The first step is the occurrence report.
There is an occurrence. An occurrence can be an accident or an incident. Under the regulations, there is a list of accidents and incidents that have to be reported to us. Operators are obligated to report that to us. There is an occurrence report that we receive. Based on that information, the investigating team, which is usually an investigator and his or her manager, decides whether to deploy to the accident site.
Once they deploy, they will assess the occurrence and decide which type of investigation to conduct. As I mentioned earlier, it can be a class 2 for a very complex investigation, all the way to a class 5, which would basically just be collection of data for statistical purposes. They will assess this and, based on the classification, the investigation will start.
The first step is the field phase. They will collect information about the wreckage. They will interview witnesses. They will discuss with manufacturers.
Then there is the analysis phase, which is basically to identify not what happened but why it happened. In that case, this would be, for example, doing further analysis in the laboratory and having follow-up discussions with the manufacturers to identify why the accident happened.
Then a report will be produced. This report is then submitted to the board. The board is me and four other board members. We take a look at the report, and this leads to a confidential draft report.
The confidential draft report is submitted to what we call “designated reviewers”. Designated reviewers are persons who may be directly affected by the board's findings. They get a copy of the confidential draft report and provide comments on the report. Once we get the comments back, we take them into consideration. We make modifications to the report if required.
Then there is a final board review, and the report is published with any applicable recommendations.