2012 in Review and Emerging Safety Challenges

and Initiatives

Asia Pacific Safety Seminar - 2012

Major Accident RateWestern-Built Commercial Jets

1999 – 2011

0.00

0.40

0.80

1.20

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

5 year running average

Major Accident Rate

Acc

ide

nt

rate

pe

r m

illi

on

de

pa

rtu

res

Source: Ascend

The Fleets - 2012

Type Western Built Eastern Built Total

Turbojets 21,479 1,065 22,544

Turboprops 4,817 1,195 6,012

Business Jets 17,642

Source: Ascend - A Flight Global Advisory Service

Major Accidents Commercial Jets

1 January 2011 to 31 December 2011

CFIT

LOC

Excursion

Date Operator Aircraft Location Phase Fatal

1 Januray Kolavia TU-154 Surgut, Russia Taxi 3

9 January Iran Air B-727 Orumiyeh, Iran Landing 78

5 March VASO AN-148 Garbuzovo, Russia Enroute 6

4 April Gegorian Airways (UN) CRJ-100 Kinshasa, DRC Approach 32

18 May Omega Air Refueling B-707 Point Mugu, CA, USA Takeoff 0

20 June RusAir TU-134 Petrozavodsk, Russia Landing 45

6 July Silk Way Airlines IL - 76 Bagram, Afghanistan Approach 9

8 July Hewa Bora Airways B-727 Kisangani, DRC Landing 83

28 July Asiana Airlines B-747F Jeju, South Korea Enroute 2

30 July Caribbean Airlines B-737 Georgetown, Guyana Landing 0

20 August First Air B-737 Resolute Bay, Canada Approach 12

7 Sept YAK Service YAK-42 Yaroslavl, Russia Takeoff 44

16 Sept TAME EMB-190 Quito, Ecuador Landing 0

28 Dec Kyrgyzstan TU-134 Osh, Kyrgyzstan Landing 0

Source: Ascend - A Flight Global Advisory Service

Major Accidents Commercial Jets

1 January 2012 to 22 October 2012

CFIT

LOC

Excursion

Date Operator Aircraft Location Phase Fatal

20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127

9 May Sukhoi SU-100 Mount Salak,Indonesia Enroute 45

2 June Allied Air B-727 Accra, Ghana Landing 0

3 June Dana Air MD-83 Lagos, Nigeria Approach 153

Source: Ascend - A Flight Global Advisory Service

Commercial Jet Major Accidents2000 through 2011

20

15

10

5

2000 01 02 03 04 05 06 07 08 09 10

17

13

19

13 13

16

11

17

19

17

19

12 Years 15.6

14

11

5 Years 17.2

Eastern Built

Major Accidents

Business Jets1 January 2012 to 22 October 2012

Date Operator Aircraft Location Phase Fatal

2 February Extrapoint, LLC Lear 35 Pueblo, CO, USA Takeoff 0

12 February Trident Aviation Svcs Gulfstream IV Bakavu-Kavumu, DRC Landing 3

1 March Asia Today, Ltd Citation X Egelsbach, Germany Approach 5

15 March Private Citation I SP Franklin-Macon, NC, USA Landing 5

18 June Triple C Devlopment Beech 400 Atlanta,Gegoria, USA Landing 0

13 July Universal Jet Aviation Gulfstream IV Le Castellet, France Landing 3

2 August Airnor Citation 500 Santiago de Compostela, Spain Approach 2

15 Sept Private Lear 24 Bornholm, Denmark Approach 0

18 Sept Dewberry Air LLC Beech 400 Macon, GA, USA Landing 0

Source: Ascend - A Flight Global Advisory Service

Business Jet Major Accidents2000 through 2011

20

15

10

5

2000 01 02 03 04 05 06 07 08 09 10

8

14

8

14

8

15

9

11 11

7

8

10.0

7

11

Major Accidents Commercial Turboprops (> 14 seats)

1 January 2012 to 22 October 2012

CFIT

Source: Ascend - A Flight Global Advisory Service

Date Operator Aircraft Location Phase Fatal30 January TRACEP AN-28 Namoya, DRC Enroute 3

2 April Utair ATR-72 Tyuman, Russia Takeoff 31

9 April Air Tanzania DHC-8 Kigoma, Tanzania Takeoff 0

28 April Jubba Airways AN-24 Galkayo, Somalia Landing 0

14 May Agni Air DO-228 Jomsom, Nepal Approach 15

6 June Air Class Lineas Aereas SW Metro III Montevideo, Uruguay Climb 2

10 June Ukrainska Shkola Pilotov LET - 410 Borodyanka, Ukraine Enroute 5

20 June ITAB Gulfstream I Pweto, DRC Landing 0

19 August ALFA Airlines AN-24 Talodi, Sudan Approach 32

22 August Mombassa Air Safari LET-410 Ngeredi, Kenya Takeoff 4

12 SeptPetropavlovsk-Kamchatsky Air Enterprise

AN-28 Palana, Russia Approach 10

28 Sept Sita Air DO-228 Katmandú, Nepal Climb 19

7 October Azza Transport AN-12 Khartoum, Sudan Enroute 13

19 October Air Mark Aviation AN-12 Shindand, Afghanistan Landing 0

Commercial Turboprop Major Accidents 2000 through 2011

2000 01 02 03 04 05 06 07 08

5

10

15

20

25

30

35

40

2322

3133

31

39

24 24

29

21

09

20

10

26.6 (12 years)

23.4 (5 years)

23

11

Approach and Landing Major Accidents

Commercial Jets 1 January 2012 through 22 October 2012

Date Operator Aircraft Location Phase Fatal

20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127

2 June Allied Air B-727 Accra, Ghana Landing 0

3 June Dana Air MD-83 Lagos, Nigeria Approach 153

Controlled Flight into Terrain Major AccidentsCommercial Jets

1 January 2012 though 22 October 2012

Date Operator Aircraft Location Phase Fatal

20 April Bhoja Airlines B-737 Islamabad, Pakistan Approach 127

9 May Sukhoi SU-100 Mount Salak,Indonesia Enroute 45

Sources: Honeywell (Don Bateman), Ascend

Over the last 6 years, 23 of 82 turboprop major accidents has been a CFIT– that’s 28%, or more than 1 of every 4 !

Aircraft Upset Major AccidentsCommercial Jets

1999 through 2011

Nu

mb

er

of

Ac

cid

en

ts

0 0

0

0

0

0

0

0

0

1

2

3

4

5

6

7

8

9

10

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

4

6

Runway Excursion

Data Update

Added 2007 - 2010

Data Base now

covers 16 Years

1995-2010

SAN RW27 9401 x 200 ft

High Energy Approach

Aircraft with High

Energy Approaches

(physical analog to

Unstable Approach)

have a higher rate of

Risk of Runway

Overrun (r50 <1200)

Risk of Runway Overrun

High Energy

Flights

Important Initiatives

• Data Sharing and Protection

• Revisiting SMS in the real world

• Refocusing SMS on Risk

• Evidence-Based Training

• Unreliable Airspeed

• Functional Check flight

02/15/201117

The World According to ICAO SMS

Regulator

•State Safety Program

•Inspector

Airline

•SMS

•Accountable Exec

Airline

•SMS

•Accountable Exec

Airline

•SMS

•Accountable Exec

Airline

•SMS

•Accountable ExecOversight

Safety

The World As It Is

Regulator•State Safety Program•Inspector

Parent Airline•SMS

•Accountable Exec Oversight

Safety

Group SafetyProgram

Subsidiary Airline B

•SMS

•Accountable Exec

Regulator B

•State Safety Program

•Inspector

State A

State B

Subsidiary Airline C

•SMS

•Accountable Exec

Regulator C

•State Safety Program

•Inspector

State C

SafetyOversight

SafetyOversight

CorporateOversight

Rescuing SMS from Itself

• SMS is becoming mature – sometimes that means

bureaucratic

– An SMS can pass an audit, but that only means it is

auditable, no effective

• 4 Questions to ask assess effectiveness

– What is most likely to cause the next accident?

– How do we know that?

– What are we doing about it?

– Is it working?

Aptitude

Testing

Type

Specific

Effective TEMEffective TEM

Training Needs Analysis

Competencies (Behaviours)

Competencies (Behaviours)

(Outcomes)(Outcomes)

Desired

Performance

Multi Crew

Job Task Analysis

Data: FDA; LOSA; Safety events; Training system; OEM in-service eventsData: FDA; LOSA; Safety events; Training system; OEM in-service events

Recurrent

EBTSingle Pilot

Training System

RAeS Flight Crew Training Conference

EBT Working Group

London, 27 September 2012

RAeS Flight Crew Training Conference

Coming Soon

From the RAeS Flight Crew Training Conference

Unreliable Airspeed (URA) – FSF Project

• Issue - Historical and recent accidents and

incidents have highlighted the increased risk

associated with unreliable airspeed (URA)

events

• Steering Group – Airbus, Boeing Bombardier,

Embraer, IATA, ALPA, A4A

• Products

– URA Philosophy

– URA Guidelines

URA Philosophy

• The keys to successfully dealing with a URA event are

recognition, procedures, and training

• The aircrew’s recognition of and initial reaction to a

URA event is critical

• Manufacturers should attempt to ensure unreliable

airspeed events are clearly identifiable to aircrews

• The most important function of the aircrew during

an in-flight URA event is to maintain control over the

aircraft’s flight trajectory and energy situation

URA Philosophy

• Crews should be aware of the instruments and

critical systems that are not affected by a URA event

(e.g. attitude displays, engines)

• Procedures and training for URA events should

include the effect of a URA event on other aircraft

systems, and potential alerts/warnings and

indication system inaccuracies that could be

expected

• Crew coordination and communication are

important

elements in successfully addressing a URA event

URA Guidelines

• URA procedures should provide information on attitude and

power settings that enable crews to maintain the aircrafts

flight parameters within normal limits during in-flight

unreliable airspeed events for all phases of flight

• URA procedures should address the availability and use of

independent alternate sources of airspeed information (e.g.

GPS, inertial, angle of attack, etc.)

• URA procedures should include memory items for critical

immediate action steps

• Training programs addressing URA should exist at beginning

(ab initio/MPL), initial, and recurrent levels

• URA training should include both simulator and academic

phases

02/15/201127

Functional Check Flight (FCF – FSF Initiative

• “Be Prepared” Paper

• FCF Guidelines Document

– Preparation

– Ground Phase

– Flight Phase (25 modules, Autopilot, Air conditioning, etc)

• FCF Symposium February 2011 in Vancouver

– FCF Symposium Materials available on FSF Website

• EASA Rulemaking on FCF – NPA Published

02/15/201128

Aviation Safety 2012

• Record year overall for commercial jets (so far)

• Record year (so far) for commercial turboprops

• Average year (so far) for business jets

• CFIT continues to be a challenge – and it is

making a strong comeback as the leading killer

• There are many challenges out there, and FSF is

addressing many of them:

– Data Sharing and Protection

– Revisiting SMS in the real world

– Evidence-Based Training

– Unreliable Airspeed

– Functional Check flight

30