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Investigation Process


Publication Date 2019-08-07
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Who we are

The Taiwan Transportation Safety Board (TTSB) is an independent government agency in charge of transportation occurrence investigation in aviation (civil and public aircraft, ultralight aircraft and unmanned aerial vehicles), marine (civil and public vessels), rail (train and mass rapid transports), and road transport, and advances transportation safety by issuing safety recommendations.  The objective of such investigation is to elevate the national transportation system safety, not to apportion blame or liability to specific person(s) or operational group(s).  The investigation report cannot be used as the sole evidence in judicial process.  The TTSB conducts its safety investigation according to international regulations (e.g. ICAO Annex 13, IMO Resolution MSC 255(84)) and domestic law (e.g. Transportation Occurrence Investigation Act.)

 

Our methodology

The TTSB investigation process can be divided into five phases: notification, on-scene, factual data collection and verification, causal factors and risks analysis, and report review. 

 

Notification phase

The TTSB assigns an on-duty officer, who are responsible for responding to occurrence notifications 24/7. When a notification is received, and verified by respective investigation division as an occurrence, a go-team would be dispatched by an investigator in-charge (IIC) in rotation to the scene.  For a suspect occurrence, an occurrence verification meeting will be convened by the respective investigation division after preliminary factual information is collected by the go-team.  The decision will be made according to the Transportation Occurrence Investigation Act and relevant international regulations.

 

On-Scene phase

The IIC organizes an investigation team of size based on the severity and complication of the occurrence.  The mission of the go-team is to collect and secure on-scene evidences that could easily vanish. For instance, aircraft tracks and tire marks, debris, crew alcohol test, and interviews. Flight recorders need to be disconnected and secured once a suspect aviation occurrence is reported. In principle, the investigation team consists of different expertise, such as operations group, maintenance group, air traffic control group, recorder group, and human factors group etc.  TTSB investigators will act as the group chairman of each group, and professional from other units, including authority, operator, (air)port unit, aircraft/vessel manufacturer, investigation authorities of state of design and state of manufacturer, and technical advisors, will act as group members.

on-scene-phase

Factual data collection and verification phase

The factual report includes all sorts of factual information, such as records of interviews, aircraft / vessel basic data, damage information, site survey and recorder data etc. The results of simulations, tests and studies carried out as requested by the investigation team are also part of the factual report. Each group must complete its own group factual report during the factual data collection phase, and the IIC will integrate them into a factual report for the occurrence investigation. The report would be published after all involved parties jointly verifying of its content.

Causal factors and risk analysis phase

Based on the factual data, the investigation team will conduct the analyses of safety risks and occurrence probable causes before proposing safety recommendations to produce a draft final report independently. If necessary, the IIC may invite all relevant parties to conduct a technical review meetings and collect their comments about the draft final report.  The draft final report would be amended if comments from parties are adopted.  Any identified safety risk, the TTSB will coordinate with the involved parties to take all necessary actions immediately, and will not wait until the final report is published.

 causal-factors-and-risk-analysis-phase

Report review phase

The draft final report will be sent to all relevant parties after reviewed by all board members during Board meeting. If the TTSB receives any comments within the next thirty, maximum sixty days, those comments will be reviewed in Board meeting and they will be amended into the draft final report as appropriate. The updated draft final report will be sent to all parties for comments once again and they may submit their intentions, within the next 15 days, to have oral presentation regarding their comments in the next Board meeting. The board members will determine whether or not to accept the presented comments, and amend them to the final report.  The final report of the occurrence investigation will be published after all these procedures are complete.

Last updated 2019-08-28
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