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likely to affect all members of the flight crew - in particular carbon monoxide or other noxious fumes that
may have contaminated the cockpit air. He must also seek evidence to eliminate or confirm the involvement
of a criminal act such as unlawful interference with the operation of the aircraft. A full examination of the
ICAO Preliminary Unedited Version — October 2008 IV-1-4
flight crew may give valuable evidence about who was controlling the aircraft at the time of the crash. In
this respect, identification has direct technical value to the investigation as distinct from judicial value.
In the major fatal aircraft accident, however, there is the possibility of deriving evidence from the cabin
crew and passengers. A main concern of this chapter is to illustrate why this opportunity must not be lost.
A full examination, particularly when it can be based upon previous experience, may reveal evidence as to
the sequence of events, the stage of flight and the degree of emergency anticipated. The pattern of injuries
may indicate clearly the type of accident - fire in flight, structural failure in flight, sudden or gradual
deceleration at impact, etc. An examination of the passengers may be the prime method of demonstrating
sabotage as an accident cause.
Human engineering and survival
The Human Factors Investigation may provide medical evidence of great value in relation to human
engineering and survival. Such evidence will be equally relevant in both fatal and non-fatal accidents but
again there may be a difference of emphasis according to whether the accident involves a large or small
aircraft.
In the case of a small aircraft accident, the examination will generally be directed to the pilot(s); however,
whether the aircraft is large or small, one should consider such factors as the relevance of the type of harness
restraint in use, the provision or lack of other items of safety equipment, and the injury-producing potential
of the controls, instruments and other cockpit structures.
In the case of a transport aircraft accident, interest will inevitably include the passengers. The Human
Factors Group will be searching for evidence of injury resulting from seat structures - with or without
adequate harness restraint - and the missile effect of the various contents of the cabin. Medical or
pathological evidence will also be available as to the adequacy or inadequacy of walkways, exits and
survival equipment.
Identification
Clearly the useful interpretation of human factor findings is dependent upon accurate identification of the
casualties involved. Identification is, therefore, pre-eminently a tool of investigation but it also has major
medico-legal significance and judicial application. The head of the Human Factors Group must be prepared
for any evidence determined by members of his group, particularly the pathologist, to be used for
medico-legal purposes. The Human Factors Group will, therefore, have special needs for co-ordination with
local or national authorities with particular regard to identification. These needs should be recognized
during the pre-planning and should not be overlooked during the investigation. There is, however, no
conflict of interests - investigation and identification are interdependent as recognized in Annex 13. In the
following sections of this chapter, they are discussed together under the same headings, in particular:
a) tasks at the accident site;
b) tasks at the mortuary;
c) evidence to be derived from the pathological examination;
d) consideration of the medical history of the crew and, where appropriate, interrogation of surviving
crew and passengers.
ICAO Preliminary Unedited Version — October 2008 IV-1-5
THE STATUS OF THE PATHOLOGIST; LIAISON
WITH THE INVESTIGATOR-IN-CHARGE
The Investigator-in-Charge may appoint as head of the Human Factors Group a specialist in aviation
medicine with experience in aircraft accident investigation. In the event that there are fatalities, he may also
appoint a pathologist, ideally with experience in aviation pathology or at least in forensic pathology, to
perform necessary full autopsy examinations on all those victims killed. If the pathologist has experience in
aviation pathology, he may be appointed as head of the Human Factors Group but this will depend on the
type of accident being investigated and on human factor considerations. The fatal accident is, generally,
more difficult to investigate than the non-fatal accident and it is for this reason that the role of the
pathologist is stressed in this chapter. In the event that no pathologist experienced in aircraft accident
investigation is available in the State investigating a major fatal accident, the Investigator-in-Charge should
　
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