Kingdom of Saudi Arabia Aviation Investigation Bureau · 2016-08-31 · 2016 -2nd Quarter Report 5 Occurrence Status The AIB receives notification 24/7 by Telephone, Facsimiles, email

2016 2nd Quarter Report i

Kingdom of Saudi Arabia

Aviation Investigation Bureau

2016 2nd Quarter Report 1

TABLE OF CONTENTS

GLOSSARY 2 INTRODUCTION 3

NOTIFICATIONS 4

Occurrences type

Occurrence Status

Occurrence Categorization

INVESTIGATIONS 7

Limited Scope Investigations (definition) 7

Safety Recommendations (definition) 8

Reports-Synopsis 9


GLOSSARY

AIB

ADREP

ANS

AOTS

ATC

ACC

ACNE

CTS

CVR

EASA

DFDR

GACA

ICAO

IIC

KAIA

KKIA

KSA

MED

NOTAM

Aviation Investigation

Bureau

Accident/Incident Data

Reporting

Air Navigation Service

Aviation Occurrence

Tracking System

Air Traffic Control

Area Control Center

Area Control North East

Correspondence Tracking

System

Cockpit Voice Recorder

European Aviation Safety

Agency

Digital Flight Data Recorder

General Authority of Civil

Aviation

International Civil Aviation

Organization

Investigator-In-Charge

King Abdulaziz

International Airport

King Khalid International

Airport

Kingdom of Saudi Arabia

Medina

Notice to Airmen

RA

SAEI

SAR

SQA

SVA

TCAS STCA

Resolution Advisory

Saudi Aerospace

Engineering Industries

Stand-Alone

Recommendation

Safety & Quality Assurance

Saudi Arabian Airlines

Traffic Collision Avoidance System Short Term Conflict Alert


INTRODUCTION

The Aviation Investigation Bureau (AIB) is honored to present to H.E. Minister of

Transport / Chairman BoD GACA, its Quarterly Report representing second quarter of

2016. The Quarterly Report focuses on AIB activities during the previous quarter, with

primary focus on the Limited Scope Investigation (LSI) reports, safety concerns and

safety recommendations tracking.

The AIB conducts LSI for incidents that do not usually involve international interested

parties to the investigation, such as, air proximity incidents and ground handling

related incidents within KSA airports. LSI reports are short reports that will be sent

directly to the concerned parties and do not take the flow of an Annex 13 format report.

A summary of the issued LSI reports will be presented respectively in the quarterly

report.

The Quarterly Report will also include a list of issued safety recommendations and the

response status to each recommendation. Tracking of recommendations is necessary

to ensure that proper action is taken to enhance safety.


NOTIFICATIONS

2nd quarter of the year 2016 has consistent notifications of the aviation occurrences

reported. Figure 1 reveals that there were 160 occurrences reported.

Fig. 1 Notifications for 2nd

Qtr -2016 –Source : AIB Safety Analysis Dept.

Occurrence Type

The AIB classifies reported aviation occurrence into four categories, accidents, serious

incidents, incidents and non-significant. The 2nd quarter 2016 occurrences are

projected in Fig.2 below are classified into four categories accidents one (1), serious

incidents are eighteen (18), incidents are ninety (90) and non-significant occurrence

are fifty one (51). The accident reported is of gyrocopter in medina.

Fig. 2 Occurrences Type for 2nd

QTR 2016-Source: AIB Safety Analysis Dept.

0

20

40

60

80

APR MAY JUN

68

37

55

Notifications Per Month 2016

Incidents, 90, 56% Non-

Significant, 51, 32%

Serious Incidents, 18,

11%

Accident, 1, 1%

Occurrence Type 2nd QTR-2016

Total Notifications

Reported: 160

Total Notifications

Reported: 160

2016 -2nd Quarter Report 5

Occurrence Status

The AIB receives notification 24/7 by Telephone, Facsimiles, email and website. During the 2nd quarter 2016 AIB received one hundred and sixty (160) notifications out which one hundred and thirty (130) are closed and Thirty (30) are In-Progress as shown in Fig 3.

Fig.3 Notification Status 2nd

QTR-2016- Source: AIB Safety Analysis Dept.

Closed- Cases Investigated, Final Report Disseminated, Safety Recommendation

Updated, Response Received or the cases with non-safety significance are classified as No Further Investigation (NFI)

In-Progress – The cases which are on-going investigations or the final report is issued but

safety recommendations are pending for response.

160

130

30

0

20

40

60

80

100

120

140

160

180

Total Notificaitons Closed In-Progress

Occurrence Status 2nd Qtr 2016

Total Notifications

Reported: 160


Occurrence Categorization

Occurrences received are categorized as per the ICAO aviation occurrence categories

taxonomy, which is the standard process, utilized internationally.

The 2nd quarter 2016, Fig 4 classification shows highest category where Bird Strike (23),

RAMP (18), and System Component Failure-Non Power Plant (18).

Fig.4 Occurrence Categorization 2nd

QTR-2016- Source: AIB Safety Analysis Dept.

31

1

1

1

1

2

2

2

3

3

4

5

8

8

8

10

11

18

18

23

OTHR: Other

RI-VA: Runway incursion – vehicle or a/c

LOC-I: Loss of control – inflight

SEC: Seurity related

AMAN: Abrupt maneuvre

ARC: Abnormal runway contact

GCOL: Ground collision

RI-VAP: Runway incursion – vehicle, a/c or person

ADRM: Aerodrome

TURB: Turbulence encounter

FUEL: Fuel related

CABIN: Cabin safety events

SCF-PP: Powerplant failure or malfunction

F-NI: Fire/Smoke (non-impact)

ATM: ATM/CNS

MAC: AIRPROX/near miss/midair collsion

WSTRW: Windshear or thunderstorm

SCF-NP: Sys malfunction (non-powerplant)

RAMP: Ground handling

BIRD: Birdstrike

Occurrence Categorization 2nd QTR-2016

Total Notifications

Reported: 160


INVESTIGATIONS

LIMITED SCOPE INVESTIGATIONS (LSI)

The AIB conducts LSI for incidents that do not usually involve international interested

parties to the investigation, such as, air proximity incidents and ground handling related

incidents within KSA airports. LSI reports are short reports that will be sent directly to the

concerned parties and do not take the flow of an Annex 13 format report. A summary of

the issued LSI reports will be presented respectively in the quarterly report.

These actions are categorized in following order:

1. Full Investigation – as per Annex 13

2. Limited Scope Investigation- low to moderate risk occurrences

3. Safety Study –on going safety study

4. Delegate- case is delegated to others

The 2nd quarter 2016 started with Thirty Three (33) investigations from previous quarter. Six (6) investigations were completed and final reports were released. Fig 5 depicts that the AIB is currently working on Forty Five (45) investigations and Seventeen (17) are delegated.

Fig.5 Investigation Status till 2nd QTR-2016- Source: AIB Safety Analysis Dept.

45

1

5

17

0

5

10

15

20

25

30

35

40

45

50

On-Going Investigations Full InvestigationsCompleted

LSI Completed Delegated

Investigation Status till 2nd Qtr-2016


SAFETY RECOMMENDATIONS

In accordance with the AIB Regulations Chapter 8, paragraph 8.2, the AIB recommend corrective or remedial actions as a result of investigations or safety studies for the purpose of preventing further aviation occurrences.

If during the course of an investigation any safety deficiency becomes known for which prompt preventative action is required, then it will be addressed through a Stand-Alone Recommendation (SAR) in accordance to AIB Regulation Chapter 6, paragraph 6.3.

Responding to Safety Recommendations

This Quarterly Report contains progress and status of all Safety Recommendations made by the AIB during 2nd Quarter 2016. Status of the Safety Recommendations is categorized in to the following categories:

1. Accepted – CLOSED Appropriate action is implemented or planned to be implemented.

2. Rejected – OPEN Further action is required.

3. Rejected – CLOSED Rejected for acceptable reasons not known at the time of publication (No further action by AIB).

4. Response awaited - OPEN

5. Superseded – CLOSED


REPORTS-SYNOPSIS

The case synopsis and recommendations mentioned below are limited scope

investigations and Full investigation reports that were completed during the 2nd quarter

2016. The recommendations for these cases are mentioned at end of each the

Recommendations section of this report.

Full Investigation:

AIB-2014-0181 : Cabin-F-NI – SCF-NP (Cabin Safety Event-Fire/Smoke (Non-Impact)

System/Component Failure or Malfunction)

Synopsis

A Saudi Arabian Airlines Airbus A-320 departed King Khalid International Airport

(OERK), Riyadh on a scheduled flight to Taif Regional Airport (OETF), Kingdom of

Saudi Arabia. After approximately 30 minutes of flight, a cabin crewmember

reported smoke and fire coming from an aft galley oven. The Pilot-In-Command

declared an emergency and the flight returned to Riyadh.

The fire was extinguished by cabin crew members during the return flight to Riyadh.

The aircraft landed safely without further incident. Two (2) cabin crewmembers were

taken to the hospital due to smoke and halon inhalation. There were no injuries to any

passengers.

Contributing Factors:

CF1- It is likely the bottom of the oven contained a built up of residue that

became overheated producing smoke.

CF2- It is likely when the cabin crew member opened the oven door, smoke was being

emitted from the oven while the heating element was electrically powered.

CF3- It is likely the red/orange color from the heating element located in the rear wall of

the oven gave the impression that a flame was in the back of the oven.

CF4- When using the fire extinguisher, the extinguishing agent forced the smoke from the

oven, introducing additional smoke into the aircraft galley and cabin area.

Safety Recommendations: Safety Recommendation AIB-2014-0181-SR-01

Status Response awaited - OPEN

Assigned To: Saudi Arabian Airlines

Saudi Arabian Airlines should review the air carrier’s current A-320 oven maintenance program and make adjustments to this program to preclude equipment failures related to corroded water fittings.


Safety Recommendation AIB-2014-0181-SR-02



Saudi Arabian Airlines should issue an alert to its cabin crewmembers noting: A) Pre-departure checks include an inspection of all ovens to ensure that no foreign objects or other flammable residues are in the ovens. B) A special emphasis should be placed on SVA firefighting practices used for combating on board fires.

Limited Scope Investigations:

AIB-2014-0221 : Airprox /Mid Air/Near miss (MAC)

Synopsis

On 22 September 2014G, Z time (12:53) . During flight of Qatari Flight Call Sign (QAF5) type (E319) from Doha to JED has received (TCAS-TA), During cruising at FL (340ft) proceeding west on airway (UG663) distance (8NM) West of (KFA- VOR) avoiding reciprocal traffic was Saudia flight Call Sign (SVA570) from RUH to Abu Dhabi on airway (UL604), at (FL338) Climbing with proximity (3NM) Horizontal separation.

Contributing Factors : CF-1 Flight data information for SVA570 was not appear on radar screen between Jeddah

ACC center and Riyadh ACC center like most of the flights Inf. on radar screen on

using sys on mode (Pre-active, Announced, Hand over..etc.) Before the flight reach

the entry point for the sector.

CF-2 The (ACNE) sector is under Jeddah ACC sector control the same as the east and

the north sectors while both sectors are under very high maneuvering area for high

and low altitude for all in and out East bound traffic from and to Riyadh airports,

caused for this incident.

CF3 There was no rest sys for controllers respect their need (food, Prayer, ext.) controllers

get used to leave the position frequently for short time only for that reason, which is

not suitable with the less sensitivity for the need of the responsibility and

respectability for the radar position, it caused un complete brief about traffic and all

sector information from present controller belief that it's not necessary to brief

receiver controller all the traffic information due to short time he might be out of the

position and forget to bass inf. About that conflicting flight.




Assigned To: GACA-ANS

GACA-ANS Need to re-evaluate the transferring radar traffic between positions to guarantee confirmation receiving traffic on radar screen between Jeddah and Riyadh radar sectors with all traffic data inf. Including the identification of the sector cod.




GACA-ANS need to Re -study the regional sectors divisions on (ACNE) sectors upper and lower to be more suitable with the traffic flow need with the concerned of the hot maneuvering areas.




GACA-ANS Need to moderate the controller rest time by using suitable sys. wish can be helpful with controllers working hours and respect their need, and implement outspread AND guarantee of position take over ( Brief) with complete and clear traffic inf.




GACA-ANS Need to find and discover all risks management in all ATC sectors to improve the procedures and enhance it the safe floe of the traffic.




GACA-ANS Need to prevent un licensed and not certified controllers from working in hot piston at any ATC Activity.


AIB-2015-0304: Crew Incapacitation

Synopsis

On 23 November 2015, a Saudi Arabian Airlines Airbus 321 aircraft was performing a

scheduled domestic flight (SVA1549) from Tabuk Airport (OETB) to King Fahad

International Airport (OEDF), Dammam, Saudi Arabia.

The Pilot Flying (PF) was the First Office, a Trainee Captain on transition from E170 to

A321, and the Pilot not Flying (PNF) was the Captain, Instructor Pilot. During the flight,

approximately 45 minutes prior to the Estimated Time of Arrival (ETA), the PF suddenly

felt unwell. When the PNF asked him if he was okay, the PF replied by saying that he was

feeling dizzy then started sweating. The PNF called the Purser to assist.

The aircraft landed safely with an emergency procedure (None ETOPs) of crew

incapacitation. The pilot was examined by a doctor upon arrival then he was transferred to

a clinic at the King Fahad International Airport, Dammam. He had been diagnosed for

having hypotension with normal blood glucose level. He had been given Intra-Venous

Fluids (IVF) and released after one hour. On the same day, he returned to his base in

Jeddah as Dead-Head-Crew (DHC) member.


The PF had been experiencing extreme and steady stress that led to a burnout during the

flight. Accumulative pressures induced by family affairs, social difficulties and the need to

execute the Line Training without the realization of their impacts on his mental and

physical conditions and his fitness for the flight resulted in PF’s incapacitation.




Saudi Arabian Airlines must emphasize on the “Stress Management” techniques for crewmembers trainings, publications and related events.




Saudi Arabian Airlines must ensure proper implementation of “Fatigue Risk Management” as applies to its mode of operations and the variations of crew assignments.





Saudi Arabian Airlines Crew Management and Corporate Safety need to promote the awareness on the “Change” and “Change Management” concepts, being an element of Safety Management System that needs to cascade down to line operations level.

AIB-2015-0305: System Component Failure (Power Plant)

Synopsis

HZ-AKI was on take-off on runway 15L and at speed approximately 70 KTS crew heard a

loud bang as per as per information in (ASR) from right engine, number #2 as per as per

information in (ASR) associated with aircraft drifting toward right direction. And crew had

aborted take-off, also flame was seen from exhaust as reported by passengers as

per information in (ASR). Aircraft taxied and returned back to gate safely, all

passengers disembarked.


Since the engine was dismantled from aircraft for overhaul, and the relevant

components that are controlling the air path are functioning adequately (manually) not in

operation, and whereas condition of the internal parts of engine i.e. rotors and combustion

chamber are normal therefore the contributing factors of the stall could be the fuel system.

Safety Recommendations:

No safety recommendations were released for this case.

AIB-2016-0150: Airprox /Mid Air/Near miss (MAC)

Synopsis

SVA1039 aircraft B789, Registration HZ-ARA departed King Khalid International Airport (OERK), Riyadh from runway 15L to King Abdul-Aziz International Airport (OEJN), Jeddah. SVA1039 was under the control of the approach lower sector, on climb to 8.000 ft. then to 9.000 ft. as cleared by ATC heading south west to join the airway from position DURMA. SVA1692 aircraft A320, Registration HZ-AS18 was enroute from Abha Regional Airport OEAB to OERK. SVA1692 was descending towards OERK under the control of the approach lower sector, heading north west and expediting to 10.000 ft. as cleared by the same approach controller. Conclusion Factors:

The TCAS-RA is a nuisance resolution probably triggered due to the rate of descent. No further investigation is required.



No safety recommendations were released for this case.

AIB-2016-0184 : Ground Collision (GCOL)

Synopsis

On 26 April 2016, EUROFLY SERVICE S.P.A. Dassault Falcon 7X aircraft, Registration

I-FFRR, was being operated on a scheduled Private-None revenue flight from JED

(OEJN), to RUH (OERK). The Pilot-In-Command (PIC) completed his Walk Around

Check (WAC) of the aircraft at the parking stand and decided to maneuver the aircraft

using its own power. The passengers were boarded on the aircraft and the PIC started

maneuvering the aircraft and taxi out.

During the maneuvering of the aircraft at the stand, the Falcon commenced a sharp turn

(270 degrees swing around) at the stand during which the right hand (RH) winglet

impacted the left hand (LH) winglet of the adjacent parked aircraft, Challenger 850,

Registration N850JL. The PIC proceeded with taxiing on taxi lane D2 heading towards

runway (RWY34) for take-off.

By the time the ground handler was communicating the incident with airport operations,

I-FFRR was already airborne.


CF1- The Pilot-In-Command failure to follow apron requirement by deciding to maneuver the aircraft at the stand using engine thrust reverser power and to make unauthorized swing around at the stand. CF2- The ground handler (SPA) failure to deny the PIC decision for not accepting the

apron requirement for pushback and marshaling services.




Assigned To: Saudi Private

Aviation (SPA)

The Saudi Private Aviation (SPA) must emphasize compliance with special ramp handling requirement pertaining to apron/stand within its Ground Handling Agreement with contracted operators.




Assigned To: Saudi Private Aviation (SPA)

The Saudi Private Aviation (SPA) must ensure aircraft operators' compliance to Ramp Handling requirement and report incompliances to the Authority.

Documents

Kingdom of Saudi Arabia Aviation Investigation Bureau · 2016-08-31 · 2016 -2nd Quarter Report 5 Occurrence Status The AIB receives notification 24/7 by Telephone, Facsimiles, email