ISSUES OF AIRCRAFT ACCIDENT INVESTIGATIONS IN INDONESIA

OETARJO DIRAN
GURUBESAR INSTITUT TEKNOLOGI BANDUNG

CHANGE AND PROGRESS IN AIR TRANSPORTATION IS INEVITABLE.

NINETY YEARS AGO, THE FIRST
POWERED FLIGHT COVERED 120 FEET IN ABOUT TWELVE SECONDS. TODAY, AIRLINE FLIGHTS CROSS OCEANS
AND CONTINENTS, CARRYING HUNDREDS OF THOUSANDS OF PASSENGERS. A TRANSPORTATION INDUSTRY
THAT DID NOT EVEN EXIST ON SUCH A GLOBAL SCALE 80 ODD YEARS AGO, NOW PLAYS AN IMPORTANT AND
CRUCIAL ROLE IN THE GLOBAL ECONOMY.

AIR TRAVEL IS ESTIMATED TO DOUBLE OVER THE NEXT TWO DECADES. AIRLINES WILL TRANSPORT
OVER 2.5 BILLION PASSENGERS ANNUALLY BY THE YEAR 2020. A CONSERVATIVE ESTIMATE IS THAT
AIRLINE ACCIDENTS WILL ALSO DOUBLE IN THAT TIME – IT IS ALSO PREDICTED THAT AT LEAST ONE AIRLINER
PER WEEK WILL CRASH SOMEWHERE IN THE WORLD!

ALTHOUGH THE WORLD RATE OF AVIATION ACCIDENTS IS RELATIVELY CONSTANT, TRANSPORTATION

NEEDS AND DEMANDS CONTINUE TO RISE. THE AVIATION WORLD IS FACING THE FACT THAT ACCIDENTS ARE
GOING TO HAPPEN. AND WE HAVE TO RESPOND. GOVERNMENTS HAVE TO ASSURE THAT THE AVIATION
WORLD AND THE TRAVELING PUBLIC WILL BE INFORMED ON THE CAUSAL FACTORS OF AN ACCIDENT.

THEREFORE, THERE IS A NEED TO MAKE SURE THAT INDEPENDENT ACCIDENT INVESTIGATIONS CAN
AND WILL SHALL BE CARRIED OUT.

THIS IS A TIME OF CHANGE , ANDFOR US WE ALL MUST CHANGE WITH THE TIMES. THE QUESTION IS,
HOW? HOW DO WE COPE WITH CHALLENGES OF AVIATION SAFETY, AND HOW CAN WE ADDRESS THESE?

TO COMPETE IN THE GLOBAL ECONOMY OF THE 21ST CENTURY, NATIONS NEED A DYNAMIC
AVIATION INDUSTRY. AN AVIATION INDUSTRY DEPENDENT ON GLOBALLY ACCEPTED LEVELS OF SAFETY.

ACCIDENTS ARE DISASTERS NOT ONLY BECAUSE OF THE LOSS OF LIVES, LOSS OF ASSETS, BUT ALSO
BECAUSE OF THE LOSS OF TRANSPORTATION CAPACITY AND SOMETIMES DISASTROUS FINANCIAL UPSETS WHICH
MAY BURDEN THE OPERATOR AND THE AIR TRANSPORT INDUSTRY IN GENERAL.

TO SUPPORT THE AVIATION INDUSTRY, THEN, THE PRINCIPAL FOCUS OF SAFETY EFFORTS SHOULD BE
ON REDUCING THE RATE OF ACCIDENTS, WITHOUT COMPROMISING THE NEED FOR A COMPETITIVE CAPABILITY.

INDONESIA, LESSONS LEARNED

AS A DEVELOPING COUNTRY, INDONESIA HAS HAD ITS SHARE OF AVIATION ACCIDENTS. HOWEVER,
THE UNAVAILABILITY OF, AND THE USUALLY UNVERIFIABLE DATA, IF ANY, MADE THE ACCIDENT STATISTICS
DOUBTFUL, AT BEST, AND PERHAPS CAN BE ONLY INTERPRETED FOR TREND ANALYSIS PURPOSES.

THE HISTORY OF INDEPENDENT AIRCRAFT ACCIDENT INVESTIGATION IN INDONESIA BEGAN IN 1994,

WHEN THE DIRECTORATE GENERAL OF AIR COMMUNICATION ESTABLISHED A WORKING GROUP TO
INVESTIGATE ALL AVIATION ACCIDENTS. IN 1997 THE INDEPENDENT AIRCRAFT ACCIDENT INVESTIGATION

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COMMISSION (AAIC) WAS CREATED IN ACCORDANCE WITH THE STANDARDS AND RECOMMENDED PRACTICES
OF ANNEX 13 TO THE CONVENTION ON INTERNATIONAL CIVIL AVIATION. IN 1999 THE AAIC FORMALLY
BECAME THE MULTIMODAL NATIONAL TRANSPORTATION SAFETY COMMITTEE (NTSC), INCLUDING AIR,
MARITIME, SURFACE AND RAIL TRANSPORTATION SYSTEMS.

SAFETY ISSUES

AT THE OUTSET, THERE ARE INDICATIONS THAT IN INDONESIA THERE IS VERY LITTLE
UNDERSTANDING OF THE MEANING OF TRANSPORTATION SAFETY AND INDEPENDENT TRANSPORTATION
ACCIDENT INVESTIGATIONS. THERE IS A LACK OF SAFETY AWARENESS AND SAFETY CULTURE. THE GENERAL
PUBLIC IN INDONESIA ACCEPTS OR CONSIDERS ACCIDENTS, AS NATURAL MANIFESTATIONS OF FATE AND THAT
ONE CANNOT ESCAPE FATE.

THUS THE INDONESIAN LEGISLATOR, REGULATOR, OPERATORS AND TRAVELLING PUBLIC IN GENERAL
SEEM TO BE OBLIVIOUS, IF NOT COMPLACENT, ABOUT TRANSPORTATION ACCIDENTS. ACCIDENTS ARE
ACCEPTED AS ACTS OF THE CREATOR. DEATH IS AN INEVITABLE EVENT IN THE LIFE OF MEN. TO DAY
ECONOMIC PROBLEMS LOOM HEAVILY IN FRONT OF THE PEOPLE, PUSHING THE URGENCY FOR SAFETY, IF NOT
HUMAN RIGHTS, WAY BACK IN THE MIND OF THE MAN IN THE STREET, OF THE MASSES.

A LEGAL VACUUM EXISTS, I.E. THERE IS NO LEGAL FRAMEWORK FOR THE CONDUCT OF INDEPENDENT
ACCIDENT INVESTIGATIONS. AS A RESULT, THERE WERE NO RESOURCES AND THERE IS NO GOVERNMENT
FUNDING OR BUDGET AVAILABLE. THERE ARE NO EXPERTS, EXPERTISE OR EXPERIENCE IN CONDUCTING
AVIATION SAFETY AND AIRCRAFT ACCIDENT INVESTIGATIONS. THERE ARE NO FACILITIES TO SUPPORT
INVESTIGATIONS. AND THEREFORE THE ONLY RECOURSE IS OUTSOURCING AND USING EXISTING EXPERTISE
AND FACILITIES IN THE UNIVERSITIES AND RESEARCH INSTITUTES AS A THE NORMAL PRACTICE IN ACCIDENT
INVESTIGATIONS. THESE ARE PROVIDED ON A VOLUNTARY BASIS, VIZ. EXPERTS ARE NOT PAID, AND
LABORATORIES WERE ONLY COMPENSATED FOR MATERIALS USED IN THE RESEARCH.

THE GA152 MEDAN AIRBUS A300B-4 AND MI185 PALEMBANG ACCIDENTS

TO GAIN AN UNDERSTANDING IN THE ISSUES OF AVIATION SAFETY, THE LESSONS LEARNED FROM
TWO MAJOR AIRCRAFT DISASTERS WILL BE TAKEN AS STARTING POINT OF THE DISCUSSION.

IN 1997, NTSC TWO MAJOR AIRCRAFT

THREE MONTHS AFTER THE ESTABLISHMENT OF THE
DISASTERS OCCURRED. IN SEPTEMBER 1997 A GARUDA INDONESIA AIRBUS 300-B4 CRASHED IN THE
HILLS NEAR MEDAN. THERE WERE 234 FATALITIES.

TWO MONTHS LATER, IN DECEMBER 1997 A SILKAIR B737 DIVED INTO THE WATERS OF THE
MUSI RIVER NEAR PALEMBANG. THERE WERE 104 FATALITIES.

AT THE TIME OF THESE ACCIDENTS, THERE WAS ONLY A VERY, VERY LIMITED NUMBER OF
EXPERIENCED INVESTIGATORS, IF ANY. THERE WERE NO SPECIALIZED AND NECESSARY FACILITIES AND
EQUIPMENT TO SUPPORT ACCIDENT INVESTIGATIONS. AND THERE WAS ONLY LIMITED EXPERIENCE, IF AT ALL,
IN CONDUCTING MAJOR ACCIDENT INVESTIGATIONS.

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 AS MENTIONED, THE CONDUCT OF THESE TWO ACCIDENT INVESTIGATIONS WAS DONE THROUGH
OUTSOURCING. THE INVESTIGATION TEAMS REQUESTED AND WERE SUPPORTED BY INTERNATIONAL TEAMS OF
INVESTIGATORS, PROFESSIONALS, EXPERTS AND EXPERTISE, FROM THE BEA (FRANCE),AAIB (UK),
THE
AND THE ATSB (AUSTRALIA), TO INVESTIGATE THE GARUDA MEDAN ACCIDENT INVESTIGATION. IN THE
SILKAIR, PALEMBANG ACCIDENT INVESTIGATION THE INVESTIGATION WAS SUPPORTED BY THE NTSB AND
THE FAA (USA), AND THE MINISTRY OF TRANSPORT OF SINGAPORE.

AS MENTIONED BEFORE, THERE WAS A LACK OF FACILITIES, AND BOTH THE INVESTIGATIONS HAD TO
RELY ON THE SUPPORT OF THE LABORATORIES OF THE INDONESIAN NATIONAL AIRCRAFT MANUFACTURING
INDUSTRIES, THE NATIONAL UNIVERSITIES, AND THE EXISTING NATIONAL RESEARCH AND DEVELOPMENT
LABORATORIES. GRATEFULLY, IN BOTH THE INVESTIGATIONS, AND OTHER ACCIDENT INVESTIGATIONS AS
WELL, MANY OTHER COUNTRIES PROVIDED LABORATORY SUPPORT: ATSB, THE NTSB, AIRBUS
INDUSTRIES AND BOEING COMPANY, THE AIR ACCIDENT INVESTIGATION BRANCH, THE DUTCH
TRANSPORTATION SAFETY BOARD, THE LUFTFAHRT BUNDESAMT, THE TAIPEI BASED AVIATION SAFETY
COUNCIL, AMONG MANY OTHER INSTITUTIONS, MANUFACTURING INDUSTRIES, PROFESSIONALS, EXPERTS AND
INDIVIDUALS.

DURING THE INITIAL FIELD INVESTIGATIONS AT THE ACCIDENT SITES THERE WAS NO LEGAL OR
REGULATORY BASE OR FRAMEWORK FROM WHICH TO WORK. IT IS NOTED THAT IN 2003 THERE IS STILL NO
LEGAL FRAMEWORK IN WHICH THE NTSC HAD TO WORK, ACCEPT THE STANDARDS AND RECOMMENDED
PRACTICES OF THE ANNEX 13 ICAO CONVENTION. NO INDONESIAN LAWS AND REGULATIONS ON
TO THE
THE CONDUCT OF INDEPENDENT INVESTIGATIONS WERE AVAILABLE. COORDINATION OF SITE ACTIVITIES WAS
DIFFICULT, AS MANY ESTABLISHED INSTITUTIONS (E.G. THE ARMED FORCES, THE POLICE, THE NATIONAL
SEARCH AND RESCUE AGENCY, THE LOCAL AUTHORITIES, ETC.) HAD TO WORK TOGETHER IN A
COORDINATED MANNER. AND ALL THESE AGENCIES CLAIMED, ACCORDING TO THEIR MANDATES, THE
EXCLUSIVE RIGHTS AND RESPONSIBILITIES FOR THE SITE INVESTIGATION AND ACTIVITIES.

FOR EXAMPLE, ACCIDENT INVESTIGATORS HAVE HAD DIFFICULTIES ENTERING THE SITES TO GATHER
EVIDENCE, AND EVEN TO INTERVIEW WITNESSES, BECAUSE THE POLICE WERE THERE EXERCISING WHAT THEY
BELIEVE TO BE THEIR MANDATE, FUNCTIONS AND TASKS.
THERE WERE OCCASIONS OF DISAGREEMENTS OVER
THE CUSTODY OF FLIGHT DATA RECORDERS AND OTHER EVIDENCE. IN ONE REMARKABLE CASE, THE POLICE
TOOK THE RECORDERS AS STATE EVIDENCE. ONLY THROUGH INTERVENTION BY THE MINISTER FOR
TRANSPORT THE RECORDERS WERE HANDED OVER BY THE POLICE, WHO DID NOT KNOW WHAT TO DO WITH
THE FLIGHT DATA RECORDERS ANYWAY.

WITH NO ACKNOWLEDGED AND ACCEPTED RULES AND GUIDELINES FOR ALL TO APPLY, THERE WAS
AN UNDERSTANDABLE CHAOS IN THE FIELD INVESTIGATIONS. MINIMUM COORDINATION EXISTED BETWEEN THE
GROUPS. THE MOST IMPORTANT TASKS OF THE INVESTIGATOR-IN-CHARGE OF THE INVESTIGATION BECAME
TO MEND FENCES, TO MAINTAIN A CONDUCIVE ATMOSPHERE IN ORDER TO GAIN ACCESS TO INFORMATION AND
EVIDENCE, TO GET PASSES TO ENTER THE SITE, ETC.

THERE WERE "VERY IMPORTANT TOURISTS" SWARMING OVER THE ACCIDENT SITE: LOCAL
AUTHORITIES, HIGH RANKING ARMED FORCES OFFICERS, POLICE, AS WELL AS OFFICIALS FROM JAKARTA.
THEN THERE WAS THE EVER-PRESENT MASS MEDIA, REPORTING ON AN HOURLY BASE THEIR SOMETIMES
SPECULATIVE ANALYSES BASED ON USUALLY LIMITED DATA AND INFORMATION. THE NEXT-OF-KIN OF THE
VICTIMS WERE THERE. AND THE REPRESENTATIVES FROM FOREIGN EMBASSIES AND CONSULATES.

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 IT IS ALSO A MATTER OF RECORD THAT LOCAL PEOPLE RAN OFF WITH WRECKAGE, PARTS AND
COMPONENTS, INCLUDING BUT NOT LIMITED TO FLIGHT DATA RECORDERS, IN THE HOPE OF SELLING IT FOR
A GAIN OR RECYCLING.

SILKAIR B737

IN THE PALEMBANG ACCIDENT INVESTIGATION THE INVESTIGATION INVOLVED THE SINGAPOREAN

ARMED FORCES AND THE INDONESIAN ARMED FORCES WORKING CLOSE TOGETHER DURING SEARCH AND
RESCUE OPERATIONS. THEY WERE COORDINATED BY THE INDONESIAN
REGIONAL MILITARY COMMAND. IT
WAS AN INTERESTING EXPERIENCE TO HAVE THE SINGAPORE ARMED FORCES AT THE SITE WITHIN HOURS
AFTER THE ACCIDENT, WITHOUT ANY OFFICIAL APPROVAL FROM THE INDONESIAN MINISTRY OF DEFENSE OR
FOREIGN AFFAIRS. THE INVESTIGATOR-IN-CHARGE, THE IIC, PERMITTED SINGAPORE ‘TO INVADE
INDONESIA’, AFTER A COUPLE OF PHONE CALLS AT NIGHT FROM THE SINGAPORE MINISTRY OF TRANSPORT
REQUESTING PERMISSION TO SEND IN THEIR EXPERTS AND PROFESSIONALS, TOGETHER WITH THE SINGAPORE
ARMED FORCES.. NATURALLY THERE WAS A HARD EXPLAINING DEMANDED FROM THE PROPER RESPONSIBLE
MINISTERS THE NEXT DAY.

AT THE PEAK OF THE FIELD INVESTIGATION ACTIVITIES IN PALEMBANG THERE WERE ON THE SITE AND
THE SURROUNDINGS, APPROXIMATELY 500 TO 800 ARMED FORCES SEARCH AND RESCUE PERSONNEL
COMBING THE FIELDS, 6 TO 8 NAVAL VESSELS SEARCHING THE RIVER MUSI AND THE SEAS BEYOND, AND
ABOUT 20 TO 25 FIXED WING AND ROTARY AIRCRAFT FLYING ALL OVER THE SKIES , ALL PROVIDED BY
INDONESIA AND SINGAPORE. HUNDREDS OF LOCAL PEOPLE HELPED IN THE RESCUE OPERATIONS, SEARCHED
THE LAND FOR PARTS AND COMPONENTS AND OTHER WRECKAGE.

THE DIFFICULTIES DID NOT STOP AT THE SITE INVESTIGATIONS AND WORK, AS WORKING WITH
PEOPLE FROM DIFFERENT COUNTRIES AND BACKGROUNDS IS A NEARLY IMPOSSIBLE TASK. DIFFERENCES
BETWEEN INVESTIGATORS HABITS, WORKING METHODS AND TECHNIQUES OF INVESTIGATION APPROACHES,
NATIONAL AND INDIVIDUAL BACKGROUNDS, CULTURES, LAWS, RULES AND PROCEDURES, ETC. HAD TO BE
SMOOTHEN OUT. OBJECTIVITY IS HARD TO REACH, GIVEN THAT INDIVIDUAL IF NOT NATIONAL SUBJECTIVE
VIEWS AND PERCEPTIONS ARE DIFFICULT TO RECONCILE

BOTH THE GARUDA, MEDAN AND THE SILKAIR, PALEMBANG INVESTIGATIONS REPORTING WERE
VERY DIFFICULT, WITH SO MANY ORGANIZATIONS AND PROFESSIONALS WORKING TOGETHER ACROSS OCEANS,
CONTINENTS AND TIME-ZONES. THE INTEGRATION OF THE RESULTS OF MANY INVESTIGATION GROUPS AND
THE REPORT WRITE UP IS A COSTLY AND PROLONGED NIGHTMARE.

ALL THESE TYPES OF DIFFICULTIES ARE FAMILIAR ISSUES TO ACCIDENT INVESTIGATORS, OF COURSE,
BUT IN AN INTERNATIONAL INVESTIGATION OF THIS SCALE, THE POTENTIAL OF CONFLICT IS VERY HIGH
INDEED. IN THE INDONESIAN EXPERIENCE THE CONFLICTING AND SUBJECTIVE INTERESTS INFLUENCE, IN A NOT
TOO SUBTLE WAY, THE INVESTIGATOR’S PERCEPTIONS, VIEWS AND OPINIONS, AFFECTING THE OBJECTIVITY OF
HIS OR HER CONCLUSIONS. THESE CONFLICTING INTERESTS ALSO AFFECT THE TEAMWORK ATMOSPHERE IN A
VERY NEGATIVE WAY.

ALL TOO OFTEN IT IS OBSERVED THAT SAFETY OFTEN TAKES A BACK SEAT WHEN OTHER INTERESTS
COME INTO PLAY – NATIONAL AND ECONOMIC INTERESTS IN PARTICULAR. REGRETFULLY, THEN, IN AIRCRAFT

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ACCIDENT INVESTIGATIONS, ALWAYS INTERNATIONAL IN NATURE, THE ISSUE OF CONFLICTING NATIONAL
INTERESTS WILL REMAIN AN ISSUE TO BE TAKEN INTO CONSIDERATION, AN ISSUE THAT HAS TO BE FACED BY
THE IIC AND THE INVESTIGATIVE TEAM.

GAINING FROM THE EXPERIENCE THEN, PERHAPS WHAT IS NEEDED TO MINIMIZE CONFLICTS IS TO
DEVELOP A SYSTEMATICALLY ORGANIZED KNOWLEDGE APPLICABLE IN AIRCRAFT ACCIDENT INVESTIGATIONS;
ESPECIALLY, A SYSTEM OF ASSUMPTIONS, ACCEPTED PRINCIPLES, AND RULES OF PROCEDURES DEVISED TO
ANALYZE, PREDICT, OR OTHERWISE EXPLAIN THE NATURE OR BEHAVIOR OF THE CONTRIBUTING FACTORS IN
AN ACCIDENT.

THERE IS A NEED TO DEVELOP AN ACCEPTABLE AND AGREED OBJECTIVE APPROACH, IF NOT A

THEORY OF ACCIDENT INVESTIGATIONS, APPLICABLE TO ALL MODES OF TRANSPORTATION SAFETY
INVESTIGATIONS, BASED ON HISTORICAL, SCIENTIFIC, OR SCHOLARLY PRINCIPLES UNDERLYING THE
INDEPENDENT AND OBJECTIVE ACCIDENT INVESTIGATION METHOD OR METHODS. THERE IS A NEED FOR
KNOWLEDGE-BASED PROCEDURES TO ANALYZE AND EXPLAIN THE FACTS AND EVIDENCE GATHERED. THERE IS
ALSO THE NEED FOR PROCEDURES FOR ORGANIZING AND COORDINATING INVESTIGATIONS, AND A COMMONLY
AGREED UPON REPORTING SYSTEM OF INVESTIGATION RESULTS. IT IS THEREFORE VERY WELL APPRECIATED
THAT THE ICAO HAS PUBLISHED PART I OF A MANUAL OF AIRCRAFT ACCIDENT INVESTIGATIONS,

IF THE INTENTION IS TO LEARN FROM INVESTIGATIONS, AND IF SO MANY CONFLICTING INTERESTS ARE
INVOLVED, INVESTIGATIONS HAVE TO MEET ONE VERY BASIC INTEREST: WHICH IS THE PURSUIT OF SAFETY.
THERE CANNOT BE EVEN THE SLIGHTEST SUGGESTION THAT ANY OTHER INTEREST INFLUENCES THE FINDINGS
OF AN INVESTIGATION. ANY SUGGESTION OF CONFLICT OF INTERESTS IS A THREAT TO THE CREDIBILITY OF
INVESTIGATIONS AND THEIR FINDINGS.

LEGAL ISSUES

IN THE INDONESIAN INTERNATIONAL AS WELL AS DOMESTIC AIRCRAFT ACCIDENT INVESTIGATIONS,

DURING AND IN THE AFTERMATH OF THE INVESTIGATIONS, THERE WERE A NUMBER OF LEGAL ISSUES
CONFRONTING THE INVESTIGATION TEAMS. THE INDONESIAN LEGAL FRAMEWORK FOR TRANSPORTATION
SAFETY AND ACCIDENT INVESTIGATION IS NOT YET READY TO PERMIT AN INDEPENDENT INVESTIGATION TO
FUNCTION, AS IT SHOULD. THE USUAL DIFFERENCES, IF NOT INCOMPATIBILITIES, WERE ENCOUNTERED
BETWEEN EXISTING DOMESTIC LAWS AND ARTICLE 3.1 OF ANNEX 13. THE NTSC HAS NOW EMBARKED
ON A PROGRAM OF CONSTRUCTING A LEGAL FRAMEWORK FOR INDEPENDENT TRANSPORTATION ACCIDENT
INVESTIGATIONS.

ACCORDING TO EXISTING DOMESTIC LAWS, IN INDONESIA, ACCIDENTS ARE INVESTIGATED BY THE

POLICE, AND THEIR OBJECTIVE IS TO ENFORCE THE LAW, TO DECIDE ON SANCTIONS OR PUNISHMENT IF
WILLFUL MISCONDUCT OR CRIMINAL INTENT CAN BE PROVEN TO BE THE CAUSE OF, OR A FACTOR IN THE
OCCURRENCE TO HAPPEN. , CAUSING THE ACCIDENT.

INDONESIAN LAW DEFINES ACCIDENTS CAUSED BY PEOPLE TO BE CLASSIFIED AS CRIMINAL CASES, IF

THE ACCIDENT CAUSED INJURIES, FATALITIES OR DAMAGE AND LOSS OF ASSETS. IT IS A COMMON
KNOWLEDGE THAT THE OBJECTIVES OF JUDICIAL AND INDEPENDENT ACCIDENT INVESTIGATIONS ARE DIFFERENT
FROM INDEPENDENT ACCIDENT INVESTIGATIONS, ALTHOUGH BOTH CLAIM THAT THE GOAL IS THE PREVENTION

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OF ACCIDENTS: THE LAW BY SANCTIONS AND PUNISHMENT, AND ACCIDENT INVESTIGATIONS BY
DETERMINATION OF CAUSE.

DURING AIRCRAFT ACCIDENT INVESTIGATIONS, NTSC INVESTIGATORS FACED INTERROGATIONS BY

THE POLICE, AND WERE REQUIRED TO PROVIDE STATEMENTS AND OPINIONS. INDEED, THEY SOMETIMES HAD
TO HAND OVER EVIDENCE, WHICH THE POLICE CALLED 'STATE EVIDENCE'. INVESTIGATORS WERE ALSO ASKED
TO APPEAR IN COURTS AS WITNESSES, AND SOME INVESTIGATORS WERE SUBPOENAED.

IN ONE OF THE RECENT INTERNATIONAL COURT CASES, THE LAWYERS, ON BEHALF OF A FOREIGN
MANUFACTURER, DEMANDED THROUGH THEIR NATIONAL COURTS SPECIFIC INFORMATION FROM SUBPOENAED
INDONESIAN AND INVOLVED INTERNATIONAL INVESTIGATORS. ONE PARTICULAR FOREIGN INVESTIGATOR, A
HUMAN FACTOR EXPERT PARTICIPATING IN AN ACCIDENT, WAS QUESTIONED ABOUT HIS INVOLVEMENT IN THE
INVESTIGATION, E.G. THE AREAS THAT THE HUMAN PERFORMANCE GROUP FOCUSED UPON, DRAFT REPORTS
THAT WERE PRODUCED BY THE HUMAN FACTORS GROUP (AND THE CONCLUSIONS OF THESE REPORTS), HIS
OPINIONS AND OR CONCLUSIONS ON A NUMBER OF ISSUES, INCLUDING EARLIER VERSIONS OF SPECIFIC
INTERNAL AND INTERIM INVESTIGATION GROUP REPORTS, THE CONTENT OF THE CVR, THE FINANCIAL
RECORDS, LIFE AND OR MORTGAGE INSURANCES, DEBTS, OF COCKPIT CREWS AT THE TIME OF THE ACCIDENT,
AND WHATNOT. THE INVESTIGATOR WAS ASKED TO PROVIDE OPINIONS ON THESE ISSUES, AND AN OVERALL
EXPLANATION OF THE WHAT WERE CALLED THE LIKELY OR PROBABLE CAUSES OF THE ACCIDENT. THE
LAWYER REPRESENTING THE PLAINTIFFS CROSS-EXAMINED THE INVESTIGATOR ON THE HUMAN FACTOR
GROUP’S CONCLUSIONS, AND HIS OPINIONS, ETC. ETC.

THIS IS QUITE SERIOUS. IT GOES RIGHT AGAINST THE NON-DISCLOSURE ISSUES OF ARTICLE 5.12
OF ANNEX 13. BUT THEN, IT IS NOT YET CLEAR WHAT IS ALLOWED, AND WHAT IS NOT. WHAT ARE THE
RIGHTS OF AN INVESTIGATOR OR ANYONE PARTICIPATING IN ACCIDENT INVESTIGATIONS? WHAT ARE THE
RIGHTS OF INVESTIGATION AGENCIES OR BOARDS OR COMMITTEES OR WHATEVER THEY ARE CALLED? ARE
ACCIDENT INVESTIGATIONS AND INVESTIGATORS PROTECTED, SUCH THAT THEY CAN WORK EFFECTIVELY?

THE BOUNDARIES BETWEEN JUDICIAL AND ACCIDENT INVESTIGATIONS ARE BLURRING, AND AFFECTING
IN A VERY NEGATIVE WAY THE IDEA OF CONDUCTING INDEPENDENT INVESTIGATIONS. THE ISSUE NOW IS TO
FIND A PROPER BALANCE BETWEEN AN ANNEX 13 BASED INDEPENDENT INVESTIGATION AND LEGAL JUDICIAL
NEEDS.

INDEPENDENT INVESTIGATIONS NEED TO BE ANCHORED IN A FRAMEWORK OF NATIONAL LAW: A

FRAMEWORK TO GOVERN THE RIGHTS, RESPONSIBILITIES, AND POWERS OF OBJECTIVE INDEPENDENT
INVESTIGATIONS AND THEIR INVESTIGATORS.
THE AIM IS TO FIND THE OBJECTIVE TRUTH ON WHAT HAPPENED,
HOW IT HAPPENED, AND WHY IT HAPPENED. ON THE OTHER HAND, JUDICIAL AUTHORITIES WOULD LIKE TO
HAVE JUSTICE DONE THROUGH SANCTIONS AND OR PUNISHMENTS. AND THE LEGITIMATE RIGHTS FOR
COMPENSATION OF ACCIDENT VICTIMS AND NEXT OF KIN ALSO HAVE TO BE CONSIDERED.

INDONESIAN LAWS AND REGULATIONS ON TRANSPORTATION SAFETY, ON INDEPENDENT OBJECTIVE

TRANSPORTATION ACCIDENTS INVESTIGATIONS ARE STILL TO BE DEVELOPED.

FUNDING ISSUES

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 THE COSTS OF THE SILKAIR ACCIDENT INVESTIGATION WAS CONSERVATIVELY ESTIMATED AT 15
MILLION US$, IF NOT MORE. THIS IS A BURDEN THAT IS DIFFICULT TO BEAR, NOT ONLY FOR ACCIDENT
INVESTIGATIONS IN THE DEVELOPING WORLD, BUT ALSO IN THE INDUSTRIALIZED COUNTRIES AS WELL.

NATIONAL AND LOCAL GOVERNMENT AGENCIES CAN INCUR SIGNIFICANT COSTS IN THE COURSE OF AN
ACCIDENT RESPONSE. THOSE COSTS CANNOT BE ANTICIPATED OR BUDGETED IN ADVANCE, AND RECOVERY OF
SUCH COSTS HAS BEEN MADE ON AN AD HOC BASIS, FURTHER COMPLICATING AN ALREADY DIFFICULT
SITUATION. GOVERNMENTS SHOULD ADDRESS THIS ISSUE, THROUGH THE CONSIDERATION OF MEASURES
SUCH AS REQUIREMENTS FOR INCREASED INSURANCE COVERAGE GAINST INVESTIGATION COSTS FOR
COMPANIES INVOLVED IN AIR TRANSPORTATION. PROVISIONS SHOULD BE MADE TO ENSURE THE AVAILABILITY
OF FUNDING FOR EXTRAORDINARY COSTS ASSOCIATED WITH ACCIDENT INVESTIGATIONS.

THE ISSUE OF SAFETY CULTURE

IN THE FINAL ANALYSIS, INDONESIA AT PRESENT FACED A SERIOUS LACK OF A SAFETY CULTURE, A
LACK OF OBJECTIVE ACCIDENT INVESTIGATION EXPERIENCE, EXPERTISE, FACILITIES, ORGANIZATION AND
MANAGEMENT SKILLS.
ADD TO THIS THE UNAVAILABILITY OF FUNDING, THE NON-EXISTENCE OF A LEGAL FRAMEWORK FOR
INDEPENDENT ACCIDENT INVESTIGATIONS AND ONE CAN EASILY SEE THAT THESE ISSUES MAKE AIRCRAFT
ACCIDENT INVESTIGATIONS, AT LEAST IN INDONESIA, AND PERHAPS IN OTHER DEVELOPING COUNTRIES, A
VERY INEFFICIENT UNDERTAKING, PERHAPS INCOMPLETE, WITH UNRESOLVED SIGNIFICANT POINTS OF
CONTROVERSY, RESULTING IN DOUBTFUL RESULTS

SO THERE IS A NEED TO CHANGE TO IMPROVE, IF NOT TO START THE DEVELOPMENT OF A NATIONAL

SAFETY CULTURE, AND ULTIMATELY PERHAPS THE ESTABLISHMENT OF A HUMAN RIGHT’S CULTURE. AND THIS
DEVELOPMENT IS NOT ONLY A MUST FOR INDONESIA, BUT MOST LIKELY FOR ALL NATIONS IN THE REGION.

REGIONAL COOPERATION

THERE IS AN OBVIOUS AND IMMEDIATE NEED TO FIND SOLUTIONS TO THE PROBLEMS MENTIONED. INDONESIA
MAY NOT BE ABLE TO COPE WITH THE PROBLEMS ON ITS OWN, AND MAY HAVE TO DEPEND ON THE
INTERNATIONAL WORLD TO DEVELOP ACCEPTABLE LEVELS OF TRANSPORTATION SAFETY. BUT IN THE POST 9-
11 ERA, THESE WILL PROBABLY BE DIFFICULT TO EXPECT.

PERHAPS THEREFORE, THE RESPONSIBILITY FOR ACHIEVING THAT CHANGE LIES WITH ALL THE
NATIONS IN THE REGION. THE NATIONS OF THE REGIONS MUST BE ABLE TO WORK TOGETHER TO MAKE THE
CHANGES THAT ARE NECESSARY TO KEEP PACE WITH THE CHALLENGES OF THE FUTURE. COMMITMENTS MUST
BE MADE AT THE HIGHEST LEVELS OF EVERY GOVERNMENT AND IN THE PRIVATE SECTORS INVOLVED.

A STRONG REGIONAL PARTNERSHIP AND RELATIONSHIP IS NEEDED TO DEVELOP AND INTEGRATE OUR
EFFORTS TO IMPROVE THE REGIONAL AVIATION SAFETY. THE NATIONS OF THE REGION HAVE TO EXPAND
THEIR COOPERATIVE EFFORTS IN AVIATION SAFETY DEVELOPMENT, IN CLOSE RELATIONSHIP WITH THE REST OF
THE WORLD. AND GIVEN THE TREMENDOUS GROWTH AND GLOBALIZATION OF THE AVIATION INDUSTRY, IT IS
CRITICAL THAT THE COUNTRIES’ AIR TRANSPORT AUTHORITIES IN THE REGION BE GIVEN THE INCENTIVES AND

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FLEXIBILITY TO BE FULL PARTNERS IN THIS EFFORT, AND BE ENCOURAGED TO MONITOR THEIR OWN
PERFORMANCE.

BECAUSE DEVELOPING COUNTRIES MAY NOT HAVE THE RESOURCES AND CAPABILITIES TO MAINTAIN
AN INTERNATIONALLY ACCEPTABLE ACCIDENT RATE, AN EFFORT TO COMBINE AND COORDINATE SAFETY
EFFORTS IN THE REGION MAY BE A WORTHY IDEAL. IN ADDITION TO IDENTIFYING AND DEFINING ISSUES AND
SOLVING THEM, EXPERIENCES SPECIFIC TO OUR REGION COULD BE CODIFIED, AND DEVELOPED INTO OUR
AVIATION SAFETY PROGRAMS, IN ADDITION TO THE EXISTING INTERNATIONAL STANDARDS AND
RECOMMENDATIONS.

ACCIDENT INVESTIGATIONS COULD BE A JOINT EXERCISE, WHERE, AT THE END OF THE DAY, WHEN
THE INVESTIGATION IS FINISHED, ONE CAN ASSESS EXPERIENCES, AND LEARN TOGETHER. ACCIDENTS ARE
EXPENSIVE, AND ACCIDENT INVESTIGATIONS OCCURRING ANYWHERE PROVIDE THE BEST TRAINING FOR
INVESTIGATORS. INVESTIGATORS SHOULD JOIN AIRCRAFT ACCIDENT INVESTIGATIONS ANYWHERE, EITHER BY
REQUEST OF THE STATE CONDUCTING THE INVESTIGATION, OR VOLUNTARILY.

THE WORLD IS CHANGING, AND SO, TOO, MUST THE INDONESIAN AND REGIONAL AVIATION POLICIES,
AND PRACTICES. THE NATIONS IN THE REGION AND THEIR AGENCIES INVOLVED IN AVIATION SAFETY ARE
CHALLENGED TO WORK TOGETHER, TO FIND SOLUTIONS FOR IMPROVEMENTS THAT WILL MAKE PASSENGERS
SAFER, REGARDLESS OF WHERE THEY BOARD THEIR FLIGHT.

AND IF NO SINGLE NATIONS HAVE THE CHANCE TO FULFILL ITS OBLIGATIONS AND AIMS FOR SAFER
SKIES, THEN PERHAPS NOW IS THE TIME FOR THE COUNTRIES IN THE REGION TO ESTABLISH THEIR OWN
SAFETY NETWORKS, RELATIONSHIPS, COORDINATION AND COOPERATION. SUCH MOVES ARE NEEDED TO
CHANGE AND IMPROVE, TO REACH ACCEPTABLE AND GLOBAL STANDARDS OF SAFETY IN THE SKIES.

THE THOUGHT BEHIND THIS REGIONAL UNDERTAKING IS THAT GOVERNMENTS CAN AND SHOULD SET
THEIR GOALS, AND THEN WORK WITH CLOSE COOPERATION WITH OTHER COUNTRIES IN THE MOST EFFECTIVE
WAY TO ACHIEVE THEM. COOPERATION DOES NOT MEAN THAT GOVERNMENTS GIVE UP THEIR SOVEREIGNTY,
AUTHORITY OR RESPONSIBILITIES.

REGIONAL COOPERATION SHOULD FIND BETTER WAYS TO ACHIEVE COMMON GOALS, SEEKING TO
REPLACE CONFRONTATION AND COMPETITION WITH COOPERATION. SUCH COOPERATION WILL BE A
TREMENDOUS STEP TO FINDING OPPORTUNITIES TO IMPROVE REGIONAL AVIATION SAFETY AND SECURITY
LEVELS. THAT IS TO SAY,INTERNATIONALLY ACCEPTABLE LEVELS OF AVIATION AND SECURITY. FOR AT THE
END OF THE DAY, THE STRATEGIC OBJECTIVE OF OUR EFFORTS IS TO ESTABLISH OUR OWN EXPERTISE,
EXPERTS, FACILITIES, EQUIPMENT AND OTHER RESOURCES. AND THE ULTIMATE GOAL IS SAFE SKIES. NOW IS
THE TIME FOR CHANGE AND IMPROVEMENT, NOW IS THE TIME FOR THE REGION TO BUILD ON THAT WORK,
AND REENGINEER ITSELF TO ADAPT TO THE DEMANDS OF THIS CENTURY.

FINAL REMARKS

IT IS THEREFORE ENVISAGED THAT THE COUNTRIES IN THIS REGION ENTER INTO A PACT OF
COOPERATION AIMED AT PROMOTING AVIATION SAFETY, AND THE REDUCTION OF THE NUMBER AND SEVERITY
OF AIR TRANSPORT ACCIDENTS IN THE REGION. THROUGH THIS COOPERATIVE EFFORT, COUNTRIES WOULD

8
SHARE FACTUAL INFORMATION OF EXPERIENCES AND LESSONS LEARNED FROM ACCIDENT INVESTIGATIONS IN
THE FORM OF REPORTS, BRIEFINGS, NEWSLETTERS AND EVENTS IN SUPPORT OF HIGH SAFETY STANDARDS.

THE VISION IS OF COOPERATION TO DEVELOP EXPERT ADVICE - PROVIDING INVESTIGATION AGENCIES

IN THE REGION; AND TAKING INTO CONSIDERATION OUR LIMITATIONS, SEEKING TO IDENTIFY AND PROMOTE
EFFECTIVE MEASURES OF ACCIDENT INVESTIGATION ON THE BASIS OF AVAILABLE METHODS AND BEST
PRACTICE, IN AREAS THAT OFFER THE GREATEST POTENTIAL FOR PROMOTING EFFICIENT AND EFFECTIVE
INVESTIGATIONS.

THE COOPERATION EFFORT WILL SEEK SOLUTIONS TO PROBLEMS OF FUNDING, EXPERTISE, THE LEGAL
FRAMEWORKS, ETC. IN ORDER TO MAINTAIN THE HIGH STANDARDS AND HIGH QUALITY OF INVESTIGATIONS
EXPECTED BY ALL.

TO BEGIN WITH PERHAPS REGULAR MEETINGS OR CONFERENCES OF THE CHAIRMEN OF INDEPENDENT

ACCIDENT INVESTIGATION AGENCIES, AND INVESTIGATORS, COULD BE CONDUCTED ONCE OR TWICE A YEAR,
TO COMPARE NOTES, LESSONS LEARNED, IDENTIFY ISSUES TO DISCUSS COMMON ISSUES AND ACCEPTABLE
SOLUTIONS TO ALL TO SHARE EXPERIENCE AND INFORMATION, EXCHANGE VIEWS, ETC

IT IS SINCERELY HOPED THAT THE COUNTRIES IN THE REGION WILL SERIOUSLY DO ALL IN THEIR
POWER TO PROMOTE THIS COOPERATION IN THE NAME OF AVIATION SAFETY PROMOTION.

JAKARTA, 28 NOVEMBER 2003