jaa 19th annual faa/jaa international conference page 1 jaa safety strategy initiative issues in...

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19th Annual FAA/JAA International Conference

JAA Safety Strategy InitiativeIssues in relation with the

CPS study

Y. Morier - JAA Regulation Director

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Contents of the Presentation

• The two activities in relation with CPS:– The Design-related ad-hoc group– The Future Aviation Safety Team

• Proposals for further co-operation

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JSSI Design Related Ad-Hoc GroupFinal Report (1)

• Problem statement– Identified by UK CAA, ref CAP 681, that, although

rarely identified as primary cause of accidents (2,2 % of the significant 589 accidents) design related issues were frequently mentioned among the contributing factors in accidents occurring to JAA & North American ops.

– Frequency depends on chosen criteria & accident sample

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JSSI Design Related Ad-Hoc Group Final Report (2)

• Tasks:– Check how issue has been addressed by JSAT’s (CFIT, ALAR,

Loss of control, Runway incursions) and by the Harmonisation Work Programme

– Validate “Design related” to remain a focus area of JSSI

– Based on above, develop a scope of work for a Design related analysis team. This should include a provisional list of accidents to be reviewed

• Input:– CAA Accident Investigation Group process & system

– 23 accidents selected by the CAA as design related

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FATAL ACCIDENTS - EUROPEAN & NORTH AMERICAN OPERATORS WITH DESIGN SHORTCOMINGS AS A CAUSAL FACTOR (1989-98)

DATE TYPE OPERATOR

LOCATION FLT PHASE

BRIEF NOTE AAG REF ACTION COMMENT

08-Jan-89 737 BMA Kegworth Landing Wrong eng shut down, crashed on m/way 89/01 Reviewed by PSM & ICR team

24-Feb-89 747 United Pacific Climb Cargo door became detached in flight 89/07 25-783 Harmonization (HWP)

15-Mar-89 YS-11 Mid Pac. nr Purdue Final app Lost height and crashed short of r/way 89/09 Ice protection harmonization-Weather JSAT

18-Mar-89 DC-9 Evergreen nr Saginaw Landing Cargo door sep., crashed turning final 89/10 25-783 Harmonization (HWP)

19-Jul-89 DC-10 United Sioux City Landing Fan fail that severed all 3 hydraulics 89/20 AC 25-1309 update. UEF SAT: inspection

20-Sep-89 737 USAir La Guardia Take-off RTO overran on t/o and fell into river 89/30 Rudder trim redesigned. HFWG-General consideration

17-Feb-91 DC-9 Ryan Int. Hopkins Int. Take-off On t/o run rolled & cartwheeled in snow 91/08 Weather JSAT

05-Apr-91 EMB-120 ASA nr Gynco Final app Prop malfunction on app. Crash & fire 91/15 Approach and Landing JSAT

26-May-91 767 Lauda Air Dan Chang Take-off Uncommanded thrust revr deployed 91/21 Reverser harm. Progr; F100/Sao Paulo in Loss of Control JSAT

11-Jul-91 DC-8 Nationair King Abdulaziz Landing Fire after t/o/crash/fire 1.5km out 91/27 AC 25-1309 update - tire burst: proposed harmonization (HWP)

20-Jan-92 A320 Air Inter Mt Saint Odile Approach Hit mt 800m at night on descent 92/02 FSF CFIT team, AC 25-1309 update

07-Jun-92 212 Executive nr Mayaguez Final app Crashed 1km out in bad weather 92/19 PSM and ICR team: reviewed similar accidents

14-Sep-93 A320 Lufthansa Okecie Airport Landing Overran r/way, hit embankment, caught fire 93/27 Approach and Landing JSAT

02-Jul-94 DC-9 USAir Charl.-Douglas Go-around Encountered windshear during go-around 94/21 Weather JSAT

08-Sep-94 737 USAir nr Pittsburgh Approach Lost control, steep dive and crashed 94/24 Loss of Control JSAT

31-Oct-94 ATR 72 Simmons nr Roselawn Hold Lost control and crashed during hold 94/34 Loss of Control JSAT

24-May-95 EMB-110 Knight Air Dunkeswick Other Crashed after problems with art. horizon 95/17 Inspection and repair, Certification & maint. Issue

21-Aug-95 EMB-120 ASA nr Carrollton Enroute Propeller fatigue failure 95/27 Inspection and repair, Certification & maint. issue

20-Dec-95 757 AA Mt San Jose Descent Flew into ridge during descent 95/46 CFIT JSAT

17-Jul-96 747 TWA nr Moriches Inlet Enroute Crashed in sea shortly after take-off 96/23 Fuels Working Group, Wiring Group, Aging Systems (ATSRAC)

05-Sep-96 747 Air France Ouagadougou Enroute Severe turbulence encounter 96/44 Turbulence JSAT reviewed similar accidents

09-Jan-97 EMB-120 Comair South of Detroit Approach Lost control, abrupt pitch down 97/02 Loss of Control JSAT - Icing Harmonization Team

02-Sep-98 MD-11 Swissair nr Halifax Approach Crashed in sea after declaring emergency 98/29 Wiring group (ATSRAC)

Data source: UK AAG Fatal Accident DatabaseTotal: 23 accidents (European operators: 7, North American: 16),18 September 2000.

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• General Conclusion– 20 out of the 23 accidents are or have been covered

in other groups as follows:• CAST Joint Safety Analysis Teams (JSAT): CFIT,

Approach & landing, Weather, Turbulence, Runway Incursion

• FAA/JAA Harmonisation (HWP)

• ATSRAC: Ageing Transport Systems Rulemaking Advisory Committee

• PSM + ICR team

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• Tire burst issue– One accident among the 23 due to tire burst– Different burst models are used in certification– CAA-UK did a study following BAC 1-11 incidents– Concorde accident– No activity under CAST of the FAA/JAA Harmonisation

Work Programme

• Recommendation to start an Harmonisation Activity

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PSM+ICR vs Loss of Control

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Power plant System Malfunction + Inappropriate Crew Response (1)

• Every year, approximately 5 such accidents still happen

• Except for items A, B and G no further action is proposed by the CAST Loss of Control Team

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Power plant System Malfunction + Inappropriate Crew Response (2)

• Request the JSSI Steering Group for guidance how to proceed on:– more realistic simulations– turbo prop flight idle potential to Loss of Control– Human Factors and negative transfer from

previous training

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Certification Maintenance issue (1)

• AAG Ref: 95/17: MANUFACTURERS/AIRLINES - MAINTENANCE – No defined overhaul standard applicable to artificial

horizons• AAG Ref: 89/20: MANUFACTURERS/AIRLINES -

MAINTENANCE – Inadequate inspection procedures at engine overhaul

resulted in failure to detect fatigue cracking.

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• AAG Ref: 92/19: MANUFACTURERS/AIRLINES - MAINTENANCE – No inspection or functional test to verify

condition/serviceability of propeller Beta Blocking Device.

• AAG Ref: 95/27: MANUFACTURERS/AIRLINES - MAINTENANCE – Inadequate and ineffective inspection and repair

techniques allowed fatigue crack development from multiple corrosion pits at taper bore hole

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• Apart from above accidents, one member of JSSI/FAST, (from Bombardier) has raised the issue of shortfalls in the 25.1309 SSA- CMR - MRB process– These concerns have been adequately

addressed in the problem statement as attached to the final report

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Accident pre-warnings, pre-cursors• The AEA rep in the JSSI StG suggested that there

were accident pre cursors in the list of 23 accidents• The team listed following accidents with “prior

warnings”:– AAG 89/07 B747 Pacific Cargo door– AAG 89/10 DC-9 Saginaw Cargo door– AAG 91/08 DC-9 Hopkins Intl Ground ice– AAG 92/02 A320 Mt St Odile CFIT– AAG 94/24 B737 Pittsburg LofC– AAG 94/34 ATR72 Roselawn LofC/Ice– AAG 97/02 EMB120 near Detroit LofC/Ice

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Accident pre-warnings, pre-cursors (2)

• Boeing problem statement:– Several accident/incident investigations have

revealed that information about a potential hazard was available to industry but not recognized.

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• During the Nov 15, 2001 Design related team meeting 5 presentations were given to set the stage:– Airbus-Systematic incident & accident analysis– Boeing-Continued Operations Safety Process– Deep Treatment analysis (Independent Expert)– 1st Occurrence treatment experiment (Fokker)– CAA-UK Safety Intervention Program

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• Discussion– Industry/Authority Deep Treatment (DTA)

Analysis group most likely output to be a “system template” which is:

• Aircraft type specific• Operator specific

– Sift out the non relevant items.– Incorporate DTA into CAST enhancement 27:

improve aviation safety through use of risk management and risk analysis methods

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• Discussion (Cont’d)

– The EU Commission has established ECCAIRS• based in ICAO ADREP 2000; link to BASIS in

progress• database controlled by Authorities --> NEEDS

AUTHORITY INITIATIVE FOR ACCIDENT PRE-CURSOR DEVELOPMENT

– Direct inspections --> audits --> ECCAIRS initiative required

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• JAA revision to JAR 21: encourage: tool development/use, safety culture

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Design-Related Ad-Hoc Group recommendations (1)

– Accept Certification-Maintenance problem statement and develop it into Terms of Reference to review JAR/FAR 25.1529 and Appendix H for improvement: this one element of the general issue of Certification/Operations/Maintenance interfaces

– That the proposed FAA/JAA harmonisation on protection from tire/wheel burst be implemented

– The JSSI StG group provides direction for the remaining PSM + ICR interventions

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Design-Related Ad-Hoc Group recommendations (2)

– The JSSI to establish a new working group with the objective “to implement an effective process for the “deep treatment of anomalies” (DTA) that would better enable prevention of accidents through systematic analysis of incidents and other service data

– Discharge the ad-hoc group

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JSSI Steering Group Conclusions

• Design RelatedFinal report was delivered on January 17 and the JSSI Steering Group agreed to the following:– 2 Terms of Reference for Harmonisation:

• Tire/wheel burst

• Certification/Maintenance Interface

– One proposal to further investigate the concept of “Deep Treatment of Anomalies/Precursors”

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Future Aviation Safety Team

• Why FAST ?– Complement methodology based on accidents/

incidents analysis– Future may not be a direct extrapolation of the

past: Changes– Many accidents are related to situations not

envisaged by the assumptions made when designing: this is in-line with CPS finding 2

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Proposals

• The follow-up of the two issue identified by the Design-Related ad-Hoc Group:– Certification/Maintenance Interface– Deep Treatment of Anomalies/Precursors

• Should be performed jointly by JAA and FAA

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JSSI: Abbreviations

• CAST: Commercial Aviation Safety Team (US)• FSF: Flight Safety Foundation• ICAO: International Civil Aviation Organisation• AHP: Analytical Hierarchy Process• CPS: Commercial Airplane Certification

Process Study• AOC: Area of Change• CRM: Crew Resources Management

jaa 19th annual faa/jaa international conference page 1 jaa safety strategy initiative issues in...

Documents

design related slide

designrelated ad

jssi design related

design related analysis

cooperation slide

group final report

related issues

harmonisation activity