EC and 2002/59/EC (OJ L 131, 28.5.2009, p.114). 
62 Regulation (EC) 216/2008 of the European Parliament and of the Council of 20 February 2008 on 
common rules in the field of civil aviation and establishing a European Aviation Safety Agency, and repealing Council Directive 91/670/EEC, Regulation (EC) No 1592/2002 and Directive 2004/36/EC 
(OJ L 79, 19.03.2008, p. 1) 
63 Not yet published 
EN 22   EN 2002. 64 The role and responsibilities of the Community in safeguarding civil aviation 
safety has thus increased significantly in the past decade. 
The changes in question aff ect the overall division of re sponsibilities between the 
MS and the Community in civil aviation sa fety. Despite the efforts of the Agency 
and NSIAs, the consequences of these change s were not so far fully reflected in the 
way accident investigation in the Community is organised. The relationship between EASA and NSIAs is not defined, neither as  concerns representation of EASA in 
accident investigation nor in respect of ex change of important safety information 
between the Agency and NSIAs, necessary to  reveal all circumstances of accidents or 
occurrences and to take appropriate safety  actions. This creates unacceptable safety 
risks, in particular since the Agency is responsible for certi fying aircraft registered in 
the Community – an issue which was recently confirmed by an audit of the International Civil Avia tion Organisation (ICAO). 
3.4.1.1.  Problem drivers and evidence 
The preamble to Regulation (EC) No 216/2008 stipulates that " Results of air 
accident investigations should be acted upon as a matter of urgency, in particular 
when they relate to defective aircraft de sign and/or operational matters, in order to 
ensure consumer confidence in air transport ".
65 The Regulation also obliges the 
Commission, when developing implementing rules for airworthiness and operations, 
to ensure that they allow for immediate reaction to established causes of accidents 
and serious incidents.66 
In addition, under the current regulat ory framework in the Community, MS 
collectively discharg e their obligations undertaken under the Chicago Convention 
when related to design of aer onautical products. It is EA SA which on behalf of the 
MS, carries out the functions and tasks of the State of Design, Manufacture and 
Registry when related to design approval,  as specified in the Chicago Convention 
and its Annexes.67 
A number of opinions were exchanged between the Commission, EASA and NSIAs 
in the past years related to  the consequences of the a doption of Regulation (EC) No 
1592/2002 (now (EC) No 216/2008) and th e establishment of EASA, on the 
organisation of accident inve stigation in the Community. This discussion focused on 
the status of EASA in accide nt investigation and the scope  of eventual participation 
rights which could be attributed to  the Agency in this respect. 
One of the aspects debated in particular concerns the right to appoint "accredited 
representatives" for the “State of Desi gn”, under Annex 13. As described in section 
2.2.1 above, a number of States participate in a safety investigation. States other than 
the State of Occurrence, with a specific inte rest related to the circumstances of the 
accident, have the right (or under certain circ umstances an obligation) to appoint an 
“accredited representative” to participate in the investigation. States appointing 
accredited representatives and the accredited representatives themselves68 enjoy 
specific rights in their resp ective areas of competence. Th ese include in particular: 
                                                 
64 c.f. 62   
65 idem , whereas clause No 17 
66 idem , Articles 5(6) and 8(6) 
67 idem,  Art.20(1) in conjunction with Art.17(e) 
68 A person designated by a State, on the basis of his or her qualifications, for the purpose of participating 
in an investigation conducted by another State (Chapter I, Definitions, Annex 13) 
EN 23   EN – The right to request the Stat e of Occurrence, that the aircraft, its contents, and any 
other evidence remain undisturbed pe nding inspection by an accredited 
representative of the requesting State;69 
– The right to participate in all aspects of the investiga tion, under the control of the 
investigator-in-change (including the ri ght to visit the scene of the accident, 
examine the wreckage, have full access to  all relevant evid ence as soon as 
possible, participate in read-outs of r ecorded media, participate in off-scene 
investigative activities, make  submissions in respect of the various elements of the 
investigation);70 
– The right of the State concer ned to appoint one or more  advisers to assist the 
accredited representative in the investigation;71 
– The right to comment on the final report form the investigation and to have its 
comments, which were not taken into account by the State conducting the investigation, attach ed to the report;
72 
At the same time, accredited representative s and their advisers are also obliged: 
– to provide the State conductin g the investigation with all relevant information 
available to them;  
– not divulge information on the progress and the findings of the investigation 
without the express cons ent of the State conduc ting the investigation.73 
In the debate concerning the scope of partic ipation rights which could be entrusted to 
EASA, two main groups of arguments we re presented by the MS authorities: 
– Arguments of legal nature : some of the MS argued that the Community legislator 
did not entrust EASA with any competences related to accident inve stigation, in 
particular the rights to appoint accredited re presentatives on behalf  of the “State of 
Design” under Annex 13, as the competence s of the Agency are limited to Annex 
8 (“Airworthiness of Aircraft”)  and do not extend to Annex 13;  
– Arguments related to independe nce of safety investigations : some of the MS 
argued that, even if possible within th e current regulatory framework, entrusting 
EASA with too broad particip ation rights, and in partic ular the right to appoint 
accredited representatives on behalf of the MS, would put in question the independence of the investig ation, as EASA could be i nvestigating design aspects 
of the accident involving aircraft initially certified by the Agency;  
EASA, as an authority res ponsible for type certificat ion, may have a potential 
conflict of interest with the tasks entrusted to the NSIA, and therefore its role in the 
investigation should be limited to what is strictly necessary. 
At the same time however, both from the lega l, but most importantly from the safety 
point of view, the current lack of clarity cannot be accepted. From the legal 
perspective, it has to be noted that Anne x 13 defines the “State  of Design” as the 
“State having jurisdiction over the organiza tion responsible for th e type design". In 
                                                
 
69 Annex 13 (Standard 3.3) 
70 idem  (Standard 5.25) 
71 In case of a State of Design it will normally be advisers, proposed by the organizations responsible for 
the type design of the aircraft, powerplant or a major component. 
72 Annex 13 (Standard 6.3) 
73 idem  (Standard 5.26) 
EN 24   EN the current EU regulatory fram ework, it is the EASA whic h, on behalf of the MS, is 
responsible for approval and continuous ove rsight over organizations responsible for 
type design. There is thus an inherent li nk between the current scope of competences 
of the Agency and the concept of th e “State of Design” under Annex 13. 
Most importantly however, and regardless of legal considerations, the current lack of 
clarity has an important safety dimension. It  is the Agency who should dispose of all 
the pertinent data related to design approva l and is legally responsible, on behalf of 
the MS, for ensuring that any safety reco mmendations concerning design aspects of 
an aircraft designed, manufact ured or registered in th e EU and involved in an 
accident, are properly acted upon. In particular  it is the responsib ility of EASA to 
issue Airworthiness Directives.74  
Aircraft of European design, manufacture or re gistry operate in al l parts of the world 
and when an accident happens involving su ch aircraft, EASA, as the responsible 
design authority, has an important safety interest in being represented during the 
investigation and acquiring al l pertinent factual information concerning the event 
without delay to take appropr iate safety action if necessa ry. EASA may have also an 
interest in acquiring factual information if an airworthiness factor  contributing to an 
accident could have been linked with the competency of organisations certified by 
the Agency.75 
Similarly, the Agency in order to properly discharge its safety related obligations, 
and in particular concerning continuing airw orthiness of a type of aircraft under its 
regulatory responsibility must have unhamp ered access to all in-service related 
information, including on any occurrences reported in this re spect, which could 
indicate potential safety hazards.  
In addition to acquiring factual info rmation, EASA, having a wide degree of 
expertise and knowledge of the type certification basis, can and s hould contribute to 
the investigation, so that the most accu rate findings can be made and follow-up 
actions taken. EASA may have for exam ple knowledge about the history of the 
events related to a particular type of aircraft or engine. 
Figure IV: Annual accidents of EU/EEA /EFTA manufactured turbine aircraft76 
                                                 
74 Airworthiness Directive is a notification to owners  and operators of certified aircraft that a known 
safety deficiency with a particular model of aircraft, engine, avionics or other system exists and must be 
corrected. If a certified aircraft has outstanding airworthiness directiv es that have not been complied 
with, the aircraft is considered not airworthy. Airw orthiness Directives usually result from reports of 
operators or from the results of aircraft accident investigations. 
75 For example a third country maintenance organisation approved by EASA and performing repairs on 
the aircraft involved in an accident. 
76 Data covering turboprop aircraft with maximum certif ied number of passengers above 15, as well as all 
turbojet aircraft 
EN 25   EN 
 
Source: Airclaims 
Since 2006, EASA and NSIAs have been trying to clarify the role of the Agency in 
accident investigation by concluding working arrangements on a voluntary basis. Up to date this issue was not adequately resolved, main reasons for this being: 
– some NSIAs argue that working arrangement s do not constitute a valid legal basis 
for the transfer of participation right s that States enjo y under the Chicago 
Convention; 
– disagreement between the NSIAs and EASA as to the scope of participation rights 
to be eventually granted to the Agen cy, without compromising independence of 
safety investigations; 
The current situation was identified as not acceptable in a recent audit of EASA 
conducted by ICAO within the framework of  the Universal Safety Oversight Audit 
Programme (USOAP) audit.
77 The report makes a finding on this particular issue and 
concludes that: " EASA has not reached a formal agr eement with the EU Member 
States regarding the modalities and st atus of participation of EASA and 
representatives of Member States bodi es in accident and serious incident 
investigations involving aircraft whose type certificate is delivered by EASA" . 
Thus for the time being the relationship between EASA and NS IAs is dealt on an ad 
hoc basis and in a number of cases, due to tensions between the NSIA and the 
Agency, the flow of important safety info rmation was hampered or delayed. Due to 
the international character of accident investigation this issue affects not only 
investigations conducted in the EU  but also in third countries. 
It is therefore of utmost importance from the safety point of view, that the mutual 
rights and obligations of EASA and NSIAs ar e clarified. At the same time, as EASA 
is involved in certific ation of aircraft and of organi sations involved in their design 
manufacture, or maintenance its role in accident investigation has to be limited to 
what is strictly necessary, in order to avoid any potential conflict of interest. 
Similarly, as the Agency plays a major role in the continuing airworthiness processes 
in Europe, it has a legitimate need for access to occurrence data, which is indispensable to support its work. Such data is required with a level of detail that 
                                                
 
77 Final Report on the Safety Oversight Audit of the European Aviation Safety Agency, 23–25 April 2008 
(confidential) . The final report is available to all Contracting Parties to the Chicago Convention through 
the ICAO Universal Safety Oversight A udit Programme (USOAP) secure website. 
EN 26   EN permits action to be taken. For example, as aircraft of a given type may differ from 
each other in respect to modificati ons applied and product improvements 
incorporated, knowledge of the serial number of the aircraft is essential to assess the 
needs for corrective action. Moreover, gi ven its newly acquired competences the 
Agency needs to develop safety inform ation based on the aircraft operated by 
operators in Europe and thus it is essent ial that information on the State of the 
operator is also made available to the Agen cy. The current restrictions envisaged in 
Directive 2003/42/EC and its implementi ng rules do not permit such access on a 
continuous basis. At the same time, su ch information, due to its sensitive and 
confidential nature, should be used by the Agency only for purposes related to improvement of safety and protected from unauthorised disclosure. 
3.5. Weaknesses in implementation  of safety recommendations 
Despite significant efforts in this respect, there is still no consistent approach in the 
Community concerning gathering, pro cessing and implementation of safety 
recommendations resulting from accident investigations. In particular, the 
establishment of a Community database of safety recommendations has not yet been 
finalised and the Community did not esta blish common requirements for transparent 
and efficient: 
– recording of the responses to the safety recommendation issued; and 
– monitoring the progress of the acti on taken in response to a safety 
recommendation; 
In addition, the number of safety recommendations addressed to the Community 
regulator and EASA has increas ed substantially in the past  years and this trend is 
expected to continue. At the same tim e, safety recommendations of EU-wide 
relevance are not followed up in a consistent  manner across the EU due to lack of 
coordination between authori ties at the national and Commu nity level. Independent 
and transparent monitoring of implementa tion of safety recommendations addressed 
to the national and Community regu lators is also not adequate. 
3.5.1.  Problem drivers and evidence 
Safety recommendations resulting from acci dent investigations are of crucial 
importance. By linking the independent pr ocess of looking into the causes of 
accidents with practical measures aimed at prevention of their re-occurrence, 
recommendations have a direct impact on th e improvement of aviation safety and are 
thus one of the most important points addressed in this IA. 
Implementation of safety recommendations is not mandatory and it is up to the 
addressee to assess its validity  and the most cost efficien t way of implementation. At 
the same time, it is important from the safety and public policy point of view that an efficient and transparent process is in place ensuring that every safety 
recommendation is always assessed, replay given and corrective measures implemented if justified. 
According to Directive 94/56/EC, the repo rts and safety recommendations are made 
public and communicated to the undertakin gs or national aviation authorities 
concerned and copies forwarded to the Comm ission. MS are also obliged to take the 
necessary measures to ensure that the safety recommendations made by the NSIAs 
EN 27   EN are duly taken into consideration, a nd where appropriate, acted upon without 
prejudice to Community law.78  
In practice, the process of follow-up and monitoring of implementation of safety 
recommendations in the MS vary considerably. Some MS have a well established process in this respect, while others relay rather on more ad hoc  practices.
79 The 
"Group of Experts", in its final report recommends " to introduce a legislative 
requirement that provides transparency in  relation to offici al replies to and 
implementation of safety recommendations ".  
There is also currently no provision in the Community law implementing the 
standard of Annex 13 requiring  issuance of safety recomm endations at any stage of 
the investigation if a preventive action is n ecessary to promptly address an identified 
safety issue.80 
In line with the overall objective of accide nt investigation, safety recommendations 
and reports should address the causes of acci dents and not create a presumption of 
blame or liability81, which means for example that the anonymity of the persons 
involved should be protected. The language of  Directive 94/56/EC is not entirely 
consistent in this respect, whereby such protection is explicitly afforded only to persons involved in incidents but not accidents
82. 
The prompt dissemination of safety reco mmendations is also affected by other 
considerations analyzed in this IA, and in particular the availability of investigation 
resources and potential tensions between  the different authorities involved in 
accident investigation. 
To facilitate exchange of safety rela ted information between the MS and the 
Community, the Commission established a central repository of civil aviation occurrences
83. As far as accident investigation is concerned, the central repository 
should contain basic factual informati on on accidents and incidents while the 
investigation is on-going, and – when the i nvestigation is completed – all relevant 
information, including when available a summary in English of the final 
investigation report. Howeve r the level of reporting is still far from being 
satisfactory, as some of the MS are concer ned about the adequate  level of protection 
of the data from unauthorised use or disclosure.  
A prototype add-on to the central reposito ry dedicated to safety recommendations 
has been also developed by the Commission, but  it is not yet fully operational. This 
is an important step towards the devel opment of a central database of safety 
recommendations at the EU level, which should be completed as soon as possible. 
(This was also recommended by the "Group of  Experts" and in responses to the 
public consultations). 
                                                 
78 Directive 94/56/EC, Article 9 "Safety recommendations" 
79 c.f. 42  
80 Annex 13, Paragraph 6.8 
81 Directive 94/56/EC, Article 10 
82 idem , Articles 7 and 8 
83 The repository is based on the software developed within the framework of ECCAIRS (European Co-
ordination centre for Accident and Incident Reporting Systems project managed by the Joint Research 
Centre of the European Commission) and uses ICAO ADREP (Accident/Incident Reporting) taxonomy. 
This repository is managed by the Joint Research Centre (JRC) of the Commission. 
EN 28   EN One of the important drivers behind the curre nt inefficiencies in implementation of 
safety recommendations is lack of the rec ognition of a Community dimension in this 
respect. This is critical esp ecially in a situation where almost all areas of aviation 
safety are regulated at the EU-level and where in significant number of cases, individual MS may be unable to implemen t safety recommendations on their own in 
a uniform and consistent manner. 
For example safety recommendations which may be addressed by a NSIA only to the 
national aviation authority or a national airline, may be of  relevance to other MS or 
all Community operators. There is howev er currently no mechanism which would 
allow for identification of such safety  recommendations on a regular basis. 
It is also important to note that there is  currently no independent mechanism allowing 
to monitor implementation of safety reco mmendations addressed to the Community 
regulator. At the sa me time the number of recomm endations addressed to the 
Commission and EASA increased substantially in the past years, and this trend is 
expected to continue give n the ongoing extension of the Community competence in 
civil aviation safety. 
Case III: Increasing role of EASA as an  addressee of safety recommendations 
The handling of the safety recommendations in an expeditious and responsible manner constitutes 
one of the pivotal responsibilities for EASA. Since the establishment of the Agency in 2002 the number of safety recommendations addressed to it has been increasing in a steep manner and this 
trend is expected to continue. 
1943 445457
0102030405060
2004 2005 2006 2007 2008Safety Recommendations addressed to EASA
Safety
Recommendationsaddressed to EASA
 
3.6. Protection of the rights of air crash victims and their families 
Aircraft accident is an unexpected and catas trophic event. Distress is an inevitable 
consequence of any accident in which people are killed or injured. In recent years, 
concern for persons who suffered distress and loss as a result of an aircraft accident 
has led to increased efforts by the intern ational community to establish means by 
which the anguish can be best mitigated84. This includes establishment of dedicated 
family assistance plans by States or of emergency procedures by the airlines. 
                                                 
84 For example Convention for the Unification of Certain Rules for International Carriage by Air done at 
Montreal on 28 May 1999, or IC AO "Guidance on assistance to ai rcraft accident victims and their 
families", Circular 285-AN/166 
EN 29   EN The EU has already developed some legi slation in this respect, including on the 
liability of the air carriers85 and insurance of this liability.86 The Community 
legislation envisages the obligation of the ai r carriers to provide advance payments to 
the eligible persons which may be require d to meet their immediate economic needs 
on a basis proportional to the hardship suffered. 
There are a number of additional elements related to this issue, including in 
particular: 
– The management of passenger manifests, whic h are an essential tool in facilitating 
search and rescue operations , identification of persons which might have been on 
board of the unfortunate flight, as well as notification of their families; 
– The rights of the air accident victims and their families to receive assistance and 
access to factual information about the circ umstances of the accident and progress 
of the investigation;  
3.6.1.  Problem drivers and evidence 
Passenger manifests  
With the exception of the security rules c oncerning reconciliation of passengers and 
registered baggage, there are no Community  requirements requir ing airlines to 
establish passenger manifests for each and ever y flight and this issue is left for the 
voluntary action of the airlines and regula tion at the national level, in accordance 
with the requirements the Chicago Convention.87 In practice, the most advanced 
protocols in this respect ar e developed by the Community airlines operating to the 
US, due to federal requirements of the US  Aviation Disaster Family Assistance Act 
of 1996 and US Foreign Air Carrier  Family Assistance Act of 1997.88 
Usually airlines compile lists of passengers using data from the gate, to avoid 
counting passengers not presenting themse lves for boarding. Such lists should 
include also infants and crews not activ e on a given flight. In addition a crew 
manifest will be also prepared. The data collected and processed by the airline, will 
usually include, name, address and contact  details, which is necessary for booking 
purposes. Interviews with some of the airlin es indicate that, this data may sometimes 
not correspond to the actual situation (for example in case of a reservation made by a 
travel agent). 
In the wake of the terrible accident of 20th August 2008 involving Spanish airline 
Spainair at the Madrid – Barajas airport a debate has arisen concerning management 
of passenger manifests and in particular th eir eventual disclosure to the general 
public and rapid availability89. Extensive experiences of the US authorities in similar 
                                                 
85 Council Regulation (EC) No 2027/97 on air car rier liability in the event of accidents, OJ 
L285,17.10.1997, p.1 
86 Regulation (EC) No 785/2004 of the European Parliament and of the Council of 21 April 2004 on 
insurance requirements for air carriers and airc raft operators (OJ L 138, 30.4.2004, p. 1) 
87 According to article 29 of the Chicago Convention, every aircraft engaged in international navigation, 
shall carry a list of passenger names, including their pl aces of embarkation and destination. Also the EC 
Regulation No 3922/91 of 16 December 1991, as amended (EU-OPS) makes a reference to national 
laws and regulations as far as passenger lists are concerned. 
88 http://www.ntsb.gov/family/Family.htm 
89 Publication of lists of airline passengers in the event of an accide nt, Information pr esented by the 
Spanish delegation at the occasion of the TTE Co uncil meeting on 9 October 2008 (Council of the 
European Union, 13660/1/08, REV1) 
EN 30   EN cases in the 1990ies, proved that it may be  difficult for airlines to ensure rapid 
availability of manifests covering "all s ouls on board" if proper procedures are not 
implemented and regularly tested in advance.90 
Due to importance of this issue, consider ation should be theref ore given whether and 
if so to what extent, improvements could be made in order to make sure that delays 
in availability of reliable manifests, c overing “all souls on board” does not negatively 
affect search and rescue operations, identif ication of victims of air accidents and 
notification of their families.  
This issue affects also the protection of personal data c ontained in the manifests in 
accordance with Directive 95/46/EC of 24 October 1995 on the protection of 
individuals with regard to the processing of personal data and on the free movement 
of such data91. The Directive lays down the legal framework for the processing of 
personal data in the Community so as to ensure the fundamental right to the protection of personal data
92.  
The information contained in the manife sts, while essential for the competent 
authorities responsible for accident investig ation, search and rescue or police, has 
therefore to be handled and pr ocessed with full respect of  data protection rules, in 
order to avoid unauthorised disclosure and use, especially without prior consent of 
the victims and families concerned.93 
Assistance to the victims of air accident and to their families  
While air crashes in commercial aviation are relatively rare, once they occur a large 
number of victims or fatalities may beco me involved, touching upon a wide range of 
families. 
Irrespective of the scal e of an accident, the victims and their families should receive 
appropriate assistance. Because of variations in the size and circumstances of aircraft 
accidents, the extent of the re sources required to provide fa mily assistance will vary 
considerably. Therefore, planning for such events is necessary to ensure that the 
assistance provided to the victims of a larg e aircraft accident and their families does 
not overwhelm the available resources. In su ch instances an institutionalized crisis 
management programme would normally provide the optimum set of guidelines, 
allowing a well-co-ordinated operation bene fiting all parties invo lved, whenever the 
need arises. 
3.7. Who is affected, in what ways, and to what extent?  
A wide scope of entities at nationa l and Community le vel are affected. 
NSIAs are affected because they cannot  fully benefit from the combined 
investigating capacity of th e EU. This affects their cost base and the overall 
                                                 
90 In consequence the NTSB asked FAA to require air carriers to standardise the reporting of passenger 
manifests (see in particular recommendations A-90-105 or A-95-56). In 1996 Congress adopted 
Aviation Disaster Family Act addressing this issue in  a comprehensive way. All airlines operating to the 
US are required by US legislation to have speci fic programmes in place addr essing assistance for air 
crash victims and their families. 
91 OJ L 281, 23.11.1995, p. 31 
92 Charter of Fundamental Rights of the European Union (Article 8) and European Convention of Human 
Rights (Article 8) 
93 This IA does not deal with the issue of informing the families about death or injury resulting from 
accident. In most jurisdictions in the EU this is the re sponsibility of the Poli ce or other competent 
governmental bodies. 
EN 31   EN efficiency and quality of safety investiga tions. The NSIAs and their staff cannot also 
fully benefit from experiences of their coun terparts in other MS . Tensions and lack 
of coordination with other authorities may also  inhibit their ability to gather evidence 
and effectively conduct invest igations. Potential of thei r safety recommendations is 
also not fully used and they cannot fully benefit from access to safety 
recommendations issued by other authorities. 
The travelling public is affected because lacks in resources, tensions between 
authorities and problems in the flow of important safety information may delay 
investigations. The travelling public is also  affected because it cannot fully benefit 
from all potential improvements cont ained in safety recommendations. 
The Community and in particular EASA as  well as the NSIAs are affected because 
their roles and respons ibilities in accident investigati on are not clearly defined which 
may affect the flow of important safety information. Aviation regulators are also 
affected, because they are responsible fo r follow-up and implementation of safety 
recommendations. 
Third countries are also affected in case of accidents occurring outside of the EU and 
involving in particular airc raft of European desig n, manufacture and registry. 
Aviation industry (airlines, manufacturers a nd service providers) is affected, because 
implementation of safety recommendations has always a certain economic dimension 
and cost attached. 
Judicial authorities are affected because tensions, concerning for example access to 
information and evidence can affect their st atutory obligations to administer justice. 
Aviation professionals are affected because they may be reluctant to share sensitive 
safety information with the investigators or file an occurrenc e report, if such 
information could be subsequently used to blame them. 
3.8. Does the EU have the right to act? 
The overall Community competence to regul ate civil aviation accident investigation 
and occurrence reporting was established on the basis of Directive 94/56/EC and 
Directive 2003/42/EC. Some aspects related to  this issue are also addressed in the 
Regulation EC No 3922/ 91 of 16 December 1991, as amended (EU-OPS)94 and 
Regulation EC 216/2008.95 
Further intervention at the EU level would be only justified if two conditions of the 
subsidiary test are met. Firstly, it is important to be sure that objectives of the proposed action could not be achieved su fficiently by the MS (necessity test). 
Secondly it is necessary to consider whet her and how the objectives could be better 
achieved by action on the part of the Community (test of European value-added).  
In this respect, an action at the Community  level is both necessary  and justified from 
the added value perspective. Interven tion at the Community level would in 
particular: 
– Ensure the necessary uniform ity of action, which is need ed in the area of civil 
aviation safety (in particular in relati on to uniform implementation of safety 
recommendations or increase in the inves tigation capacity of th e EU as a whole); 
                                                
 
94 c.f. 57 
95 c.f. 62 
EN 32   EN – Allow to address the inefficiencies of in stitutional nature, including in particular 
clarification of the role of the Co mmunity in accident investigation; 
3.8.1.  The added value of Community Action 
The Community action would bring safety benefits by strengthening the preventive 
function of accident investigation and occu rrence reporting. This would be achieved 
in particular by: 
– Increasing the overall investigation capaci ty of the EU (better sharing of 
resources, building up uniform exper tise of NSIA and investigators); 
– Reducing tensions between the various au thorities involved in the investigation 
(better coordination between the aut horities, protection of evidence); 
– Updating the existing regulatory framework for accident investigation, following 
the adoption of EU safety legislation, transfer of certain certification tasks to the Community level and establishment of EASA  (clarification the role of EASA and 
Commission in accident investigation, defi ning the rights and obligations of NSIA 
and the Agency); 
– Strengthening implementation of safety  recommendations in a uniform manner 
across the EU (building an EU database of safety recommendations, transparent 
process for replying to safety recomme ndations, process for identification of 
safety recommendations of EU wide relevance); 
– Strengthening the protection of the rights of victims of air accidents and of their 
families, in particular by setting mini mum standards at the EU level concerning 
assistance to be provided a nd rapid availability of re liable passenger manifests, 
covering "all souls on board"; 
3.8.2.  The proportionality of the Community action 
Any Community intervention should be proportionate and addressing only the 
problems which cannot be adequately solved at the level of the individual MS. Also 
from the public policy point of view, and given the limitations in the investigating 
capacity of NSIAs, both the Community as well as national resources should be focused on investigation of events from wh ich the biggest safety benefits can be 
acquired. 
Currently, Directive 94/56/EC obliges MS to investigate all ac cidents and serious 
incidents regardless of the nature of the ope ration or the size of the aircraft involved. 
At the same time many accidents involving esp ecially light aircraft are repetitions of 
past occurrences and the be nefits and lessons acquired through the investigations 
may not always justify the resources allocated. 
In this context it has to be recalled that  in 2008 there were 1220 accidents reported to 
EASA and involving civil aircraft regist ered in the EU/EEA/EFTA MS - vast 
majority of them being accidents of sma ll general aviation aircraft below 2.250 kg 
MTOM. If only the bigger aircraft of MTOM above 2.250kg are taken into account, 
the average annual number of accidents invo lving civil aircraft registered in the 
EU/EEA/EFTA MS in the period 1997 – 2008 could be estimated at 72.  
At the same time aircraft below 2.250 kg MTOM, with the exception of the "Annex 
II" aircraft, are currently within the scope of the Community competence, and 
certified by EASA. Some of those aircraft include high-performance turbine powered 
aircraft such as the “Very Light Jets”. 
EN 33   EN In this respect should an ac tion at the EU level be taken, appropriate thresholds 
would need to be established in order to take into account the safety lessons to be 
learned in determining the extent of the investigation, the proc edure to be followed 
by the NSIAs and the degree of involvement of the Community bodies. 
In any case from the safety perspective it is important that all accidents and serious 
incidents should be notified to the comp etent authorities at  the national and 
Community level, which should be allowed to  initiate an invest igation or join an 
ongoing one, if they consider  that safety lessons could be learned. From the EU 
perspective, the minimum threshold fo r the involvement of EASA should be 
accidents or serious incidents involvi ng aircraft certified by the Agency. 
4. OBJECTIVES  
4.1. What are the general policy objectives? 
4.1.1.  Enhancement of civi l aviation safety 
The general objective of the different policy op tions analysed in this IA is to enhance 
civil aviation safety in line with the st rategic goals of the Community transport 
policy, as set out in the Communicati on from the Commission: "Keep Europe 
moving - Sustainable mobility for our contin ent (Mid-term review of the European 
Commission’s 2001 Transport White Paper)"96, and the institutional changes which 
took place following the establishment of a European certification authority (EASA). 
This objective has to be set in a realis tic manner. While the elimination of all 
accidents is certainly desirable, absolute sa fety cannot be achieve d, especially in the 
dynamic context of such a complex activity as modern aviation. Also, even if full 
regulatory compliance is achie ved, it will be far from gua rantying absolute safety. 
No human activity can be guaranteed to be absolutely free from hazards despite the 
best efforts to prevent them. 
The approach that this IA takes to safe ty benefits is by identifying areas creating 
risks which need to be addressed and th en by proposing the most cost-efficient 
means of addressing them. This IA is w ithout prejudice to a ny projects concerning 
the development of Safety Performance In dicators (SPI) in the EU and does not 
attempt to quantify safety benefits with precise figur es (e.g. "x" % reduction of 
accidents by year "y"), as this would necessitate the ability to predict when and where the next accident might happen. Given that accidents in civil aviation have 
become rare to the point of  constituting almost random ev ents, this is not possible 
and would be speculative. 
4.1.2.  Promoting legal certainty 
Accident investigation requires legal certain ty. When an accident happens time is of 
essence and the roles and tasks of all the parties have to be known in advance and clearly defined. This concerns in particul ar the role of the NSIAs and EASA, access 
to important safety information, as well as  coordination between all the authorities 
which may be involved in the investigat ion or search and rescue operations. 
One of the important objectiv es of the Community should be thus to strengthen the 
required legal certainty, in part icular given the fact that the current regulatory regime 
necessitates involvement of entities at bot h national as well as Community level. 
                                                
 
96 COM(2006) 314 final, Brussels, 22.06.2006 
EN 34   EN 4.1.3.  Maintaining independence of safety investigations 
To reveal all circumstances of an accident , the NSIA must be st rictly objective and 
totally impartial and should be established in a way to be able to withstand political 
or other interference or pressure.97 Its only objective should be the enhancement of 
safety and the safety investigation should be independent from any other proceedings 
which could conflict with this objective. 
The NSIA is tasked with determining the causes of an accident and making safety 
recommendations, while the responsibility for their implementation rests with operators and civil aviation administrati on. This division of responsibility is 
appropriate since civil aviation administ ration has overall responsibility for the 
regulatory framework of avia tion and its development. 
It is important that the principle of inde pendence of safety investigations is fully 
respected and strengthened by all the policy options analysed in this IA. The principle of the separation of accident i nvestigation from regulatory and oversight 
activities should apply both at the MS as well as at the Community level. This is 
important especially in the context of th e extension of the EU competences to new 
areas of aviation safety in accordance with the "total system approach". This would 
apply for example to particip ation rights given to EASA, as  an authority responsible 
for type certification of aircraft. 
4.2. What are the specific objectives? 
The objectives of the proposed EU action shou ld tackle the problem areas identified 
in the Chapter 2 above and address directly their root causes. These objectives should 
be specific, measurable, accepted, realistic and time-dependent.  
The Specific and operational objectives, as  well as relationship between these 
objectives and the identified problem ar eas are outlined in Table II below. 
4.3. Consistency with horizontal policies of the European Union 
The objectives of this proposal  are consistent with the overall policie s of the EU. 
Firstly, by improving safety of air transpor t in the EU, they contribute to the 
attainment of the wider objectives of the Lisbon Agenda and EU consumer protection policy. In addition, by reducing te nsions between accident investigations 
and judicial proceedings, and in particul ar by ensuring appropriate protection of 
sensitive safety information, the objectives  of this proposal strengthens the respect 
for the fundamental rights of the EU citizens. 
                                                
 
97 Doc 9756 “Manual of Aircraft Accident and Incident Investigation” - Part I Organization and Planning  
 
EN 35   EN Table II: Specific and operational objectives and their relationship with problem areas 
Specific Objectives Increase the investigating 
capacity of the EU Reduce tensions between 
authorities involved in 
the investigation Clarify the role of the 
Community in safety 
investigations Better implement safety 
recommendations Strengthen the rights of 
the victims and families 
 
 
Operational 
objectives  Better coordinate the 
resources of NSIAs Harmonise training and 
qualification 
requirements for 
investigators Regularly monitor the 
investigating capacity 
of NSIAs Better coordinate 
activities of the 
authorities involved Better protect sensitive 
safety information Define the mutual 
rights and 
obligations of EASA 
and NSIAs Ensure that 
independence of 
safety investigation 
is not compromised Establish community 
database of safety 
recommendations Ensure that every 
recommendation is 
assessed and a reply 
given in a timely and 
transparent process Ensure a mechanism 
identifying 
recommendations of 
EU wide relevance Organise efficient 
support for the 
families and victims  Ensure availability 
of reliable pax 
manifests after 
accident  
Problem Areas  
Lack of Uniform 
investigating 
capacity √ √ √          
Tensions between 
investigations and 
other proceedings    √ √        
Unclear role of 
Community in 
safety investigations      √ √      
Weaknesses in 
implementation of 
safety 
recommendations        √ √ √   
Protection of the 
rights of the victims           √ √ 
 
EN 36   EN 5. POLICY OPTIONS  
This section outlines the policy options which have been considered by the 
Commission to address the problem areas de scribed in Chapter 2 and to meet the 
policy objectives identified in Chapter 3. 
5.1. Possible policy options 
(1) Policy Option No 1 "Baseline Scenario - Do Nothing" 
This policy option is a reference or a “b aseline” scenario and means that no 
additional action at the EU level would be  taken in addition to the already ongoing 
initiatives.  
Not taking any new action at the EU level does not necessarily mean that there is no 
change at all, as the MS would continue  to develop cooperati on within the current 
regulatory framework. However, based on the evidence available, recommendations 
of the "Group of Experts", as well as the results of the public c onsultations, this IA 
argues that taking no action would not be a cceptable form the public safety point of 
view. 
Review of recent or  ongoing initiatives 
The cooperation between the EU NSIAs ha s been recently strengthened with the 
establishment of the Council of European Safety Inves tigation Authorities (the 
Council), which is composed of the Heads of the NSIAs of the EU MS. The Council 
coordinates and harmonises the activity  of NSIAs without hampering their 
independence.  
In addition a “Code of Conduct on Co-operati on” was endorsed at the beginning of 
2006 by the ECAC MS. This agreement, consis tent with the relevant provisions of 
Annex 13 and Directive 94/56/EC, provide s for a convenient framework for co-
operation outside the context of a speci fic investigation. The ECAC Group of 
Experts on accident investigation has also developed "A checklist on assistance" 
which constitutes a useful tool to assist stat es in self-assessment of their needs related 
to investigations and identification of  possible practical or legal obstacles. 
As far as global cooperation in  the area of accident inves tigation is concerned, it is 
worth mentioning the conclusions of the last ICAO Accident Investigation and 
Prevention (AIG) Divisional Meeting (M ontreal 13 – 18 October 2008), which 
resulted in numerous recommendations to  improve the global regulatory framework 
for civil aviation accident i nvestigation and prevention. Th e EU actively participated 
in that meeting tabling 7 Working Papers  coordinated also with the non-EU ECAC 
MS. One of the most important actions undertaken by ICAO as a follow-up to the 
AIG meeting is the currently ongoing comprehensive revision of Annex 13.98  
As far as the activities in the EU  are concerned, the ongoing work on the 
development of implementing rules to th e Regulation (EC) No 216/2008 as well as 
the extension of the Community and EA SA competence to safety aspects of 
aerodromes as well as ATM/ANS have to be mentioned. Extension of the 
Community competence in this respect is exp ected in particular to increase the role 
of EASA and the Community regulator as an addressee of safety recommendations. 
                                                 
98 ICAO State Letter, AN 6/1.2-09/36 
 
EN 37   EN Impact of recent or ongoi ng initiatives on the id entified problem areas 
Lack of uniform investigation capacity in the EU  
Given the establishment of "the Council", and development of tools such as "the 
checklist on assistance" and "the Code  of Conduct", the overall investigating 
capacity of the NSIAs is expect ed to increase. These initiatives contribute to better 
coordination of resources, training activities  and harmonisation of qualifications of 
investigators. 
Given however the previous experiences w ith the Joint Aviation Authorities, which 
led to establishment of EASA, it is not e xpected that full harmonisation of accident 
investigation standards and methodol ogy can be achieved through voluntary 
cooperation only. More structured cooperati on may be also needed in case of 
situations whereby a number of accident s occur in the same period of time and 
necessitate extended simultaneous engagement of a few NSIAs. 
Tensions between safety invest igations and other proceedings  
It is difficult to assess to what extent th e coordination between th e various authorities 
involved in the investigation can be impr oved. Experiences of at least some MS 
suggest that voluntary cooperation between  NSIAs and judicial  authorities can 
improve the situation.99 This can be for example achieved by concluding in advance 
appropriate arrangements between the NSIAs and other services (judicial, search and 
rescue etc). This practice is reco mmended in the ICAO guidance material.100 
In the current revision of  Annex 13 initiated by ICAO101 the issue of better 
coordination of proceedings is also going to  be addressed, in particular in providing 
additional guidelines to the States on how coordination between the accident investigation authorities and the judicial authorities regarding in particular the 
control of the wreckage could be achieved. 
However, it has to be stressed that  without a sound mechanism supporting such 
cooperation, its full potential may be hard  to achieve on the EU  scale. Voluntary 
cooperation may also be not sufficient to ensure protection of sensitive safety information, such as witness testimonies or other statements, accounts and notes taken or received by the NISA s, where legal certainty is  of paramount importance. 
Unclear role of Community in safety investigations
 
It can be expected that the role of Comm unity and of EASA in accident investigation 
will continue to be dealt with on an ad hoc  basis. So far the NSIAs and the Agency 
did not manage to agree on comm on protocols in this respect . It has to be also noted 
that from the very beginning, the draft of the working arrangements negotiated 
between the Agency and NSIAs was consider ed to be only of a transitional nature 
and would cease to exist should the EU adopt  binding regulations covering this issue. 
Lack of legal certainty in this respect may, as already experienced in the past, lead to 
situations where the flow of important sa fety information between NSIAs and EASA 
needed to take corrective safety action or disclosure of all the circumstances of an 
                                                 
99 c.f. 50 
100 c.f. 35 
101 c.f. 98 
 
EN 38   EN accident, is hampered. As indicated in  the ICAO USOAP report on EASA, this 
affects in particular aircra ft certified by the Agency. 
Weaknesses in implementation of safety recommendations  
Certain improvements can be expected from the ongoing revision of Annex 13, 
where in particular a deadline of 90 days is  proposed for informing an originator of 
the recommendation about the pr eventive action taken or u nder consideration, or the 
reasons why no action will be taken. "The Counc il" is also trying to better coordinate 
the exchange of safety recommendations. 
Overall however, inefficiencies are expected to continue as far as exchange and 
follow up to safety recommendations in a uniform manner in the EU is concerned. This issue is mainly related to the institutional and regulatory changes which in the past decade took place in the EU in the area of aviation safety.  
It would be important for the EU to have a central database of safety 
recommendations and an efficient and tran sparent mechanism for assessing, replying 
and monitoring follow-up to safety reco mmendations. This mechanism should cover 
recommendations addressed to the indus try and national and Community bodies, 
especially given the increasing role of th e Community as an addressee of safety 
recommendations. It would be also necessary to have a process which would identify 
recommendations of EU wide relevance. This could be achieved for example by mandating each entity in the EU issuing or  receiving a recomm endation to have a 
uniform process for: 
– recording the responses to the sa fety recommendation issued, and 
– monitoring the progress of the acti on taken in response to the safety 
recommendation; 
All recommendations and replies thereto s hould be also recorded in the central 
repository in order to facilitate sharing of this important safety information, 
transparent monitoring of the implementa tion of recommendations and analysis of 
trends in safety deficienci es at the EU wide level. 
Protection of the rights of air crash victims and their families 
Community airlines and especially those ope rating to the US do have procedures for 
management of passenger manifests. The problem analysed in this IA concerns 
however the quality of those procedures, their regular testing and consistency in 
application across the EU. Lack  of harmonisation in this respect may affect the rights 
of families to prompt information about the fate of their loved ones or inhibit safety investigation or search and rescue operati ons. Equally, similar level of protection in 
terms of assistance and information provided to the victims and families of air accidents should be available across the EU. 
(2) Policy Option No 2 "Promotion of voluntary cooperation" 
Under this policy option the Community  would actively promote voluntary 
cooperation between the NSIAs. This pol icy option would not involve any new 
legislative action and rely on the al ready existing regulatory framework.  
1. How this policy option would be implemented? 
This policy option is based on the resources already existing in the MS and the 
experiences of the existing informal c ooperation of the NSIA  (“the Council of 
European Aviation Safety Investigation Aut horities”). Under this policy scenario, the 
 
EN 39   EN Commission would engage in an active di alogue with this grouping of NSIAs on all 
issues concerning development and implem entation of EU civ il aviation accident 
investigation and prevention policy. This re lationship could be formalised through a 
decision, similar to the Commission Decision  of 29 July 2002 establishing European 
Regulators Group for Elect ronic Communications Networks and Services102 
(however, a decision of the EU Council rath er than of the Commission would be 
necessary to maintain the i ndependent status of the NS IAs). This would respond to 
the recommendation formulated by the “Gro up of Experts” which called for a 
"formal recognition of the coordinating role of Aviation Safety Investigating 
Authorities in a European context ". Such a decision would define the mandate of the 
grouping. 
Regular meetings between the NSIAs, Co mmission and EASA would contribute to 
greater uniformity, better implementation and enforcement of the Community civil aviation accident investigation legislation. It  would also strengthen the investigating 
capacity of the EU and the preventive fu nction of accident investigation by 
promoting a more coordinated cooperat ion between the NSIAs, Commission and 
EASA, while fully retaining the independent status of NSIAs. 
The structure of the coordination groupi ng of NSIAs would remain unchanged. It 
would be composed of the respective heads of the NSIAs of all the MS. It would 
appoint its Chair and its Vice-Chair(s) from  among its members, subject to its rules 
of procedure. It could estab lish technical groups to deal with specific issues such 
flight recorders, human factors or safety recommendations. 
The grouping of NSIAs would retain an independent status. Its members would 
neither seek nor accept instructions from a ny public or private groupings or entities. 
The Commission and EASA would however pa rticipate in its meetings for those 
subject matters which do not raise issues of conflict of interest. 
Specific support of the Co mmission to the grouping c ould be provided through an 
annual grant assigned on th e basis of the Council Regulation (EC, Euratom) No 
1605/2002 of 25 June 2002 (the Financial Regulation)
103. To minimise administrative 
burden and avoid the creation of a fully fledged administ ration, this annual grant 
would be allocated to the chairman of th e grouping who would be  responsible for the 
use of the grant and the formal contra ctual counterpart of  the Commission.  
The specific responsibilities of the groupi ng of NSIAs supported under this policy 
option would be to: 
– Issue opinions and advising Community inst itutions on all aspects related to the 
development of the EU civ il aviation accident investigation and prevention policy; 
– Actively promote a more structured c ooperation between the NSIAs and between 
the NSIAs, Commission and EASA; 
– Coordinate training activ ities of the NSIAs; 
– Promote best investigation practices  and develop a common EU accident 
investigation methodology; 
– Organise "peer reviews" allowing to st andardise the NSIAs on a voluntary basis; 
                                                 
102 OJ L 200, 30.07.2002, p.38. 
103 OJ L 248, 16.9.2002, p.1. 
 
EN 40   EN – Promote dialogue between the NSIAs and law enforcement authorities to better 
coordinate involvement of various entities in accident investigation; 
– Promote a European database of safety recommendations, exchange of safety data 
between the EU safety authorities and id entify important recommendations of EU 
wide relevance; 
– Coordinate the development of volun tary occurrence reporting systems; 
The specific activity which could be supporte d under this policy option would be the 
development of a mechanism for sharing of investigation resources available in the 
MS. This would be similar to some of th e functions of the "Community mechanism 
for civil protection"104 and constitute a one-stop-shop of civil aviation accident 
investigation means available in the EU, th rough which the NSIAs would be able to 
make an appeal for assistance. 
2. Expected benefits 
Increasing the investigation capacity of the EU 
This policy option is expected to strengthen the overall investigating capacity of the 
EU and of individual NSIA s. This would be achieved in particular through the 
mechanism for sharing of the investigation resources available in the MS. The skills 
and expertise of investigators are also e xpected to increase through coordination of 
training activities and development of common training and qua lification guidelines. 
However, given the past experiences with  voluntary cooperation in aviation, it is not 
expected that full harmonisation can be achieved only through this policy option. 
Strengthening the dialogue on safety matters in the EU 
The grouping of NSIAs, to be supporte d under this policy option, although having 
advisory and opinion making powers only, w ould at the same time represent the 
single voice of the NSIAs and thus constitute  a strong counterpart to both national 
and EU institutions in a dialogue related to all issues related to the development of 
civil aviation safety investigation polic y and regulation in the Community. This 
policy option is expected to further increa se the transparency and quality of the 
dialogue on air safety matters in the EU. 
Better coordination between authorities involved in accident investigation 
This policy option is not expected to strengthen protection of evidence and of 
sensitive safety information, in line with A nnex 13. It is also not sufficient to provide 
better protection for occurrence reports fr om being used in non-safety related 
proceedings. 
Better implementation of safety recommendations 
Some safety benefits are e xpected due to more struct ured cooperation between the 
NSIAs, Commission and EASA. Better implem entation of safety recommendations 
could be also achieved through closer exch ange of information and promotion of a 
central database of safety recommendatio ns. This policy option however is not 
sufficient to establish a common pro cess in the EU for managing safety 
recommendations (lack of legal accountability). 
                                                 
104 2007/779/EC,Euratom: Council Decision of 8 November 2007 establishing a Community Civil 
Protection Mechanism 
 
EN 41   EN Clarifying the role of the Community in safety investigations 
This policy option is not expected to adequa tely address the issue of lack of clarity 
concerning the mutual rights and obliga tions of NSIAs and EASA in accident 
investigations. 
Protection of the rights of air crash victims and their families 
This policy option is not expected to addr ess the issue of passenger lists and to a 
limited extent the issue of assistance to the victims of air accidents and their families. 
Maintaining independent status of safety investigations 
The independent status of NS IAs and of the investigatio ns would not be affected 
under his policy option. 
Results of the public consultations 
This policy option is expected to have suppor t from the NSIAs, majority of which in 
the public consultations e xpressed the view, that "improved efficiency could be 
achieved by better coordination and promotion of voluntary cooperation".  It does not 
necessitate establishment of new structur es or significant admi nistrative burden for 
the Community, NSIAs or industry. It is  based on the alrea dy existing cooperation 
and resources available in the MS. The only cost for the Community budget would 
be the annual grant. 
Simplification and better regulation 
This policy option would be in line with  the Commission's strategy of "Better 
Regulation", by relying on promotion of  voluntary cooperation rather than 
regulation. 
(3) Policy Option No 3 "The European Network of Civil Aviation Safety 
Investigation Authorities" 
This policy option relies on promotion of  voluntary cooperation which objectives 
would be enshrined in a legally binding fr amework. It would be implemented on the 
basis of a directly applicable Regulati on adopted under Article 80(2) of the EC 
Treaty and repealing Directive 94/56/EC. 
1. Promotion of voluntary cooperation… 
The first “building block” of this policy option is similar to Policy Option No 2 
"Promotion of voluntary cooperation". It w ould also build on the resources already 
available in the MS and experiences of th e existing informal grouping of NSIAs (the 
Council of European Aviation Safety Inves tigation Authorities). This would be done 
by responding to the recommendation formul ated by the "Group of Experts" which 
called for a " formal recognition of the coordi nating role of Aviation Safety 
Investigating Authorities in a European context ".  
However, under this policy option the cu rrent informal cooperation between the 
NSIAs would be transformed, through th e new Community Regulation, into a 
European Network of Civil Aviation Sa fety Investigation Authorities ("the 
 
EN 42   EN Network"). The new Regulation would defi ne the mandate of “the Network” as 
promotion of aviation safety through independent safety investigations.105 
"The Network" would contribute to gr eater uniformity, better implementation and 
enforcement of the Community civil aviatio n accident investigation legislation. It 
would also strengthen the investigating capacity of th e EU and the preventive 
function of accident investigation by pr omoting a more structured cooperation 
between the NSIAs, the Commission and EA SA, while retaining a fully independent 
status. An important function of “the Netw ork” would be also to facilitate the 
exchange of safety related in formation between the NSIAs. 
"The Network" would be composed of the respective heads of the NSIAs of all the 
MS. It would appoint its Chair and its Vice-Chair(s) from among its members, 
subject to its rules of procedure. "The Netw ork" would have the capacity to establish 
technical groups to deal with specific issues  such flight recorders, human factors or 
safety recommendations. 
"The Network" would have an important function of enhancing the investigating 
capacity of the EU and NSIAs. To this  end "the Network" would promote the 
development of a mechanism for sharing of investigation resources available in the 
MS. This would be similar to some of th e functions of the "Community mechanism 
for civil protection"106 and constitute a one-stop-s hop of civil aviation accident 
investigation means availabl e in the EU, through which NSIAs would be able to 
make an appeal for assistance. "The Netw ork" would also coordinate the training 
activities and organise regular  "peer reviews" of NSIAs, to gradually build up a more 
uniform investigation capacity of the EU. 
"The Network" would retain an independent  status. Its members would neither seek 
nor accept any instruction from any government, from the Commission, or from any other public or private groupings. The Commission and EASA would however 
participate in the meetings of "The Netw ork" for those subject matters which do not 
raise issues of conflict of interest.  
In order to avoid the creation of a new Community body, “the Ne twork” would have 
no legal personality under the Community  law and its mandate, which would be 
clearly described in the Regul ation, would be limited to  advisory and coordination 
tasks. "The Network", would constitute a body pursuing an aim of general European 
interest, within the meaning of Article  108 (1)b of the Council Regulation (EC, 
Euratom) No 1605/2002 of 25 June  2002 (the Financial Regulation)
107, which would 
allow the Community to support its activitie s with an annual grant. To minimise 
administrative burden and avoid the creation of a fully fledged administration, this 
annual grant would be allocated to the ch airman of “the Network” who would be 
responsible for the use of the grant and th e formal contractual counterpart of the 
Commission. Grants to be awarded to “the Network” would be subject to an annual 
                                                 
105 Similar to the European Union Network for the Implementation and Enforcement of Environmental 
Law (IMPEL) which is  an international association of the environmental authorities of the MS, 
acceding and candidate countries of the European Union and EEA countries, 
http://ec.europa.eu/environment/impel/index.htm  Also the Joint Aviation Authorities (JAA), the 
predecessor of EASA, had a status of a foundation base d on Dutch law (Final Report of the Future of 
JAA working Group, http://www.jaa.nl/ ) 
106 2007/779/EC,Euratom: Council Decision of 8 November 2007 establishing a Community Civil 
Protection Mechanism (recast) (Text with EEA relevance) 
107 OJ L No 248/1 of 16.9.2002 
 
EN 43   EN work programme agreed by the Commission. The work programme would be also 
made public. 
The specific responsibilities of "the Netw ork", supported under this policy option 
would be to: 
– Issue opinions and advising the Community institutions on all aspects related to 
the development and implementation of  the EU civil aviation accident 
investigation and prevention policy; 
– Actively promote a more structured c ooperation between the NSIAs and between 
the NSIAs, Commission and EASA; 
– Coordinate training activ ities of the NSIAs; 
– Promote best investigation practices  and develop a common EU accident 
investigation methodology; 
– Strengthen the investigation capacity of  the NSIA by developing and managing a 
mechanism for sharing of investigating resources; 
– Organising "peer reviews" allowing to  standardise the NSIAs on a voluntary 
basis; 
– Promote dialogue between NSIAs and law enforcement and judicial authorities 
(for example with structures such as Euro just) to better coordinate involvement of 
various entities in accident investigations; 
– Promote a European database of safety recommendations, exchange of safety data 
between the EU safety authorities and id entify important recommendations of EU 
wide relevance; 
– Coordinate the development of volun tary occurrence reporting systems; 
The activity of “the Network” would be re gularly monitored in accordance with the 
principles established in the new Regula tion. In particular the Network would be 
obliged to submit an annual report on its activities, which would be made public. 
Such monitoring is necessary to ensure the accountability of the Network and to 
control the efficiency of its work. The re spect for the principles of the Community 
financial discipline in the disbursement of the grants awarded to the Network would 
also need to be ensured in accordance  with the EC financial regulations. 
2. Backed by obligations enshrined in law… 
The main drawback of a policy option i nvolving voluntary cooperation only is lack 
of a legal obligation to act within the framework of a clearly defined mandate. 
Voluntary cooperation is also not expected to adequately resolve issues where legal 
certainty is needed, such as protection of sensitive safety information, defining the mutual rights and obligati ons of NSIAs and EASA in safety investigations or 
establishing uniform requirements in term s of processing of safety recommendations. 
To avoid such drawbacks, which are at th e centre of the improvement needed to 
address the problems identified in Section 3 of this IA, this po licy option would back 
the voluntary cooperation by a number of  obligations enshrined in law. 
The new Regulation would recognise the coor dinating role of "the  Network" in the 
European context and give it a clear mandate to act. In addition, it would update the 
current regulatory framework for civil avia tion accident investig ation and occurrence 
 
EN 44   EN reporting and address issues which are not expected to be adequately solved by 
voluntary cooperation only. 
From the legal point of view, using a Regul ation, rather than a Directive would be 
necessary to address the rights and obliga tions of EASA. A Re gulation would also 
contribute to better implementation, as the same law would apply in each MS 
without the need for transposition measures , enable immediate application and focus 
the attention of the Community on enforcement.  
The key provisions of the Regulation e nvisaged under this policy option would: 
– Update and modernise the main provisions  of the former Directive 94/56/EC, 
taking into account in particular  the ongoing revision of Annex 13; 
– Strengthen the efficiency of safety i nvestigations by implementing into the 
Community law the recommended standards of ICAO related to the protection of 
evidence and sensitive safety inform ation, in accordance with Annex 13; 
– Strengthen the protection of occurrence re ports from being used in non-safety 
related proceedings; 
– Establish common requirements in te rms of organisation of NSIAs; 
– Require the NSIAs to conclude appropria te arrangement with  other authorities 
(judicial, search and rescue) likely to be  involved in accident investigation to 
ensure better coordination between them; 
– Clarify the mutual rights and obliga tions of EASA and NSIAs without 
compromising independence of safety i nvestigations, and using Annex 13 as a 
reference (see below); 
– Specify the criteria on the basis of which NSIAs would appoint accredited 
representatives for the "State of Design"; 
– Establish common requirements for Community  airlines regardi ng passenger lists, 
and minimum standards concerning provisi on of assistance to the victims and 
families in the immediate aftermath of an air accident; 
– Better protect anonymity of persons i nvolved in accident (currently under 
Directive 94/56/EC such protection is afforded only to pe rsons involved in 
incidents).108 
– Establish a legal requirement for every entity in the EU issuing a safety 
recommendation or receiving it  to have a process for: 
(a) recording the responses to the safety recommendation issued; 
(b) monitoring the progress of the acti on taken in response to a safety 
recommendation; 
3. Expected benefits 
Increasing the investigation capacity of the EU This policy option is expected to strengthen the overall investigating capacity of the 
EU and of individual NSIA s. This would be achieved in particular through the 
mechanism for sharing of the investigating resources available in the MS. The skills 
                                                
 
108 Articles 7 and 8 of the Directive 94/56/EC 
 
EN 45   EN and expertise of investigators are also e xpected to increase through coordination of 
training activities, “peer reviews” and the developm ent of common training and 
qualification guidelines. However, given the past experiences with voluntary 
cooperation in aviation, it is not expected that full ha rmonisation can be achieved 
through this policy option. 
Strengthening the dialogue on safety matters in the EU 
"The Network", although having advisory and opinion making powers only, would at 
the same time represent the single voice of the NSIAs and thus constitute a strong 
counterpart to both national and EU ins titutions in a dialogue related to the 
development of civil aviation safety i nvestigation policy and regulation in the 
Community. This policy option is expected to  further increase the transparency and 
quality of the dialogue on ai r safety matters in the EU. 
Better coordination between authorities in volved in accident investigation 
Better efficiency of safety investigations  (as well as other proceedings) would be 
achieved by providing a more structured platform for coordination between the 
various authorities. 
In addition better protection of sensitive safety information would be achieved by 
incorporating into the Community law the relevant standards and recommended 
practices of ICAO in this respect. 
Better implementation of safety recommendations 
Significant safety benefits are expected due  to more structured cooperation between 
the NSIAs, Commission and EASA as well as better implementation of safety recommendations. This would be achieved through closer exchange of information 
through "the Network", establishment of a central database of safety recommendations and a common process fo r managing safety recommendations in 
the EU. 
Protection of the rights of air crash victims and their families 
This policy option would allow to strength en the rapid availability of reliable 
passenger lists in the aftermath of an acci dent and to adequa tely protect data 
contained in the lists from unauthorised us e or disclosure. It would also allow to 
establish minimum requirements across the EU concerning provision of assistance to 
the victims and families in the immediate aftermath of an air accident.  
Clarifying the role of Community  in safety investigations 
Safety benefits are expected from clarifica tion of the rights and obligations of EASA 
and NSIAs in accident investigations. This  would cover the right of EASA, as a 
responsible design authority, to  be represented during the in vestigation and to obtain 
without delay any factual information whic h may be needed to take an immediate 
safety action in an aftermath of an accident . EASA would be also granted the right to 
participate in the exchange and analysis  of information stored in the central 
repository of occurrences.  
Two scenarios will have to be distinguish ed: (1) events where a MS of the EU is 
conducting the investigation; (2) events where a third country  is conducting the 
investigation: 
EASA should be also obliged to contribute to  the investigation, so that more accurate 
findings and safety recommendations can be made. 
 
EN 46   EN The new Regulation would also define the criteria on the basis of which the NSIAs 
would appoint accredited representatives for th e "State of Design". 
Maintaining independent status of safety investigations 
The independent status of investigations would not be affected, as "the Network" 
would retain a status of an association of  NSIAs, and be independent from any other 
body which interests could conflict with th e objectives of safety investigations. 
Results of the public consultations 
This policy option is expected to have suppor t from the NSIAs, majority of which in 
the public consultations e xpressed the view, that "improved efficiency could be 
achieved by better coordination and promotion of voluntary cooperation".  It does not 
necessitate establishment of new structur es or significant admi nistrative burden for 
the Community, NSIAs or industry. It is  based on the alrea dy existing cooperation 
and resources available in the MS. The only cost for the Community budget would 
be the annual grant assigned to support "T he Network" on the basis of an agreed 
work programme.  
Simplification and better regulation 
This policy option would be in line with  the Commission's strategy of "Better 
Regulation", by relying on co-regulation a nd promoting better implementation of 
legislation in a proportionate manner. 
4. Implementation risks 
The main implementation risks which can be associated with this policy option relate 
to: (1) practical implementation of the esta blished principles re lating to coordination 
between judicial authorities and NSIA, including in the area of evidence gathering and protection of certain safety related information, which is expected to be a 
sensitive issue; (2) accountability of addres sees from third countries for assessment 
and reply to safety recommendations  issued by the EU authorities. 
Concerning the issue of coordination of different proceedings, the main mitigating 
measure will be provided for in the new Regulation, which should ensure a proper 
balance between the interests of the safety  authorities on the one  side and judicial 
authorities on the other. It is however difficult to predict at this stage, to what extent 
exactly the implementation risk s in this respect can be mitigated. The role of “the 
Network” as a body promoting a more stru ctured dialogue between NSIAs and law 
enforcement and judicial authorities w ill be important in this respect.  
The global standards concerning management  of safety recommendations cannot be 
addressed through a Community  Regulation only. In addition the final decision 
regarding implementation of a safety recommendation always rests with its 
addressee. However, the currently ongoing di scussion concerning the revision of the 
Annex 13
109 within the framework of ICAO in cludes proposals on new standards in 
this respect and if adopted will signifi cantly contribute to the establishment of 
globally accepted standards for management of safety recommendations; 
Last but not least, due to th e fact that this policy option may involve engagement of 
resources from the Community budget, the risk  of fraud will also have to be taken 
                                                 
109 c.f. 98 
 
EN 47   EN into account and managed appropriatel y, in particular through appropriate 
monitoring of the activit ies of “the Network”. 
(4) Policy Option No 4 “European Civil Aviation Safety Board" 
The last policy option which could be envisage d to address all the issues identified in 
Chapter III, would be to establish a Eur opean Civil Aviation Safety Board ("the 
European Safety Board"), tasked with inve stigation of accidents on behalf of the MS. 
The European Safety Board could be establ ished for all modes of transport or for 
civil aviation only. Given however that multimodal boards exist in a few MS only 
and that the highest level of harmonisa tion of accident investigation has been 
achieved in civil aviation, th is policy option in pract ice would be focused on a 
dedicated civil aviation body. 
1. How this policy option would be implemented? 
The European Safety Board would be es tablished as a fully fledged Community 
agency for civil aviation accident investigation, similar to the U.S. National Transportation Safety Board (NTSB).
110 It would actually conduct investigations of 
accidents occurring in the EU and participat e, through accredited representatives, in 
investigations led by third countries. The European Safety Board would also manage 
a central EU database of safety recomme ndations and issue safety recommendations 
to all entities at the national or Community level. 
Under this policy option the NSIAs would be either replaced by the European Safety 
Board or a proportionate threshold would be established whereby the NSIAs would 
be responsible for investigation of sma ller but most numerous accidents involving 
general aviation aircraft. Under this latte r solution, the NSIAs would also act as 
national offices of the European Safety  Board, providing a link with the local 
authorities in the MS and ensuring that i nvestigation can be instigated in a rapid 
manner pending arrival of the team from  the central body. The European Safety 
Board would standardise the NSIA and ensu re uniform level of quality in safety 
investigations and training of investigators across the EU. 
This policy option would necessi tate a radical change in the current institutional and 
legal framework for civil aviation accident investigation in the EU. However, EU 
wide, it would be expected to have the stronge st safety benefits due  to the fact that 
investigation of all major accidents would be performed by a single specialised body 
on the basis of common standards and by centrally trained investigators.  
The European Safety Board should carry ou t its tasks independently, impartially and 
transparently. It should be independent from any public or  private organisation at the 
national or Community level whose inte rests could conflict with its tasks. 
This policy option would be implemented through a directly a pplicable Regulation 
adopted on the basis of Article 80(2) of the EC Treaty and repealing the current 
Directive 94/56/EC. Given the fact that it would pursue tasks assigned to it by the 
Communities and have its activities finan ced from the Community budget (an annual 
subsidy), European Safety Board would constitute a Community body within the 
                                                 
110 The National Transportation Safety Board is an independent US federal agency charged by US 
Congress with investigating every civil aviation accide nt in the United States and significant accidents 
in the other modes of transportation -- railroad, highway, marine and pipeline -- and issuing safety 
recommendations aimed at pr eventing future accidents. 
 
EN 48   EN meaning of the Council Regulation (EC, Euratom) No 1605/2002 of 25 June 2002 on 
the Financial Regulation applicable to  the general budget of the European 
Communities.  
In addition to the establishment of the European Safety Board, and definition of its 
mandate under this policy opti on, the new Regulation would: 
– Update and modernise the main provisions  of the former Directive 94/56/EC, 
taking into account in particular  the ongoing revision of Annex 13; 
– Define the eventual role of the NSIAs vi s a vis the European Safety Board (should 
the NSIAs retained); 
– Establish the investigation methodology to  be followed by the European Safety 
Board and NSIAs; 
– Establish common requirements in term s of organisation of the NSIAs; 
– Establish requirements in terms of tr aining and qualifications of the EU 
investigators; 
– Strengthen the efficiency of safety i nvestigations by implementing into the 
Community law the recommended standards of ICAO related to protection of 
evidence and sensitive safety inform ation, in accordance with Annex 13; 
– Strengthen the protection of occurrence re ports from being used in non-safety 
related proceedings; 
– Clarify the mutual rights a nd obligations of the European Safety Board, EASA 
and NSIAs without compromising indepe ndence of safety investigations; 
– Better protect anonymity of persons involved in accident (currently under 
Directive 94/56/EC such protection is afforded only to pe rsons involved in 
incidents).111 
– Establish common requirements for Community  airlines regardi ng passenger lists, 
and minimum standards concerning provisi on of assistance to the victims and 
families in the immediate aftermath of an air accident; 
– Establish a requirement for every entity in the EU issuing a safety 
recommendation or receiving it  to have a process for: 
(a) recording the responses to the safety recommendation issued; 
(c) monitoring the progress of the acti on taken in response to a safety 
recommendation 
The mandatory standards would be adopted  by the Commission in the framework of 
a comitology procedure, and its applicati on by NSIAs would be verified through 
mandatory standardisation inspections. 
2. Implementation risks 
Implementation of this policy option is characterised by specific risks, which merit 
closer attention.  
First of all, it is difficult to assess if successful implementation of this option would 
not be hampered by the fact that the Europ ean Safety Board would have to operate as 
                                                 
111 Directive 94/56/EC, Articles 7 and 8 
 
EN 49   EN an IIC in 27 different jurisd ictions of the EU MS. This consideration is critical, 
having in mind a close link between judicial procedures and accident investigations and the inherent need for the ICC to work  in close cooperation with the local law 
enforcement authorities. The specificities of  the local situation may also play an 
important role in implementation of this  policy option, havi ng in mind the very 
operational nature of ac cident investigation.  
As indicated above, these risks could be m itigated to a certain extent by having the 
European Safety Board assisted by NSIAs wh ich would act as its regional offices and 
provide a link with the specificities of the local situation. This would however 
increase the costs of this particular policy option and in consequence reduce the 
benefits of the expected economies of scale. 
3. Expected benefits 
Increasing the investigation capacity of the EU This policy option is expected to signifi cantly strengthen the overall investigating 
capacity of the EU. All investigations w ould be conducted by a central, independent, 
specialised body, according to a common methodology and by centrally trained 
investigators. The European Safety Board could be also assisted by NSIAs acting as 
its national offices and provi ding appropriate link with the local situation in each 
MS. 
More transparency and independence in safety matters 
The European Safety Board would represen t a strong counterpart to all regulators 
and certifying authorities at the national a nd Community level. It would be very well 
placed to issue safety recommendations and to monitor their implementation. It would also have resources adequate to be at par with the largest manufacturers and airlines. This policy option would thus signi ficantly contribute to the promotion of 
transparency and independence in safety investigations.  
Better implementation of safety recommendations 
Significant safety benefits are expected due  to the fact that the European Safety 
Board would be well placed to issue safety recommendations addressed to entities at 
the national and Community level as well as industry. It would also manage the 
central database of safety  recommendations, identify re commendations of EU wide 
relevance and ensure management of r ecommendations in a standardised manner 
across the Community. All en tities issuing or receiving safety recommendations 
would be legally accountabl e for their assessment and appropriate follow up.  
Clarifying the role of Community  in safety investigations 
Significant safety benefits are expected  through definition of the relationship 
between the European Safety Board (its local offices) and EASA. This would cover 
the right of EASA to be represented durin g the investigation a nd to obtain without 
delay any factual information which may be  needed to take an immediate safety 
action in an aftermath of an accident. In addition EASA would be obliged to 
contribute to the investigation, so th at more accurate findings and safety 
recommendations can be made. EASA would be  also granted the right to participate 
in the exchange and analysis of informa tion stored in the ce ntral repository of 
occurrences. 
 
EN 50   EN Similarly to the previous po licy option, two scenarios will ha ve to be distinguished: 
(1) events where the European Safety Bo ard (or its local offi ce) is conducting the 
investigation; (2) ev ents where a third country is conducting the inve stigation and 
where the European Safety Board particip ates through its accred ited representatives. 
Better coordination between authorities in volved in accident investigation 
Better efficiency of safety investigati ons would be achieved by providing a more 
structured platform for coordination between  the various authorities involved in the 
investigation. In addition better protection of sensitive safety information would be achieved by incorporating into the Community law the relevant standards and recommended practices of ICAO in this respect. This would cover also protection of 
occurrence reports from use in non-safety related proceedings. 
Protection of the rights of air crash victims and their families 
This policy option would allow to strength en the rapid availability of reliable 
passenger lists in the aftermath of an acci dent and to adequa tely protect data 
contained in the lists from unauthorised us e or disclosure. It would also allow to 
establish minimum requirements across the EU concerning provision of assistance to 
the victims and families in the immediate aftermath of an air accident. 
Maintaining independent status of safety investigations 
The independent status of investigations would not be affected, as the European 
Safety Board would not be involved in an y tasks which could conflict with the 
objectives of safety investigations. The Eu ropean Safety Board would be obliged to 
carry out its tasks independently, impartially and transparently. 
Results of public consultations 
Opinions expressed in public consultations varied considerably as to the added value 
of establishing a single European safety  investigation authority. Most of the 
respondents representing MS authorities in dicated that this policy option is not 
feasible in the current situation, where by some argued that it could be a good option 
for the future. On the other side, majority of the respondents representing manufacturing industry fa vored this policy option. 
4. Why EASA or the Commission could not be  tasked with the functions of the 
European Safety Board? 
One could envisage assigning the tasks of the European Safety Board to an already 
existing institution such as EASA or Co mmission. In particular EASA, as a body 
with significant experience in safety matters, could be tasked with these functions. Although this solution could be deemed as attractive from practical and cost-
efficiency point of view, it would also have serious deficiencies. 
It is necessary that the EU fully resp ects the principle of independent safety 
investigations and contributes to its strengthening. In this  context it has to be noted 
that EASA, as an entity involved in airc raft certification, c ould be in a potential 
conflict of interest with th e objectives of safety investigation. Similar conflicts of 
interest would exist if the Agency would be  issuing safety recommendations to itself. 
One could envisage trying to address the c onflict of interest issue by putting in place 
appropriate mitigating measures such as establishment of an independent unit in the Agency, similar the EASA Board of Appeal , which is responsible  for deciding on 
appeals against the decisions of the Execu tive Director of EASA. However, this 
 
EN 51   EN solution is not considered as credible a nd also not expected to get the necessary 
support from the MS authorities and industry. 
Similarly one could envisage giving to the Commission the tasks of the European 
Safety Board. Similarly however, this soluti on could raise questions  as to the respect 
for independence of safety investigations, especially in situations where the circumstances of an accident would be indicating weaknesses in Community 
standards. In addition the Commission doe s not have the adequate capacity and 
expertise to efficiently discharge such f unctions (which are of  a very operational 
nature) without the s upport of an Agency. 
6. A
NALYSIS OF IMPACTS  
6.1. Introduction and rating of impacts 
All presented policy options have strong and weak points,  including in particular 
trade-offs between safety and cost-efficienc y. It is thus necessary to assess not only 
their economic, social and environmental impacts but most importantly safety impacts, which are an overriding fact or within the context of this IA. 
The costs of implementation and administ rative burden involved has to be also 
carefully considered, as some of the polic y options envisage establishment of new 
structures and would impact on the Community and MS budgets. 
Rating of Impacts Weighting of impacts 
Positive impacts or savings (intensity): 
√ to √√√ 
Negative impacts or costs (intensity):  
- √ to - √√√ Safety  impacts  and implementation  risks  are given the 
highest relative weight, followed by costs of 
implementation  and all other  impacts (see point 8.1 below 
for detail weighting of impacts); 
6.2. Safety impacts related to identified problem areas 
This section presents safety impacts of each policy option 
Policy Option 2 "Promotion of voluntary cooperation" 
Justification Rating 
– Investigation capacity  of NSIA is expected to be strengthened (more structured cooperation of 
NSIA, establishment of a mechanism for sharing of  resources, coordination of training activities, 
development of best investigation practices and guidance material); 
– Some improvements in implementation of safety recommendations  can be expected (closer 
exchange of information, common platform for identifying recommendations of EU wide relevance, promotion of the EU safety recommendations database); 
– Not adequate to strengthen protection of evidence and sensitive safety information ; 
– Not adequate to ensure protection of occurrence reports  from use in non-safety related 
proceedings; 
– Not expected to define the mutual rights and obligations of EASA and NSIAs ; 
– Not adequate to ensure a common process for managing  safety recommendations  in the EU 
(including accountability of the addressee for follow up); 
– Not adequate to address the issue of passenger manifests, and only to a certain extent of the  
assistance provided to the victims and families;  √ 
 
EN 52   EN Policy Option 3 "European Network of Civil Aviation Safety Investigation Authorities" 
Justification Rating 
Additional benefits  expected (compared to Policy Option 2): 
– More certainty in obtaining all rele vant safety information which is necessary for the success 
of a safety investigation  (better protection of sources of information); 
– More safety data on occurrences  to analyse (better protection of  occurrence reports from use in 
non-safety related proceedings); 
– Better flow of factual safety information  (defining mutual rights and obligations of NSIA and 
EASA); 
– More uniform investigation process  (Common requirements in terms of organisation of NSIAs); 
– Better implementation of safety recommendations (establishing common requirements for 
processing of safety recommendations in the EU); 
– Less tensions between the authorities  involved in accident investigation (better coordination 
through advance arrangements); 
– Better protection of the rights of the victims and families  in the aftermath of an air accident √√ 
Policy Option 4 "European Civil Aviation Safety Board" 
Justification Rating 
Additional safety benefits  expected (compared to Policy Option No 3): 
– Fully harmonised investigation process  (single body conducting all major investigations, 
common investigation methodology, centrally trained investigators, standardisation of NSIAs 
through mandatory inspections); 
– Better and more transparent implemen tation of safety recommendations (independent 
mechanism for issuing safety recommendations and monitoring of their implementation, centrally managed database of safety recommendations).
 √√√ 
6.3. Economic, social and environmental impacts 
The considerations presented below are common to all the options 
Assessment criteria Rating Justification of the rating  
Economic impacts112 √  
to  
√√√ Some positive economic impacts can be expected, mainly under Policy 
Option No 3 and 4 which should further strengthen the perception of EU air 
carriers and aircraft of European design as safe and reliable. The quantitative dimension of these impacts is however difficult to assess, mainly due to lack 
of a reliable methodology. 
Social Impacts113 √  
to  
√√√ Some positive impacts are expected esp ecially under policy option No 3 and 4 
due to strengthening of the rights of EU citizens to safe air transport. Positive impacts are also expected as far as prot ection of the rights of air crash victims 
and their families are concerned. Positive impacts on the working 
environment of aviation professionals are also expected through stronger 
                                                 
112 Economic impacts in the context of this IA are understood as reflecting factors important from the 
competitiveness point of view (in this case competitiveness of the European air transport industry).  
113 Social impacts address issues related to quality of jobs including health and safety at work as well as 
fairness. Impacts on fundamental rights of the EU c itizens and consumer protection are also covered by 
this section 
 
EN 53   EN protection of occurrence reports. The quantitative dimension of these impacts 
is however difficult to assess, mainly due to lack of reliable methodology. 
Environmental 
Impacts114 0 No substantial environmental impact s are expected as a result of the 
implementation of the policy options considered. 
6.4. Impacts on fundamental rights 
All Commission proposals have to be compatible with the EU Charter of 
Fundamental Rights115, and it is thus necessary to assess the potential impacts of the 
proposed policy options on the fundamental rights as laid down in the Charter. 
Aviation safety is directly linked to the mo st important basic human right, the right to 
life. Aviation takes place in a hostile envi ronment, in which a passenger has no 
control and is enclosed in a vulnerable cocoon, outside of which human life cannot 
be supported. Under these circumstances, it  is of paramount importance to offer 
protection against threats to life.116 In this context the link between the safety impacts 
(see above) of each option and the right to life has to be stressed in particular. 
The considerations presented below are common to all the options 
Rating Justification of the rating  
√ to √√√ The proposed policy options are expected to have overall positive impacts on the right 
of EU citizens to safe communication by ai r. The intensity of these impacts will be 
related to the intensity of the safety impacts discussed above.  
Common rules on the management of passenger manifest and minimum standards 
concerning assistance to the victims of air accidents and their families is expected to 
positively contribute to the protection fundamental rights of EU citizens. 
Better protection of the sensitive safety information, including in particular of 
occurrence reports, from use in non-safety related procedures to attribute blame or 
liability is expected to positively impact on working conditions, as aviation 
professionals should be more willing to report safety incidents without the fear of being prosecuted. 
Protection of sensitive safety information from being used to attribute blame or liability 
and closer cooperation between the safety and judicial authorities is also expected to positively impact on the rights of the persons involved by reducing the risk of self-
incrimination and speedin g up evidence gathering. 
6.5. Geographical scope of impacts incl uding on international relations 
Due to the fact that inves tigation of accidents in civil aviation may involve both EU 
and non-EU countries, it is necessary to assess the scope and intensity of international impacts of th e policy options considered. 
Policy Option 2 "Promotion of voluntary cooperation" 
  
Justification of the rating  
                                                 
114 Environmental impacts estimate to what extent the proposed measures will lead to additional emissions 
(or reduction of emissions) of carbon dioxide or other greenhouse gas emissions 
115 http://ec.europa.eu/justice_home/unit/charte/index_en.html 
116 ICAO Working Paper, DGCA/97-IP/5, “Safety Oversi ght, An International Responsibility”, 20 October 
1997 
 
EN 54   EN This policy option is expected to have no impacts  on international relations. 
Policy Option 3 "European Network of Civil Aviation Safety Investigation Authorities" 
  
Assessment criteria Justification of the rating  
International impacts This policy option is expected to have small impacts  on international relations. 
MS would continue to appoint accredited re presentatives (on the basis of the common 
criteria). EASA would be allowed to be repr esented in accident investigation in the EU 
and to join a MS appointed accredited repr esentatives in case of accidents occurring 
outside of the EU where the interests of the Agency are involved. 
Policy Option 4 "European Civil Aviation Safety Board" 
  
Assessment criteria Justification of the rating  
International impacts This policy option is expected to have significant  impacts  on international relations. 
The European Safety Board would not only conduct investigations in the EU but also 
participate, through accredited representatives , in accident investigation led by third 
countries and liaise with the foreign accide nt investigation authorities. In addition, 
similar to policy option No 3, EASA would be allowed to be represented in accident 
investigations both in the EU and oversea s where the interests of the Agency are 
involved. This policy option would necessitate notification of ICAO by all the MS 
about the delegation of respon sibilities in accident investigation to the European Safety 
Board. 
6.6. Risk analysis 
The analysis which follows identifies and examines risks associated with 
implementation of each policy option. 
Policy Option 2 "Promotion of voluntary cooperation" 
Assessment criteria Rating Ju stification of the rating  
Implementation risks 
and obstacles to 
compliance 0 Due to voluntary nature of this policy option, there are no substantial 
additional risks associated with its implementation. 
Policy Option 3 "European Network of Civil Aviation Safety Investigation Authorities" 
Policy Option 4 "European Civil Aviation Safety Board" 
Assessment criteria Rating Ju stification of the rating  
- √  Practical implementation of the established principles relating to cooperation 
between judicial authorities and NSIA, including in the area of evidence 
gathering and protection of certain safety related information is expected to 
be a sensitive issue. 
- √ Accountability of addresses from thir d countries for assessing and replying 
to safety recommendations issued by the EU NSIAs cannot be guaranteed. Implementation risks 
and obstacles to 
compliance 
- √ (Only Option No 4) Certain risks exist related to acceptance by third 
countries of accredited repr esentatives appointed by the European Safety 
 
EN 55   EN Board (experiences with EASA show that these risks can be managed). 
- √√ (Only Option No 4) High risks are associated with this policy option, which 
involves significant reform of the Euro pean system for civil aviation accident 
investigation. The European Safety Board would have to efficiently operate 
as an IIC in 27 jurisdictions of the MS. These risks are expected to be 
particularly high in the initial phase of the operation of the European Safety 
Board.  
7. COST-EFFICIENCY AND ADMINISTRATIVE BURDEN  
Safety risks can be reduced and managed but  not eliminated completely. Also drastic 
risk reduction cannot be often achieved w ithout incurring prohibi tive costs. On the 
other side significant safety benefits can be sometimes achieved with relatively low costs (for example by ensuring that all the necessary safety data  and information is 
shared amongst the interested parties). Cost benefit analysis  is thus necessary for all 
the policy options. 
The below analysis addresses costs associ ated with implementation of the policy 
options by commercial operat ors, national authorities a nd the Community. It does not 
cover costs associated with the implemen tation of safety recommendations - this 
analysis has to be conducted on a case by case basis by the addressee of the recommendation and is beyond the scope of this IA. 
Policy Option No 2 “Promotion of voluntary cooperation” 
This policy option relies on the already ex isting cooperation betw een the NSIAs. It 
does not envisage establishment of new stru ctures at the Community level and builds 
on the resources available in the MS. Th e implementation risks and administrative 
burden of this policy option is thus expected to be negligible. As far as costs of implementation are concerned, the only addi tional cost would be an annual grant 
from the Community budget to support the coordination functions of the NSIAs. 
The costs incurred by the MS would not rise substantially. Already now the NSIAs 
cooperate regularly within the framework  of the Council of European Safety 
Investigation Authorities. On the othe r side, support of the Community for 
development of a mechanism for shar ing of resources between NSIAs or 
coordination of training is e xpected to bring savings and economies of scale and thus 
reduce the overall costs of  functioning of NSIAs. 
The size of the annual grant, which would cover mainly items related to 
administrative management, is estimat ed at between 500.000 and 600.000 EURO in 
the initial year of operations. This is comparable to the costs incurred by the 
Commission to finance the administrativ e management of the Community civil 
protection mechanism.
117 According to the principle of co-financing applicable to the 
grants from the Community budget, the to tal annual contribution for all the MS 
would similarly reach at the maximum between 500.000 and 600.000 EURO. 
                                                 
117 Commission Decision of 18.12.2008 on the annual work programme for the actions to be financed in 
2009 pursuant to Council Decision No.2007/162/EC, Euratom establishing a Civil Protection Financial 
Instrument (C(2008)8411) 
 
EN 56   EN This policy option is not expected to involve any additional costs or administrative 
burden for the industry. 
Policy Option No 3 “Establishment of the European Network of Civil Aviation Safety 
Investigation Authorities” 
Similarly to the previous policy option, the establishment of “the Network”, although 
in this case enshrined in law, would not n ecessitate establishment of new structures 
or significant administrative burden for the Community, NSIAs or industry. It is 
based on the already existing cooperation and resources available in the MS. The 
main cost for the Community budget would be the annual grant assigned to support "The Network". 
The size of the annual grant, which would cover mainly items related to 
administrative management, is estimat ed at between 500.000 and 600.000 EURO in 
the initial year of operations. This is comparable to the costs incurred by the 
Commission to finance the administrativ e management of the Community civil 
protection mechanism.
118 According to the principle of co-financing applicable to the 
grants from the Community budget, the to tal annual contribution for all the MS 
would similarly reach at the maximum between 500.000 and 600.000 EURO. 
Savings are expected for the NSIAs as a consequence of the establishment of a 
central mechanism for sharing resources, coordination of trai ning activities and 
closer cooperation and exchange of data  between the NSIAs. This policy option 
would also benefit the MS by providing more  legal certainty and predictability in 
relation to issues such as support in accident investiga tion, access to information and 
responsibilities of the various parties involved in the investigation. 
Compared to the previous policy option, addi tional administrative burden for at least 
some of the MS could be expected due to establishment of a common process for 
managing safety recommendations as well as ensuring that the authorities involved in 
accident investigation cooperate appropria tely within the framework of advance 
arrangements.  
Some additional costs for the MS can be exp ected due to more frequent meetings of 
"the Network" and its techni cal groups, as well as from new requirements concerning 
monitoring of processes for the management  of passenger manife sts by the airlines. 
Some additional costs for the MS can be also  expected due to the need to fulfil the 
common requirements concerning minimum sta ndards for the provision of assistance 
to victims of air accidents and their families. 
No substantial administrative burden or implementation costs are expected for the 
operators and the industry. Harmonisation of standard s for passenger manifests 
should be considered as codifying already existing practices rath er than imposition of 
a completely new requirement. 
Compared to policy option No 2, this po licy option would provide for additional 
safety benefits through more structur ed cooperation between the NSIAs, better 
protection of evidence and sensitive safe ty information, defining the rights and 
obligations of EASA and NS IAs in accident investigation and establishing a common 
process for managing safety recommenda tions. Standards for management of 
passenger lists would be also harmonised, thus  reducing the risk of  an investigation 
                                                 
118 idem  
 
EN 57   EN or search and rescue operation being hampered  by the lack of a re liable list covering 
"all souls on board". Similarly minimum requirements concerning assistance to the 
victims and families would provide additiona l social benefits for the EU citizens. 
Policy Option No 4 “European Civil Aviation Safety Board” 
This policy scenario, from the EU wide pers pective, would be expected to offer the 
most significant safety benefits. Investig ation of all major accidents would be 
performed by a single, inde pendent, specialised body on  the basis of common 
methodology and by centrally trained investigator s. At the same time this is also the 
most costly policy option and the one affect ed by the highest implementation risks. It 
would necessitate a substant ial overhaul of the curren t regulatory framework and 
establishment of a new Community body in the form of an Agency. 
To calculate an estimate cost of implem entation for this policy option, two main 
components have to be distinguished: (1) the costs of establishing and maintaining 
the central investigating body, and (2) the savings made at the level of Member 
States, deriving from substitution or significant downscaling of NSIAs. 
Using the example of the US NTSB, it can  be assumed that about 200 full time 
equivalent posts would be necessary in orde r to secure proper staffing of the central 
body.119 Given the fact that the European Safety Body would be a Community 
agency, the "average costs" for the estimates on human resources in the context of EU legislative proposals have to be used in this context.
120 This would give a figure 
of about €25 million for staff costs. In addi tion, the most substantial costs to be 
covered under this policy option would in clude operational expenses: leading of 
investigations and participation in invest igations as an accredited representative, 
investigation equipment, examinations, resear ch and publications. In this respect, the 
total costs associated with the establishment of the European Safety Body can be estimated at around €40 million. 
Given the fact that the tota l annual costs of the combined  27 NSIAs in the EU can be 
estimated at €78 million
121, the annual savings expected from substituting the NSIAs 
with the central body would be in the orde r of €30 million. These savings would be 
however smaller, should the NS IAs continue to work in pa rallel as national offices of 
the European Safety Body. In this latter cas e, the NSIAs would also have to bear 
costs to comply with the common standard s for training of investigators and conduct 
of technical investigations in their areas of competence. In this policy scenario the 
annual workload of the European Safety Body could be estimated at 70 investigations of aircraft  with MTOM of at least 2.250kg, plus participation in 
investigation overseas as an accredited representative. 
The administrative burden associated w ith this policy option would be also 
substantially higher than for previous po licy options. The European Safety Body, as 
a Community body would be obliged to fulf il all the requirements of the EU law 
related to financial issues, staffing policy, internal audit, procurement policy etc. 
                                                
 
119 The Net costs of the aviation related activates  of NTSB in 2008 were $42 million (National 
Transportation Safety Board, Fiscal Year 2008 and 2007 Performance and Accountability Report, 
http://www.ntsb.gov/publictn/2008/SPC0802.pdf , accessed on 11 May 2009) 
120 European Commission guidelines  on Preparation of the Legi slative Financial Statement, 
http://www.cc.cec/budg/pre/legalbasis /pre-040-020_preparation_en.html  
121 External impact assessment study, ECORYS Nede rland BV and National Aerospace Laboratory NLR 
 
EN 58   EN No substantial implementation costs are asso ciated with this policy option from the 
industry perspective. Harmonisation of st andards for passenger manifests should be 
considered as codifying already existing practices rather than imposing a completely new requirement. At the same time th e industry would benefit from a fully 
standardised invest igation process. 
Some additional costs for the MS can be expected due to the need to fulfil the 
common requirements concerning minimum sta ndards for the provision of assistance 
to victims of air accidents and their families. 
8. C
OMPARING THE OPTIONS  
8.1. Which method was applied and how impacts have been weighted? 
The above analysis presented various impact s of each of the policy options, including 
risks and obstacles to compliance. It is  now necessary to compare the presented 
policy options in order to indicate which of them would bring the most added-value 
from the Community perspective taking in to account the criteria of effectives, 
efficiency and proportionality. 
In order to properly take into account the various dimensions of the analysis, a multi-
criteria approach will be applied. This met hod is best suited to measuring trade-offs 
within and between the various policy opti ons, especially between safety and cost-
efficiency. 
Multi-criteria analysis requi res weighting in advance th e importance of the various 
criteria, which inherently includes an elemen t of subjectivity. For the purpose of this 
analysis the enhancement of sa fety in civil aviation, as an  overriding objective in the 
context of this IA, is given the highest priority. At the same time the analysis takes into account that drastic risk reducti on cannot be achieved without incurring 
prohibitive costs. 
As indicated in point 4.1.1, this IA does not a ttempt to monetise direct safety benefits 
resulting from implementation of the various policy options, as this would require the 
ability to meaningfully pred ict the level of reduction in  the number of accident or 
incidents in civil aviation. Sa fety benefits should be ra ther looked at from the 
perspective of risk management, where by the risks are quantified and reduced by 
appropriate mitigating measures if considered as not acceptable. 
 "Voluntary cooperation" "the Network" "EU Safety Board" 
Safety benefits √ (4) √√ (8) √√√ (12) 
Implementation risks 0 - √√ (-4) - √√√√  (-8) 
Economic, social and 
environmental impacts  √ (1) √√ (2) √√√ (3) Criteria Weighting Criteria Weighting 
Safety impacts √ = 4 points Economic, social and environmental impacts √ = 1 point 
Implementation 
Risks -√ = - 2 points Impact on fundamental rights √ = 1 point 
 
EN 59   EN Impact on fundamental 
rights √ (1) √√ (2) √√√ (3) 
Annual costs for the 
Community 600.000€ (small) 600.000€ (small) around 40 million € 
(high) 
Annual costs for the MS Expenditures up to 
600.000€ for all the MS 
(co-financing of the grant) 
√ (net savings) Expenditures up 
to 600.000€ for 
all the MS (co-
financing of the 
grant) 
√ (net savings) √√ to √√√ (net savings) 
Costs for the industry 0 0 0 
Administrative burden 0 (negligible) √ (small) √√ (moderate) 
8.2. Results of the weighting between the policy options 
Policy option of promotion of voluntary cooperation offers moderate safety benefits 
at a reasonably low cost for the Community budget as well as some savings for the MS. The administrative burden of implementa tion of this policy option is negligible. 
It also does not impose additional costs on the industry. 
Establishment of the "European Network of Civil Aviation Safety Investigation 
Authorities" offers additional safety benefits as compared to the promotion of 
voluntary cooperation only. However it is also characterised by additional 
implementation risks (see above). The co sts of implementation for the Community 
budget are comparable to the "Promo tion of Voluntary Cooperation". The 
administrative burden for the MS may be howev er slightly higher in  particular due to 
the new requirements concerning manageme nt of safety recommendations and 
coordination of different au thorities involved in the i nvestigation. Some additional 
costs for the MS are also expected due to th e need to participate in the co-financing 
of the grant for “the Network”, as well as fulfilling new requirements concerning 
monitoring of processes for the management  of passenger manife sts by the airlines, 
and implementation of minimum requirements on assistance for the victims and families. On the other side savings are expected for the MS due to better coordination of investigation resources of NSIAs a nd more efficient cooperation between the 
various authorities involve d in the investigation. 
The last policy option (The European Safety Board), offers the highest safety 
benefits as compared to the other tw o policy options. However, it is also 
characterised by the highest implementa tion risks and cost for the Community 
budget. Although the administrativ e burden involved in this policy option is expected 
to be the highest, it is also envisaged that  it could bring the biggest savings for the 
MS. 
8.3. Which of the policy options has the biggest added value? 
The Policy Option No 3, "Establishment of the European Network of Civil Aviation 
Safety Investigation Authorities" has th e biggest added value form the Community 
perspective. It is the most proportional policy option which, while fully respecting 
the principle of independence of safety  investigations, would allow, without 
establishing any new structures at the Comm unity level, to significantly enhance the 
 
EN 60   EN overall efficiency of the current regulat ory framework for civil aviation accident 
investigation in the EU. 
This policy option is sufficient to adequate ly address all the problem areas identified 
in this IA, without going beyond what is st rictly necessary. It can be implemented 
with relatively low cost for the Community budget and in addition is also expected to 
reduce the overall costs of the MS, while ha ving little impact in terms of additional 
administrative burden. 
By lending supporting to the already exis ting voluntary cooperation between the 
NSIAs, this policy option is also expected to have suppor t from the stakeholders and 
MS, which should facilitate its implemen tation. The additional regulatory elements 
of this policy option, which would be ensh rined in the new Regulation implementing 
this policy option, were also supported in the public consu ltations and in the 
recommendations of the "Group of Experts". 
There are limited implementation risks rela ted to this policy option, notably when 
compared to policy option No 4, and which are not expected to jeopardise the envisaged policy objectives. This policy option, by relying on co-regulation and support for voluntary cooperati on, is also in line with the "Be tter Regulation" 
objectives of the Community. Using Regulat ion instead of a Directive is also 
expected to contribute to better impl ementation and eliminate the need for 
transposition measures. 
9. M
ONITORING AND EVALUATION  
9.1. Indicators and methods for the monitoring of the preferred policy option 
(“Establishment of a European Network of  Civil Aviation Safety Investigation 
Authorities”) 
Indicators and methods allowing to measur e progress made towards the achievement 
of the desired policy objectiv es will need to be established. These would include: 
Increase the investigatin g capacity of the EU:  
– The level of support provided  by the central mechanism for sharing of resources;  
– The overall annual costs incurred by the NSIAs; 
– The percentage of investigations co mpleted in the recommended 12 months 
period; 
– The results of the “peer reviews”  coordinated by "the Network"; 
– Training activities coordina ted by the "the Network"; 
Reduce tensions between th e authorities involved in accident investigations: 
– Number of investigations, delayed or hampered due to lack of coordination 
between the authorities; 
– Trend in occurrence reports filed by aviation professionals in the EU; 
Clarify the role of Community  in safety investigations : 
– Number of cases where cooperation betw een EASA and NSIAs was not adequate; 
Better implement safety recommendations: 
 
EN 61   EN – Number of safety recommendations regi stered in the centr al database of 
recommendations; 
– Number of "closed" safety recommendations registered in the central database of 
recommendations; 
Reduce risks from inadequate passenger manifests 
– National authorities of the MS to check  compliance of the scheme with the 
common requirements in the certification pr ocess of the airline and via regular 
inspections; 
– Number of passenger manifest s non-reconciled properly; 
The administrative burden associated with re porting obligations is not expected to be 
high. MS already now provide to the Commi ssion most of the relevant information, 
including occurrence reports and final reports from the investigations. Some new 
administrative burdens can be expected for the MS authorities due to the need to 
verify compliance of the operators with the minimum standards envisaged for the 
management of passenger manifests and implementation of minimum requirements 
on assistance for the victims and families. 
 
EN 62   EN Annex I 
Recommendations of the Group of Exp erts to advise th e Commission on a 
strategy to deal with accidents in  the transport sector (aviation)122 
Since 1991 Aviation Safety Investigation Au thorities have esta blished coordination 
and meet regularly within an ECAC context. Additionally the aviation sector has had ten years experience of working with the provisions of Counc il Directive 94/56/EC, 
“Establishing the fundamental principles gov erning the investigation of civil aviation  
accidents and incidents” . 
The Aviation Working Group’s primary task  was a review of Member State’s 
experience of working within the framewor k of the Directive. In December 2004 the 
Aviation Working group sent a comprehens ive questionnaire to Member States and 
detailed responses were received from 23 of the 25 States. 
In early 2006 the Commission has launched a procedure for internally assessing the 
options for revision of Directives 94/56 and 2003/42. The Experts group’s The 
Experts group’s recommendations contribute to that exercise. 
Present Situation 
Information gathered from Member States c onfirmed that a number of issues arise in 
relation to safety investigation of av iation accidents and incidents such as:  
– Difficulties and tensions between the safety investigation and judicial 
investigations; 
– Issues in relation to the publication of Safety reports relati ng to accident and 
incident; 
– Lack of a follow-up system for safety recommendations in most Member States 
and the fact that current reporting requi rements are overly onerous and often a 
cause for delays of safety investigation of more important ai r transport accidents 
or incidents; 
– In particular smaller Member States id entify a need for European Union based 
training for investigators, both on the coordination of tr aining and in relation to 
training standards; 
As a result of this current situ ation the Commissi on is advised: 
– to revise the Directive 94/56/EC taking into account the items Member States 
raised in relation to the Expert Groups  request for information (see above), for 
example, relations with judicial proceedi ngs, the protection of confidential aspects 
of investigations and the possi bility to select the events that are to be investigated, 
– to consider whether the Memorandum of Understanding between the accident 
investigation bodies and the State Prosecutor in the UK could be used as a model 
for a European wide initiative to resolve the current difficulties between the safety 
and judicial investigations, 
– to introduce legislative protection from disclosure for confidential documents 
listed in Chapter 5.12 of Annex 13 to the Chicago Convention, 
                                                
 
122 Experts participating in the work of the Avia tion Working group were: Mr Ken Smart (UK) as 
chairman and Mr Paul Louis Arslanian (France). Ad hoc experts invited to this group were Mr Yves 
Benoist, Mr Kevin Humphreys, Mr Akrivos Tsolakis and Mr Lou Van Munster 
 
EN 63   EN – to introduce a legislative requirement that provides transparency in relation to 
official replies to and implementa tion of safety recommendations. The 
Commission is asked to initiate the establishment of a European database for safety recommendations for aviation; 
– to formally recognise the coordination role of Aviation Safety Investigation 
Authorities in a European context; 
Discussion of aviation expert s identified a need for a mo re developed coordination 
structure for Safety Investigation Author ities involved in aviation accidents at 
European level, in the li ght of existing coordination fora as well as the establishment 
of the European Aviation Safety Agency. 
 
EN 64   EN Annex II 
Bibliography 
1. EU POLICY AND REFERENCE DOCUMENTS  
2008 Annual Safety Review, European Aviation Safety Agency, Cologne 
2008 Annual Safety Recommendations Review , European Aviation Safety Agency, 
Cologne 
Impact Assessment on the modification of Directives 94/56/EC and 2003/42/EC 
(Framework Contract for Ex-ante evaluations and Impact Assessments, TREN/A1/46-2005), Final Report, Rotterdam 20 July 2007 
Commission Decision of 11 June 2003 setti ng up a group of experts to advise the 
Commission on a strategy for dealing with  accidents in the transport sector 
(2003/425/EC) 
Final report of the "Group of Experts to advise the Commission on a strategy to deal 
with accidents in the transport sector" 
Mid-term review of the European Commission’s 2001 Transport White Paper" 
(COM (2006) 314 final, Brussels, 22.06.2006) 
Communication from the Comm ission to the European Parliament, the Council, the 
European Economic and Social Committee and the Committee of the Regions - 
Single European sky II: towards more su stainable and better performing aviation, 
Brussels, 25.6.2008, COM(2008) 389 final 
Report of the High Level Group for the Fu ture European Aviation Regulatory 
Framework, Brussels, July 2007 http://ec.europa.eu/trans port/air/doc/hlg_2007_07_03_report.pdf
 
"Just Culture" (JC) Definition and Implem entation of a JC Concept, Working Paper 
(AIG/08-WP/33), presented by France on beha lf of the European Community and its 
Member States by the other Member St ates of the European Civil Aviation 
Conference and by EYROCONTROL), Accident  Investigation and Prevention (AIG) 
Divisional Meeting, Interna tional Civil Aviation Organi sation, Montreal 13 – 18 
October 2008; 
EU charter of Fundamental Rights 
2. EU REGULATIONS AND DIRECTIVES  
Council Directive 80/1266/EEC of 16 Decem ber 1980 on future cooperation and 
mutual assistance between the Member St ates in the filed of air accident 
investigation (OJ L 375 of 31.12.1980, p.32) 
Council Directive 94/56/EC of 21 Novemb er 1994 establishing  the fundamental 
principles governing the investigation of civil aviation accidents and incidents (OJ L 
319 of 12.12.1994, p.14) 
Directive 2003/42/EC of the European Pa rliament and of the Council of 13 June 
2003 on occurrence reporting in civi l aviation (OJ L 167 of 4.7.2003, p.23) 
Regulation (EC) 216/2008 of the European Parliament and of the Council of 20 
February 2008 on common rules in the fiel d of civil aviation and establishing a 
 
EN 65   EN European Aviation Safety Agency, and repealing Council Directive 91/670/EEC, 
Regulation (EC) No 1592/2002 and Direct ive 2004/36/EC (OJ L 79, 19/03/2008, p. 
1)  
Commission Regulation (EC) No 1 321/2007 of 12 November 2007 laying down 
implementing rules for the integration into  a central repository  of information on 
civil aviation occurrences exchanged in accordance with Direc tive 2003/42/EC of the 
European Parliament and of the Council (OJ L 294, 13/11/2007 p.3) 
Commission Regulation (EC) No 1 330/2007 of 24 September 2007 laying down 
implementing rules for the dissemination to in terested parties of information on civil 
aviation occurrences referred to in Artic le 7(2) of Directive 2003/42/EC of the 
European Parliament and of the Council (OJ L 295, 14.11.2007 p.7) 
Council Regulation (EEC) No 3922/91 of  16 December 1991 on the harmonization 
of technical requirements and administrative procedures in the fiel d of civil aviation, 
as amended, (OJ L 373, 31.12.1991, p. 4) 
Commission Regulation (E C) No 474/2006 of 22 Ma rch 2006 establishing the 
Community list of air carriers which are s ubject to an operat ing ban within the 
Community referred to in Chapter II of Regulation (EC) No 2111/2005 of the 
European Parliament and of the Council (OJ L 084, 23/03/2006 p.14) 
Commission Decision of 29 July 2002 esta blishing the European Regulators Group 
for Electronic Communications Netw orks and Services (2002/627/EC) 
Council Regulation (EC) No 2027/97 on air carrie r liability in the event of accidents, 
(OJ L285,17.10.1997, p.1) 
Regulation (EC) No 785/2004 of the European  Parliament and of the Council of 21 
April 2004 on insurance requirements for air carriers and aircraft operators (OJ L 
138, 30.4.2004, p. 1) 
3. INTERNATIONAL CONVENTIONS AND RELATED DOCUMENTATION  
Convention on International Civil Aviation, signed in Chicago on 7 December 1944, 
ICAO Doc. 7300/8 
Annex XIII to the Convention on Internati onal Civil Aviation, Airc raft Accident and 
Incident Investigation", 9th edition, July 2001 
ICAO Manual of Aircraft Accident and Incident Investigation (ICAO Doc 9756) 
Training Guidelines for Aircraft Ac cident Investigat ors (ICAO Cir 298) 
ICAO Safety Management Manual (S MM), Second Edition — 2009, ICAO Doc 
9859 
Final Report on the Safety Oversight Audit of the European Aviation Safety Agency, 
23 – 25 April 2008 ( confidential) . The final report is ava ilable to all Contracting 
Parties to the Chicago Convention thr ough the ICAO Universal Safety Oversight 
Audit Programme (USOAP) secure website 
Guidance on Assistance to Aircraft A ccident Victims and their Families (ICAO 
Cir.285-AN/166) 
Progress report on the implementation of th e ICAO Universal Safety Oversight Audit 
Programme (USOAP) under the comp rehensive systems approach, 36th session of the 
 
EN 66   EN General Assembly of ICAO, A36-WP/64, 02.08.07, 
http://www.icao.int/Assembly36/  
ICAO Working Paper, DGCA/97-IP/5, “S afety Oversight, An International 
Responsibility”, 20 October 1997 
4. OTHER GOVERNMENTAL DOCUMENTS , STUDIES AND REFERENCE MATERIAL  
U.S. National Transportation Safety Boar d Fiscal Year 2008 and 2007, Performance 
and Accountability Report, http://www.ntsb.gov/publictn/gen_pub.htm  (accessed on 
11 May 2009) 
Cost of Aviation Accidents and Incident s, Bureau of Transport and Regional 
Economics report 113, Commonwealth of Australia 2006 
Terms of Reference of the Council of Eu ropean Aviation Safety Investigation 
Authorities  
Challenges of Growth 2008, Eurocontrol, Air Traffic Statistics and Forecasts 
http://www.eurocontrol.in t/statfor/public/subsite _homepage/homepage.html  
Memorandum of Understanding agreed between the Crown Prosecution Service 
(CPS) and the Air Accidents Investigati on Branch (AAIB), the Marine Accident 
Investigation Branch (MAIB) and the Rail  Accident Investigation Branch (RAIB) 
(United Kingdom) http://www.aaib.gov.uk/cms_resources/MOU%20AIB-CPS.pdf   
Federal Family Assistance Plan for Av iation Disasters, Prepared by National 
Transportation Safety Board Office of Tran sportation Disaster Assistance (December 
2008) http://www.ntsb.gov/family/Family.htm   
Legal and Cultural Issues in relation to ATM Safety Occurrence Reporting in 
Europe, Report Commissioned by the Performance Review Commission, 
Eurocontrol, September 2006 
Publication of lists of airl ine passengers in the event of an accident, Information 
presented by the Spanish delegation at th e occasion of the TTE Council meeting on 9 
October 2008 (Council of the European Union, 13660/1/08, REV1) 
5. PROCEEDINGS OF THE INTERNATIONAL CONFERENCES  
Proceedings of the ICAO Accident Invest igation and Prevention (AIG) Divisional 
Meeting 2008 (AIG/08), http://www.icao.int/aigdiv08/   
6. COURT CASES  
ECJ Judgment of 13.06.1958, in case 9/58, Meroni, ECR, 1958, p.11; 
ECJ Judgment of 14.05.1981, in case 98/80, Romano, ECR 1981, p.1241 
7. MONOGRAPHS  
Reason, J.T., Managing the risks of or ganizational accidents, Aldershot 1997 
Dekker, S., Just Culture: Balancing Sa fety and Accountability, Ashgate 2008 
Hollngel, E., Barriers and Acci dent Prevention, Ashgate 2004 
 
EN 67   EN 8. ARTICLES , SPEECHES AND NON-GOVERNMENTAL REFERENCE DOCUMENTS  
Independent Accident Investigation: Every Citizen's Right, Society's Duty, Speech of 
Pieter van Vollenhoven, 23rd January 2001, European Transport Safety Council 
Transport Accident and Incide nt Investigation in the Eu ropean Union, Brussels 2001 
European Transport Safety Council 
AON, airline insuran ce market outlook 2009 
9. ACCIDENT INVESTIGATION REPORTS  
Aircraft accident report, Helios Ai rways Flight HCY522, Boeing 737-31S at 
Grammatiko, Hellas on 14 August 2005 (11/20 06, Hellenic Ministry of Transport 
and Communications, Air Accident Inve stigation & Aviation Safety Board) 
Preliminary report of the Dutch Safety Boar d, Crash of the Turkish Airlines, Boeing 
737-800, TC-JGE, April 28, 2009 ( http://www.onderzoeksraad.nl/en/ , accessed on 10 
May 2009). 
Final Report of the Agenzia Nazionale per la Sicurezza del Volo of 20 January 2004, 
Accident involving Aircraft: Boeing MD -87 registration SE-DMA and Cessna 525-
A, registration D-IEVX, Milano Linate Airport October 8, 2001. 
 
EN 68   EN Annex III 
List of the consulted parties a nd summary of the consultations 
1. Consultations on the Internet website 
(a) Ministries or Aviation Authorities (M inistry of Transport Germany, Civil 
Aviation Authority from Germany (LBA -GE) and Civil Aviation Authority 
from Iceland (CAA-IS)); 
(b) 2 Accident Investigating Bodies  (AIBs) (Iceland and Poland); 
(c) 6 Airline Operators (Air Berlin, KLM, Spanair, Swiss, Transavia and Virgin 
Atlantic); 
(d) 1 labour Union (Filt-Cgil); 
(e) 1 stakeholder association (Eur opean Helicopter Association); 
(f) 1 University (Massey from New Zeeland); 
(g) 1 aerodrome operator (Zurich Airport); 
(h) 1 European not-for-profit organisation (Peopil); 
(i) 6 private citizens 
2. Replies to questionnaire distri buted by external consultant 
Respondent group Number of replies 
Civil Aviation Authorities 19 
Accident Investigation Bodies 19 
ATM/ANS Providers 20 
Aircraft, engine and system manufacturers 9 
Trade unions and associations  representing employees 11 
Other 9 
3. Parties interviewed by the external consultant 
(a) Direction Générale de l’Av iation Civile (DGAC, France); 
(b) Bureau d’Enquêtes et d’Analyses pour la  sécurité de l’av iation civile (BEA, 
France); 
(c) Civil Aviation Authority (CAA, United Kingdom); 
(d) Air Accidents Investigation Br anch (AAIB, United Kingdom); 
(e) Hellenic Civil Aviation Au thority (HCAA, Greece); 
(f) Hellenic Air Accident Investigation & Aviation Safety Board (Greece); 
(g) European Aviation Safety Agency (EASA); 
(h) Eurocontrol; 
(i) European Civil Aviati on Conference (ECAC); 
 
EN 69   EN (j) Airbus Industries; 
(k) Swedish Civil Aviation Authority (CAA, Sweden) 
(l) Swedish Accident Inves tigation Board (Sweden) 
(m) Estonian Ministry of Economic Affair s and Communications (AIB Estonia) 
(n) Estonian Civil Aviation Authority (CAA, Estonia) 
(o) Joint Research Centre (JRC, Italy) 
(p) National Transport Safety Board, USA 
(q) Civil Air Navigation Servi ces Organisation (CANSO) 
(r) International Air Transport Association (IATA) 
(s) European Cockpit Association (ECA) 
(t) International Transport Sa fety Association (ITSA) 
 
EN 70   EN Annex IV 
Summary of the public consultations 
Summary results of public consultations on the Internet  
1. The Commission asked the respondents about their opinion on the ne ed to revise the 
Directives 94/56/EC and 2003/42/EC: 
(1) 68% of respondents (i.e. 15) agreed with such a need; 
(2) 18% (i.e. 4) were against; 
(3) 9% (i.e. 2) stated to have no opinion; 
(4) The remaining has not replied to this question 
2. Commission presented four policy option for the consideration of respondents 
(1) Option No 1 "Do Nothing" 
(2) Option No 2 "Promotion of voluntary co-ordination" 
(3) Option No 3 "Establishment of central functions" 
(4) Option No 4 "Establishment of a central  European safety investigation body" 
Policy option 3 and 4 were most supported. However the latter was also the most 
controversial; 
Most of the suggested central functions were at least partially supported by the 
overwhelming majority of respondents. 
The need to look at the “tot al aviation system” (i.e. simp lified and consistent rules 
across all domains) was stressed. 
Some stakeholders asked more chances fo r passengers to report, and the widest 
possible dissemination of safety  information, among industry. 
Summary results of consultations co nducted by the external consultant 
The respondents of the questionnaires were  asked if they saw any problems in the 
current situation. Almost all of  them are of the opinion th at there are problems that 
need to be addressed. These problems can  be divided into three categories: 
– Occurrence reporting 
– Incident and accident investigations 
– Information gathering and dissemination 
Occurrence reporting 
The respondents indicated that  there are problems in rela tion to occurrence reporting. 
They remarked that the development of the “Just Culture” is essential to create an environment in which everybody feels secure enough to file a repor t, without fearing 
criminalization. However, this should not re sult in a “Carte Blanche” for all involved 
parties. The creation/further development of a “Just Culture” throughout Europe can 
not be accomplished through the revision of the Direct ive 2003/42/EC alone, though 
it could facilitate this development.  Some of the changes proposed by the 
respondents relate to the terminology of th e Directive which should be clearer (gross 
negligence in article 8 for example). A clear definition of “Just Culture” was also advocated by some of the respondents. 
 
EN 71   EN Incident and accident investigations 
A number of respondents mentioned that in cidents that are reported are sometimes 
not investigated, due to a lack  of resources. However, it is questioned by some of the 
respondents if it is effective to  investigate all incidents. 
Some respondents argued that in certain  countries there are problems with the 
mobilization of investigators with sufficient detailed technical expertise. This does not apply to all European Member States. Some argued that this was caused by the 
variation in exposure to airc raft accidents and budgets. Al l of the respo ndents, apart 
from the AIBs, indicated that there is no central European mechanism that could 
arrange for the sharing of available investigat ors. The AIBs stated that initiatives are 
already developed by the AIBs themselves. 
Another problem signalled by the respondents is the lack of common requirements 
for the training and qualifications of acci dent investigators. Again the AIBs 
mentioned that they themselves are already taking actions in this field. 
As is the case with occurrence reporti ng, the development of the relation with 
judicial authorities is said to be essent ial for incident and accident investigation. 
Many of the respondents indicated that the i nvolvement of judicial authorities often 
hampers the course of the investigations. These investigations should have as sole 
goal to learn and increase safety levels , without giving a “Carte Blanche”. 
Cooperation with the judicial authorities is  essential in order to spread the “Just 
Culture” throughout Europe. 
It was also argued that th ere are discrepancies in th e terminology used in the 
Directives, ESARR2 and ICAO. These mainly relate to the definition of occurrences 
and incidents, which could create confus ion and an overlap in responsibilities. 
Information gathering and dissemination 
Many respondents indicated th at there are problems in relation to obtaining and 
distributing information on a European level.  One of the problems mentioned is that 
available recommendations are often not shar ed. Also it is seen as a problem that 
there is no mechanism that regulates the ac countability for addressees to reply to 
safety recommendations. The lack of a centr al repository of accident investigations 
reports (e.g. abstracts of the reports, conc lusions and recommendations) is seen as a 
problem by most of them. Most of the responde nts agreed or partially agreed that the 
multitude of languages in which accident and incident reports are written forms a problem. ECCAIRS is seen as a possible so lution for much of the problems in this 
field, but it has to be  further developed.  
Some of the respondents did agree that the safety recommendations do not take into 
account the associated consequences of these recommendations (such as cost 
effectiveness) and that th is is a problem. However,  many respondents argued that 
main goal of these recommendations should be safety and the addressees of the 
recommendations should work out how they can implement the recommendations as efficient as possible. 
Options 
The results of the questionnaire clearly show ed that a revision of  the Directives is 
desired by the respondents. They were asked on the possible effects and their 
preferred ranking of the following options: 
 
EN 72   EN Option 1: “Do Nothing” 
Option 2: Promotion voluntary coordination mechanisms among AIBs Option 3: Modification of Directives: establish a set of central functions 
Option 4: Establish a central European body on accident investigations When asked on the possible e ffects, the respondents’ answ ers show that Option 3 is 
expected to contribute the most in terms of positive safety effects. Option 2 is expected to have relatively neutral effects. Option 4 is expected to come at higher 
costs than Option 3, without showing any ex tra significant positive safety effects 
compared to Option 3. Option 3 was favoured the most by the respondents, though some indicated that this should be the fi rst step in the direction of Option 4. The 
majority of the AIBs that responded preferred Option 2. 
 
Central European functions 
The majority of the respondent groups ag ree that most of the proposed functions 
should be addressed centrally in Eur ope. These functions include a Central 
European: 
– Filing system of occurrence reports, in the context of a 'just culture'  
– Common training and competence scheme for investigators 
– European safety data repositories for i nvestigation reports and recommendations 
serving AIBs, EASA, NAAs, Eurocontrol 
– Summaries of investigation reports and recommendations can best be written in 
English (the majority of the unions/ass ociations respondents partially agreed) 
– Coordination mechanism that arranges fo r the sharing of inve stigators, meaning 
that member states could make use of the expertise of AIBs in other member states through a central coordination mechanism (40%  of the AIB respondents 
disagreed) 
 
EN 73   EN – Mechanism that ensures that all safety recommendations, issued by national 
investigating authorities, are disseminated to all interest parties within Europe 
– Mechanism that regulates the accountability for the addressees to reply to safety 
recommendations (the respondent group Other, mostly agreed partially) 
– Mechanism that monitors the status of the implementation of safety 
recommendations (AIBs mos tly agreed partially) 
However with respect to “Investigation re ports can best be written in an ICAO 
language (the concerned AIB can choose one of the three ICAO languages)” the 
respondents did not fully agree. This, because  it is thought to be very important that 
reports are also written in the local language and local la nguages should not be 
discriminated against. A European transla tion agency was proposed to tackle this 
problem by making the reports available in a local language and in English.