mid region annual safety report · 2014-05-19 · mid region annual safety report – second...

RASG-MID Annual Safety Report – Second Edition

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Regional Aviation Safety Group -

Middle East

(RASG-MID)

MID Region

Annual Safety Report

MID Region Annual Safety Report – Second Edition

Second Edition, January 2014 Regional Aviation Safety Group – Middle East (RASG-MID) This document is disseminated under the sponsorship of the Regional Aviation Safety Group – Middle East (RASG-MID) in the interest of information exchange. The RASG-MID assumes no liability for its contents or use thereof.


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RASG-MID

Annual Safety Report

Table of contents 1. Executive Summary…………...…………………………………………………………………………. 2 1.1 Regional Traffic Volumes…………………………………………………………………………….3 2. Safety Information and Analysis…………………………………………………………………………4 2.1 Reactive Safety Information………………………………………………………………………....4 2.1.1 Regional Accidents Rates …………………………….……………………………………….…4 2.1.2 Regional Fatal Accidents …………………………….……………………………………. …...5 2.1.3 Analysis of MID Accidents between 2008 and 2012 ……………………………………... …...5 2.1.3.1 Accidents categories and analysis…………………………………………………….......... 5 2.1.3.2 Safety Focus Areas for MID Region (2008 to 2012)..……………………………………....9 2.1.3.3 MID Region Safety Performance – Safety Indicators(Reactive)…………………….. ....12 2.2 Proactive Safety Information……………………………………………………………………… 13 2.2.1 Analysis of Audits……………………………………………………………………................ 13 2.2.1.1 ICAO USOAP-CMA ……………………....………………………………………............ 13 2.2.1.2 IATA Operational Safety Audit (IOSA) ………………....…………………………….….……... 15 2.2.1.3 IATA Safety Audit for Ground Operations (ISAGO) .……………..…………............................ 15 2.2.2 Analysis of incidents and occurrences……………………………………………………...… 17 2.2.2.1 Incidents and Occurrences Reported by States ………………………………………… 17 2.2.2.2 STEADES data ………………………………………………………………………….… 18 2.2.2.3 Incidents and occurences reported by airlines ………………………………………….. 20 2.2.3 On demand analysis of identified risks or hazards………………………………………….. 21 2.2.3.1 Call-sign Confusion………………………………………………………………………... 21 2.2.3.2 Laser Attack ………………………………………………………………………………..22 2.2.4 MID Region Safety Performance – Safety Indicators (Proactive) …………………………..23 2.3 Predictive Safety information……………………………………………………………………....24 2.3.1 FDM Trends and FOQA Data………………………………………………………………….24 2.3.1.1 FDX data …………………………………………………………………………………....24 2.3.2 Hazard Identification and Risk Assessment…………………………………………………..25 2.3.2.1 State Safety Program (SSP) ……………………………………………………………….25 3. Final Conclusions……………………………………………………………………………............27 List of Acronyms ………………………………………………………………………………….................28


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1. Executive Summary The objective of the RASG-MID Annual Safety Report is to gather safety information from different stakeholders and to identify the main aviation safety risks in the Middle East Region in order to deploy mitigation actions for enhancing aviation safety in a coordinated manner. Every entity involved in aviation safety collects safety data and produces safety information with a different perspective. To ensure that all safety efforts are properly coordinated, the region should first agree on the key risks areas. The Second RASG-MID Annual Safety Report provides Member States and the aviation community with a high-level analysis of the air transport safety trends and indicators in the MID Region. It presents a snapshot of safety performance within the civil aviation system in the MID Region, while providing helpful information about the numerous efforts to develop collaborative responses to safety concerns at the National and Regional level. It comprises three main sections, one for each safety information category: 1. Reactive Information 2. Proactive Information 3. Predictive Information The safety information presented in this report is based on the compilation and analysis of data provided by: Boeing, the International Air Transport Association (IATA), the International Civil Aviation Organization (ICAO), airline operators, and States. Analysis of the reactive safety information showed that the three top fatal accident categories for the 2008-2012 period are: 1. Runway and Ground Safety (RGS) 2. Loss of Control In-flight (LOC-I) 3. Controlled Flight Into Terrain (CFIT) By contrast, the proactive safety information in this report, extracted from the results of the ICAO Universal Safety Oversight Audit Programme (USOAP), showed that 77% of audited Sates in the MID Region are with overall effective implementation (EI) over 60%. It should be noted that the Reactive Information represents the largest portion of the Report. As the system matures and the processes for the collection of predictive information in the MID Region are established, balance between the contents of the three sections will be reached. RASG-MID is committed to improving aviation safety and enabling seamless cooperation and communication among the main aviation safety stakeholders in the MID Region.

1.1 R

Traffic Million de

Traffic Million de

Regional Tr

Note:

0

0.2

0.4

0.6

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2010

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was used.

2012

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1.07

2012

1.41

2

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2

10


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2. Safety Information and Analysis

The following sections show the results of safety information analysis grouped as reactive, proactive and predictive safety information.

2.1 Reactive Safety Information

In accordance with the MID Region Safety Strategy, it was agreed to progressively reduce the accident rate to be in line with the global average by the end of 2017.

The process followed by the Annual Safety Report Team (ASRT) to analyse reactive information consisted of retrieving safety data from IATA, ICAO and Boeing. For the IATA data, an effort was required to narrow the search to include only the fifteen (15) States of the Middle East Region.

2.1.1 Regional Accidents Rates

Year 2008 2009 2010 2011 2012

MID Accident Nr. 8 12 6 6 2 Accident rate 8.06 11.78 6.43 6.23 2.13

World rate 3.17 2.69 2.73 2.58 2.06

9.07

4.734.40

8.06

11.78

6.43 6.23

2.13

3.46

2.342.92 3.17

2.69 2.73 2.58

2.06

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2.00

4.00

6.00

8.00

10.00

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5. Top Two flight phases when accidents occur in the MID region are LND and TOF 6. Top three fatal accidents categories for the MID region are;

i. LOC-I ii. Runway/Taxiway Excursions iii. CFIT

In order to facilitate the identification and prioritization of the main Focus Areas (FAs), the accidents are categorized in term of frequency and severity. The severity assessment is based on the fatalities, injuries and damage to aircraft, property and equipment. The level of severity is categorized as follows:

1- Catastrophic: multiple deaths; serious damage to aircraft/equipment (destroyed); 2- Major: serious injury/fatalities; major aircraft/equipment damage; and 3- Minor: little consequences.

Accordingly, the following matrix shows the assessment for the top accidents categories;

Frequency

Severity

1 2 3 4 5

1 1 2 3 4 5

2 2 4 6 8 10

3 3 6 9 12 15

Loss of Control In-flight (LOC-I)

1. Trend 2008 to 2012

Year 2008 2009 2010 2011 2012

MID Accident Nr. 3 3 0 1 0 Accident rate 3.02 2.72 0 0.78 0

World rate 0.41 0.41 0.27 0.29 0.22

2. Severity of Outcomes Fatal Accident Nr. 6Non-Fatal Accident Nr. 1Total Fatalities 415


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Runway Excursion

1. Trend 2008 to 2012

Year 2008 2009 2010 2011 2012

MID Accident Nr. 1 2 1 3 1 Accident rate 1.01 1.81 0.80 2.34 0.71

World rate 0.81 0.69 0.58 0.48 0.58


Controlled Flight into Terrain (CFIT)

1. Trend 2008 to 2012

Year 2008 2009 2010 2011 2012

MID Accident Nr. 0 0 1 0 1 Accident rate 0 0 0.80 0 0.71

World rate 0.20 0.06 0.20 0.28 0.16


In-flight Damage

1. Trend 2008 to 2012

Year 2008 2009 2010 2011 2012

MID Accident Nr. 2 1 1 0 0 Accident rate 2.02 0.91 0.80 0 0

World rate 0.47 0.27 0.26 0.14 0.11



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In accordance with the agreed matrix for the assessment of the top accidents categories, the following table represents the categorization/assessment for the MID Region:

Based on the above, the top three (3) Focus Areas (FAs) in the MID Region are: a) Runway and Ground Safety (including RWY/TWY Excursions); b) Loss of Control In-flight (LOC-I); and c) Controlled Flight Into Terrain (CFIT)

2.1.3.3 MID Region Safety Performance - Safety Indicators (Reactive)

Safety Indicator Safety Target MID Remark Number of accidents per million departures

Reduce the accident rate to be in line with the global average by the end of 2017

2.13 (2012)

World 2.06 (2012)

Number of fatal accidents per million departures

Reduce the rate of fatal accidents to be in line with the global average by the end of 2017.

0.71 (2012)

World 0.41 (2012)

Number of Runway excursion-related accidents as a percentage of all accidents

Reduce Runway Excursions-related accidents by 50% by the end of 2017

Refer to the table below

Number of LOC-I related accidents as a percentage of all accidents

Reduce LOC-I related accidents by 50% by the end of 2017


Number of In-flight Damage related accidents as a percentage of all accidents

Reduce In-flight Damage related accidents by 50% by the end of 2017


Number of CFIT related accidents as a percentage of all accidents

Maintain CFIT related accidents below the global rate


Year 2008 2009 2010 2011 2012 MID Total accident 8 12 6 6 2

MID RWY Excursions-related accidents 1 2 1 3 1 % of All Accidents 12.5% 16.7% 16.7% 50% 50%

MID LOC-I -related accidents 3 3 0 1 0 % of All Accidents 37.5% 25% 0% 16.7% 0%

MID In-flight Damage -related accidents 2 1 1 0 0 % of All Accidents 25% 8.3% 16.7% 0% 0%

MID CFIT -related accidents 0 0 1 0 1 % of All Accidents 0% 0% 16.7% 0% 50%

Accident Category Frequency Severity Frequency/Severity Runway / Taxiway Excursions 1 2 2 Loss of Control In-flight 2 1 2 Hard Landing 3 3 9 Gear-up Landing / Gear Collapse 4 3 12 In-flight Damage 5 2 10 Controlled Flight Into Terrain (CFIT)

6 1 6

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- 20 -

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- 22 -

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2.2.4 MID Region Safety Performance - Safety Indicators (Proactive)

Safety Indicator Safety Target MID Remark Number of States with an EI score less than 60% for more than 2 areas (LEG, ORG, PEL, OPS, AIR, AIG, ANS and AGA)

Max 3 States with an EI score less than 60% for more than 2 areas and an overall EI over 60%, by the end of 2015

6 States

6 States with an EI <60% for more than 2 areas 1 State with an EI <60% for 2 areas 2 States with an EI <60% for 1 area 4 States with an EI >60% for all areas 8 States have an EI <60% for ANS

Number of States with an overall EI over 60%

All the 15 MID States to have at least 60% EI by the end of 2016

10 States

Number of Significant Safety Concerns

No significant Safety Concern by end of 2016

1

Number of certified international aerodrome as a percentage of all international aerodromes

50% of the international aerodromes certified by the end of 2015; and 80% of the international aerodromes certified by the end of 2016

41%

(28 of 68)

Use of the IATA Operational Safety Audit (IOSA), to complement safety oversight activities

Maintain at least 60% of the MID airlines to be certified IATA-IOSA by the end of 2015 at all times; and All MID States to accept the IATA Operational Safety Audit (IOSA) as an acceptable Means of Compliance (AMC) by 2015 to complement their safety oversight activities.

Number of Ground Handling service providers in the MID Region having the IATA Safety Audit for Ground Operations (ISAGO) certification, as a percentage of all Ground Handling service providers

50% of the Ground Handling service providers to be certified IATA-ISAGO by the end of 2015 All Ground Handling service providers to be certified IATA-ISAGO by the end of 2017 The IATA Ground Handling Manual (IGOM) endorsed as a reference for ground handling safety standards by all MID States by end of 2015


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2.3 Predictive Safety Information

Until the end of 2012, the Middle East Region did not fully develop mechanisms for gathering and processing predictive safety information at regional level. However, initiatives have been undertaken to advance capabilities to gather and analyze predictive safety information within the framework of the MID- Safety Support Team (MID-SST). A Safety Management Workshop was held in Oman on 11-12 June 2013. The purpose of the Safety Management Workshop was to promote the RASG-MID and in particular its SST activities related to safety management and stimulate a dynamic exchange of knowledge and experience on the development and effective implementation of SSP/SMS with an emphasis on the need to improve the reporting and sharing of safety data at national and regional level.

Under this section of the report, the aim is to collect and analyse safety data to proactively identify safety concerns before accidents or incidents occur, to develop timely mitigation and prevention measures.

2.3.1 FDM Trends and FOQA Data 2.3.1.1 FDX data

One good source for predictive data is airline operators’ Flight Data Monitoring systems (FDM) and Flight Operations Quality Assurance Programmes (FOQA). To assist in the access of such data, IATA has established the Flight Data Exchange (FDX) database. Flight Data eXchange (FDX) is an aggregated de-identified database of FDA/ FOQA type events that allows the user to identify commercial flight safety issues for a wide variety of safety topics, for many types of aircraft, across a global database; as well as allows flight operations and safety departments to proactively identify safety hazards.

Due to low participation of MENA airlines in the FDX database, the following chart was developed based on FDX data related to AFI and MENA participating airlines. Future editions of the Annual Safety Report would include more representative charts of the Middle East.

-2.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0Excessive Vertical Acceleration in Flight - Low

Stick ShakerLow Speed on Approach (Below 500 ft)

GPWS - Too Low FlapTake-Off Configuration Warning - Spoilers

GPWS - Too Low TerrainExcessive Vertical Acceleration in Flight - High

Take-Off Configuration Warning - No ModeLate Flap Configuration (Below 500 ft)

GPWS - GlideslopeExcessive Localizer Deviation (1000 - 500)

Excessive Glideslope Deviation - Above (Below 500 ft)Excessive Glideslope Deviation - Above (1000 - 500)

High Speed on Approach (1000 - 500)Low Power on Approach (Below 500 ft)

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3. Final Conclusions

In regard to Reactive Safety Information, the data analyzed for the MID Region demonstrated that Runway and Ground Safety (RGS), Loss of Control In-flight (LOC-I) and Controlled Flight Into Terrain (CFIT) represent the three (3) Focus Areas (Fas). In term of fatality, LOC-I continues to be the top fatal accident category for the 2008 - 2012 period.

Although In-Flight Damage (IFD) is no longer considered as one of the main risk areas according to the matrix of identification and prioritization of the main FAs, it will be addressed under the Emerging Risks Area.

The top contributing factors identified in the analysis include:

1- Safety Management 2- Aircraft Malfunction 3- Maintenance Events 4- SOP Adherence / SOP Cross-verification 5- Unstable Approaches 6- Log/floated/bounced/firm/off-centre/crabbed land 7- Monitor/cross check 8- Overall crew performance

Proactive safety information shows that the Average Overall EI of the audited States (13 States) in the MID Region is 69.85%, which is above the World Average 61.70 %, and that 10 States are with an overall EI over 60%. Areas of PEL, OPS and AIR still show the highest EI in the MID Region. Effort should be made to improve States’ safety oversight capabilities in the area of ANS and Aerodromes as well as the AIG capabilities.

All accident rate in the MID Region was above the World accident rate by an average of 3.86; whereas, all MID accident rate among non-IOSA registered operators was above the World accident rate by an average of 6.23.

The major incidents categories for the MID Region based on reports received directly from airlines are:

1. Laser Attacks 2. Communication and Navigation 3. Air Traffic Management 4. Airside Infrastructure

Mechanisms for gathering and processing predictive safety information at regional level should be developed in order to collect and analyse safety data to proactively identify safety concerns before accidents and/or incidents occur, to develop timely mitigation and prevention measures.

MID-ASRT will be working on collection and analysis of Predictive Safety Data within 2014, to drive safety activities under RASG-MID.

The RASG-MID Annual Safety Report is a timely, unbiased and transparent source of safety related information essential for all aviation stakeholders interested in having a tool to enable sound decision-making on safety related matters.


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List of Acronyms ANSP Air Navigation Service Provider ATC Air Traffic Control ATS Air Traffic Services ASRT Annual Safety Report Team CFIT Controlled flight into terrain FDA Flight Data Analysis FOQA Flight Operations Quality Assurance DIP Detailed Implementation Plan GASP ICAO Global Aviation Safety Plan IATA International Air Transport Association ICAO International Civil Aviation Organization LOC-I Loss of control - inflight MID Middle East region (ICAO region) MENA Middle East & North Africa (IATA region) RAST Regional Aviation Safety Group RE Runway excursion(departure or landing) RI Runway Incursion SEI Safety Enhancement Initiative SMS Safety Management System SOP Standard Operating Procedure SSP State Safety Programme UAS Undesirable Aircraft State USOAP Universal Safety Oversight Audit Programme


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CREDITS

RASG-MID thanks all those who contributed to the elaboration of this RASG-MID Annual Safety Report

and provided necessary support and information to the members of the MID Annual Safety Report Team (MID-ASRT). Special thanks go to:

Ms. Ruby Sayyed

International Air Transport Association (IATA)

Mr. Mohamed Smaoui and Mr. Mashhor Alblowi International Civil Aviation Organization (ICAO)

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mid region annual safety report · 2014-05-19 · mid region annual safety report – second...

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