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 Nok Air
Safety Management Manual
(SMM)

Issue: 2 Revision: 0

Accepted by the Civil Aviation Authority of Thailand

(CAAT)

Chula Sul<ma
Director General
The Civil Aviation ~uthority of Thailand

_AY_ 2_0_19_ __
Date of Acceptance: _ _ _ 2_1_M
 Safety Management Manual

® Chapter 13
Safety Investigation

13 SAFETY INVESTIGATION
13.1 INTRODUCTION

This section details the practices and procedures to be followed

subsequent to an accident or incident that is investigated by Corporate
Quality, Safety, Security, Environment and Support Department (PV) or
other Department as delegated by PV.

An investigation is a process conducted for the purpose of accident

prevention which includes the gathering and analysis of information, the
determination of findings causes and when appropriate, the development
of safety actions to reduce the risk of recurrence. Investigations will identify
active failures, inadequate defences and organisational factors .

The sole objective of the investigation of an accident or incident shall be

the prevention of accidents and incidents. It is not the purpose of this
activity to apportion blame or liability.

It should be emphasised that investigations are focused on the facts of an

occurrence, to identify the causal factors underlying the occurrence and to
facilitate the development of agreed actions to prevent recurrence. Active
failures and local factors need to be identified. However, from the
perspective of safety enhancement, it is more important to identify systemic
weakness such as inadequate defences and organisational
factors.Investigations will be conducted in a Just Culture environment.

Issue 2, Revision 0, 21 MAY 2019 Nok Airtines Public Company Limited 13-1
 Safety Management Manual

® Chapter 13
Safety Investigation

13.2 DECISION TO INVESTIGATE

Safety investigations may be initiated from the daily review of Safety

Reports, by advice and reporting through external agencies, or by
activation of the Crisis Response Plan.

The decision to investigate, and the priority and scope of each investigation
should be based on;

(a) Potential safety value gained by conducting an investigation

(b) Opportunity for learning from the occurrence,
(c) Occurrence Risk
(d) Media profile of the occurrence
(e) Resources available
(f) Response from external authorities such as the CAAT

Issue 2, Revision 0, 21 MAY 2019 Nok Airlines Public Company Limited 13-2
 Safety Management Manual

® Chapter 13
Safety Investigation

13.3 INVESTIGATION INITIATION AND NOTIFICATION

The Corporate Quality, Safety, Security, Environment and Support

Department(PV) is responsible for the initiation and notification of an
investigation. This involves:

(a) Determininginvestigation priority

(b) Developing investigation scope
(c) Appointing a Lead Investigator
(d) Notifying the Heads of relevant departments

The priority of the Investigation will guide the scope of the investigation and
style of investigation report that will be used. As a minimum the scope of
the investigation should include:

(a) Identification and assessment of factors that led to the occurrence,

including human performance aspects;
(b) Identification of contributory factors at a local and organisational
level that contributed to the occurrence;
(c) Development of findings and actions to prevent recurrence

The Corporate Quality, Safety, Security, Environment and Support

Department(PV) carries primary ownership of investigation activities.
Where appropriate, PV may delegate an investigation to other Departments
within NOK. The decision to delegate an investigation will guide the
appointment of the Lead Investigator.

For large investigations, it may be necessary to form an investigation team.

In these instances, the Safety Manager shall liaise with the relevant
Department Heads to ensure appropriate availability of resources.

13.3.1 Engineering

For incidents due to technical causes, Head of Quality Control (TQ) will
manage the investigation.

13.3.2 Ground Handling

For ground incidents occurring at a line station the Station Manager or

Station Representative or Agent will carry out the necessary investigation
as requested .

Issue 2, Revision 0, 21 MAY 20 19 Nok Airlines Public Company Limited 13-3

13.1 U'VIU1

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