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Safety Regulation Commission

Annual Safety Report 2016

EUROCONTROL

SRC Annual Safety Report 2016 ■ page 3

FOREWORD BY KARSTEN TILENDA, SRC CHAIRMAN

The SRC’s 2016 Annual Safety Report builds on EUROCONTROL’s safety measurement techniques and presents enhanced trend information on the safety performance of the ATM system.

Overall, the data for 2015 shows an increase in the total number of reported ATM-related incidents compared with 2014. In addition, the analysis of the achieved levels of safety shows that the ECAC safety objective continues to be met for accidents with ATM contribution.For the second consecutive year, the Report includes analysis based on data submitted by 40 Member States. The achievement of reaching such a high level of reporting is in no small way the result of the dedication of the SRC’s Safety Analysis Team and the national AST Focal Points and their advisors. However, the noted lack of sufficient resources and qualified staff at national level allocated to the tasks in safety data collection, coding, assessment and analysis remains a priority factor of concern. It should be noted that these capabilities cannot, and will not, be quickly improvised if safety suddenly becomes a key issue in the context of new developments.

Overall, that effort contributed to a number of improvements at national level (e.g. improved coding, completion of ATM data, RAT classification) and also helped to find solutions for the submission of complete and quality AST reports over the past months.

In addition to the extra effort made in the working interfaces with Member States, the SRC has also been able to maintain the robustness of the AST data validation process. Such validation is based on a direct interface with those involved at national level and the thorough and dedicated technical assessment of the data received.

As a result, the SRC is in position to underline the high reliability of the AST data. It is the view of the SRC that this provides EUROCONTROL with a solid platform for further developments in the field of ATM safety analysis.

It is the intention of the SRC and the Agency to maintain that added value and progress further enhancements, notably in regard to the alignment of the AST reporting mechanism with the requirements contained in Regulation (EU) No. 376/2014.

2015 occurrences vs rolling 3-year average (normalised per million flight hours)

Average (2012-2014)2015

Average 2012-2014 - 897.9Average 2015 - 548.9

450

400

350

300

250

200

150

100

Aircraft deviation from applicable ATM regulation

Aircraft deviation from ATC clearance

Aircraft deviations from applicable published ATM

procedures

Deviations from aircraft ATM-

related equipment

carriage and operations, as mandated in applicable

regulation(s)

Inadequate separation

Level Bust (LB) Near Controlled Flight Into

Terrain (CFIT)

Prolonged Loss of Communication

(PLOC)

Runway excursion by aircraft

Runway incursion

Separation minima

infringement

Unauthorised penetration of

airspace

50 47.5 40.3

0

316.3

131.9

71.7 71.878.7 75.7

5.6 3.1

34.7 34.7

7.1 5.4

96.089.7

151.8 150.2

306.4

282.0

3.6 10.0

97.7

389.2

CONTENTS

FOREWORD 3

CONTENTS 5

CHAPTER 1 – ATM SAFETY PERFORMANCE 6

General Considerations 6

Evolution of the AST Mechanism 6

Reporting Levels and Under Reporting 7

CHAPTER 2 – DETAILED ANALYSIS OF OCCURRENCE DATA 8

Completeness of AST Data 9

Severity Classification of ATM Incidents 9

Accidents 10 Accident Categories 10 Accidents with Direct and Indirect ATM Contribution 11

ATM-Related Incidents 12 General Trends 13

Separation Minima Infringements 15

Runway Incursions 16 Feedback from EVAIR on Runway Incursions 17

Unauthorised Penetrations of Airspace / Airspace Infringements 18

Aircraft Deviations from ATC Clearance 20

Level Busts 22 Feedback from EVAIR on Level Busts 23

Near Controlled Flight into Terrain (Near CFIT) 24

Laser Interference 25

Remotely Piloted Aircraft Systems (RPAS) / Drones 27

ATM-Specific (Technical) Occurrences 28 Communications 28 Surveillance 29 Flight Data Processing and Distribution 29

ANNEX 1 – PERFORMANCE SCHEME REGULATORY FRAMEWORK 30


CHAPTER 1 ATM SAFETY PERFORMANCE

GENERAL CONSIDERATIONS

Based on the Annual Summary Template (AST) reporting mechanism, run since its inception in 2000, this report contains the analysis of ATM Safety Performance, with a record 40 EUROCONTROL Member States submitting their AST reports to EUROCONTROL’s Safety Regulation Commission (SRC) by the end of September 2016.

This is yet again a remarkable achievement that was only made possible through continuous hard work, dedication and cooperation of the AST Focal Points and their advisors. This has even a greater value when considering the scarce resources available in this area in many Member States and also the continuous changes of the FP positions.

Only one EUROCONTROL Member State did not report the AST, although in terms of aggregated ATM safety occurrence data, it does not greatly affect the results of the analysis presented in this report.

EVOLUTION OF THE AST MECHANISM

For more than 15 years, the AST has been the mechanism run by EUROCONTROL to collect mandatory safety data of ATM-related occurrences taking place in the airspace of the EUROCONTROL Member States, in accordance with the CN Decision No. 80 of 12 November 1999, as amended by CN Decision No. 115 of 02 December 2009.

Following the implementation of EU Regulation No. 376/2014 on 15 November 2015, EU Member States had to adapt their national occurrence reporting systems in order to meet the new regulatory basis.

The expected evolution of the AST mechanism addresses, among other features, the extension of the current list of reportable types of ATM related occurrences, on voluntary basis, to ensure a level playing field for EU and Non-EU EUROCONTROL Member States in the ATM domain.This proposal has already approved by SRC53 in September 2016 and expected to be implemented starting with the 2017 Annual Safety Report.

This approach is fully in line with the discussions held between EUROCONTROL, EASA and the EC concerning the ‘Roadmap for Safety’ following the PC44 decision. According to this, the AST mechanism shall continue, in the current format, until the end of RP2 with a view to allow the European Central Repository (ECR) the necessary time to increase the quality of its safety occurrence data in the ATM domain.

In 2013, first time after a continuous increase in the number of ATM related occurrences reported by the Member States, a decrease of almost 17% compared to the previous years was noted, despite the slight increase of the traffic levels (0.4%). This trend continued in 2014 (8%) followed by slight increase in 2015 (4.4%).

However, as in the previous years’ reports, a considerable gap remains between the average ECAC reporting rate and the Member States reporting at the highest levels.


REPORTING LEVELS AND UNDER REPORTING

The reporting levels are measured by normalising the total number of ATM-related incidents as reported by a Member State against the number of flight hours (movements for Runway Incursions). The number of ATM – related incidents used in the analysis is derived directly from the AST reports submitted to EUROCONTROL.

The ‘level of reporting’ not only measures the reporting maturity, but also the effectiveness of the national safety data flows which allow the AST Focal Points to have all the data available for their reports. EUROCONTROL supports the Member States in this field, by providing appropriate tools and training (e.g. e-Tokai, RAT, EASTER) for improving the data coding, quality, completeness and consequently the national and European safety data flows.

In previous years the subject of under reporting was brought to the attention of both the SRC and the Provisional Council (PC). Consequently, following a period of monitoring and measuring, it was observed that many Member States increased their reporting levels in comparison with previous years.

Current vs. possible reporting levels Number of occurrences per million flight hours

Average best 3 reporters (2001-2015)

Average ECAC rate

200920082007200620052004200320022001 2010 2011 2012 2013 2014 2015

0

1000

4000

3000

2000

5000

6000

7000

Impr

ovem

ent O

ppor

tuni

ty

CHAPTER 2 DETAILED ANALYSIS OF OCCURRENCE DATA

page 8


It is to be noted that there is a continuous decrease in the percentage of SMI that were either severity not classified or Severity Category D (Not Determined) from 24% in 2012 to 3% in 2015. The same trend is seen also for the RI where the severity not classified or Severity Category D (Not Determined) occurrences decreased from 36% of the total number in 2011 to 8-9% in 2014 and 2015.

This evolution could be related to the obligation of the Member States to use the RAT Methodology for the determination of these types of occurrences in the scope of the Performance Scheme Regulation.

It is interesting to note that, in case of other types of ATM related safety occurrences where the use of the RAT methodology is not mandatory, despite the descending trend, in 2015, the percentage of the occurrences either severity not classified or Severity Category D (Not Determined) is much higher amounting to 19-20% of the total number of such occurrences.

In conclusion, the number of incidents where the severity is not classified, as reported through the AST mechanism, has shown a remarkable decrease compared with the previous years. Nevertheless, continued and sustainable effort shall be put in place by the Member States to ensure that the number of ATM related occurrences not severity classified, continues to decrease.

The availability of adequate resources for coding reported ATM-related occurrences and their data-entry into the national databases is critical for the analysis performed by each Member State and, in particular and the EUROCONTROL Safety Analysis Team at the ECAC level.

Percentage of occurrences severity NOT classified or NOT determined

2011 2012 2013 2014 2015

0%

10%

30%

20%

40%

50%

60%

SMIRIISUPACLR

2015 completness of the AST data

Empty

Not collected

Total number of occurrences

ATM contribution

Airspace class

Flight rules

Phase of flight

Type of flight

Type of operations

0

5000

10000

15000

20000

25000

COMPLETENESS OF AST DATA

The chart below illustrates the situation with respect of the completeness of the safety occurrence data submitted by the Member States via the AST Reporting.

SEVERITY CLASSIFICATION OF ATM INCIDENTS

To allow for full visibility of the actual risk levels, it is of vital importance that ANSP’s and Member States apply and report consistent severity assessment of ATM occurrences in order to achieve any meaningful safety analysis at national and European level. The analysis of the level of severity assessment of ATM-related occurrences as reported through the AST reporting mechanism has initially indicated that these assessments were deteriorating in numbers. As signposted before in the actions taken, as approved by the EUROCONTROL Provisional Council, the number and completeness of severity assessments is subject to continuous monitoring and as such this section provides the latest update based on the data submitted for 2015.

The graph shows the number of ATM-related incidents not severity classified for different types of safety occurrences.

It is to be noted with concern that some of the basic safety data required by the AST mechanism is not included in the filed reports. As such, ‘Type of Flight’ and ‘Type of Operations’ is either missing or ‘Not collected’ in over 60% of the reported occurrences.

ACCIDENTS

Based on the AST reports submitted by a record number of 40 Member States and the data available from ICAO (covering all ECAC States), 85 accidents were reported out of which 18 accidents were fatal.

Contrary to the previous years (2012-2013) where none of the reported accidents had either a direct or indirect ATM contribution (for accidents involving aircraft above 2,250 kg MTOM), in 2015, one accident had a direct ATM Contribution. It is a non-fatal ground collision where the aircraft involved were destroyed.

Accidents with direct + indirect ATM contribution

Accidents with direct ATM contribution

ECAC traffic levels

Linear (Accidents with direct + indirect ATM contrubution)

MID-AIR collisions

Controlled Flights Into Terrain (CFIT)

GND-aircraft

Airborne-ground

GND-aircraft/other

Total

Number of accidents per category (aircraft with MTOW above 2250 kg)

2011 2012 20152013 2014

0 0

5 25

10 50

15 75

20 100

Accident CategoriesThe graph opposite presents the number of accidents in the categories that are specifically tracked in the AST reporting system. The data for 2015 shows that the most significant accident category is ‘Collisions on the ground between a/c and vehicle/person/obstruction(s)’, with 11 accidents reported. The following main category is ‘CFIT’ with 7 reported accidents.

Accidents in ECAC with ATM contribution and traffic levels – aircraft above 2250kg MTOM

20102009 2011 2012 2013 2014 2015

0 0

5

11

2

11

5,000,000

10 10,000,000

15 15,000,000

20 Number of accidents Flight hours 20,000,000


Accidents with direct + indirect ATM contribution

Accidents with direct ATM contribution

ECAC traffic levels

Linear (Accidents with direct + indirect ATM contrubution)

It should be noted that almost three quarters of the reported accidents were put in the category ‘Other’. For future reporting sessions, the DPS/SSR Safety Analysis Team will further support Member States in improving the quality of accident coding in the national databases in co-operation with the Safety Investigation Authorities and other national stakeholders. Overall, 18 accidents were indicated as being fatal. Three fatal accidents were placed in category CFIT, 1 accident was catego-rised as a Ground collision, 2 accidents as ‘Collisions between airborne a/c and vehicle/another a/c on the ground’ and 12 accidents were marked in the category ‘Other’.

None of the reported fatal accidents have been indicated as having an ATM contribution. The number of fatal accidents is in line with the levels reported during the previous 4 years, varying from 16 to 18 events.

Accidents with Direct and Indirect ATM ContributionThis Report covers accidents involving aircraft above 2,250 kg MTOM, irrespective of whether the ATM domain contributed to the event or not.

The safety data submitted by the Member States via the AST reporting mechanism in 2015, and the available information and datasets from ICAO, indicate a total of 91 accidents involving air-craft above 2,250 kg MTOM, out of which 18 were fatal.

The crash of the German Wings flight number 9525 that took place on 25 March 2015 in the French Alps is not included in the fatal accidents statistics.

In the context of traffic levels increasing again (by 2%) compared to 2014, it is important to note that, in 2015 compared with the previous year, one of the reported accidents had a direct ATM contribution. This non-fatal accident was classified as a collision on the ground and caused structural damage to the aircraft involved.

Total vs fatal number of accidents

2011 2012 2013 2014 2015

0

25

50

75

100

TotalFatal

Accidents in ECAC with ATM contribution and traffic levels – aircraft above 2250kg MTOM

20102009 2011 2012 2013 2014 2015

0 0

5 5,000,000

10 10,000,000

15 15,000,000

20 Number of accidents Flight hours 20,000,000

11

2

11

ATM-RELATED INCIDENTS

The classification of ATM-related incidents is based on the severity of their effect on the safe operation of aircraft and occupants.

Following the decrease in the previous two years in the number of ATM related occurrences reported via the AST mechanism, an increase of 4.4% is noted in 2015. If we consider the traffic growth, the increase is only 2.42%. The number of ATM-related occurrences is at a lower level than the first 3 years of the period analysed below. The reason for this decrease is mainly linked to an increased ability of the EUROCONTROL Safety Analysis team to better separate the ATM related occurrences from the ADREP based repository covering all aviation domains.

In respect of the evolution of the risk posed by the reported incidents on the ATM system, it is to be noted that there is a small (5%) decrease in the number of reported serious incidents whilst the major events have increase by the same amount (5%). Increases have been seen in other occurrence categories as well. The number of the incidents not severity classified has seen an increase compared with the previous year’s data (5.4%).

Taking into account the entry into force of Regulation (EU) No. 376/2013 on 15 November 2015, in a number of Member States work is still underway to update their reporting and coding mechanisms. Hence, some Member States do have a considerable backlog of ATM related occurrences still to be processed and transfer into the national databases. This state of affairs is due to the increased number of reports generated by the above mentioned Regulation combined with the considerable shortage of resources available at national level, fact that had been identified for a number of years already as a key risk area and constituted the object of a number of recommendations issued by the EUROCONTROL Provisional Council. The EUROCONTROL Safety Analysis Team was again confronted with a number of problems in processing the reported AST data, ranging from incorrect coding of ATM occurrences in ECCAIRS databases by Member States, non-standard/incorrect reporting formats, occurrence data processing backlog and invalidated data-sets.

In addition, all the available tools for the automatic extraction and processing of the AST reports by the Member States needed updating in order to support the implementation of Regulation (EU) No. 376/2014. To this end, we would like to express our thanks to the JRC for the excellent co-operation and continuous support that enabled us to achieve these results.

Total ATM related incidents per severity

20152011 2012 2013 2014

0

15000

10000

5000

25000

30000

20000

35000

ABCEDNot assessed


Total ATM related incidents Occurrence per million flight hours and severity

2011 2012 2013 2014 20150

1500

1000

500

2000

2500

ABCEDNot assessed

General Trends

This trend analysis is based on the AST reports submitted by 40 EUROCONTROL Member States (from 41). To ease interpretation, incident-related performance indicators (the trends up to 2015) are normalised based on millions of flight hours, except for runway incursions which are normalised based on millions of aircraft movements (departure and arrivals). There was a 2% increase in the number of flight hours in ECAC States and a similar number of arrivals/departures as the previous year. One incident can be sub-categorised in more than one type of incident. For example, one incident can be categorised as a Deviation from ATC Clearance, Level Bust and Separation Minima Infringement. As opposed to accidents analysis, there is no MTOM limit (2,250 kg.) for the ATM-related incidents.

The 4.4% increase in the total number of incidents reported in comparison with 2014 underlines the reporting enhancement opportunities as indicated in an earlier section of this report related to the “under-reporting” issue.

The number of serious incidents (severity class A) decreased by almost 7% when normalised by traffic numbers. Major incidents (severity class B), saw a small increase of 2.9% in 2015, compared with the 2014 data when measured against the traffic levels. A significant improvement was seen in the number of occurrences not severity classified, which decreased from over 12615 (2012), to close to 5800 in 2013, to just less than 2,000 occurrences in 2014, reaching a level comparable to the 2008 reported AST figures. In 2014 these categories increased to over 3,000, but remained at relatively low numbers.

Despite the encouraging progress achieved from 2012 to 2015 in reducing the risk bearing ATM related occurrences, Member States need to ensure sufficient resources in numbers, competency and training, to deal with reporting, investigation, storing, analysis and severity assessment of ATM-related safety occurrences.

An overall boost in occurrences reported is expected for the whole aviation industry, especially following the implementation of Regulation (EU) No. 376/2014 that came in force in November 2015.

Total ATM related incidents Severity A and B per million flight hours

2011 2012 2013 2014 20150

40

10

20

30

50

60

AB

SEPARATION MINIMA INFRINGEMENTS

The initial data reported for 2015 shows a slight decrease in the number of reported separation minima infringements (SMI) compared with the previous year’s figures (2338 vs. 2359). This is despite a 2% increase in traffic levels.

When taking into account the traffic growth the decrease amounts at almost 3%. This decrease followed a continued increase shown during the previous 4 years. There is room for improvement in the classification of separation minima infringements in the national databases, especially when taking into consideration the other category of loss of separation, which is inadequate separation. The correct distinction is only possible after full investigation and national data flows should be able to capture this information.

The number of events with no safety effect has increased in absolute numbers from 660 in 2014 to 909 in 2015. In addition, a significant decrease is noticed in the number of SMI in severity category D (78%) and not severity classified (43%).

The number of SMIs not severity classified decreased by 2.4% in 2015, to 56, which represents almost 16% fewer than was reported in 2012. This quite remarkable achievement is, most probably, due to the fact that in many Member States the severity assessment of the SMI is left with the ANS Providers, hence where these take the decision to assess only in those occurrences to which they/ANSP had either a direct or indirect contribution.

It could also be the result of the need for EU Member States to use the RAT methodology for the severity assessment of the SMI in the context of Commission Implementing Regulation (EU) No. 390/2013.

More importantly, the number of the risk bearing events is decreasing. The number of serious (Severity A) incidents, decreased (in absolute numbers 23 in 2014 and 20 in 2015). The number of major occurrence (Severity B) saw a more important drop, in absolute numbers, from 250 in 2014 and 221 in 2015).

• Serious incidents (severity class A) decreased in absolute numbers from 23 to 20,

• Major incidents (severity class B) decreased in absolute numbers from 250 to 221,

• Significant incidents (severity class C) decreased in absolute numbers from 1268 to 1119.


AB

0

120

80

40

160

Separation Minima InfringementsOccurrences per million flight hours and severity

Separation Minima InfringementsOccurrences per million flight hours and severity

2011

2011

2012

2012

2013

2013

2014

2014 2015

2015

0

10

5

15

20

25

ABCEDNot assessed

RUNWAY INCURSIONS

The preliminary data for 2015 shows a decrease of over 3% in the absolute number of such events. When taking into account the variation of the traffic level the decrease in the number of RI reaches almost 5%. During 2015, the SRC’s AST Focal Point (AST-FP) Group discussed and generally agreed on a number of 14 typical scenarios of runway-related occurrences to better classify the reported runway incursions as per the definition that was also agreed with the EUROCONTROL NM Safety Team and CANSO.

In absolute figures the number of 2015 serious (severity class A) runway incursions has significantly decreased from 26 events in 2014 to 11, reaching the lowest level during the period under review. A small increase is observed in the number of major events (severity class B) 12% and reached, in absolute numbers, the highest number in the last 5 years (83).

The percentage of incidents “not classified” in this category has marginally increased from the previous year from 3.3% to 3.6% of the total number of such occurrences. When taking into account the number of RI severity categorised D the percentage reaches 8.8%. Therefore, it is paramount that Member States ensure that adequate resources are made available for the investigation and further analysis of this type of Key Performance Indicators (KPI) and, in addition, to ensure the quality and completeness of the safety data both at national and European level.

An important improvement is seen in the number of significant runway incursions (431) which is the lowest figure in the last 5 years.

The same evolution in seen in the number of risk bearing runway incursions when expressed against normalised figures, The evolution of this important category of ATM related events will be further monitored until the end of RP2 (end of 2019).

The percentage of incidents “not classified” is similar to the figures of last year (3.6 vs 3.3%) of the total number of occurrences. It is seen that the good progress achieved last year is maintained, most probably due to the fact that the application of the RAT methodology is the second safety KPI in the framework of the Performance Scheme Regulation (EU 390/2013).

Therefore, the PC shall urge the EUROCONTROL Member States to use the RAT methodologies for determining the overall severity of the reported runway incursions to the utmost possible.

page 16

ABCEDNot assessed

AB

Runway incursionsOccurrences per million flight hours and severity

Runway incursionsOccurrences per million flight hours and severity

0

60

50

40

20

10

30

90

80

70

2011 2012 2013 2014 2015

0

5

4

3

2

1

6

7

2011 2012 2013 2014 2015


StatesLocationsAOs

DirectIn-directNo involvement

Runway incursions states, locations and air operators

0

0

30

30

25

25

20

20

10

10

5

5

15

15

35

35

Absolute figures

Absolute figures

2011

2011

2012

2012

2013

2013

2014

2014

2015

2015

Feedback from EVAIR on Runway Incursions

The AST mechanism only provides aggregated overall figures and therefore does not provide an indication as to where those runway incursions have occurred. To this end, we have liaised with EVAIR in order to have a closer look at the number of loca-tion and operators who voluntarily reported runway incursions during the period in question.

According to the chart above, during the last three years EVAIR recorded, in absolute figures, a decrease in the number of Member States, locations and Air Operators voluntarily repor-ting Runway Incursions.

If we focus our attention on five states with more than 9 Runway Incursions, these five states make up 86% of the total Runway Incursions for the period 2011-2015.

For the period 2011-2015, 67 different locations were identified where Runway Incursions were reported. Nine of these locations recorded 58% of the total number of reported Runway Incursions.

In respect of the ATM System Contribution to the reported runway incursions, 26% of the reported events had a direct ATM contribution.

Four contributory factors (air/ground communication, mis-takes, lapses and traffic information) accounted for almost 70% of the factors that had a Direct ATM Contribution. The spread of the ‘ATM System Contribution’ shows that over the last four years EVAIR has recorded a decrease in the number of events where the ATM system had a direct contribution to the event.

In case of runway incursions where the ATM system had an indirect contribution to the event, there is a decreasing trend followed by a maximum reached in 2013 that is further fol-lowed by a drop.

It is important to note that the number of runway incursions where the ATM system had ‘No Involvement’ to the occur-rences was always higher than the aggregated number of events where the ATM system had a Direct and an In-direct contribution to the event. This may suggest that the airborne/airport part is more often the causal factors for the reported runway incursions.

Out of 197 RWY incursions, 108 had ‘No involvement’ from the ATM system. For the remainder, the most frequent issues where the ATM system had a contribution are related to:

• Hear back omitted, • Misunderstanding/misinterpretations, • Handling of radio frequency.

In respect of the ATM Airborne part, the analysis of the vo-luntarily reported runway incursions indicates that ‘Landing without an ATC clearance’ was one of the contributory factors identified in a number of incidents that bring the higher risk to those occurrences (9 cases over five years’ data).

Runway incursions

ATM involvement

55%

26%

19%

UNAUTHORISED PENETRATIONS OF AIRSPACE / AIRSPACE INFRINGEMENTS

In the past years, after the adoption of several recommendations by the Provisional Council in respect of the implementation by Member States of “the provisions of the European Action Plan for Airspace Infringement Risk Reduction”, a remarkable range of actions has been taken by all regulatory/oversight authorities, ANSPs, Military, General Aviation (GA) Community and other stakeholders at national level, supported by EUROCONTROL.

In 2015, the number of airspace infringements (UPA) increased by 1.5% compared with 2014 data. When calculated against the traffic growth we notice a decrease of 0.4% compared with the previous years’ data. The data shows that the number of airspace infringements (UPA) – in absolute numbers – remained at the level of 2014 (with a very slight increase from 4325 to 4392 events).

The number of occurrences not being severity classified in this category has increased to over 13% of the total number of reported events compared to over 3.6% calculated in 2014.

A small increase is seen in the number of serious incidents (severity A) – 12 in 2015 from 9 in 2014), whilst the number of major incidents (severity B) increased more significantly from 51 in 2014 to 76 in 2015. The number of significant airspace infringements (Category C) saw an increase of 9 events (1231 in 2014 vs. 1240 in 2015).

In addition, the number of occurrences placed in ‘severity category D’ (severity not determined) increased significantly (from 284 in 2014 to 291 in 2015). The highest increase in seen in the number of UPAs not severity classified (from 157 to 606).

The Airspace infringements with no safety effect (severity E) have decreased by 16.4% and represents around 50% of the total number of such occurrences.

The EUROCONTROL Safety Analysis Team will continue to promote the use of the RAT methodology for the severity/risk assessment of the UPAs both in the Safety Management Tools User Group (SMTUG) and the AST-FP Group, with the view to supporting the Member States’ stakeholders in decreasing the number of such events not severity classified.

page 18

ABCEDNot assessed

AB

Unauthorised Penetration of AirspaceOccurrences per million flight hours and severity

Unauthorised Penetration of AirspaceOccurrences per million flight hours and severity

0

250

200

150

50

100

400

350

300

2011 2012 2013 2014 2015

0

5

4

3

2

1

6

7

2011 2012 2013 2014 2015


Unauthorised Penetration of Airspace (UAP)Percentage of Losses of Separation (LoS)

2011 2012 2013 2014 2015

60

40

60

160

140

120

100

80

180

200

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

There is a close link between the risk associated with UPAs and the numbers ending up in a loss of separation (LoS) - i.e. the “opportunities” that the infringing aircraft enters into conflict with another aircraft. Both the percentage of occurrences not being severity classified and severity not determined (severity class D) have seen an increase compared with the 2014 data.

This represents an area of concern when this evolution is seen together with the number of events not severity classified, as assessing the severity of such events is paramount for driving the safety improvement.

The chart shows the number and percentage of UPAs which resulted in a LoS. The percentage of LoS in the overall number of ‘Unauthorised penetrations of airspace’ (UPA) has seen an increasing trend comparing with 2014 data, reaching over 4% of the total number of UPAs, the level reported in 2013. It is to be noted that only 1 out of 179 airspace infringements that ended up in a loss of the prescribed separation minima between the aircraft involved was assessed as a serious occurrence (severity class A). There is a close link between the risk associated with the UPAs and the number of those ending up in a LoS (i.e. the “opportunities” that the infringing aircraft enters into conflict with another aircraft).

Number of LoS in UAP

Percentage of LoS in UPA

AIRCRAFT DEVIATIONS FROM ATC CLEARANCE

The preliminary safety data for 2015 indicates an almost 13% increase in absolute numbers compared to previous years. When measured against the traffic level, the increase is around 10%.

The number of events not severity classified has seen a significant increase from almost 8.5% of the total number of deviations from ATC clearance in 2014 to almost 16% in 2015. In absolute numbers, the amount of such events not severity classified is more than double compared with 2014 data and the highest value since 2013.

The number of risk bearing incidents is at a level similar to the previous’ year data: serious deviations from the ATC Clearance (severity A) decreased from 12 events in 2014 to 11 in 2015 whiles the number of major events went up from 100 events in 2014 to 111 in 2015.

The percentage of deviations from the ATC clearance with no safety effect (Severity category E) is at the level of 2014 amounting at around 50% of the total number of events reported in this category.

page 20

ABCEDNot assessed

AB

Aircraft Deviation from ATC ClearanceOccurrences per million flight hours and severity

Aircraft Deviation from ATC ClearanceOccurrences per million flight hours and severity

0

250

200

150

50

100

400

350

300

2011 2012 2013 2014 2015

0

5

4

3

2

1

6

7

8

2011 2012 2013 2014 2015

LEVEL BUSTS

The preliminary data for 2015 shows a decrease of nearly 13% in the total number of incidents reported, almost reaching the level of 2013. When calculated against the traffic growth the decrease is over 14.5%.

The highest decrease is shown in severity category E (no safety effect), which number represents over 55% of the total number of occurrences reported in this category. It is to be noted that the number of occurrences not severity assessed amounts to over 10%.

The risk bearing Level Busts (severity A and B) represents 3.4% of the total number of events in this category both in absolute figures and when normalised against the variation of the traffic levels.

The number of serious incidents remains at the level of 2014 (4) whilst an increase is noticed in the number of major incidents (severity B) when compared to 2014 (2014: 31 and 2015: 36).

Last but not least, it is to be noted that from a coding pers-pective, a ‘Level bust’ event should have been, in addition, classified (correctly) as ‘Deviation from ATC Clearance’. Howe-ver, 18% of these occurrences were not adequately classified when analysing the 2015 safety data. The Safety Analysis Team of EUROCONTROL will continue to provide customised support to Member States to ensure consistent coding of the reported occurrences throughout ECAC area.

The number of Level Busts that ended up in a loss of separa-tion between the aircraft involved amounted to 10% of the total number of events, which is consistent with the data reported in the previous years.

page 22

AB

Level BustsOccurrences per million flight hours and severity

2011 2012 2013 2014 20150

2.5

2.0

1.5

1.0

0.5

3.0

3.5

ABCEDNot assessed

ABCEDNot assessed

Level BustsOccurrences per million flight hours and severity

0

60

50

40

20

10

30

90

80

70

2011 2012 2013 2014 2015

Level Busts and percentage resulting in Loss of SeparationNumber of occurrences per severity category

20152011 2012 2013 2014

0%

20

10

0

4%

40

2%

30 6%

50

8%

60

10%

14%

16%

70

12%

80

% Loss of Separation


StatesLocationsAOs

DirectIn-directNo involvement

Level bust states, locations and air operators

0

80

60

40

20

100

Absolute figures

Absolute figures

2011 2012 2013 2014 2015

Feedback from EVAIR on Level Busts

To better understand the severity of the reports and the barriers which acted to prevent the worsening of the situation, it should be noted that in 12.4% of the Level Busts TCAS RA and GPWS were activated to prevent further ero-sion of the separation minima.

Through the period 2011-2015, the number of Member States where Level Bust occurrences were reported was quite stable, from 20 to 25. The lowest number was re-corded in 2015: 20 Member States. During the whole period there were in total 42 different Member States reporting Level Bust events. Seven of them had more than 10 reports, which made 58.5% of the overall number of the reports.

A similar picture is seen when analysing the number of Air Operators. During the said period there were 67 Air Ope-rators who were involved in the Level Busts occurrences. Yearly, there were from 24 to 36 Air Operators involved in such occurrences.

For the period 2011-2015, ATM System direct involvement was 34% and indirect 14%. The most frequent part of the ATM system contribution is related to the air-ground com-munication, especially hear-back and read-back areas. It is worth of mentioning the contribution of Call Sign Confu-sions to the Level Bust occurrences. There were not too many of them, however they had the higher risk.

It is notable that more than 50% of the reported Level Bust occurrences the ATM System had no contribution to the event.

0

60

50

40

20

10

30

2011 2012 2013 2014 2015

70

80

NEAR CONTROLLED FLIGHT INTO TERRAIN (NEAR CFIT)

The data reported for 2015 indicates a significant decrease in absolute numbers (48 in 2015 versus 62 in 2014). In the risk bearing incidents, there were 4 serious incidents (severity A) reported in 2014 and 2015. The number of major incidents (severity B) shows an increase from 6 in 2014 to 10 last year. The total number of N-CFIT occurrences is back to the level of 2013 which is the lowest during the analysed period.

The number of severity C classified occurrences in this category is similar to the ones reported in the previous year (22 in 2015 versus 20 in 2014).

Coincidentally or not, CFIT is amongst the main categories of accidents reported in 2015.

Finally, it is to be noted that all Near CFITs reported in 2015 were severity classified. Only one event (out of 48) was classified as Severity D. This constitutes an important improvement compared to the situation seen in 2012 (55/131 not severity classified).

page 24

ABCEDNot assessed

AB

Near Controlled Flight Into TerrainOccurrences per million flight hours and severity

Near Controlled Flight Into TerrainOccurrences per million flight hours and severity

0

6

4

2

12

10

8

2011 2012 2013 2014 2015

0

0.5

0.4

0.3

0.2

0.1

0.6

0.7

0.8

0.8

1

2011 2012 2013 2014 2015

LASER INTERFERENCE

Similar to the previous years, the AST-FP Group members have provided the information gathered in their States on developed activities and actions taken with respect to laser interference as well as the numbers of this type of occurrences reported both domestic and abroad.

The information as provided clearly shows, despite the limited number of States reporting laser interferences that this type of occurrence represents a Key Risk Area at European level.

A number of Member States have taken initiatives at national level, mainly in the regulatory area and enfor-cing the aviation law through prosecution, supported by media and police. Others Member States have addressed the issue at local level because of interference seasonal hotspots. Additional actions had been taken due to laser interference reports received from abroad by aircraft operators.

The AST-FP Group will continue to monitor laser interfe-rence-related developments and gather information and best practices employed in the ECAC area. In addition, co-ordination is ensured with the EUROCONTROL volun-tary ATM incident reporting scheme (EVAIR) to comple-ment the overall picture with data on such occurrences received from the flight deck in respect of the severity of reported events, laser colour and possible hot spots.


2011 2012 2013 2014 2015

0 0

2000

20

15

1000

10

5

3000

4000

5000 25

Laser interferences reported by Member States via the AST mechanism

Total

Number of Member States

REMOTELY PILOTED AIRCRAFT SYSTEMS (RPAS) / DRONES

As part of the AST-FP Group’s discussions on the ATM-related key risk areas, RPAS/Drones come up strongly as a new risk area. Based on initial feed-back received from numerous Member States, the SRC’s Safety Analysis Team has started to collect a number of reports on this type of occurrence.

According to the data received, the highest number of reports amounts over 40 events in 2015. However, at this stage, it is more important to note what actions are being taken both at EUROCONTROL and EU level to address this emerging issue.

EUROCONTROL contributes to overall RPAS activities and is one of the RPAS’ centre of expertise in Europe. The main pillars of the Agency’ strategy is to contribute to the seamless accommodation and integration of RPAS into the European ATM.

The accommodation phase is already on-going and expected to continue up to 2023. Due to the absence of regulation and industry standards larger IFR capable RPAS are to be accommodated in controlled airspace using AFUA techniques. This is a daily occurrence in the Mediterranean for military RPAS. This phase of accommodation can easily be maintained due to the relatively low numbers of RPAS operations.


2015201420132012

RPAS related occcurrences

0 5 10 15 20 25 30 35 40 45 50

State 1

State 4

State 7

State 10

State13

State 16

State 19

State 22

State 25

State 28

State 31

State 34

State 37

State 40

State 43

The integration phase continues from 2023 onwards and expects that with the availability of regulatory, operational and technical provisions required shall progressively facilitate the integration of the civil and military RPAS as a legitimate category of airspace user in the Pan-European ATM environment.

Following on the work done under the umbrella of the AST mechanism further co-ordination was also ensured with EVAIR to allow for a clearer picture on this rising key risk area in ATM.

As such it is to be noted that the reports received in 2015 (17), although still rather low have seen a consistent increase compared with the previous years. In respect of the RPAS/drones involved in the occurrences, they were all part of the ‘Open’ category and took place in controlled airspace at low altitudes.

The AST-FP Group will continue to gather information and monitor the developments seen in this Key Risk Area as part of the future AST reporting sessions.

ATM-SPECIFIC (TECHNICAL) OCCURRENCES

The analysis below embraces the evolution of the availability of a number of services (COM, SUR, Flight Data Processing and Distribution) delivered by the ANS Providers. The failure of each service is analysed independently by severity and normalised by a million flight hours. In addition, the total number of occurrences in each category normalised by million flight hours is displayed in green. As a result, the scales used in all 3 charts are identical and do not represent absolute number of occurrences but normalised figures that facilitate comparison between the last five years.

The total number of reported ATM-specific (Technical) Occurrences has seen a significant increase of 35% in absolute numbers compared with the previous year’s data (16648). However, one Member State has ‘contributed’ to almost 50% of the total number of ATM Specific Occurrences (ASO) reported by 41 EUROCONTROL Member States.

When the total number of such events is normalised against flight hours, the increase is slightly lower (32%). This is contrary to the decrease observed last year, when the lower number of technical occurrences was expected to be linked to the approach taken by Member States in respect of what technical failures were to be considered as an ATM-specific occurrence. However, a considerable variation has been noted in the level of such reports filed by different Member States with similar traffic levels. With respect to the severity of the reported occurrences, it is noted that the number of risk bearing occurrences concerning severity categories AA has almost halved (12 in 2015 and 21 in

page 28

2014) while severity category A remained at a similar level to the previous years (93).

Severity category B decreased by 4 occurrences (from 352 to 348) compared to the previous year. The increase seen in severity category C (Ability to provide safe but degraded services) was also remarkable (around 10%) compared with the 2014 figures. The highest increase however was observed in severity category E, where the percentage increased by 90% compared to 2014. As was mentioned earlier, this increase is mainly due to one Member State, reporting a very high number of occurrences.

Communications

The ‘Failure of the Communication Function’ has seen a decrease of 12% compared with the previous year’s data. The total number of failures has reduced in absolute numbers to 3029, which is the lowest compared to the previous two years.

The number of risk bearing losses of COM function (severity categories AA, A and B) has decreased compared to the levels of the previous year (3090 vs. 3440 in 2014). The number of failures placed in severity category AA has decreased by 2, resulting in 7 ‘Total inability to provide COM services’ events. Calculated against the increased traffic levels, the risk bearing COM failures represent around 4% of the total number of such technical events and less than 1% of the total number of ASO. The number of occurrences ‘not severity classified’ has decreased from 304 events in 2014 to 54, which represents the lowest figure in the analysed period.

Total ATM specific occurrences Occurrences per million flight hours and severity

Severity of COM failures in relation to overall numbers Occurrences per million flight hours

0

60

0

20

80

400

200

1000

1200

800

40

100

120

140

160

180

600

AAABCEDNot assessed

AAABCEDNot assessed

Total number OF ALL occurrences

0

600

400

200

1200

1000

800

2011 2011 2012 2013 20142012 2013 2014 2015 2015


Surveillance

Based on the 2015 preliminary AST data, the total number of ‘Failures of the Surveillance Function’ was 2679, which is over a 50% increase compared with the previous year’s data.

It is to be noted that the number of total inability to provide the SUR function decreased from 2 events in 2014 to 1 event, reaching the level of 2013. The other risk bearing severity category A more than doubled from 12 in 2014 to 31 in 2015.

Severity category B slightly decreased compared to last year. When presented against traffic levels, the risk bearing SUR failures amount to over 4% of the total number of such technical events, which is similar to the previous years’ final figures. The number of occurrences not severity classified has decreased to approximately 1% of the total number of occurrences in this category.

Flight Data Processing and Distribution

The failure of the ‘Flight Data Processing and Distribution Function’ is the final category of technical failure analysed in this report.

Based on the 2015 preliminary AST data, the total number of events decreased compared to last year’s figures by 21% (following a similar trend compared to the year before). However, when normalised against the traffic level, the decrease is even higher (23%).

The risk bearing events show there was no severity AA failure of the ‘Flight Data Processing and Distribution Function’. The severity category A decreased to 2 events (from 13 in 2014), while category B is higher in absolute figures compared to 2014 data (54 vs.44).

The events placed in severity category C show a significant increase in absolute numbers when compared with 2014 (693 vs. 287). This evolution is substantial compared with previous year’s report.

Notably, the number of events where the severity is ‘not classified’ has decreased considerably compared with the previous year (27 vs. 618). This is a great improvement compared to the previous year.

Severity of SUR failures in relation to overall numbers Occurrences per million flight hours

Severity of FDPS failures in relation to overall numbers Occurrences per million flight hours

0 0

60 60

0 0

20 20

80 80

400 400

200 200

1000 1000

1200 1200

800 800

40 40

100 100

120 120

140 140

160 160

180 180

600 600

AAABCEDNot assessed

AAABCEDNot assessed

2011 20112012 20122013 20132014 20142015 2015

ANNEX 1 PERFORMANCE SCHEME REGULATORY FRAMEWORK

ASSOCIATED KEY PERFORMANCE INDICATORS FOR SAFETYCommission Implementing Regulation (EU) No. 390/2013 “laying down a Performance Scheme for Air Navigation Services and Network Functions”, defines a number of Key Performance Indicators (KPI) for safety during RP2(2015-2019).

It is to be noted that, contrary to the previous reference period, the Commission has set targets for the application of the RAT Methodology for deriving the severity for both ATM Ground and ATM Overall of Separation Minima Infringements, Runway Incursions and ATM-specific occurrences reported by the Member States and ANS Providers (second KPI for safety).

During RP2, the RAT methodology is only mandatory for deriving the severity of A, B and C reported separation minima infringements (SMI) and runway incursions (RI), respectively AA, A, B and C severity for ATM Specific Occurrences (ASO).

The Commission Implementing Regulation (EU) No. 390/2013, including the use of the RAT Methodology, may not be applicable at airports and traffic units with less than 70000 IFR movements per year. Therefore, it is of utmost importance to determine at the level of individual occurrence (SMI, RI and ASO) whether it is to be considered in the scope of the Performance Scheme Regulation based on severity, location (traffic higher than 70000 IFR movements) and scope. As such, Member States may be confronted with situations where the application of the RAT methodology could be mandatory for the ATM Ground and not for the ATM Overall scope or vice-versa.

Despite the fact that some Member States could be confronted with the difficult situation where the determination of the Overall severity is mandatory without having the possibility to use the results of the RAT methodology application, by the ANS, for the determination of the ATM Ground severity, the entire harmonisation of the severity assessment process achieved, to a great extent, at the end of RP1, may be at stake.

During 2015, EUROCONTROL DPS/SSR has continued to support its Member States to define their national arrangements for the application of the RAT Methodology in RP2 both at national, regional or FAB level.


SEPARATION MINIMA INFRINGEMENTS

During RP2, the analysis of the application of the RAT methodology for deriving the severity for the reported SMI is split by the scope of the assessment: ATM Ground and ATM Overall. In each of the two cases the main elements are the total number of occurrences for which the application of the methodology is mandatory and the percentage of application. The most important consequence of the changes seen in RP2 is that the total number of SMI is not anymore equal to the total number of SMI for which the application of the RAT methodology is applicable. Moreover, there are different numbers for ATM Ground and ATM Overall.

Last but not least, the total number of SMI is provided for your reference to indicate the workload posed by the application of the RAT methodology in the framework of the Performance Scheme Regulation in each Member State.

According to the chart above, the application of the RAT Methodology for 9 Member States was not applicable for ATM Ground. In two of these States no SMI was reported during 2015. In the other 7 cases the application of the RAT methodology was not mandatory due to the A-C filtering or the level of traffic at the unit where the SMI took place. 19 Member States achieved a percentage between 98-100% of

use of the RAT methodology for the determination of the ATM Ground severity whilst two Member States have scored below the target that is to be achieved by the end of 2017 (80%).

In respect of the ATM Overall severity the use of the RAT methodology was not applicable for only 5 Member States. In two of those there was no SMI reported.

In 18 Member States the use of the RAT methodology for the determination of the ATM Overall severity was applied in 100% of the cases where it was mandatory.

The rate of achievement for the use of the methodology for the ATM Overall severity determination, in 7 Member States, was between 0%-33%. DPS/SSR will channel its efforts and resources to support these Member States in improving their score during the remaining years of RP2.

In terms of workload, it is remarkable that State 20, despite having to apply the RAT methodology for the ATM Ground severity determination for over 350 SMI of a total amounting close to 700, has managed to achieve 100% use of the methodology.

2015 Application of RAT methodology - Separation Minima Infringements - ATM GROUND

2015 Application of RAT methodology - Separation Minima Infringements - ATM OVERALL

2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 25 26 28 29 31 32 33 39States 10 0

50100

150

300200

400250

500300

600350

700

400

450

500 Number of Separation Minima Infringements 800

100200

2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 25 26 28 29 31 32 33 39States 10 0

50100

150

300200

400250

500300

600350

700

400

450

500 Number of Separation Minima Infringements 800

100200

RAT applicable SMIRAT used SIMTotal number SMI

RAT applicable SMIRAT used SIMTotal number SMI

0 0

10

30

40

50

60

70

80 Number of Runway Incursions 300

250

200

150

100

50

20

RUNWAY INCURSIONS

According to the chart below in 8 Member States the application of the RAT Methodology for ATM Ground was not applicable. In 3 of these States no RI was reported during 2015. In the other 5 cases the application of the RAT methodology was not mandatory due to the A-C filtering or the level of traffic at the unit where the RI took place.

In 5 Member States the RAT methodology was not used to determine the ATM Overall severity for any of the reported RI. 17 Member States have applied the RAT methodology for a percentage of 80-100% of the number of applicable cases for the determination of the ATM Overall severity of the reported RI. Another 8 Member States did not meet the 80% target for the application of the RAT methodology for deriving the ATM Overall severity.

In respect of the resources to be made available by the Member States and ANS providers for the application of the RAT methodology, similarly to the case of SMI, Member State 20 reported the highest number of RI (275) and managed to achieved more than 90% in the use of the methodology both for ATM Ground and ATM Overall.

2015 Application of RAT methodology - Runway Incursions - ATM OVERALL

2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 25 26 28 29 31 32 33 39States 1

RAT applicable RIRAT used RITotal number RI

2015 Application of RAT methodology - Runway Incursions - ATM GROUND

2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 25 26 28 29 31 32 33 39States 10 0

10

30

40

50

60 Number of Runway Incursions 300

250

200

150

100

50

20

RAT applicable RIRAT used RITotal number RI

18 Member States achieved a percentage of 94%-100% of use of the RAT methodology for the determination of the ATM Ground severity whilst 4 Member States have scored below the target that is to be achieved by the end of 2017 (80%).

In 5 Member States the determination of the Overall severity using the RAT Methodology was not mandatory for any of the reported RI in the framework of the Performance Scheme Regulation. In 3 of these States no RI was reported. For the other cases the reported RI were either not in the severity span A-C or taking place at ATS Units with a traffic level lower than 70,000 IFR movements per year.


ATM SPECIFIC OCCURRENCES

Concerning the use of the RAT methodology for the severity determination of the ATM Specific Occurrences 23 Member States (out of 30) achieved more than 80% of the occurrences for which the use of the methodology was mandatory in the framework of the Performance Scheme Regulation. For the particular case of this type of occurrence the scope of the severity assessment is only ATM Overall.

2015 Application of RAT methodology - ATM Specific Occurences

2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 25 26 28 29 31 32 33 39States 10 0

200

600

800

1000

1200

1400 Number of ATM Specific Occurrences

6000

7000

8000

9000

5000

4000

3000

2000

1000

400

RAT applicable ASORAT used ASOTotal number ASO

In one Member State, the use of the methodology was not mandatory for any of the reported ATM specific occurrences whilst in 2 cases the methodology was not used for any of the reported occurrences.

According to the chart above, Member States 20 and 21 together reported more ATM Specific Occurrences than the other States together (13,000). However, taking into account the new filtering rules applicable in RP2 (severity AA-C) the number of such occurrences to be RAT assessed are considerably lower than the ones in RP1. Hence the Member States stand a better chance of meeting the targets proposed in the CID, once this becomes applicable at the end of 2017.

January 2017 - © European Organisation for the Safety of Air Navigation (EUROCONTROL)

This document is published by EUROCONTROL for information purposes. It may be copied in

whole or in part, provided that EUROCONTROL is mentioned as the source and it is not used for

commercial purposes (i.e. for financial gain). The information in this document may not be modified

without prior written permission from EUROCONTROL.

www.eurocontrol.int

SRC Document 56

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