Rule of Confidentiality applies to all content
MINUTES OF THE 407TH MEETING OF THE UK FLIGHT SAFETY COMMITTEE HELD ON TUESDAY 10TH JULY AT CAA AVIATION HOUSE, GATWICK
Present:
Chris Brady Vice-Chairman easyJet Pavan Johal Treasurer Titan Airways Simon Searle Non-Executive Brd Member Flight Data Services Dai Whittingham Chief Executive UKFSC Dimuthu Adikari Thomson Airways Andrew Badham CAA Craig Baker Gael Ltd Christopher Barclay Jet2.com Martin Barrow Malaysia Airlines Nick Bather Thomas Cook Shaneen Benson GATCO Phil Breeze-Lamb Acropolis Aviation Roger Chandler Ocean Sky (UK) Stuart Cocks Flight Data Services Peter Cox BALPA Tom Curran Aer Lingus Margaret Dean AAIB Stuart Dobbyn Aer Arann Anthony Duff Bond Offshore Helicopters Ian Dugmore UK Airprox Board Jack Durcan Air Contractors David Elliott Belfast International Airport Carolyn Evans BALPA James Fahey Jet2.com Capt. Alex Fisher GAPAN Ian Fitter Royal Navy Jerry Flaxman AIC Steve Griffin Ascent Flight Training John Hamshare BAA Max Harris Navtech Steve Hull RTI Lauren Kelly RTI Robert Kubiak Ryanair Dermot McCarthy Irish Aviation Authority Nigel McClure Suckling Airways Stuart Mckie-Smith Vistair Peter Richards RAeS Nick Robinson TAG Aviation Carl Rowland Air Contractors Alan Rutter AQD Steph Sanderson Manhattan Jets Mike Storey CityJet Alistair Stenton bmi regional Mark Susca Jet2.com Wg Cdr Andrew Tait MAA
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Capt. Ooi Teong Siew Malaysia Airways Cengiz Turkoglu City University London Steve Westlake Manhattan Jets Alex Wood Atlantic Airlines Jonathan Woodrow Chartis Europe Ltd
Opening Remarks
The Vice-Chairman opened the meeting at 1030 and outlined the agenda before introducing those attending for the first time.
Introductions
Capt. Dermot McCarthy - IAA (taken over from Harry McCrink) Steve Griffin - Ascent Flight Trng (Applying for M/Ship 2day) Stephanie Sanderson - Jet Management Steve Westlake - Jet Management Lauren Kelly - RTI (with Steve Hull) Charlotte Marfleet - Holman, Fenwick Willan (with Edward Spencer) James Fahey - Jet2.com Chris Barclay - Jet2.com Mark Susca - Jet2.com Carl Rowland - Air Contractors Dimuthu Adikari - Thomson Airways Nick Bather - Thomas Cook
Those present were reminded of the following Confidentiality Warning which applies to these minutes and to the contents discussed therein:
These minutes record the proceedings of matters discussed under the Rule of Confidentiality. Circulation to non-UKFSC members, either in whole or in part, is to respect the Rule of Confidentiality which states:
“Details of accidents, serious incidents and incidents which may be discussed at this meeting are to be regarded as confidential. You are entitled to make use of the information within your own organisation but please use it with discretion and do not quote anyone by name or organisation without their prior authority.”
ITEM 1 Apologies for absence:
Capt. Castro, Phil Woodley, Giles Wilson, Adrian Bateman, Alan Whiteside, Gavin Spink, Mark Brosnan, Justin Wood, Jacob van Eldik, John Kirke, Peter Tait, George Davis, Diane Parry, Peter Jackson, David Harvey, John Badley, Martin Ring, Simon Brailsford, John O’Connell, Neil Woollacott, Mike Jackson, Rory McLoughlin, Peter Hogston
ITEM 2 Approval of Minutes of 406th Meeting
2.1 With no requests for factual changes have being received by the UKFSC office and none forthcoming from the floor, the Vice Chairman signed the Minutes of the 406th Meeting.
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ITEM 3 Matters Arising from 406th Meeting
3.1 The request for membership from Irwin Mitchell was raised. The Chief Executive replied that he had received a message from Mr Morris who remained concerned about the potential conflict of interest that might arise during the information exchange. Members expressed their own concerns relating to Irwin Mitchell’s core business as plaintiff lawyers and the risk that information gleaned at meetings could ultimately end up being used to the detriment of members. The Committee members did not feel that the membership application was appropriate. The Chief Executive would notify Irwin Mitchell accordingly.
ITEM 4 Chief Executive’s Report
4.1 The Chief Executive reminded members that details of the meetings he had attended since the last SIE were available on the UKFSC website, and pointed out that access to the website could be shared with other staff within members’ safety offices. He noted that the new Executive Board would be meeting during the summer to discuss the way ahead for the Committee; it is hoped there would be increased involvement of cabin crew and maintenance and ground handling staff. He would also be seeking membership from flight training organisations. He would be inviting attendees at future meetings to consider presenting some fully investigated incidents in more detail; this would have the added benefit of allowing members to consider other investigation techniques and not just learn from the outcomes. In addition, he intended to revisit the ‘Top 5 risks’ exercise and would be asking members to review this aspect of their own operations ahead of the next meeting.
4.2 The Chief Executive then discussed the FOCUS magazine and its position as a key output from the Committee. It was important that the Committee began to develop some ‘thought leadership’ and so original articles would be sought from members. Cengiz Turkoglu had also kindly agreed to participate in an editorial board, which would help maintain the status of the publication. In the subsequent discussion it was agreed that an electronic distribution would be helpful; members would be asked to review the number of hard copies they required. Max Harris would look at the requirements for an EFB-friendly version for distribution to flight crews.
ACTION: (a) Chief Executive to ask members to review hard-copy FOCUS requirements. (b) Members to consider submitting original articles for FOCUS.
ITEM 5 Information Exchange
5.1 AAIB – Margaret Dean
A Super Puma had ditched in the North Sea on 10 May following loss of MGB oil pressure. The emergency lubrication system then also failed, for which the FRH required an immediate landing. A controlled daylight ditching in moderate seas was carried out, all (2 crew and 12 pax) survived. The ac was recovered and engineering investigation showed failure of the drive to both oil pumps. It was possible that the failure of the emergency system was a false indication. An SB was issued and the company continues to apply some operating restrictions.
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5.2 MAA – Wg Cdr Andy Tait
Much of the MAA’s work had focused on regulatory activity, particularly for CAM. NPAs had been issued regarding essential airfield equipments and the Release to Service process. Some fundamental changes to regulations could be expected. An assurance report following the second round of Duty Holder audits was being prepared. Some weaknesses had been identified. The MAAIB was supporting a number of Service Inquiries, including the recent Tornado mid-air (RAF Lossiemouth). The external audit conducted in April had shown strong evidence of improvements to the governance of military aviation; the report can be accessed at MAA audit. There is still significant work required to embed the changes but there were good signs of progress in the required direction of travel.
5.3 RN – Cdr Ian Fitter
Significant increase in RI events at Yeovilton and Culdrose, not contractor-related, education campaign under way. Laser attacks continue. o Discussion. Laser attacks on military ac are not currently reported to the CAA. It was requested that the Services (or the MAA) informed the CAA as this would help form a better picture of the UK problem.
ACTION: MAA to consider reporting arrangements for laser attacks on MOD ac.
There had been 22 infringements of EGD36 by end-May. All infringing ac had apologised but the root cause appeared to be poor planning. The dangers of infringing a live-firing range should be obvious!
5.4 BALPA – Peter Cox
Space weather – the peak of the 11-year cycle would occur in May 2013. This could affect airports due to possible impacts on power supplies. Most airports no longer use standby generators and rely on having 2 independent suppliers instead. However, the National Grid routinely links all suppliers during solar flare events, with implications for redundancy. Lithium batteries. Increasing reports of incidents? Circumstantial evidence for 20 fires. Ground handling staff don’t ask pax about LBs when putting hand-baggage into holds and in any case don’t know which PEDs contain LBs and which don’t. There was a potential for thermal runaway up to an hour after recharging of LBs. Emergency hand signals – more education required. V poor levels of knowledge amongst pilots and cabin crew. NATO and ICAO fire and ground evacuation signals differ. Callsign confusion – an incident at LHR had been generated by a mis-hear of a ‘Delta’ callsign suffix (BA) by a Delta Airlines crew. BA had now dropped the Delta suffix but there was no pressure on other operators to do the same. o The Chief Executive had raised the issue with EASA and Eurocontrol. The official position was that too many callsign combinations would be denied if all
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alpha-numeric suffixes were deconflicted. Change to the current system was unlikely. BALPA had produced a draft safety plan that had already been presented to the RAeS. A copy would be sought for the website.
ACTION: (a) Chief Executive to sponsor joint civil/military publicity campaign on fire signals. (b) BALPA to provide a copy of its latest safety plan.
5.5 CAA – Andrew Badham
Olympic RZ/DZ was due to go live with full restrictions from 14 July. Slots active from 21 Jul – 15 August Request to limit use of 121.5 for the duration of the Olympic period.
5.6 BAA - John Hamshare
Presentation on FOD Most FOD items relate to ac and airfield maintenance. LHR FOD radar operates 0500-2300. 2% of all finds are manual. Solutions include better tool control (shadow boards etc).
5.7 UK Airprox Board – Ian Dugmore
Presented stats for Mar 11 – Feb 12, 92 CAT Airprox events. Bulk occurred in Class G. Only 8 of risk-bearing incidents involved ac under radar-based ATC service. Survey flights (or flts in weather) using BS. IF training flts using BS instead of TS. Even with TS, some pilots simply ignore conflicting traffic and rely on becoming visual. Reminder, TCAS needs vertical avoidance vice azimuth. IFR traffic does not have priority over VMC traffic in Class D. Pilot responsibilities – ask for deconfliction service in Class D. 2 x recent Airprox involved callsign confusion between ac from the same companies. o Discussion . Eurocontrol deconfliction tool being refined. Appetite for removal of alpha-numeric suffix homonyms is low – it would deny too many callsign options, harmonised approach across Europe not possible (for example, no ‘W’ in Portuguese alphabet!).
5.8 RAeS – Peter Richards
SAFITA paper - update in progress, new edition will include consideration of composites, crew training, PEDs and Lithium batteries.
5.9 Malaysian Airlines – Martin Barrow
Capt Richard de Crespigny’s book on QF32 now available (QF32)
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Risk register exercise should look at two levels: generic (such as management of automation) and specific risks.
5.10 Malaysian Airlines – Capt Ooi
Introduction of A380 ops, more outsourcing than previously, coincided with a period of low morale. A380 used as an icon for change. First ac delivered was used as a ground simulator, including door training for cabin crew. 3 full rehearsals from check-in to pushback, plus meal service. Everyone involved in A380 ops at KLIA got to see and touch the ac before first commercial flight. o Discussion. Low morale can often be reflected in low reporting rates for safety incidents.
5.11 Air Lingus – Tom Curran
High proportion of birdstrikes occurring at Malaga – 15% of company total. Discussion – easyJet having a similar experience.
5.12 Thomas Cook – Nick Bather
Internal FS magazine broadening scope to include more cabin and ground safety aspects. Lasers. High no of attacks at Glasgow but any activity in previous 30 mins now being reported via ATIS. Strathclyde Police taking laser attacks more seriously. Recent 9-month sentence for one offender.
5.13 GAPAN – Alex Fisher
Callsign confusion – trying to remove all possible confusions was a hopeless task and crews needed to be vigilant. Technology should provide many of the answers. Already possible for ATC to have ac ident signalled on incoming VHF transmissions.
5.14 City University – Cengiz Turkoglu
Reported on recent ECAST meeting. A decision will be made soon on whether EASA should regulate on training for GA below DH. Evidence from approx 1 million flts shows 97% of unstable approaches continue to landing.
5.15 Pen-Avia
Reported laser attack at 13000ft on departure from Milan. The crew commented that the main distraction had been their efforts to persuade Italian ATC to accept a report when the controller was clearly uninterested in so doing.
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5.16 flybe
Incident at Paris CDG with the new IGOM pushback procedures; on the crew declaring ‘ready for pushback’ the tug driver immediately commenced the push without clearance or further checks. flybe is adopting a non-IGOM SOP to prevent a recurrence.
ITEM 6 Presentations
6.1.1 Presentation from Tom Curran on accident investigation.
ITEM 7 Applications for Membership
7.1 The application for Full Membership from Ascent Flight Training Ltd was unanimously approved.
ITEM 8 AOB
8.1 Nil pre-notified.
8.2 Discussion on development of the UKFSC. ‘Thought leadership’ role should be encouraged. Broadening membership to include cabin crew, MRO and ground handling organisations was endorsed. Question raised about development, capture and dissemination of ‘best practice’; the flybe cognitive walk-through process was worthy of closer examination.
8.3 The AF447 report had been published and revealed significant issues for the industry in areas such as crew training and the absorption of new technology. The report can be found at AF447 final
ITEM 9 Next Meeting
9.1 The 408th SIE Meeting would be held at 1030 on Tuesday 11 September at City University, London.
Closing Remarks
The Vice Chairman thanked the CAA for the use of the facilities and the catering, the speakers for their contributions, and the Members for their attendance despite the attractions of Farnborough week. The meeting was closed at 1440 hrs.
Signed……………………….. Signed…………………………… Chief Executive Chairman UKFSC 17 July 2012
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