International Civil Aviation OrganizationEuropean and North Atlantic Office

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ICAO EUR HLSC Preparatory Seminar9-11 February 2010

Baku, Azerbaijan

Theme 3: Other Safety IssuesTopic 3.2:Safety initiatives arising from recent accidents

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Air France Flight AF447

Reference – Interim Report №2 dated 17 December 2009Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile (BEA)

• Date of accident: 1st June 2009 at around 02:15

• Aircraft A330-203; Operator – Air France

• Airport of departure – Rio de Janeiro Galeao

• Destination – Paris Charles de Gaulle

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Air France Flight AF447 - Findings

• Site of accident: Near TASIL point, in international waters,

Atlantic Ocean;

• Was in contact with Brazilian ATLANTICO ATC on the

INTOL-SALPU-ORARO route at FL350; INTOL is an RNAV

waypoint located in the Atlantic Ocean, 565 km from Natal,

Brazil. The TASIL waypoint is located 1228 kilometers from

Natal. TASIL, the following waypoint, is at the border of the

Recife FIR and Dakar Oceanic FIR.

• The last radio exchange between the crew and Brazilian ATC

occurred at 01:35:15. The plane was arriving at the edge of

radar range of the Brazilian control centers;

•

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Air France Flight AF447 - Findings

• At 02:01, the crew tried, without success for the third time ,

to connect to the Dakar ATC ADS-C system;

• No further communications after passing INTOL;

• At 02:10 a position report and maintenance messages were

transmitted by ACARS;

• Up to the last automatic position point, received at 02:10:34,

the flight had followed the route indicated in the flight plan;

• The flight was not transferred between the Brazilian and

Senegalese control centers;

• Between 08:00 and 08:30, the first emergency alert messages

were sent by the Madrid and Brest control centers;

•

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Air France Flight AF447 - Findings

• The first bodies and airplane parts were found on 6

June;

• At this stage, in the absence of any data from the

flight recorders, the main parts of the airplane and

any witness testimony on the flight, the precise

circumstances and causes of the accident are not

yet determined

• Consequences – 216 passenger +12 crew members

– all killed

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Air France Flight AF447 - Recommendations

Recovery of accident data

Air traffic management in oceanic and remote areas

Search and Rescue

NEED FOR IMPROVEMENTS -

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Air France Flight AF447 - Recommendations

Recovery of accident data;

Continuous or triggered transmission of FDR/CVR

Deployable FDR/CVR/ELT

Extra lightweight combination FDR/CVR located in

the vertical stabilizer: and

Underwater location beacons (ULB) improvement,

with greater range and longer battery life.

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Air France Flight AF447- Recommendations

Search and Rescue- Guidance material supporting existing SAR alerting SARPs Better coordination between ATS informing Rescue Coordination Centers (RCC) Provisions on carriage of Emergency Locator

transmitters

Air traffic management in oceanic and remote areas-

Improve communications and surveillance by:

Implementing ADS-C and CPDLC and FMC WPR

Improved procedures for HF communications

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Issues to consider

Interdependencies

Cost-benefit relationship

Global perspective

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Spanair Flight JKK 5022

• Date of accident: 20st August 2008 at 12:25 UTC

• Aircraft MD80; Operator – Spanair

• Airport of departure – Barajas, Madrid

• Destination – Gran Canaria

Reference – Interim Report dated 17 August 2009By the Spanish Civil Aviation Accidents and Incidents Investigation Commission (CIAIAC)

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Spanair Flight JKK 5022Injuries:Of the 172 people on board, - 154, including all crew members, killed;- 18 seriously injured

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Spanair Flight JKK 5022-Findings

The following safety barriers were defeated:

The checklist to confirm and verify the

airplane’s actual configuration; and

Improper takeoff configuration warning system

(TOWS).

The takeoff manoeuvre was performed with the flaps and slats retracted

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A concept of accident causation

ORGANIZATION

Activities over which any organization has a reasonable degree of direct control

Factors that directly influence the efficiency of people in aviation workplaces.

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate

adverse effect.

Resources to protect against the risks that organizations involved in production activities generate and must control.

Conditions present in the system before the accident, made evident by triggering factors.

RegulationsTrainingTechnology

DefencesErrors

andviolations

PeopleWorking

conditions

WorkplaceManagement decisions and organizational

processes

Organization

Latent conditions trajectory

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Errors and safetyA non linear relationship

Statistically, millions of operational errors are made before a major

safety breakdown occurs

Source: Dedale

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Accident investigation Once in a million flights

Flaps omitted

Checklist failure

Unheeded warning

Error Deviation Amplification Degradation /breakdown

Incident /accident

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Spanair Flight JKK 5022Recommendations ICAO, FAA and EASA jointly hold an

international conference

Objective - Draft directives on good practices in the area of aviation operations in regard to checklist design, personnel training and improved procedures and cockpit work methods so as to ensure that crews properly configure aircraft for takeoffs and landings

Attendance – Authorities, industry, academic and research institutes, professional association, etc.

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ICAO provisions on Human-centered flight deck interventions

• Standard operating procedures (SOP);

• Checklists; and

• Flight crew briefings.

Incorporated into the PANS-OPS Doc 8168

Supported by ICAO Human Factors Training manual (Doc 9683)

o Reflects the results of the practically-oriented Human Factors research and industry best practices

Annex 6 – Operation of Aircraft. Introduces a requirement a human performance training within the operators initial and recurrent flight crew training syllabi

Crew Resource Management (CRM)

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Safety Management Principles

Safety Risk Management

Safety Assurance

Threat and Error Management (TEM) as an early example of the safety management principles integration to flight deck activities

The TEM requirement was included in Annex 1 – Personnel Licensing and Annex 6 – Aircraft Operation

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Integration of Safety Management Principles Broaden interventions to take operational

context into consideration

Shift the micro view of pure Human Factors Interventions to safety performance enabling macro view

A balanced approach

The role of the State in the acceptance and surveillance of the effectiveness of the implementation

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Conclusions

Activities listed herewith provide the foundation for reviewing ICAO Provisions and guidance material

ICAO to review relevant ICAO provisions and propose within 18 months any amendment that might be required