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ANNUAL SAFETY RECOMMENDATIONS REVIEW 2014 SAFETYANNUAL RECOMMENDATIONS Annual Safety Recommendations Review 2014 EUROPEAN AVIATION SAFETY AGENCY AVIATION EUROPEAN EUROPEAN AVIATION SAFETY AGENCY SAFETY ANALYSIS AND RESEARCH DEPARTMENT Designed in Luxembourg Strategy & Safety Management Directorate Safety Intelligence & Performance Department Annual Safety Recommendations Review 2014 Disclaimer: Neither the European Aviation Safety Agency, nor any person acting on behalf of the European Aviation Safety Agency is responsible for the use which might be made of the following information. The Annual Safety Recommendation Review is produced by the European Aviation Safety Agency (EASA). This edition provides an overview of the safety recommendations that have been addressed to EASA in 2014. It also presents the replies produced during the year. This annual review aims at providing a feedback on the follow-up given to Safety Recommendations in the con- text of openness, transparency and accountability that characterises the European Public Administration. Apart from its safety related information character, this review is also expected to provide relevant information related to raised safety concerns, both for EASA itself, as well as its stakeholders, including the European public. © European Aviation Safety Agency, 2015. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 2014 Annual Safety Recommendations Review Contents 1. Executive Summary 4 2. Introduction 6 3. Safety Recommendations Received in 2014 9 Overview of Safety Recommendations Received in 2014 ��������������������������������������������������������������������������10 Origin of the Safety Recommendations Received in 2014 �������������������������������������������������������������������������11 4. Safety Recommendation Replies in 2014 13 Overview of Safety Recommendation Replies in 2014 ������������������������������������������������������������������������������14 Status of the Safety Recommendation Replies in 2014 ������������������������������������������������������������������������������15 5. Overview of Safety Issues Processed and Actions Carried Out in 2014 17 Situational Awareness-/Flight Path Management Under Unusual Conditions �����������������������������������������18 Increased Reliance on Aircraft Automation by Flight Crews ���������������������������������������������������������������������19 Ice Contamination of Aircraft Critical Surfaces ������������������������������������������������������������������������������������������19 Aircraft Localisation in Emergency Situations ��������������������������������������������������������������������������������������������19 Crash Survivability ���������������������������������������������������������������������������������������������������������������������������������������19 Helicopter Off-shore Operations �����������������������������������������������������������������������������������������������������������������20 Unexpected Auto Pilot Behaviour on Glide Slope Interception ����������������������������������������������������������������20 Personal Electronic Equipment Induced Fire in Cabin �������������������������������������������������������������������������������21 Erroneous Take-off Data Parameters Input ������������������������������������������������������������������������������������������������21 6. Conclusions 22 ANNEX A: List of 2014 Safety Recommendations Replies 24 ANNEX A: List of 2014 Safety Recommendations responses ���������������������������������������������������������������������25 ANNEX B: Definitions 189 ANNEX C: Safety Recommendations classification 192 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 Executive Summary ANNEX A. ANNEX B. ANNEX C. 2014 Annual Safety Recommendations Review Executive Summary PAGE 5 Executive Summary The Annual Safety Recommendations Review is produced by the European Aviation Safety Agency (EASA). This edition provides an overview of both the safety recommendations that were addressed to EASA in 2014 and of the replies to open safety recommendations that were produced by EASA during 2014. This annual review aims to provide visibility on the follow-up of Safety Recommendations in the context of open- ness, transparency and accountability that characterises the European public administration. In addition, the review highlights a range of safety issues that are both of interest to the European Aviation Community and the public at large and which is a key source of information for the Agency’s safety improvement efforts. Since 2011, a process to assess and mitigate safety risks at European level has been an integral part of the Euro- pean Aviation Safety Programme (EASP). It represents a move towards a more pro-active approach that attempts to anticipate potential safety risks in order to further reduce the likelihood of an accident. The outcome of this process is a European Aviation Safety Plan (EASp), which describes the major safety risks in Europe’s aviation sys- tem, together with the numerous actions that are underway to mitigate them. Information about this process can be found at www.easa.europa.eu/sms. As Safety Recommendations contain information on the hazards as well as the solutions that are proposed to mitigate the associated safety risks to the aviation system, they constitute a knowledge base and are therefore a valuable input to the safety risk management process at the European level. Several EASp actions originate from Safety Recommendations that were received by the Agency. CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 Introduction ANNEX A. ANNEX B. ANNEX C. 2014 Annual Safety Recommendations Review Introduction PAGE 7 Introduction At the European Union level, the principles that govern the investigation of accidents and serious incidents are defined in Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation. Regulation (EU) No 996/2010 implements international standards and recommended practices as described in Annex 13 to the Chicago Convention on International Civil Aviation. It sets an obligation for each Member State of the European Union (EU) to establish an independent permanent national civil aviation safety investigation authority, which shall investigate accidents and serious incidents in order to improve aviation safety and prevent future occurrences without apportioning blame or liability. Investigation reports and the related safety recom- mendations shall be communicated to the concerned aviation authorities for consideration and appropriate action, as necessary. Regulation (EC) No 216/2008 as amended (“the Basic Regulation”) transferred to the EU the competence for regulating civil aviation safety in the areas of initial and continuing airworthiness, environmental certification, aircrew licensing, air operations, ATM/ANS and aerodromes. The principal objective of the Regulation is to estab- lish and maintain a high, uniform level of civil aviation safety in Europe. Results of accident investigations play an important role in achieving this objective. This is fully recognised in the preamble to the Basic Regulation, stat- ing that “Results of air accident investigations should be acted upon as a matter of urgency, in particular when they relate to defective aircraft design and/or operational matters, in order to ensure consumer confidence in air transport”. EASA assigns a high priority to the follow-up of safety recommendations and has established procedures to that effect. In addition, EASA publishes this annual review of the safety recommendations that were handled during the year pertaining to the review, including a statistical overview of the situation. The aim of this Annual Safety Recommendations Review is twofold: § the review presents general statistical data of the safety recommendations that the safety investiga- tion authorities have addressed to EASA in 2014. § it presents the replies that EASA produced in 2014 to safety recommendations and shows the safety issues that were managed together with their follow-up. 2014 Annual Safety Recommendations Review Introduction PAGE 8 Evolution of the EASA Safety Recommendations Process The safety recommendations process is subject to continuous internal monitoring: Regulation (EU) No 996/2010 mandates that the addressee shall issue the first reply within 90 days. The safety investigation authority shall in- form the addressee whether or not it considers the issued reply adequate and, in cases of a decision to take no action, shall provide justification should there be disagreement. Therefore, the Agency receives an assessment of the issued response, enabling it to assess divergent opinions. In this context, in 2014 EASA initiated an inter- nal audit of its safety recommendations process, to identify potential areas for improvement and ensure that the assessment given by the safety investigation authority on the appropriateness of the mitigation measures be considered when closing the recommendation. In September 2014, EASA underwent an Agency-wide restructuring. As part of the process, mechanisms were created to enhance the level of coordination and to support the consolidation of EASA responses through the in- volvement of domain specific expertise. This in turn assists in the identification and prioritisation
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