a comprehensive review of airworthiness accidents & … · 2019-05-13 · 2007 2008 2009 2010...

A COMPREHENSIVE REVIEW OF

AIRWORTHINESS ACCIDENTS & SERIOUS INCIDENTS

09 May 2019

Jennifer Insley & Cengiz Turkoglu

MSc Safety & Human Factors in Aviation

Jennifer Insley

Cranfield Safety & Accident Investigation Centre

Disclaimer: Unless clearly cited and referenced, all views presented in the following slidesare my opinion and not necessarily reflect the views of any of the organisations I aminvolved in or associated with or work for.

VP Technical Vice Chairman

Senior Lecturer &Course Director MSc Airworthiness

Cengiz Turkoglu


PRESENTATION CONTENT

• Safety Performance of the Commercial Air Transport Industry

• European Approach to Safety Risk Management & Safety Risk Portfolios

• Rationale for the two Cranfield MSc Reseach Projects

• Analysis of the Occurrences, Serious Incidents & Accidents

• An IFA Initiative – Demystifying the High Risk Areas in Airworthiness

General Aviation

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 0 0 0 0 0 0 0 0 0 0 0

Serious 1 1 0 0 0 3 0 1 0 0 1

Minor* 0 12 2 0 0 19 0 1 0 0 0

2…2…2…2…2…2…2…2…2…2…2…Minor* 0 100

Axi

s Ti

tle

UK General …

Source: UK DfT Aviation Safety Statistics available @ https://www.gov.uk/government/statistical-data-sets/aviation-statistics-data-tables-avi

UK Aviation Safety StatisticsCasualties caused by accidents involving G Registered aircraft in UK Airspace

Commercial Air Transport Accidents / Incidents

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 19 10 15 8 7 6 8 7 23 6 14

Serious 6 9 13 9 9 8 10 9 7 6 7

Minor* 25 26 33 20 21 18 11 20 11 14 10

https://www.gov.uk/government/statistical-data-sets/aviation-statistics-data-tables-avi

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 19 10 15 8 7 6 8 7 23 6 14

Serious 6 9 13 9 9 8 10 9 7 6 7

Minor* 25 26 33 20 21 18 11 20 11 14 10

General Aviation

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 0 0 0 0 0 0 0 0 0 0 0

Serious 1 1 0 0 0 3 0 1 0 0 1

Minor* 0 12 2 0 0 19 0 1 0 0 0

2…2…2…2…2…2…2…2…2…2…2…Minor* 0 100

Axi

s Ti

tle

UK General …





2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 0 0 0 0 0 0 0 0 0 0 0

Serious 1 1 0 0 0 3 0 1 0 0 1

Minor* 0 12 2 0 0 19 0 1 0 0 0

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 19 10 15 8 7 6 8 7 23 6 14

Serious 6 9 13 9 9 8 10 9 7 6 7

Minor* 25 26 33 20 21 18 11 20 11 14 10

General Aviation

2…2…2…2…2…2…2…2…2…2…2…Minor* 0 100

Axi

s Ti

tle

UK General …





2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Fatal 0 0 0 0 0 0 0 0 0 0 0

Serious 1 1 0 0 0 3 0 1 0 0 1

Minor* 0 12 2 0 0 19 0 1 0 0 0



2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Minor* 25 26 33 20 21 18 11 20 11 14 10

Serious 6 9 13 9 9 8 10 9 7 6 7

Fatal 19 10 15 8 7 6 8 7 23 6 14

0

10

20

30

40

50

60

70

NU

MB

ER O

F C

ASU

ALT

IES

UK General Aviation Accidents



Source: ICAO Safety Report 2018

Global Commercial Air Transport IndustryAn Ultra Safe System

ULTRA-SAFE SYSTEM & CHALLENGES

https://youtu.be/IgDyhvXW8jM

https://youtu.be/IgDyhvXW8jM

101 92 84 11930 34 20 26

843

514

423272

-200

0

200

400

600

800

1000

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013

Global Commercial Air Transport Safety Statistics

Number of Accidents Number of Fatal Accidents Fatalities

Source: All accidents in this review were taken from Flight Safety Foundation – Aviation Safety Network Database and the data was analysed by Cengiz Turkoglu (https://aviation-safety.net/database/dblist.php?Year=2018)

101 92 84 119 9730 34 20 26 21

843

514

423272

972

-200

0

200

400

600

800

1000

1200

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014




101 92 84 119 97 8830 34 20 26 21 12

843

514

423272

972

543

-200

0

200

400

600

800

1000

1200

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014 2015




“What we call here a Black Swan is an event with the following threeattributes. First, it is an outlier, as it lies outside the realm of regularexpectations, because nothing in the past can convincingly point to itspossibility. Secondly, it carries an extreme impact . Third, in spite of its outlierstatus, human nature makes us concoct explanations for its occurrence afterthe fact, making it explainable and predictable. “

Source: ‘Black Swan’ by Nassim Nicholas Taleb

101 92 84 119 97 88 8930 34 20 26 21 12 17

843

514

423 272

972

543

315

-200

0

200

400

600

800

1000

1200

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014 2015 2016




101 92 84 119 97 88 89 9330 34 20 26 21 12 17 15

843

514

423 272

972

543315

57

-200

0

200

400

600

800

1000

1200

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014 2015 2016 2017




101 92 84 119 97 88 89 93 9830 34 20 26 21 12 17 15 17

843

514

423 272

972

543315

57

556

-200

0

200

400

600

800

1000

0

100

200

300

400

500

600

700

800

2010 2011 2012 2013 2014 2015 2016 2017 2018


Number of Non-Fatal Accidents Number of Fatal Accidents Fatalities


DATA SOURCE

• All accidents in this review were

taken from Flight Safety

Foundation – Aviation Safety

Network Database (https://aviation-

safety.net/database/dblist.php?Year=2018)

• Only Commercial Air Transport

Accidents were included in this

review based on the criteria on

the right side.

SCOPE OF THE REVIEW

Included Events

Ambulance

Cargo

Domestic Non Scheduled Passenger

Domestic Scheduled Passenger

Executive

International Scheduled Passenger

Int'l Non Scheduled Passenger

Passenger

Scheduled Passenger

Excluded events

Demonstration

Ferry/positioning

Illegal Flight

Military

Official state flight

Parachuting

Private

Survey/research

Test

Training

Unknown

Fire fighting

2018 ACCIDENT REVIEW (by Cengiz Turkoglu)

1219%

5081%

Fatal Accidents

Non-fatal Accidents

2018 GLOBAL COMMETCIAL AIR TRANSPORT ACCIDENTS

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Runway Excursion

Loss of control

Ground collision with other aircraft

Tailstrike

Ground Collision with Vehicle

Gear up landing

Tyre burst during takeoff

Taxiway Excursion

Aircraft Damage due to seperation of landing gear…

RTO due to Birdstrike

Ground collision with animal during takeoff

Uncontained Fan Blade Failure

Air Turnback due to Engine Fire

Main Landing Gear Collapse during landing

Wing-tip scraped during touchdown

Hard Landing causing structural damage

Forced Landing outside airport

Ground collision with airport floodlight pole

Collision with light during landing

Hard Landing causing damage to NLG

Unsecured cargo caused damage

Landing on water short of runway

Collision with light during takeoff

Damage during takeoff

2018 CAT All Accidents - Categories

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Runway Excursion

Loss of control

Ground collision with other aircraft

Tailstrike


Gear up landing


Taxiway Excursion

Aircraft Damage due to seperation of landing gear door during…

RTO due to Birdstrike

Ground collision with animal during takeoff

Uncontained Fan Blade Failure

Air Turnback due to Engine Fire

Main Landing Gear Collapse during landing

Wing-tip scraped during touchdown

Hard Landing causing structural damage


Ground collision with airport floodlight pole

Collision with light during landing

Hard Landing causing damage to NLG

Unsecured cargo caused damage

Landing on water short of runway

Collision with light during takeoff

Damage during takeoff

TAILSTRIKE 4 GROUND COLLISION WITH OTHER AIRCRAFT 8

LOSS OF CONTROL 10 RUNWAY EXERCUSIONS 17

Fatal Accident CategoriesNumber of Accidents

Number of Fatalities

Loss of control 8 477

Runway excursion 2 53

Landing on water short of runway 1 1

Uncontained Fan Blade Failure 1 1

2018 ACCIDENT REVIEW – CAT FATAL ACCIDENTS

Ambulance (AM)

Cargo (FR)

Domestic Non Scheduled Passenger (DNSP)

Int'l Non Scheduled Passenger (INSP)

Passenger (PX)

Scheduled Passenger (SP)

Domestic Scheduled Passenger (DSP)

Executive (EX)

International Scheduled Passenger (ISP)

2018 ACCIDENT REVIEW - LIST OF FATAL ACCIDENTS

Date Type Nature Registration MCTMICAO TD (WTC)

Operator Fatalities

11-Feb-18 Antonov An-148-100B DSP RA-61704 M Saratov Airlines 71

18-Feb-18 ATR 72-212 DSP EP-ATS M Iran Aseman Airlines 66

11-Mar-18 Canadair Challenger 604 EX TC-TRB 18201 kg M MC Aviation 11

12-Mar-18 DHC-8-402Q Dash 8 ISP S2-AGU M US-Bangla Airlines 51

17-Apr-18 Boeing 737-7H4 (WL) DSP N772SW M Southwest Airlines 1

18-May-18 Boeing 737-201 Adv. DSP XA-UHZ M Cubana, lsf Global Air 112

10-Jul-18 Convair CV-340 DNSP ZS-BRV 21319 kg M Rovos Air 1

04-Aug-18 Junkers Ju-52/3mg4e DNSP HB-HOT 7600 kg M Ju-Air 20

28-Sep-18 Boeing 737-8BK (WL) DSP P2-PXE M Air Niugini 1

29-Oct-18 Boeing 737 MAX 8 DSP PK-LQP M Lion Air 189

09-Nov-18 Boeing 757-23N ISP N524AT M Fly Jamaica Airways 1

20-Dec-18 Antonov An-26B FR 9S-AGB M Gomair 7

https://aviation-safety.net/database/record.php?id=20180211-0












Date Type Nature Registration MCTMICAO TD (WTC)

Operator Fatalities

11-Feb-18 Antonov An-148-100B DSP RA-61704 M Saratov Airlines 71

18-Feb-18 ATR 72-212 DSP EP-ATS M Iran Aseman Airlines 66

11-Mar-18 Canadair Challenger 604 EX TC-TRB 18201 kg M MC Aviation 11

12-Mar-18 DHC-8-402Q Dash 8 ISP S2-AGU M US-Bangla Airlines 51

17-Apr-18 Boeing 737-7H4 (WL) DSP N772SW M Southwest Airlines 1

18-May-18 Boeing 737-201 Adv. DSP XA-UHZ M Cubana, lsf Global Air 112

10-Jul-18 Convair CV-340 DNSP ZS-BRV 21319 kg M Rovos Air 1

04-Aug-18 Junkers Ju-52/3mg4e DNSP HB-HOT 7600 kg M Ju-Air 20

28-Sep-18 Boeing 737-8BK (WL) DSP P2-PXE M Air Niugini 1

29-Oct-18 Boeing 737 MAX 8 DSP PK-LQP M Lion Air 189

09-Nov-18 Boeing 757-23N ISP N524AT M Fly Jamaica Airways 1

20-Dec-18 Antonov An-26B FR 9S-AGB M Gomair 7

Ambulance (AM)

Cargo (FR)

Domestic Non Scheduled Passenger (DNSP)

Int'l Non Scheduled Passenger (INSP)

Passenger (PX)

Scheduled Passenger (SP)

Domestic Scheduled Passenger (DSP)

Executive (EX)

International Scheduled Passenger (ISP)

2018 ACCIDENT REVIEW - LIST OF FATAL ACCIDENTS













0 1 2 3 4 5 6 7

Runway excursion

Loss of control

Ground collision with another aircraft

Gear up landing


Taxiway Excursion

Engine IFSD and Diversion (Uncontained Fan Blade…

Air Turnback (Engine Fire)

Landing Gear Collapse during landing



Ground collision with pole

2018 GLOBAL AIRWORTHINESS ACCIDENT CATEGORIES

Fatal Airworthiness Accident Categories

Number of Accidents

Number of Fatalities

Loss of control 3 261

Runway Excursion 1 1

Engine IFSD and Diversion 1 1

2018 ACCIDENT REVIEW – FATAL AW ACCIDENTS

2018 ACCIDENT REVIEW – AIRWORTHINESS ACCIDENTS

“I have read Lord Cullen’s report into the 1988 disaster, and the reports on DeepwaterHorizon, Nimrod, Texas City, Buncefield – the list goes on. While the precisecircumstances and contexts of these incidents differ in some respects, at heart I am leftwith the feeling that there are no new accidents. Rather there are old accidentsrepeated by new people.”

Judith Hackitt, Chair, HSE @ the 25th Anniversary of the Piper Alpha Tragedy

“I have read Lord Cullen’s report into the 1988 disaster, and the reports onDeepwater Horizon, Nimrod, Texas City, Buncefield – the list goes on. Whilethe precise circumstances and contexts of these incidents differ in somerespects, at heart I am left with the feeling that there are no new accidents.Rather there are old accidents repeated by new people.”

Judith Hackitt, Chair, HSE @ the 25th Anniversary of the Piper Alpha Tragedy

Almost all future accidents will be

Next accident can be predicted

VS

Focuses onwhat went

RIGHT

Focuses onwhat went

WRONG

SAFETY III

So keep sharing data, information and intelligence

But don’t forget to learn lessons from accidents/incidents as

well as your partners’, suppliers’ and competitors’ best practice

Hollnagel, E. (2014).

OR AND

Annual Safety ReviewWHAT HAPPENED & WHY IT HAPPENED?

European Plan for Aviation SafetyWHAT TO DO TO PREVENT FUTURE ACCIDENTS?

Rulemaking & Safety Promotion ProgrammeHOW & WHEN TO DO IT?

EUROPEAN APPROACH TO SAFETY MANAGEMENT

Source: Annual Safety Review 2017 available @ https://www.easa.europa.eu/sites/default/files/dfu/209735_EASA_ASR_MAIN_REPORT_3.0.pdf

HOW EPAS IS DEVELOPED THROUGH SRM PROCESS

https://www.easa.europa.eu/sites/default/files/dfu/209735_EASA_ASR_MAIN_REPORT_3.0.pdf

42







EASA ANNUAL SAFETY REVIEWS 2016 & 2017

CAT – Aeroplanes Safety Risk Portfolios‘Aircraft Maintenance’ is one of the many identified safety issues

EASA ANNUAL SAFETY REVIEW 2017

LOSS OF CONTROL ACCIDENTS

RUNWAY EXCURSIONS

Jennifer InsleyMSc Safety & Human Factors in Aviation

Jelle HiemingaMSc Airworthiness

Two independent / intertwined MSc Research Projects

112 Accidents & Serious Incidents from ASN & Skybrary (2003-2017)

3912 incident reports from the European Central

Repository (2012-2016)

More detail in the data but still challenging

Less detail in the data but more volume for trend analysis


Analysis of Occurrence Reports

1. Base the taxonomy on familiar descriptions and the maintenance process (level 1):

2. Make sure that there is sufficient level of detail in the second level (67 different options provided).

The purpose is to categorise what went wrong, most reports do not allow analysis of the causes.

Job access / job set-up

Working practices

Trouble shooting

Lubrication / servicing

Inspection / testing

Installation/removal

Modification / repair

Activation / deactivation

Job close-up

Development of a Custom taxonomy

Maintenance documentation

Parts supply / tracking / life limits

Tools

Maintenance Control

Occurrences - Top event categories1. Maintenance Control 308 25%

2. Maintenance documentation 39 3%

3. Parts supply/tracking/life limits 118 10%4. Tool issue 9 1%5. Job access/job set-up issue 17 1%6. Working practices 88 7%7. Troubleshooting issue 2 0%8. Lubrication/servicing issue 29 2%9. Inspection/testing issue 39 3%10. Installation/removal issue 360 29%11. Modification/repair issue 60 5%12. Activation/deactivation issue 33 3%13. Job close-up 130 11%

Analysis of Accident & Serious Incidents

Review of Accidents & Serious Incidents – CODED OUTPUT

5953

33

16 1717 10

8 33

2

Level 3 - Maintenance Factors

Inadequate maintenance Incorrect maintenance

Inspection AMM

Organisational Oversight

Check Overhaul

Airworthiness directive Human Factors

FOD

44

38

84

44

4 21111

Level 2 - Associated Event System /

Component

Engine Landing gear

Flight controls Electrical power

Instrumentation and indication Steering

Structure Fuel

Insulation Pressurisation

Windscreen Workload

2322

18

15 13

8

74

11

Level 1 - Occurrence Consequence

Runway-related occurrence Diversion or Air Turnback

Collision LG-related occurrence

Landing-related occurrence Structural damage

Fire Depressurisation

Cabin fume event In-flight shutdown


5953

33

16 1717 10

8 33

2



Inspection AMM


Check Overhaul


FOD

44

38

84

44

4 21111


Component

Engine Landing gear



Structure Fuel


Windscreen Workload

2322

18

15 138

7411







5953

33

16 1717 10

8 33

2



Inspection AMM


Check Overhaul


FOD

2322

18

15 13

8

74

11







44

38

84

44

4 21

11

1

Level 2 - Associated Event System / Component

Engine Landing gear Flight controls

Electrical power Instrumentation and indication Steering

Structure Fuel Insulation

Pressurisation Windscreen Workload


44

38

84

44

4 21111


Component

Engine Landing gear



Structure Fuel


Windscreen Workload

2322

18

15 13

8

74

11







5953

33

16 1717 10

8332


Inadequate maintenance Incorrect maintenance Inspection AMM

Organisational Oversight Check Overhaul

Airworthiness directive Human Factors FOD

32, 209, 6

14, 391, 6

9, 111, 3

16, 115, 3

5, 10, 3

3, 47, 3

8, 169, 2

15, 155, 2

5, 107, 2

-50

0

50

100

150

200

250

300

350

400

450

-5 5 15 25 35

Nu

mb

er o

f Fa

talit

ies

Number of Occurrences

Level 3 Top 9 Fatal Accident Relationship

Inadequate maintenance procedures

Operator's inadequate maintenance oversight

Non-airworthy component released into service

Inspection does not identify defect

Overhaul not undertaken

Regulator's inadequate maintenance oversight

Incorrect component installed

Incorrect installation

Inspection not undertaken

Ø = n occurrences with fatalities

44, 232, 8

8, 2, 23

4, 102, 1

4, 20, 11, 0

38, 4, 1

4, 165, 2

1, 88, 1

4, 0

2, 0

-50

0

50

100

150

200

250

300

0 10 20 30 40 50

Nu

mb

er

of

Fata

litie

s


Level 2 Fatal Accident Relationship

Engine

Flight controls

Instrumentation and indication

Structure

Insulation, Pressurisation and Windscreen

Landing gear

Electrical power

Workload

Steering

Fuel


23, 4, 1

22, 0, 1

18, 606, 11

15, 0, 1

13, 21, 3

8, 0, 1

7, 3, 1

4, 0, 1

1, 0

-50

50

150

250

350

450

550

650

750

0 10 20 30

Nu

mb

er

of

Fata

litie

s







Cabin Fume Event and IFSD


Review of Accidents & Serious Incidents – RESULTS

32, 209, 6

14, 391, 6

9, 111, 3

16, 115, 3

5, 10, 3

3, 47, 3

8, 169, 2

15, 155, 2

5, 107, 2

-50

0

50

100

150

200

250

300

350

400

450

-5 5 15 25 35

Nu

mb

er o

f Fa

talit

ies













44, 232, 8

8, 2, 23

4, 102, 1

4, 20, 11, 0

38, 4, 1

4, 165, 2

1, 88, 1

4, 0

2, 0

-50

0

50

100

150

200

250

300

0 10 20 30 40 50

Nu

mb

er

of

Fata

litie

s



Engine

Flight controls


Structure


Landing gear

Electrical power

Workload

Steering

Fuel


23, 4, 1

22, 0, 1

18, 606, 11

15, 0, 113, 21, 3

8, 0, 1

7, 3, 14, 0, 11, 0

0

100

200

300

400

500

600

700

800

0 5 10 15 20 25 30

Nu

mb

er

of

Fata

litie

s



Runway-related occurrence Diversion or Air Turnback Collision

LG-related occurrence Landing-related occurrence Structural damage

Fire Depressurisation Cabin Fume Event and IFSD



32, 209, 6

14, 391, 6

9, 111, 3

16, 115, 3

5, 10, 3

3, 47, 3

8, 169, 2

15, 155, 2

5, 107, 2

-50

0

50

100

150

200

250

300

350

400

450

-5 5 15 25 35

Nu

mb

er o

f Fa

talit

ies













23, 4, 1

22, 0, 1

18, 606, 11

15, 0, 1

13, 21, 3

8, 0, 1

7, 3, 1

4, 0, 1

1, 0

-50

50

150

250

350

450

550

650

750

0 10 20 30

Nu

mb

er

of

Fata

litie

s










44, 232, 8

8, 2, 23

4, 102, 1

4, 20, 1

1, 0 38, 4, 1

4, 165, 2

1, 88, 1

4, 0

2, 0

0

50

100

150

200

250

300

0 5 10 15 20 25 30 35 40 45 50

Nu

mb

er

of

Fata

litie

s



Engine Flight controls

Instrumentation and indication Structure

Insulation, Pressurisation and Windscreen Landing gear

Electrical power Workload

Steering Fuel


44, 232, 8

8, 2, 23

4, 102, 1

4, 20, 11, 0

38, 4, 1

4, 165, 2

1, 88, 1

4, 0

2, 0

-50

0

50

100

150

200

250

300

0 10 20 30 40 50

Nu

mb

er

of

Fata

litie

s



Engine

Flight controls


Structure


Landing gear

Electrical power

Workload

Steering

Fuel


23, 4, 1

22, 0, 1

18, 606, 11

15, 0, 1

13, 21, 3

8, 0, 1

7, 3, 1

4, 0, 1

1, 0

-50

50

150

250

350

450

550

650

750

0 10 20 30

Nu

mb

er

of

Fata

litie

s










32, 209, 6

14, 391, 6

9, 111, 3

16, 115, 3

5, 10, 3

3, 47, 3

8, 169, 215, 155, 2

5, 107, 2

0

50

100

150

200

250

300

350

400

450

0 5 10 15 20 25 30 35 40

Nu

mb

er

of

Fata

litie

s



Inadequate maintenance procedures Operator's inadequate maintenance oversight

Non-airworthy component released into service Inspection does not identify defect

Overhaul not undertaken Regulator's inadequate maintenance oversight

Incorrect component installed Incorrect installation



• DATA QUALITY / INTEGRITY (Occurrence Reporting)

• Will 376/2014 make a difference?

• We hope so but this will take a long time (5 – 10 years?)

• LACK OF HF/HP ANALYSIS IN OCCURRENCE / ACCIDENT

INVESTIGATIONS

• So far the data only enables us to categorise events

(occurrences / serious incidents / accidents) by outcome but not

by causation (particularly from continuing airworthiness /

maintenance perspective)

Conclusions from the two projects

Phase 1

Phase 2

Phase 3

Analysis of Occurrences, Serious Incidents & Accidents

Two MSc projects analysed data related to airworthiness events to identify

trends.

Collection of data at workshops around the world

We collected data from participants of workshops about the high risk areas in

continuing airworthiness and maintenance and the mitigation strategies. We

also asked them to prioritise the top categories from both projects

Interviewing executives / postholders in CAMOs/AMOsWe are asking them about the most significant risks in their own organisation

as well as across the entire industry. We also ask them about the most cost-

effective mitigation strategy that regulators can/should use to influence the

next EPAS.

An IFA Initiative – Demystifying the High Risk Areas in Airworthiness

FOUR KEY QUESTIONS

• Tell us the key risks in airworthiness / maintenance domain

(before they see the results of the studies conducted)

• Rank the top event categories (Occurrence Data Analysis)

• Rank the top event categories (Accident Data Analysis)

• Tell us the most significant risks and potential mitigation actions

PHASE 2 – DATA COLLECTION THROUGH WORKSHOPSDallas, Paris, Amsterdam, Hong Kong, Dubai

0

5

10

15

20

25

Installation/RemovalIncorrect - 16.2%

Scheduled tasks overdue -6.0%

Close up not performedcorrectly - 4.4%

Tools/parts/FOD left behind- 5.1%

Defect deferred withincorrect

procedure/reference/followup - 9.0%

CHC EASA CAT-CAG ICSC HKIE IFA Dubai

RANKING OF OCCURRENCE REPORTS CATEGORIES

CHC Safety & Quality Summit – Dallas - Oct 2018 ICSC Conference – Amsterdam – Nov 2018Hong Kong Institute of Engineers Airworthiness Course – HK – Nov 2018 IFA Conference & Workshops – Dubai – Nov 2018

Similar to Frenc hworkshop, partici pants ofeach worksho p wecollected data, ranked th eoccurrenc e reportscategories DIFFERENTL Y.There was no co nsensu son whic h ev ent categor ypresented the mo stsignificant risk.

0

5

10

15

20

25

Installation/RemovalIncorrect - 16.2%

Scheduled tasks overdue -6.0%

Close up not performedcorrectly - 4.4%

Tools/parts/FOD left behind- 5.1%

Defect deferred withincorrect

procedure/reference/followup - 9.0%



Similar to French workshop, participants of each workshop we collected data,

ranked the occurrence reports categories DIFFERENTLY. There was no consensus

on which event category presented the most significant risk.

RANKING OF OCCURRENCE REPORTS CATEGORIES


0

5

10

15

20

25

30

35

Operator'sinadequate

maintenanceoversight

(14, 391, 6)

Inadequatemaintenanceprocedures(32, 209, 6)

Inspection does notidentify defect

(16, 115, 3)

Incorrectinstallation(15, 155, 2)

Inspection notundertaken(5, 107, 2)

Non-airworthycomponent

released to service(9, 111, 3)


(16, 115, 3)

Incorrectcomponent

installed(8, 169, 2)


In the case of acciden ts/seri ous incide ntscategories , the p articipa nts mai nlyindicated that high est num ber of fa talaccidents a nd fataliti es shoul d be prior ityfor taking mitigation actions.

RANKING OF ACCIDENTS/SERIOUS INCIDENTS CATEGORIES


0

5

10

15

20

25

30

35

Operator'sinadequate

maintenanceoversight

(14, 391, 6)

Inadequatemaintenanceprocedures(32, 209, 6)


(16, 115, 3)

Incorrectinstallation(15, 155, 2)

Inspection notundertaken(5, 107, 2)

Non-airworthycomponent

released to service(9, 111, 3)


(16, 115, 3)

Incorrectcomponent

installed(8, 169, 2)


In the case of accidents/serious incidents categories, the participants

mainly indicated that highest number of fatal accidents and fatalities

should be priority for taking mitigation actions.

RANKING OF ACCIDENTS/SERIOUS INCIDENTS CATEGORIES

• Installation ErrorsFailing to follow procedures

• Personnel / Skills ShortageGrowth outpaces supply (Despite ICAO NGAP)

• New Technology Inevitably Brings Complexity Effectiveness of training

• Commercial Pressure (Self-induced & Management)Internal and External Factors (Legislation vs Management Style / Business Model etc.)

CONCLUSIONS FROM WORKSHOPS DATA ANALYSIS

KEY ISSUES & CAUSAL FACTORS

Failing to Follow Procedures – FAA Initiative

Please ask your colleagues (CAMOs / AMOs) to participate or

let me know if you wish to have a discussion.

[email protected]

(30 minutes – 5 questions) interview

Thank you

for your attention

Clarification on Mx Factors Coding

HF's 9Inadequate training 2

Lack of training 2

Maintainer fatigue 2

Misleading paperwork 1

Poor resource planning 1

Time pressure 1

Inadequate mx 53

Inadequate instructions 5

Inadequate mx documentation 8

Inadequate mx procedures 31

Inadequate reporting 2

Part missing 5

Part not reattached 1

Part not secured 1

Incorrect mx 54

Incorrect adjustment 8

Incorrect assembly 5

Incorrect component installed 8

Incorrect installation 16

Incorrect procedure 15

Incorrect rigging 2

Inspection 29

Inspection does not identify defect 12

Inspection not undertaken 5

Insufficient inspection 9

NFF 3

Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be:

Page 2 of 6DEN04LA023the operator's improper maintenance and servicing of the airplane's nose landing gear assembly,

resulting in the collapse of the nose landing gear during the landing roll. Contributing factors include the nose section of the

airplane's subsequent contact with the runway, the impact of several fractured propeller pieces into the fuselage, and the

operator's inadequate maintenance and servicing procedures

EXAMPLE OF ‘INADEQUATE MAINTENANCE”

Next Steps to Influence EPAS

“We risk becoming preoccupied with high-frequency/low-consequence things:not wearing safety glasses; having coffee in a cup without a lid. Then wemistake low counts on these for a safety culture—low counts that we tabulate,share with stakeholders, and celebrate. The fiction is that we have a safetyculture because we have low numbers on irrelevant things, and the paperworkto show it.And then we blow stuff up.”

Sidney Dekker

Source: http://www.safetydifferently.com/safety-culture/

http://www.safetydifferently.com/safety-culture/

“We risk becoming preoccupied with high-frequency/low-consequence things: not wearingsafety glasses; having coffee in a cup without a lid. Then we mistake low counts on thesefor a safety culture—low counts that we tabulate, share with stakeholders, and celebrate.The fiction is that we have a safety culture because we have low numbers on irrelevantthings, and the paperwork to show it. And then we blow stuff up.”

Sidney Dekker

Source: http://www.safetydifferently.com/safety-culture/

http://www.safetydifferently.com/safety-culture/

RESEARCH STUDY - Review of Accidents & Serious IncidentsCONSEQUENCES OF OVER-REGULATING

The challenge

• Thesis project was set up, using a download from the ECR that included raw (anonymous) data for 7158 incident reports (2012-2016).

• Aim was to see if this data could be used to:

• Find a top-10 of safety issues in aviation maintenance

• Compare this to previous analysis

• The idea was that this huge collection of reports would show us which areas of the maintenance process are more susceptible to errors.

The project itself…

1. Initial analysis on the download.

2. Background research into maintenance errors, possible taxonomies.

3. Structuring and analysing the data.

4. Develop a taxonomy that fits the brief for this project.

5. Evaluate the taxonomy and validate the method.

1. Initial analysis• Practical issues: 3 different worksheets, 2 categorisations

(Outcomes and Causal & Contributory, or ‘event type’, factors), line numbers in the three sheets did not match up due to multiple categories per incident.

• Excel workbook was built so that the data from three sheets could be collated on one page, with options to either exclude the incident record, or categorise it.

1. Initial analysis - continued

• A large percentage of reports could not be used (68% of 3912 reports). Main reasons:

• Narrative is empty (28%)

• Language not in English (21%)

• Not enough information in narrative (8%)

• Incident is not related to maintenance (5%)

• Inclusion of incidents like these may be due to the categorisation: ‘Maintenance Inspections / Controls / Servicing’

22/07/2014 Airbus A330According to the report(s) received by FCAA, incorrect defect logging procedures were used.

03/08/2014 Boeing 757When a crew member reached for the handle on the entrance door on station two to close the door, and stepped out on the stair outside it started to move away from the aeroplane.

2. Possible taxonomies

• Several options:

• CAA paper 2009/05 (developed for analysing MORs)

• CAP 1367 (modified from above)

• MEDA (Boeing tool to investigate maintenance events)

• HFACS-ME (US Naval Safety Center, to investigate HF causes in maintenance events)

• The first two looked promising, but turned out to be restricted in the level of detail available.

• Both MEDA and HFACS are more suited to an immediate investigation than a retroactive analysis of reports.

CAA paper 2009/05

• Very broad first level categorisation

• Most detail available for Maintenance Control category

• Other categories remain sketchy in their descriptions

• Level of detail limited due to lack of information in MORs

CAP 1367 taxonomy

• Level 1 only

• More detail available than in CAA

2009/05

• Definitions may not be appealing

to a reporter

• No further definitions behind

these categories available in

report

Maintenance Occurence

Part-M

Installation error

Approved data not followed

Servicing error

Poor troubleshooting standards

Poor maintenance practices

Poor inspection standards

Misinterpretation of approved data

MEDA (Boeing)

• Tool was developed to investigate maintenance events

• Further level of detail available to narrow down the event

• Some categories are more about the outcome than the cause (5-7)

Major categories:

1. Installation failure

2. Servicing failure

3. Repair failure

4. Fault isolation, test, or inspection failure

5. Foreign object damage/debris

6. Airplane or equipment damage

7. Personal injury

8. Maintenance control failure

9. Other…

HFACS-ME (US Navy – modified)

• Tool was developed from original HFACS model to investigate maintenance events

• Two further levels of detail available to narrow down the event

• Requires the user to evaluate as well as report the facts

• Aimed more at evaluating supporting conditions than pure facts

Major categories:

1. Management conditions (latent)

2. Maintainer conditions (latent)

3. Working conditions (latent)

4. Maintainer acts (active)

2. Possible taxonomies

• Points to keep in mind for a good taxonomy (Wiegman & Shappell, 2001):

• Reliability

• Comprehensiveness

• Diagnosticity

• Usability

• Validity

• In this case the taxonomy had to work well in two situations:

1. Input (as report)

Taxonomy2. Output (to

MX organisations)

1.

2.

4. Custom taxonomy

1. Base the taxonomy on familiar descriptions and the maintenance process (level 1):

2. Make sure that there is sufficient level of detail in the second level (67 different options provided).

The purpose is to categorise what went wrong, most reports do not allow analysis of the causes.

Job access/job

set-up

Working practices

Troubleshooting

Lubrication/servicing

Inspection/testing

Installation/removal

Modification/repair

Activation/deactivation

Job close-up

Maintenance documentation

Parts supply/tracking

/life limitsTools

Maintenance Control

4. Custom taxonomy

• Ideally, a taxonomy creates separate categories where one report fits into a single category only.

• This turned out to be impossible without sacrificing comprehensiveness.

6.1 Incorrect procedure used or procedure applied incorrectly

10.1 Installation/

removal incorrect

10.9 Wrong fastener

used

10.3 Part missi

ng

1.

3.2.

01/04/2013 Boeing 737After replacement of HMU on l/h engine the engine actuator test was performed with the fuel spar valve closed, not iaw maintenance manual. Then an engine idle run was performed and aircraft was returned to service. The actuator test without fuel supply can be the reason for the engine fuel pump fail.

04/04/2013 Boeing 737C/B for FWD door area heater found popped. T/S revealed that connectors to heater M2174 on R FWD overwing exit was wrongly connected.

07/05/2013 ATR 42Engineer was tasked with changing the unserviceable T6 thermocouple from LH engine. Upon removing the cover plates to gain access, it was found that the thermocouple was missing.

17/05/2013 Boeing 737Data plates attached to engines using rivets drilled into fan case flanges. Modification documentation calls for 20 gauge locking wire.

4. Custom taxonomy

• <Discuss printed taxonomies>

Broad spectrum categories are always at the top and coloured.

As a tip, other categories to consider may be provided in third column.

Contrasting Safety Theories

High Reliability Theory• Accidents can be prevented through good organizational design and management.

• Safety is the priority organizational objective.• Redundancy enhances safety: Duplication and overlap can make "a reliable system out of unreliable parts."

• Decentralized decision-making is needed to permit prompt and flexible field level responses to surprises.

• A "culture of reliability" will enhance safety by encouraging uniform and appropriate responses by field-level operators.

• Continuous operations, training, and simulations can create and maintain high reliability operations.• Trial and error learning from accidents can be effective, and can be supplemented by anticipation and simulations.

The competing safety perspectives between Sagan's postulated "High

Reliability Theory" and "Normal Accidents Theory" led by Professor

Charles Perrow are listed below. The summary material provides a

framework for thinking about safety and aviation system efficiency.

Normal Accidents Theory• Accidents are inevitable in complex and tightly coupled systems.

• Safety is one of a number of competing objectives.• Redundancy often causes accidents: it increases interactive complexity and opaqueness and encourages risk - taking.

• Organizational contradiction: decentralization is needed for complexity, but centralization is needed for tightly coupled systems.

• A military model of intense discipline, socialization, and isolation is incompatible with democratic values.

• Organizations cannot train for unimagined, highly dangerous, or politically unpalatable operations.• Denial of responsibility, faulty reporting, and reconstruction of history cripples learning efforts.

https://books.google.co.uk/books?id=QrFBDgAAQBAJ&lpg=PT12&ots=vKNxJZQTzp&dq=patterns in safety thinking google book&pg=PP1#v=onepage&q=patterns%20in%20safety%20thinking%20google%20book&f=false

High Reliability Theory• Accidents can be prevented through good organizational design and

management.

• Safety is the priority organizational objective.

• Redundancy enhances safety: Duplication and overlap can make "a reliable system out of unreliable parts."

• Decentralized decision-making is needed to permit prompt and flexible field level responses to surprises.

• A "culture of reliability" will enhance safety by encouraging uniform and appropriate responses by field-level operators.

• Continuous operations, training, and simulations can create and maintain high reliability operations.

• Trial and error learning from accidents can be effective, and can be supplemented by anticipation and simulations.

The competing safety perspectives between Sagan's postulated "High

Reliability Theory" and "Normal Accidents Theory" led by Professor

Charles Perrow are listed below. The summary material provides a

framework for thinking about safety and aviation system efficiency.

Normal Accidents Theory• Accidents are inevitable in complex and tightly coupled systems.

• Safety is one of a number of competing objectives.

• Redundancy often causes accidents: it increases interactive complexity and opaqueness and encourages risk- taking.

• Organizational contradiction: decentralization is needed for complexity, but centralization is needed for tightly coupled systems.

• A military model of intense discipline, socialization, and isolation is incompatible with democratic values.

• Organizations cannot train for unimagined, highly dangerous, or politically unpalatable operations.

• Denial of responsibility, faulty reporting, and reconstruction of history cripples learning efforts.

Contrasting Safety Theories

https://books.google.co.uk/books?id=QrFBDgAAQBAJ&lpg=PT12&ots=vKNxJZQTzp&dq=patterns in safety thinking google book&pg=PP1#v=onepage&q=patterns%20in%20safety%20thinking%20google%20book&f=false

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