air accident investigation sector - ssp and air accid… · • the uae aais investigates all...
TRANSCRIPT
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AIR ACCIDENT INVESTIGATION SECTOR
Ismaeil Al Hosani ADG- Air Accident Investigation Sector
11/23/2015 AAIS, October 2015- SST, Cairo 1
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Objectives At the end of this presentation, the attendees will know about the AAIS: Legislation Structure Responsibilities Main processes Software Strategic activities New capabilities Integration with the UAE SSP
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Legislation Tiers
AAIS’s Procedures
Civil Aviation Law No. 20 of 1991 Ch. 7- Aircraft Accidents
Civil Aviation Regulations CAR Part VI, Ch. 3- Air Accidents
and Incidents Investigation
Publications
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GCAA Structure
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Ismaeil Abdel Wahed Assistant Director General - AAIS
AAIS Structure
Ibrahim Al Addasi Chief Investigator
Darren Straker Chief Investigator
Mohammed Al Kayat Senior Investigator
Abdelati Al Fadil Senior Investigator
Fazal AliBaksh Senior Investigator
Elias Nikolaidis Chief Investigator
Usman Karappath Administration Senior Officer
Naser al messabi Technical Assistant
Khalid Al Raisi Director –
Air Accident Investigation
Thomas Curran Chief Investigator
Mariam Al Hussaini Administration Assistant
Jeremias Malaihollo Senior Investigator
Muna Dewani Executive Assistant
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AAIS Mandate
• Establish, maintain and update air accident investigation policies and procedures
• Conduct investigations of aviation accidents and incidents which occur within the UAE territories in accordance with annex 13
• Participate to investigations outside UAE territories if UAE-registered aircraft is involved
• Share knowledge with the national and international accident and incident investigation community
• Publish the results of investigations • The UAE AAIS investigates all accidents and selected serious
incidents in the UAE territory and when A6- registered aircraft are involved in events outside the UAE territories
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Strategic Activities
• MENASASI • ICAO initiative: RAIO • ICAO AIGP
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MoUs Agreements with: • TSB, Canada • AAIB, the United Kingdom • IAC, Regional Organization • BEA, France • AAIB, Singapore • Civil Aviation Affairs, Kingdom of Bahrain • Central Directorate for Accidents, Egypt • Central Directorate for Accidents, Sudan • CARC, Jordan • Falcon Air Services, UAE (For air transportation to the accident site) • ADAT, UAE • AAIB, the United Kingdom • Ministry of Interior, UAE • Civil Defence, Dubai, UAE • Armed Forces, UAE
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Investigation Software
• INVESTIGATION SMART MANAGER (ISM) • ECCAIRS 5 • Q-PULSE • FLIGHT RECORDERS
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Investigation Smart Manager (ISM) Investigation Smart Manager
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• Small Unmanned Aircraft for Accident Site Aerial Imagery • Flight data analysis “Plane Sciences” • Laser scanner for accident site “FARO”
AAIS New Capabilities
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Flight Data Analysis • The original owners of Flightscape, formed Plane Sciences primarily to
provide flight data subject matter expertise to the aviation community with focus on accident investigation and prevention.
• Recently, Flightscape is focusing more in Flight Data Monitoring software
• FAS (flight data analysis software) integrates/interfaces with COTS solutions to take maximum advantage of high volume affordable applications such as Google Earth, X-plane, MATLAB, Excel, iCharts and Adobe Illustrator that can be bought and used
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Laser Scanner
Mount on a tripod
Rotate 360 degrees
Digitally record everything within about 300 feet
Accurately correlating the time for the signal to return to help build not only 3-D still photos
Digital simulations of past events
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FAS Features
– Google Earth and X-Plane 3D visualization
– Synchronized animation, plot, list, audio and video
– Excel audio transcription template for subtitles
– FAS can be executed over the web for disseminating animations without any resident software required
– The worlds largest library of data-maps (older and new flight data map and configuration are available)
– FAS is the only software in the world that uses FRED (Flight Recorder Electronic Documentation) natively (it does not require FFD file as the Flightscape)
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Benefits
The data gathered from the scanners can be digitally reassembled to provide information accurate enough to measure tire skid marks or even the deformation of damaged object.
The digital scanners also mean that simulations can offer viewers the opportunity to put themselves at any location to observe what occurred before or during an accident.
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Main Processes
• DI Notification • Initial Investigation • File Opening Decisionmaking • Investigation • Report Making • Safety Recommendations
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AAIS, October 2015- SST, Cairo 19
Sends emails to the DAAI and cc:
ACCID DI_ Notification
Calls DAAI, and get instructions
for calling or emailing the DI-
Notifications group
Is the occurrence accident
or serious Incident?
Departs to the site
Communicates with the Site
Safety providers or delegates to AAI investigator
Arrives to the site, custody
Hands over the site to the IIC
Completes online 035
Notifies the States Other States
Completes online 035
DI receives a call
NO YES
DI
IIC
DI Notification Process
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File Opening Decision-making
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Review Reading
Corporate Communication Confirmation
Consultation Sector’s Approval
Approvals
Draft report is completed by the
IIC and Team
Made Public
Report Making Process
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AAIS Reports
• Preliminary Report
• Interim/Progress Report
• Final Report
• Summary Report
• Safety Study Report
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AAIS web site http://www.gcaa.gov.ae/en/departments/airaccidentinvestigation/pages/default.aspx
AAIS, October 2015- SST, Cairo
Website: www.gcaa.gov.ae
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Fokker MK.050 EP-LCA
Date: 10 FEBRUARY, 2004 Location: 2.6 nm final to Sharjah International Airport, United Arab Emirates Runway 12 . Probable Cause : The Investigation team determined that most probable cause of the accident that The power levers were moved by a pilot from the flight idle position into the ground control range, which led to an irreversible loss of flight control. Injuries: There were a total of 43 fatalities and 3 survivors. Nature of Damage: Most of the aircraft was completely destroyed on impact and only the tail section was relatively intact.
Major Accidents
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Augusta Westland AB139 -A6-BBB
Date: 3rd of June 2008 . Location: Near Al Futaisi Island, Abu Dhabi-UAE. Probable Cause : The Investigation team determined that most probable cause of the accident was human factor due to crew disorientation following an unusual attitude. Injuries: All crew members including the three passengers were fatally injured (2 Crew+ 3 Passenger = 5 ). Nature of Damage: The aircraft was totally destroyed and its wreckage scattered over the shallow water.
Major Accidents
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Bell 212, A6-ALV
Date: September 3rd, 2008. Location: Rashid Drilling Rig, MAERSK RESILIENT , Dubai –UAE. Probable Cause : The Investigation Team determined that the most probable cause of this accident has to be identified as loss of situational awareness due to loss of visual reference and the inability to determine the correct attitude of the Helicopter and react to this condition. Injuries: All crew members including the Five passengers were fatally injured (2 Crew+ 5 Passenger = 7 ). Nature of Damage: The aircraft was totally destroyed as a result of significant impact forces and subsequent fire.
Major Accidents
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• Date: 21 October 2009. • Location: 1.6 kilometers from the end of
runway 30 (threshold of RWY 12), Sharjah International Airport.
• Probable Cause : the departure of the No. 4 engine core cowls;
• the consequent disconnection of No. 4 engine EPR Pt7 flex line;
• the probable inappropriate crew response to the perceived No. 4 engine power loss;
• the Aircraft entering into a stall after the published maximum bank angle was exceeded; and
• the Aircraft LOC that was not recoverable. • Injuries: All 6 crew members were fatally
injured . • Nature of Damage :Aircraft completely
destroyed by ground impact and consumed by fire.
Boeing 707-330C, ST-AKW
Major Accidents
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• Date: 03 September 2010. • Location: nine nautical miles south west of
Dubai International Airport,Dubai. • Probable Cause : The uncontained cargo fire
directly affected : • the control cables and toxic smoke into the cockpit
area, affecting the visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels, and the view outside the cockpit which prevented the pilots from seeing anything, including the checklists , flight display warnings and the radio panels.
• the crew oxygen system, leading to an over heat failure which caused the Captain to be incapacitated due to toxic smoke poisoning.
• Injuries: the 2 crew members were fatally injured .
• Nature of Damage :Aircraft completely destroyed by ground impact and consumed by fire.
Boeing 747-44AF, N571UP
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Safety Recommendations Process
Send/forward to
GCAA SA
Organization All SRs entered and followed-up via Q-
Pulse
The State AAIA or NAA or ICAO
SR issued by AAIS or received from a foreign authority
The addressee provides his
response
The IIC makes his decision on the
response and status
Update the Q-Pulse
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Detailed SR Process
AAIS, October 2015- SST, Cairo
Annex 13 Investigation /
Safety Study
SR addressed to GCAA SA and/or GCAA
Certificate Holder
Occurrence Accident/ Incident
SR response
queried or accepted by AAIS
SR response queried or
accepted by State AAIA
SR sent to the State AAIA or NAA or ICAO
for action
State SSP
GCAA SA receives SRs
from PRP
SRs remains open/accepted
fully/accepted in part or
AMC/rejected
NO
YES: GTP14
All SR Status
NO
YES
NO
YES
GCAA Cert Holder
receives/ respond to SRs
SRs Issued by State AAIA conducting the investigation
YES
Feedback
AAIA- Air Accident Investigation Authority AAIS- GCAA Air Accident Investigation Sector NAA – State National Aviation Authority GCAA SA – GCAA Safety Affairs SSP – State Safety Program
YES/No: Info to All SRs
entered and
follow-up via Q-Pulse
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SR Process in Qpulse
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SR Process in Qpulse
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SR Process in Qpulse
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SR Process in Qpulse
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Integration with the UAE SSP
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1. State’s Safety Policy and Objectives. a. Safety Standards b. Safety Responsibilities and Accountabilities c. Accident and Incident Investigation d. Enforcement Policy
2. State’s Safety Risk Management a. Safety Requirements for Service Providers SMS b. Approval of Service Providers Acceptable Levels of Safety
3. State’s Safety Assurance a. Safety Oversight b. Safety Data Collection, Analysis and Exchange c. Safety Data Driven Targeting of Oversight on Areas of Greater Concern or Need
4. State’s Safety Promotion a. Internal Training, Communication and Dissemination of Safety Information b. External Training, Communication and Dissemination of Safety Information
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Air Accident Investigation Sector
Serious Incident
- Draft Final Report -
AAIS Case No: AIFN/0016/2014
Fire in the Passenger Cabin
Operator: Make and Model: Nationality and Registration: Place of Occurrence: State of Occurrence: Date of Occurrence:
Integration with the UAE SSP
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Integration with the UAE SSP
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Thank you for your attention
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