EASA Annual Safety Review 2014 Published
EASA Annual Safety Review 2014 Published The European Aviation Safety Agency (EASA) Annual Safety Review for 2014 is now available at: https://www.easa.europa.eu/newsroom-and-events/general-publications/annual-safety-review-2014 Worldwide in 2014, 16 fatal accidents involved Commercial Air Transport (CAT) aeroplanes (excluding MH17, that was considered to be a hostile act). This was two more than 2014, but still significantly below the average number of fatal accidents for the previous 10 years (2004-2013). The number of fatalities however rose from 185 in 2013 to 648 in 2014. In the foreword EASA Executive Director Patrick Ky comments: 2014 has been a very challenging year for the European Aviation Safety Agency (EASA) and for aviation safety in general. The disappearance of Malaysia Airlines MH370, the dramatic loss of MH17, the crash of Air Asia [Indonesia] QZ8501 and the radar interferences over central Europe have reminded us that the safety of passengers can never be taken for granted. Commercial Air Transport Aeroplane Performance In the 32 EASA Member States (the 28 European Union Member States plus Iceland, Liechtenstein, Norway and Switzerland) there was one fatal CAT Aeroplane accident (MD-83 EC-LTV operated by Spanish airline Swiftair in Mali on 24 July 2014, resulting in 116 fatalities). There were 26 non-fatal accidents (up from 22 the previous year) and 66 serious incidents (down from 74). In the EASA Member States, no more than one fatal accident CAT Aeroplane accident has occurred per annum since 2005 (with none in 2010 and 2013). EASA has identified the 5 top risk areas for CAT Aeroplanes as: Loss of Control – Inflight (LOC-I in the CAST/ICAO Common Taxonomy Team [CICTT] taxonomy) System Component Failure (SCF = SCF-PP + SCF-NP) Airprox / Mid air Collision (MAC) Abnormal Runway Contact / Runway Excursions (ARC/RE) Ground Collisions / Ground Handling (GCOL/RAMP) Interestingly Controlled Flight into Terrain CFIT does not make the list. Commercial Air Transport Helicopter Performance EASA say 2014 was a better year for CAT Helicopter safety: There was 1 fatal accident in 2014 resulting in 2 fatalities. This is compared with 3 fatal accidents in 2013,resulting in 11 fatalities. There was also a 34% reduction in the number of non-fatal accidents and a 71% reduction in serious incidents compared with the 10 year average. Based on the past fatal accident history the top 5 helicopter risk areas, in descending order, are SCF, LOC-I, CTOL, CFIT and ARC (although Low Altitude Operation, LALT and ARC are very close). General Aviation Performance 2014 has also been a positive year for General Aviation safety, with a 20% reduction in the number of fatal accidents and an 18% reduction in the number of fatalities when compared with the 10 year average. However, there were still 173 fatalities in General Aviation, highlighting the importance of the continued safety improvement efforts. Strategic Safety Matters Patrick Ky also noted the agency is moving to a “more proportionate and performance-based approach to safety” with an reorganisation that creates : A new Strategy and Safety Management Directorate…to develop a single, more transparent, evidence-based and data-driven strategy, which will drive the Agency’s work programme. The rulemaking activities were incorporated into ‘operational’ directorates, in order to increase synergies and to benefit from a better and direct operational feedback. This year’s review includes more detailed analyses of the causes of safety occurrences. It also starts to include Sector Safety Risk Portfolios. These will directly support the European Aviation Safety Plan (EASp) which is being...
read moreAircraft Maintenance: Going for Gold?
Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes? Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with the UK Air Accidents Investigation Branch [AAIB]) made the point that after a generation of attention on maintenance errors, similar occurrences were still repeating. Professor King challenged the audience to think about a next generation approach to human factors in engineering. Over the last 10-15 years, much attention has been focused on maintenance human factors training, reporting errors, investigating errors (for example using Boeing’s MEDA) and taking corrective actions. While we could concentrate on simply doing more of these and certainly can find ways to do these things better, perhaps the next generation approach needs to include a wider range of activities. For example, the UK Civil Aviation Authority (CAA) has commented that: Human Factors training alone is not considered sufficient to minimise maintenance error. Most of the [contributing factors] can be attributed to the safety culture and associated behaviours of the organisation. Perhaps we should we start treating maintenance personnel more like athletes who need to achieve peak performance every day? During a similar time frame British Cycling has gone from a historically rather lacklustre performance, for example wining two bronze medals in the 1996 Olympics, to producing spectacular performances. By the London 2012 Olympics, Britain was ranked number one in the world and British riders won 12 medals, including 8 of the available 14 gold medals, with Sir Chris Hoy winning a UK record 6th gold medal. The same year Sir Bradley Wiggins became the first Briton to win the Tour de France, a feat repeated in 2013 and 2015 by Chris Froome. There have been many reasons for this, not least the availability of funding from the National Lottery to support deserving British sports. However, this success is not just due to investment, but to talent, individual commitment and a highly effective strategy for improving performance. Much of the latter has been credited to Sir Dave Brailsford, first performance director of British Cycling (until 2014) and since 2010 general manager of Team Sky. Brailsford, who describes himself as a conductor not a manager, says: Sport is about continuous improvement, it’s about getting better. It’s about being better next year than you are this year. It’s a bit like Formula One. You have a car and the designers might say ‘we can’t think how we’re going to make this any better’. But ultimately you can. And that’s what we’ve got to do. We’ve got to keep looking, researching and working – trying things. And that’s what it’s all about. One of the more quotable examples is his concept of ‘marginal gains’ (very much akin to a Japanese kaizen philosophy). Brailsford advocates a near obsessive attention to detail, to focus on every element that can affect human performance, seeking out opportunities to make small improvements, that collectively lead to noticeable performance improvement. This includes the ‘secret squirrel club’ dedicated to technological advances to enhance human performance (even hi-tech socks). UPDATE 15 August 2016: To understand just how far the obsession with marginal gains went for Rio 2016 read: How scientific rigour helped Team GB’s saddle sore cyclists on their...
read moreFatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014. This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a private site near Gillingham Hall, Norfolk, UK with little nearby cultural lighting, at night and in fog, impacting the ground shortly after. The four occupants, including millionaire Northern Irish peer Edward Haughey, Baron Ballyedmond (Chairman and CEO of Norbrook), were all fatally injured. Pre-Flight Preparation and the Take-off The AAIB note that the crew had been monitoring the deteriorating weather that afternoon and that while departure had been planned for 18:30, the passengers had not been ready until 19:20. At least one of the crew was concerned according to the Cockpit Voice Recorder (CVR) transcript: One said: “[unintelligible] i don’t mind telling you i’m not **** very happy about lifting out of here”. The other replied: “it should be ok it’s… i don’t think it is because you can still see the moon”. The Commander (the Pilot Flying) had briefed for a vertical departure, but shortly after the helicopter pitched progressively nose-down. The Co-Pilot twice said ‘Nose Low’. The AAIB could not determine if these were to highlight the nose-down pitch attitude or prompt for more nose-down pitch. In both cases they were however followed by a further nose-down pitch. The last nose-down pitch attitude recorded by the combined voice and flight data recorder (CVFDR) was 25° with the helicopter 82 ft above the ground, descending at 2,400 ft/min, with a ground speed of 90 kt. The aircraft was destroyed in the impact with the ground. The AAIB discuss Somatogravic Illusions and possibly misidentify headlights on a car as as static lights. Organisational Factors, a Past Accident and Safety Management Haughey Air (a subsidiary of Norbrook Laboratories) had been formed in 1993 and had held an Air Operators Certificate (AOC) until 2008. During this period Norbrook had suffered another accident, while privately using Sikorsky S-76B G-HAUG in Ireland on 12 December 1996. Having examined the Irish Air Accident Investigation Unit (AAIU) report on that accident, the UK AAIB comment: Similarities exist between the causal factors determined in that case and those around the loss of G-LBAL. The AAIU found that the primary cause of the accident to G-HAUG was ‘loss of situational awareness’ on the part of the pilot flying, and it is apparent that the pilot or pilots of G-LBAL experienced a similar condition. This suggests a failure to learn (a topic Aerossurance has discussed recently). Regulations The AAIB note that: In the absence of an AOC, there was no regulatory requirement for an operations manual or safety management system for private flying. Some evidence suggested that an operations manual, including type-specific matters, procedures to be employed by pilots flying together, such as briefings and standard calls, and a safety management system had existed, at least in draft form, in recent years, but none was in use at the time of the accident. Although in this case it appears the draft material had not progressed to publishing, we have previously written about ‘safety shelfware’, where policies and procedures are documented but in practice either ignored or ineffective. The European Aviation Safety Agency (EASA) has published Part NCC, covering...
read moreBA Changes Briefings, Simulator Training and Chart Provider After B747 Accident
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident According to a recently released UK Civil Aviation Authority (UK CAA) FACTOR (Follow-up ACTion on Occurrence Report), British Airways (BA) have enhanced their simulator training and changed chart provider in response to a ground accident in South Africa. The Accident On 22 December 2013, BA G-BNLL sustained substantial damage when its right wing hit a building while taxying at Johannesburg-O.R. Tambo International Airport (JNB). Four people in the building were injured by flying debris. The crew had originally expected that they would be using a different route after pushback (another example of the risks of late changes in plan which we have recently written about). The South African Civil Aviation Authority (SA CAA) summarise the Captain’s statement in their report (South Africa does not have a separate air accident investigation body but does have an separate department within the CAA): The aircraft remained on what was perceived to be still taxiway Bravo. The taxiway edge lights illuminated in a continuous straight line with no signage indicating the change of the two taxiways Bravo & Mike. Also, some of the green centreline lights on taxiway Bravo were not illuminated in sequence thus leading to a false perception that the aircraft is still on taxiway Bravo. …while going through the before take-off procedure and checklist, after we entered the taxiway Mike, the Co-pilot voiced a concern about the width of the taxiway Mike and proximity of the building on the right side of the taxiway. The Co-pilot could not judge the proximity of the aircraft from the building because of the strong apron background glare. The SACAA concluded that the cause was: The loss of situational awareness caused the crew to taxi straight ahead on the wrong path, crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point. Following aircraft stand taxilane Mike; they collided with a building on the righthand side of Mike. They identified the following contributory factors: The crew did not conduct a briefing to discuss the cleared route, nor did they refer to the correct taxiway information in chart 10-6. In combination with the ground movement visual aids, this created confusion and loss of situational awareness when taxiing on taxiway Bravo. The SA CAA Safety Recommendations The SA CAA raised 10 recommendations, which did include important recommendations on airport markings/lighting and their inspection by the SA CAA. Two recommendations were directed to the UK Air Accidents Investigation Branch (AAIB). These however were picked up by UK CAA and the subject of FACTOR F4/2015: Briefings / Simulator Training SA CAA recommended: …AAIB enter into consultations with the operator (British Airways) about the crew’s non-adherence to applicable briefing and taxi policies, procedures and requirements. The AAIB to communicate to AIID what the appropriate corrective action shall be to prevent recurrence. The UK CAA report that a new training package, including simulator exercises, has been designed and delivered to all BA crews. The package, designed by the Human Factors Standards Group (HSFG) in conjunction with fleet Training Standards Captains (TSCs) from a variety of BA fleets, consists of a non type specific human factors briefing that discusses decision-making and change identification. This is followed by Full Flight Simulator exercises to put into practice the human factors briefing....
read moreBeware Last Minute Changes in Plan
Beware Last Minute Changes in Plan The US National Transportation Safety Board (NTSB) has recently reported on an EC130 helicopter accident that illustrates the dangers of last minute changes in plan that are not fully planned or risk assessed. The Wire Strike Accident The accident occurred in Colorado on 3 July 2015 to Airbus Helicopters EC130B4, N974BR of now defunct Aspen Heli Charter. The NTSB report: The pilot had flown multiple trips into and out of the ranch prior to the accident. He also had seen wires in the area and had a discussion with local fishing guides regarding the location of wires in the area. As the pilot was preparing to depart the ranch with the last load of passengers he was approached by a guide who wanted to video the helicopter for their website. The pilot agreed and after lifting off, made a pass near the ranch for the video. The pilot stated he was flying toward the mountains when he heard a “small ting” and he knew the helicopter contacted a wire. He made an uneventful off airport landing in a nearby clearing. Although the pilot stated he never saw the wire it was later determined the helicopter contacted was a small copper static wire. A postaccident inspection of the helicopter revealed two of the three main rotor blades were beyond repair, at least two of the Fenestron blades were beyond repair, and the entire Fenestron stator blade assembly needed to be replaced. Fortuitously no one was injured and the awaiting tour party, who had been on a fly-fishing trip, returned to Aspen by Jeep. Other Cases of Last Minute Changes of Plan Aerossurance has previously discussed a fatal helicopter accident where a last minute distraction at a mining camp and a recent change in work practice fatally combined: When Habits Kill – Canadian MD500 Accident and a military accident where adding passengers to a training sortie at short notice had fatal consequences ‘Procedural Drift’: Lynx CFIT in Afghanistan. A request to extend the planned mission and a last minute change of aircraft type were factors on a Japanese accident: Fatal Police Helicopter Double Engine Flameout Over City Centre. We have also discussed the lessons of an experimental aircraft accident were the full implications of a hardware change were not understood: Breaking the Chain: X-31 Lessons Learned UPDATE 11 September 2016: Another case where a last minute change of plan was partly responsible for an accident: Final Report: AS365N3 9M-IGB Fatal Accident UPDATE 25 June 2017: Similarly, during an air ambulance positioning flight: Impromptu Flypast Leads to Disaster Wire Strike Resources We have written on other wirestrikes: Sécurité Civile EC145 SAR Wirestrike Firefighting Helicopter Wire Strike Helicopter Wirestrike During Powerline Inspection Fatal MD600 Collision With Powerline During Construction Fatal Wire Strike on Take Off from Communications Site Fatal Wisconsin Wire Strike When Robinson R44 Repositions to Refuel UPDATE 26 July 2020: Impromptu Landing – Unseen Cable UPDATE 20 September 2020: Hanging on the Telephone… HEMS Wirestrike UPDATE 23 January 2021: US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude UPDATE 5 March 2021: Wire Strike on Unfamiliar Approach Direction to a Familiar Site UPDATE 21 August 2021: Air Methods AS350B3 Night CFIT in Snow UPDATE 14 August 2022: Second Time Unlucky: Fatal Greek Wirestrike High-Wire Illusion UPDATE 3 September 2022: Garbage Pilot Becomes Electric Hooker UPDATE 4 February 2024: HEMS Air Ambulance...
read moreMisfuelling Accidents
Misfuelling Accidents Misfuelling aircraft with kerosene based Jet A-1 rather than Aviation Gasoline (AVGAS) continues to be a source of accidents. PA31 15 Sept 2015 Manitoba The Canadian Transportation Safety Board (TSB) has recently released an update on the 15 September 2015 accident involving twin engined Keystone Air Service Piper PA31-350 Navajo C-FXLO at Thompson, Manitoba. Shortly after takeoff the aircraft experienced a malfunction and the crew attempted to land back at Thompson. The aircraft impacted terrain less than 1 nautical mile from the airport. All 8 persons on board survived. The TSB say: The ongoing investigation has confirmed that the aircraft received an incorrect type of fuel in Thompson, Manitoba, prior to departing for Winnipeg. The twin piston-engine aircraft requires aviation gasoline (AvGas), but was re-fueled with turbine engine fuel (Jet A1). The aircraft was destroyed by impact with trees and terrain; however, the aircraft cabin section remained largely intact. Almost all of the fuel was dispersed throughout the crash site from ruptured fuel cells but a sufficient quantity remained to obtain samples. There was no post-impact fire. The occupants sustained varying serious injuries but were able to assist each other and exit the aircraft. UPDATE 10 November 2015: Transport Canada has now suspended the operator’s AOC (for a third time since 2002). UPDATE 8 September 2016: The TSB release their report. The refuelling technician, who had been working for the fuelling company for a just over a month, and had no prior aviation experience, had fuelled another aircraft with Jet A1 before the Keystone aircraft arrived and drove the Jet A1 truck to where the PA-31 had parked. The aircraft commander had intended to relay the fuel requirements to the technician, but the Co-Pilot, who was escorting passengers, had noticed that the fuel technician was having trouble with the fuel filler openings. The Co-Pilot assisted the technician and asked for required fuel. The Captain overhead this conversation and so did not talk to the refueller. Neither pilot noticed that the truck was a jet fuel truck. The technician did not spot the aircraft placard specifying aviation gasoline. When the technician couldn’t get the flared fuel filler nozzle to fit, he switched to a narrower nozzle, defeating a defence to prevent Jet A1 being used on a piston engined aircraft, but was sometimes required on aircraft that needed Jet A1. Prior to departure, the Captain returned to the fuel providers office to collect the fuel slip but it was unoccupied The crew then performed an abbreviated check before taking off. TSB say: The Esso fuel dealer at Thompson Airport was Mara-Tech Aviation Fuels Ltd, which operated the Imperial Oil owned facility and equipment under an aviation dealer agreement. In addition to its day-to-day operation of the facility, Mara-Tech was responsible for staffing the facility and training the employees. Training materials were supplied by Imperial and consisted of a series of CDs or VHS tapes whose content was organized into modules. Each module was accompanied by a corresponding multiple-choice quiz. Aviation dealer agreements require that fuel dealers adhere to Imperial’s operating standards and procedures. Under the aviation dealer agreement, fuel dealers have a licence to use Imperial brand trademarks, such as Esso and Esso Aviation, in marketing their businesses. The [fuel technician’s] training consisted of reading the Imperial training material, viewing the CDs, and completing the corresponding multiple-choice quizzes. Additional certifications, such as Airside Vehicle Operator’s Permit and Transportation of Dangerous Goods, were administered by the manager at Mara-Tech’s Thompson facility. The...
read moreFrench Skyscraper HESLO: Helicopter Underslung Load
French Skyscraper HESLO: Helicopter Underslung Load A stunning video, from Bouygues Construction, shows the construction of the the tower on top of the €124 million Incity building in Lyon, the third highest in France. The last two components of the tower were lifted into place by an Airbus Helicopters AS332C helicopter on Sunday 21 June 2015 as a Helicopter External Sling Load Operation (HESLO). The spire, which is 50 metres high and weights a total of 25.9 tonnes, took the building to its final height of 200 metres. Aerossurance has previously written about the replacement of a TV antenna on a 153m tower in Croydon South London by helicopter, the use of helicopter human external cargo by a power company in California and a UK lighthouse support contract. Also see our articles: What the HEC?! – Human External Cargo, Keep Your Eyes on the Hook! Underslung External Load Safety UPDATE 2 July 2020: Erickson videos: Aerossurance has extensive air safety, helicopter operations (inc HESLO) and contracting experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreAerossurance Sponsors HF in Aviation Safety Conference
Aerossurance Sponsors Human Factors in Aviation Safety Conference Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015. Aerossurance was keen to sponsor this event as it is such an excellent independent professional forum for discussion and exchanging of ideas on the very latest research, development and application of Human Factors in Aviation Safety. The 2 day event is just £199 (or £129 for one day) excluding VAT and includes a period of free membership of CIEHF. To book a place click here. The conference was doubled from 1 to 2 days after the organising committee reviewed over 50 high quality submissions. Monday November 9th Time Title Presenter 09:30 Registration 10:00 Welcome Address TBC 10:10 Developing a safety culture at EasyJet Sian Evans, Easyjet 10:30 Human Factors and Aircraft Ground Handling Loading Activities Rebecca Grant, Coventry University 10:50 Culture and Decision-Making Steve Scott, Coventry University 11:10 The assessment of just culture in civil aviation – learning from work on High Reliability Organisations Colleen Butler, Health and Safety Laboratory 11:30 Removing the error, from pilot error Donough Wilson, Coventry University Technocentre 11:50 Discussion and questions 12:10 Lunch 12:50 Understanding and mitigating rate and scale of change within the aviation industry. Jocelyn Clark, NATS 13:10 Tightening the link between safety and human factors in design Andrew Kilner, Eurocontrol 13:30 NATS Automation Principles: The Practicalities of Advanced Air Traffic Controller Assistance Tools. Lisa Aldridge, NATS 13:50 Feeding Human Performance into Design – Learning Lessons from SESAR Renee Pelchen, Eurocontrol 14:10 Discussion and questions 14:30 Break 14:50 An Appropriate Framework For The Safety Assessment of UAS Ground Systems used in UK Civil Aviation Applications Bob Bastow, BAE Systems – Defence Information 15:10 Integrating Unmanned Aircraft Systems into current and future airspace Fiona Cayzer, BAE Systems 15:30 Key Human Factors trends in UK military aviation Victoria Cutler, Royal Air Force Centre of Aviation Medicine 15:50 Human-Computer Interactions in Aviation: Pilots’ Visual Behaviour, Attention Distribution, Situation Awareness and Decision-making during Flight Operations Wen-Chin Li, Cranfield University 16:10 ‘Doing more with less’ – Single operator control of multiple UAVs Dale Richards, Coventry University 16:30 – 17:00 Discussion, questions and close 17:00 Drinks reception Tuesday November 10th Time Title Presenter 08:30 Registration 09:00 Pilot Monitoring Skills – the final safety net Jo Davies, ESE Associates Ltd 09:20 By products of commercial pressure: Human factors implications of fuel savings policies for airline operations Jorge Delgado, Independent HF Consultant and A330 Captain 09:40 A Human Factors Review of Pilot Training in UK Aviation Georgina Fletcher, Frazer-Nash Consultancy 10:00 Putting the Science Back into CRM; Promoting Distributed Cognition on the Flight Deck Don Harris, Coventry University 10:40 Break 11:00 Team and Collective Training Needs Analysis for Single Pilot Operations John Huddlestone, Coventry University 11:20 The Challenges and Opportunities for Crew Human Factors Training David Moriarty, Zeroharm Solutions 11:40 Mode Confusion; the Nemesis of Uniformity David Thompson, Wessex Human Factors Ltd 12:00 Discussion 12:20 Lunch 13:00 Using STAMP to bridge the gap between Human Reliability Analysis and Technical System Safety Peter Gibson, BAE Systems 13:20 A systematic safety work method for addressing blind spots in accident / incident investigation Jonas Lundberg, Linköping University 13:40 The Geometry of NMAC Brian Peacock, SIM University 14:20...
read moreCritical Maintenance Tasks: EASA Part-M & -145 Change
Critical Maintenance Tasks: EASA Part -M & -145 Change Commission Regulation (EU) 2015/1536 was issued on of 16 September 2015. Technically it amends Regulation (EU) No 1321/2014 “as regards alignment of rules for continuing airworthiness with the ‘Basic Regulation’ Regulation (EC) No 216/2008“. Critical Maintenance Tasks (CMTs) One of the most important parts of the amendment relates to CMTs, which are defined as: …a maintenance task that involves the assembly or any disturbance of a system or any part on an aircraft, engine or propeller that, if an error occurred during its performance, could directly endanger the flight safety. The European Aviation Safety Agency (EASA) has said that this change: …addresses a safety issue related to the risk of errors made during the performance of critical maintenance tasks and the need for maintenance organisations to implement methods to capture those errors before the certificate of release to service is issued. The change primarily enhances M.A.402 for Continuing Airworthiness Management Organisations (CAMOs). It also introduces 145.A.48 on the Performance of Maintenance for maintenance organisations (with 145.A.65(b) adjusted to be consistent with 145.A.48), which include tool control. Previously the expectation would be that the CAMO would ensure that M.A.402 defined standards were achieved by the maintenance organisation. Now effectively they are both accountable, the Part-145 to ensure the requirements are met and the Part-M to assure they are. Note: M.A.402 (a) previously referred to ‘flight safety sensitive maintenance tasks’ and 145.A.65 (b)(3) to ‘critical systems’. For background and the history of the rule making see: Terms of Reference for the Rule Making Team: Review Group ToR RMT.0222 (MDM.020) – Issue 1 Notice of Proposed Amendment: NPA 2012-04 Comment Response Document: CRD 2012-04 (193 comments were received) Opinion 06/2013 – Explanatory Note Draft amendment to Commission Regulation (EC) No 2042/2003 The NPA was in part prompted by following three safety recommendations addressed to the Agency: AIBN recommendation 12/2006, Report on the aircraft accident at Bergen Airport Flesland, Norway, on 31 January 2005 involving ATR 42-320, OY-JRJ, operated by Danish Air Transport, when control problems were experienced an elevator bolts loosened and fell out. The self-locking nuts were not tightened with the required torque. UK AAIB Safety Recommendation 2005-123 in Report 3/2005 on the serious incident to Boeing 757-236 G-CPER, operated by British Airways, on 7 September 2003. Maintenance errors that had culminated in the failure to reinstall two access panels on the right-hand outboard flap and incorrect engine oil top up. UK AAIB Safety Recommendation 2006-030 AAIB Bulletin: 11/2006 EW/C 2004/10/03 on the fatal accident to a privately operated Mooney Aircraft Corporation M20J, G-EKMW. A defect was discovered within the engine’s dual magneto, which had recently been refitted following a 500 hour inspection, affecting both ignition systems. This led to a loss of power shortly after take off and the aircraft impacting the ground while attempting to return to the airfield When discussed at the EASA Management Board, issue of whether the Type Certificate Holder was better placed to identify critical tasks. EASA clarified that this text is dealing with errors that occur during performance of maintenance, hence the responsibility is a continuing airworthiness one. The associated AMC and GM is expected to be published this autumn. However CRD 2012-04 indicates what can be expected. In particular the AMC and GM to 145.A.48 will cover implementing maintenance error capturing methods, that may include Independent Inspections and other techniques such as functional checks. Other Changes Although we...
read moreThe Missing Igniters: Fatigue & Management of Change Shortcomings
The Missing Igniters: Fatigue & Management of Change Shortcomings On 15 September 2015 the UAE General Civil Aviation Authority (GCAA) issued their investigation report into a Serious Incident that affected both engines of a Dash 8. Their report highlights the importance of Management of Change both at a macro level, when undertaking corporate restructuring (highly topical for air operators in the oil and gas sector with $50 / barrel oil) and at the micro level, when introducing new tasks. It is also the latest of a series of investigations to discuss maintenance personnel fatigue and alertness. The Incident Flight On 9 September 2012, Bombardier Dash 8 / DHC-8-315Q A6-ADB, operated by Abu Dhabi Aviation and chartered by a local oil and gas company, departed Abu Dhabi International Airport on a scheduled 35 minute passenger flight to Das Island, about 100 nm away and home to multiple oil and gas facilities. A crew of 3 and 46 oil and gas workers on board. Several minutes intro the flight, a concerned passenger informed the cabin crew member about paint blisters forming on the right hand engine inboard cowling. Although no fire warnings were generate the crew decided to return to the international airport and landed 10 minutes after take off. It was only after a safe landing that it was discovered that similar damaged had occurred on the left hand engine outboard cowling too. The engine cowlings were damaged because of: …of hot engine gases escaping through an open igniter boss on the engine casing. The hot gas was impinging on the nacelle, engine case drain line and engine support strut. The Maintenance History – Management of Change at the Micro Level The operator has suffered from unscheduled engine removals due to environmentally induced performance deterioration. Several engine wash options are available for the Pratt & Whitney Canada PW123. The operator had been conducting turbine washes since May 2009. Until December 2011, these were conducted using a task card, that contained technical instructions and was used to record the sign-off by both mechanic and certifying engineer. However to “reduce paperwork” and “improve process efficiency” these were replaced by a procedure that described the task and required a technical log entry, signed just by the certifying engineer. In July 2012 supervisors locally, without reference to management, decided to trial doing a compressor wash at the same time as a turbine wash on one engine. As the investigators note, unfortunately the trial was briefed verbally and inconsistently and conducted in an even less controlled manner than the compressor washes as: …the work was being performed based on experience alone, and without any referral documentation from the AMM [Aircraft Maintenance Manual] to perform the physical task. In addition, the work was being conducted without any sign-off by the mechanic, or the engineer, and without any updates being entered into the electronic data system of the Operator. They go on to report that: On the night prior to the Incident flight, the duty Engineer in charge of the shift had physically prepared both engines for turbine washes… He removed engine access panels 415AL and 425AL, the igniter leads and the left igniter from each engine. The removed igniters were left inside the recess of the engine compartment without placing them in protective bags. The duty Engineer returned to the ‘control office’ where he proceeded to update the electronic data system for work done inside the hangar. He allocated two mechanics to perform...
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