CAA Safety Risk Analysis Process & Analysis Results RETRE - - PowerPoint PPT Presentation

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CAA Safety Risk Analysis Process & Analysis Results RETRE - - PowerPoint PPT Presentation

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CAA Safety Risk Analysis Process & Analysis Results RETRE Conference 17 November 2009 Content Background CAA Safety Risk Analysis Process Analysis Results Questions RETRE Conference 17 November 2009

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RETRE Conference – 17 November 2009

CAA Safety Risk Analysis Process & Analysis Results

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RETRE Conference – 17 November 2009

Content

  • Background
  • CAA Safety Risk Analysis Process
  • Analysis Results
  • Questions
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UK Commercial Air Transport Aeroplane High-Severity Occurrence Rate

35.8 30.3

10 20 30 40 50 60 Mar05 Jun05 Sep05 Dec05 Mar06 Jun06 Sep06 Dec06 Mar07 Jun07 Sep07 Dec07 Mar08 Jun08 Sep08 Dec08 Mar09 Jun09 Sep09 12-Months Ending: Rate (per million flights) Actual Rate Monitoring Line

Background

  • Safety Performance Indicator (SPI) 2
  • ‘Partnership in Safety’ Conference 2009
  • SPI 2 WG
  • Task Forces
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  • Post crash fire
  • Loss of control
  • Controlled flight into terrain
  • Runway excursions

CAA Safety Risk Analysis Process

Identification of Main Risks Worldwide AAG

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  • Airborne conflict
  • Ground conflict (including runway

incursions)

  • Ramp incidents

CAA Safety Risk Analysis Process

Identification of Main Risks Worldwide AAG Identification of Additional Risks in the UK Environment THREAT

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Further Analysis and Development of Mitigations

CAA Safety Risk Analysis Process

Identification of Main Risks Worldwide AAG Identification of Additional Risks in the UK Environment THREAT CAA Task Forces

Task Forces

Airborne Conflict Loss of Control Airborne & Post Crash Fire Runway Overrun

  • r Excursion

Controlled Flight into Terrain Ramp Incidents Ground Collision & Runway Incursion

Task Forces

Airborne Conflict Loss of Control Airborne & Post Crash Fire Runway Overrun

  • r Excursion

Controlled Flight into Terrain Ramp Incidents Ground Collision & Runway Incursion

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CAA Safety Risk Analysis Process

Prioritisation of Safety Risks and Definition of CAA Safety Plan Further Analysis and Development of Mitigations CAA Task Forces Identification of Main Risks Worldwide AAG Identification of Additional Risks in the UK Environment THREAT Identification of Precursors

  • f Main Risks
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THREAT Dataset

  • Grade A or B MORs
  • G-registered or UK operated (AOC):
  • Jet and turboprop aeroplanes > 5,700 kg
  • Turbine helicopters > 3,175 kg
  • Passenger and cargo operations only
  • Occurring worldwide since 1 Jan 2005
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Analysis Overview

THREAT analysed:

  • 112 high-severity occurrences in 2005-08
  • 1 fatal accident
  • 12 other accidents, 37 serious incidents, 62
  • ccurrences
  • 2 grade A occurrences
  • 18 occurrences involving aircraft damage
  • 10 occurrences involving injuries
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Overall Trend

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Location and Phase of Flight

Location:

  • Half in UK, half abroad
  • Foreign included: Spain (11), USA (9), France (6) and

Germany (5) Phase of flight:

  • Approach and landing (34)
  • Take-off and climb (28)
  • Cruise (18)
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Aircraft Class

Aircraft Class Number Aeroplane 103 Helicopter 9 Aircraft Class Rate (per million flights) Aeroplane 21.3 Helicopter 13.0

12-Month Moving Average Rate by Aircraft Class

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Dec05 Mar06 Jun06 Sep06 Dec06 Mar07 Jun07 Sep07 Dec07 Mar08 Jun08 Sep08 Dec08 12-Months Ending: High-Severity Occurrence Rate (per million flights) Aeroplane Helicopter

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Propulsion Type

Propulsion Type Number Jet 82 Turboprop/ Helicopter 30 Propulsion Type Rate (per million flights) Jet 19.9 Turboprop/ Helicopter 21.3

12-Month Moving Average Rate by Propulsion Type

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Dec05 Mar06 Jun06 Sep06 Dec06 Mar07 Jun07 Sep07 Dec07 Mar08 Jun08 Sep08 Dec08 12-Months Ending: High-Severity Occurrence Rate (per million flights) Jet Turboprop/Helicopter

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Nature of Flight

Nature of Flight Number Passenger 109 Cargo 3 Nature of Flight Rate (per million flights) Passenger 20.2 Cargo 20.8

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Event Groups

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Event Types

Event Group Top-Ten Event Types (not mutually exclusive) Airborne Conflict Airprox 27 Damage to Aircraft Damage to aircraft 18 Hard Warnings TCAS RA 12 Aircraft Technical Malfunction/Failure Instrumentation (including all flight deck displays) 9 Medical Injury (non-fatal) 9 Aircraft Technical Malfunction/Failure Engine (including loss of power for any reason) 7 Loss of Control On ground 6 Abnormal Runway Contact Hard landing 5 Airborne Conflict Loss of separation 5 Hard Warnings Stall warning/stickshake 5 Runway Excursions/Overruns Runway excursions/overruns 5 Terrain Conflict Flight below safety altitudes/decision heights 5 Turbulence Encounter Wake turbulence 5

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Causal Factor Groups

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Causal Factors

Causal Factor Group Top-Ten Causal Factors (not mutually exclusive) Crew Omission of action/inappropriate action 20 Crew Failure in CRM 19 Other Caused by other aircraft/vehicle 18 Crew Poor professional judgement/airmanship 18 Crew Flight handling 17 Aircraft Design Design shortcomings 17 ATC/Ground Aids Incorrect or inadequate instruction/advice 15 Infrastructure Incorrect, inadequate or misleading information to crew 13 Crew Lack of awareness of circumstances in flight 12 ATC/Ground Aids Failure to provide separation – airborne 12

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Potential Catastrophic Outcomes

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Positive Factors

Some form of providence was present in 21 (or 19%) of all occurrences

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THREAT Observations

  • Lack of in-depth understanding by pilots of how

aircraft operate beyond their interface with the technology

  • Operators could make better use of FDM to

identify and correct non-standard operating technique, which if uncorrected could lead to an accident

  • Importance of pilots understanding the level of

protection afforded by ATS provision in different types of airspace and knowing when heightened lookout is required

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THREAT Observations

  • It has been identified that some operator’s

Operations Manuals do not reflect the Aircraft Flight Manual nor the manufacturer’s recommended procedures

  • Need for the CAA to better share lessons

learnt, through the investigation of safety data, with the aviation community in general

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Summary

  • Increasing trend in overall number and rate of

high-severity occurrences

  • Wide variety of events and causes
  • Providence features strongly
  • Relatively low number involving helicopters

and cargo operations – are we seeing the true picture?

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Thanks For Your Attention Any Questions?