2012 in review safety challenges - caa.gov.t in review safety challenges.pdf · 2012 in review and...
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Major Accident RateWestern-Built Commercial Jets
1999 – 2011
0.00
0.40
0.80
1.20
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
5 year running average
Major Accident Rate
Acc
ide
nt
rate
pe
r m
illi
on
de
pa
rtu
res
Source: Ascend
The Fleets - 2012
Type Western Built Eastern Built Total
Turbojets 21,479 1,065 22,544
Turboprops 4,817 1,195 6,012
Business Jets 17,642
Source: Ascend - A Flight Global Advisory Service
Major Accidents Commercial Jets
1 January 2011 to 31 December 2011
CFIT
LOC
Excursion
Date Operator Aircraft Location Phase Fatal
1 Januray Kolavia TU-154 Surgut, Russia Taxi 3
9 January Iran Air B-727 Orumiyeh, Iran Landing 78
5 March VASO AN-148 Garbuzovo, Russia Enroute 6
4 April Gegorian Airways (UN) CRJ-100 Kinshasa, DRC Approach 32
18 May Omega Air Refueling B-707 Point Mugu, CA, USA Takeoff 0
20 June RusAir TU-134 Petrozavodsk, Russia Landing 45
6 July Silk Way Airlines IL - 76 Bagram, Afghanistan Approach 9
8 July Hewa Bora Airways B-727 Kisangani, DRC Landing 83
28 July Asiana Airlines B-747F Jeju, South Korea Enroute 2
30 July Caribbean Airlines B-737 Georgetown, Guyana Landing 0
20 August First Air B-737 Resolute Bay, Canada Approach 12
7 Sept YAK Service YAK-42 Yaroslavl, Russia Takeoff 44
16 Sept TAME EMB-190 Quito, Ecuador Landing 0
28 Dec Kyrgyzstan TU-134 Osh, Kyrgyzstan Landing 0
Source: Ascend - A Flight Global Advisory Service
Major Accidents Commercial Jets
1 January 2012 to 22 October 2012
CFIT
LOC
Excursion
Date Operator Aircraft Location Phase Fatal
20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127
9 May Sukhoi SU-100 Mount Salak,Indonesia Enroute 45
2 June Allied Air B-727 Accra, Ghana Landing 0
3 June Dana Air MD-83 Lagos, Nigeria Approach 153
Source: Ascend - A Flight Global Advisory Service
Commercial Jet Major Accidents2000 through 2011
20
15
10
5
2000 01 02 03 04 05 06 07 08 09 10
17
13
19
13 13
16
11
17
19
17
19
12 Years 15.6
14
11
5 Years 17.2
Eastern Built
Major Accidents
Business Jets1 January 2012 to 22 October 2012
Date Operator Aircraft Location Phase Fatal
2 February Extrapoint, LLC Lear 35 Pueblo, CO, USA Takeoff 0
12 February Trident Aviation Svcs Gulfstream IV Bakavu-Kavumu, DRC Landing 3
1 March Asia Today, Ltd Citation X Egelsbach, Germany Approach 5
15 March Private Citation I SP Franklin-Macon, NC, USA Landing 5
18 June Triple C Devlopment Beech 400 Atlanta,Gegoria, USA Landing 0
13 July Universal Jet Aviation Gulfstream IV Le Castellet, France Landing 3
2 August Airnor Citation 500 Santiago de Compostela, Spain Approach 2
15 Sept Private Lear 24 Bornholm, Denmark Approach 0
18 Sept Dewberry Air LLC Beech 400 Macon, GA, USA Landing 0
Source: Ascend - A Flight Global Advisory Service
Business Jet Major Accidents2000 through 2011
20
15
10
5
2000 01 02 03 04 05 06 07 08 09 10
8
14
8
14
8
15
9
11 11
7
8
10.0
7
11
Major Accidents Commercial Turboprops (> 14 seats)
1 January 2012 to 22 October 2012
CFIT
Source: Ascend - A Flight Global Advisory Service
Date Operator Aircraft Location Phase Fatal30 January TRACEP AN-28 Namoya, DRC Enroute 3
2 April Utair ATR-72 Tyuman, Russia Takeoff 31
9 April Air Tanzania DHC-8 Kigoma, Tanzania Takeoff 0
28 April Jubba Airways AN-24 Galkayo, Somalia Landing 0
14 May Agni Air DO-228 Jomsom, Nepal Approach 15
6 June Air Class Lineas Aereas SW Metro III Montevideo, Uruguay Climb 2
10 June Ukrainska Shkola Pilotov LET - 410 Borodyanka, Ukraine Enroute 5
20 June ITAB Gulfstream I Pweto, DRC Landing 0
19 August ALFA Airlines AN-24 Talodi, Sudan Approach 32
22 August Mombassa Air Safari LET-410 Ngeredi, Kenya Takeoff 4
12 SeptPetropavlovsk-Kamchatsky Air Enterprise
AN-28 Palana, Russia Approach 10
28 Sept Sita Air DO-228 Katmandú, Nepal Climb 19
7 October Azza Transport AN-12 Khartoum, Sudan Enroute 13
19 October Air Mark Aviation AN-12 Shindand, Afghanistan Landing 0
Commercial Turboprop Major Accidents 2000 through 2011
2000 01 02 03 04 05 06 07 08
5
10
15
20
25
30
35
40
2322
3133
31
39
24 24
29
21
09
20
10
26.6 (12 years)
23.4 (5 years)
23
11
Approach and Landing Major Accidents
Commercial Jets 1 January 2012 through 22 October 2012
Date Operator Aircraft Location Phase Fatal
20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127
2 June Allied Air B-727 Accra, Ghana Landing 0
3 June Dana Air MD-83 Lagos, Nigeria Approach 153
Controlled Flight into Terrain Major AccidentsCommercial Jets
1 January 2012 though 22 October 2012
Date Operator Aircraft Location Phase Fatal
20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127
9 May Sukhoi SU-100 Mount Salak,Indonesia Enroute 45
Sources: Honeywell (Don Bateman), Ascend
Over the last 6 years, 23 of 82 turboprop major accidents has been a CFIT– that’s 28%, or more than 1 of every 4 !
Aircraft Upset Major AccidentsCommercial Jets
1999 through 2011
Nu
mb
er
of
Ac
cid
en
ts
0 0
0
0
0
0
0
0
0
1
2
3
4
5
6
7
8
9
10
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
4
6
SAN RW27 9401 x 200 ft
High Energy Approach
Aircraft with High
Energy Approaches
(physical analog to
Unstable Approach)
have a higher rate of
Risk of Runway
Overrun (r50 <1200)
Risk of Runway Overrun
High Energy
Flights
Important Initiatives
• Data Sharing and Protection
• Revisiting SMS in the real world
• Refocusing SMS on Risk
• Evidence-Based Training
• Unreliable Airspeed
• Functional Check flight
02/15/201117
The World According to ICAO SMS
Regulator
•State Safety Program
•Inspector
Airline
•SMS
•Accountable Exec
Airline
•SMS
•Accountable Exec
Airline
•SMS
•Accountable Exec
Airline
•SMS
•Accountable ExecOversight
Safety
The World As It Is
Regulator•State Safety Program•Inspector
Parent Airline•SMS
•Accountable Exec Oversight
Safety
Group SafetyProgram
Subsidiary Airline B
•SMS
•Accountable Exec
Regulator B
•State Safety Program
•Inspector
State A
State B
Subsidiary Airline C
•SMS
•Accountable Exec
Regulator C
•State Safety Program
•Inspector
State C
SafetyOversight
SafetyOversight
CorporateOversight
Rescuing SMS from Itself
• SMS is becoming mature – sometimes that means
bureaucratic
– An SMS can pass an audit, but that only means it is
auditable, no effective
• 4 Questions to ask assess effectiveness
– What is most likely to cause the next accident?
– How do we know that?
– What are we doing about it?
– Is it working?
Aptitude
Testing
Type
Specific
Effective TEMEffective TEM
Training Needs Analysis
Competencies (Behaviours)
Competencies (Behaviours)
(Outcomes)(Outcomes)
Desired
Performance
Multi Crew
Job Task Analysis
Data: FDA; LOSA; Safety events; Training system; OEM in-service eventsData: FDA; LOSA; Safety events; Training system; OEM in-service events
Recurrent
EBTSingle Pilot
Training System
RAeS Flight Crew Training Conference
Unreliable Airspeed (URA) – FSF Project
• Issue - Historical and recent accidents and
incidents have highlighted the increased risk
associated with unreliable airspeed (URA)
events
• Steering Group – Airbus, Boeing Bombardier,
Embraer, IATA, ALPA, A4A
• Products
– URA Philosophy
– URA Guidelines
URA Philosophy
• The keys to successfully dealing with a URA event are
recognition, procedures, and training
• The aircrew’s recognition of and initial reaction to a
URA event is critical
• Manufacturers should attempt to ensure unreliable
airspeed events are clearly identifiable to aircrews
• The most important function of the aircrew during
an in-flight URA event is to maintain control over the
aircraft’s flight trajectory and energy situation
URA Philosophy
• Crews should be aware of the instruments and
critical systems that are not affected by a URA event
(e.g. attitude displays, engines)
• Procedures and training for URA events should
include the effect of a URA event on other aircraft
systems, and potential alerts/warnings and
indication system inaccuracies that could be
expected
• Crew coordination and communication are
important
elements in successfully addressing a URA event
URA Guidelines
• URA procedures should provide information on attitude and
power settings that enable crews to maintain the aircrafts
flight parameters within normal limits during in-flight
unreliable airspeed events for all phases of flight
• URA procedures should address the availability and use of
independent alternate sources of airspeed information (e.g.
GPS, inertial, angle of attack, etc.)
• URA procedures should include memory items for critical
immediate action steps
• Training programs addressing URA should exist at beginning
(ab initio/MPL), initial, and recurrent levels
• URA training should include both simulator and academic
phases
02/15/201127
Functional Check Flight (FCF – FSF Initiative
• “Be Prepared” Paper
• FCF Guidelines Document
– Preparation
– Ground Phase
– Flight Phase (25 modules, Autopilot, Air conditioning, etc)
• FCF Symposium February 2011 in Vancouver
– FCF Symposium Materials available on FSF Website
• EASA Rulemaking on FCF – NPA Published
02/15/201128
Aviation Safety 2012
• Record year overall for commercial jets (so far)
• Record year (so far) for commercial turboprops
• Average year (so far) for business jets
• CFIT continues to be a challenge – and it is
making a strong comeback as the leading killer
• There are many challenges out there, and FSF is
addressing many of them:
– Data Sharing and Protection
– Revisiting SMS in the real world
– Evidence-Based Training
– Unreliable Airspeed
– Functional Check flight