ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
SAFETY REVIEW OF CIVIL AVIATION FOR 2013
In accordance with EU Regulation 996/2010 of the European Parliament and of the Council of 20th October 2010 on the investigation and prevention of accidents and incidents in Civil Aviation and repealing Directive 94/56/EC which came in force on the 2nd December 2010, article 4, paragraph 5 foresees that: “In order to inform the public of the General Aviation Safety Level, a Safety Review shall be published annually at national level. In this analysis, the sources of confidential information shall not be revealed”
Also in accordance with Directive 2003/42/EC of the European Parliament and of the Council of 13th June 2003, the Reporting of Incidents is mandatory which occur in Aviation and in accordance with Regulation 334/2005 of the Cyprus Republic, the Aircraft Accident and Incident Investigation Board is hereby appointed as the appropriate official authority for the evaluation and analysis of the incidents which are mentioned in the Regulation and recommending the implementation of any preventive actions that it considers necessary to be taken promptly to enhance Aviation Safety.
The AAIIB as the official investigation body is obliged by the regulation to publish a Safety Review annually in order to inform the Public of the General Aviation Safety Level annually at national level.
DEFINITIONS
Accident: ”Accident means an occurrence associated with the operation of an aircraft which, in the case of a manned aircraft takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight and the primary propulsion system is shut down, in which:
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
a) a person is fatally or seriously injured as a result of: being in the aircraft, or, direct contact with any part of the aircraft, including parts which have become detached form the aircraft, or, direct exposure to jet blast except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or
b) the aircraft sustains damage or structural failure which adversely affects the structural strength, performance or flight characteristics of the aircraft, and would affected component, except for engine failure or damage, when the damage is limited to a single engine, (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes) or minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike, (including holes in the radome): or
c) the aircraft is missing or is completely inaccessible;
Serious incident: “Serious incident means an incident involving circumstances indicating that there was a high probability of an accident and is associated with the operation of an aircraft, which in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time it comes to rest at the end of the flight and the primary propulsion system is shut down.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
Incident: “Incident means an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.”
In Regulation 996/2010 and the Cyprus Civil Aviation Law 2002-2012 all accidents and serious incidents are investigated. The sole objective of the investigation is the improvement of the safety level and the prevention in the future and not to apportion blame or liability.
During the year 2013 no accident has taken place neither in the Airspace of the Cyprus Republic, nor in the flight information region (FIR).
The AAIIB was informed of 3 Serious Incidents which occurred in ATC, on airports or airlines.
The 3 serious incidents have been investigated by the AAIIB and the Final Reports were sent to all considered useful to have these Final Reports.
From the above mentioned investigation of these serious incidents, the AAIIB has issued 15 Recommendations. These recommendations were sent to the Minister of Communication and Works and then to the Civil Aviation Department. When these recommendations are adopted the Civil Aviation Controls their implementation.
All the above recommendations have been adopted by the Minister of Communication and Works.
The recommendations do not create a presumption of blame or liability for any accident, serious incident or incident.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
In accordance with Regulation 996/2010, the present regulation is not valid for investigations concerning accidents or serious incidents where the aircraft involved is used for military, customs, police or similar services, except if this is defined by the interested member state.
Concerning the incidents occurred during the year 2013, the AAIIB received from Cyprus Airways totally 76 reports which were evaluated, elaborated, categorized and proceeded with suggestions for taking measures where it was considered necessary.
From the Air Traffic Control Services we received 273 reports during 2013. The Air Traffic Control Services consists of the Air Traffic Control Centre (ATCC) Nicosia, which controls all the flights within the Nicosia FIR (overflying of flights in and out of the recognized airports of the Cyprus Republic). It includes also the Towers of Larnaca and Paphos Airports. Hermes Airports as the administrators of the two International Airports have submitted 159 incident reports.
The Control Towers of Larnaca and Paphos also submitted separately 54 reports concerning incidents with laser beams directed towards aircraft in the Air.
From the total reports received from Cyprus Airways 15 reports concern bird strikes on aircraft. From the total reports received from Hermes Airports at LCA and Paphos Airports, 106 reports concern bird strikes on aircraft. 58 Bird strikes occurrence forms which received form Air Traffic Control Tower concern bird strikes on aircrafts of other various aircraft companies.
In total the AAIIB received during 2013 620 incident reports in comparison with 517 incidents occurred in 2012 and 3 Serious Incidents with no accident in comparison with 6 Serious Incidents during 2012.
The AAIIB submitted 15 Safety Recommendations during 2013 in comparison with 27 during 2012.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
ANALYSIS
Analyzing the General Safety Aviation Level in Cyprus, we can suggest that the levels of Aviation Safety during 2013 are considered satisfactory when compared with previous years.
Please note that the further reduction of Cyprus Airways fleet has contributed in further reduction of the volume of Air Safety Reports we receive.
The Regulation 996/2010 and also the formation of ENCASIA (Network) have contributed immensely in upgrading the Safety Levels in Pan European Level, something for which the European Committee considers very important. The forthcoming voting of regulation by the European Council for the compulsory reporting of incidents will further contribute in increasing even more the levels of Aviation Safety, because this is the most important part for the prevention of accidents.
All implicated parties involved they have to realize that submitting reports even for small incidents, the evaluation and elaboration and suggestions for the implementation of correct safety measures is very important not to allow a small incident to develop in a serious incident or accident.
The AAIIB except issuing 15 Safety Recommendations in their Final reports of Serious Incidents in 2013 has also sent 3 letters on different subjects to different organizations for implementation of corrective actions.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
Many of them have been adopted and solved, some they are in the process of being resolved and some must be solved the soonest possible.
Finally concerning the Safety Recommendations, Regulation 996/2010, in articles 17 and 18 foresee strict procedure for these recommendations and the observation of progress of the action taken for the implementation of these Safety Recommendations.
(Captain Ioannis (John) Loizou) Member of Cyprus Aircraft Accident & Incident Investigation Board
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
PUSH BACK WITH YAKUDIA (SYL9924) REGISTRATION VQ BOY (B737-800)
LARNACA AIRPORT – 25 SEPTEMBER 2011
SERIOUS INCIDENT
FILE NO.: 16.15.01.12/11
SYNOPSIS
The AAIIB was notified by the Department of Civil Aviation (DCA) Cyprus that an incident occurred at Larnaca Airport involving a B737-800 type of aircraft call sign YAKUDIA SYL9924 registration VQBOY. This incident occurred during push back from stand 45 at 2240 local time. Aircraft taxied back to stand checked by engineers and departed for KRASNODAR. Unfortunately this incident was not investigated at the time due to the absence of our employees from office at that particular period and not noticed by the investigators due to a series of similar incidents and the subsequent issue of our recommendations at a later date covering this incident as well.
Following the completion of the pushback, the removal of the by-pass pin and the disconnection of the headset and while the pushback driver was walking towards the truck the Captain applied engine power and started taxying without clearance the pin was not shown and no all clear signal was given by the push back driver. The aircraft taxied out and hit the Swissport towing truck damaging it.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
Following this, the aircraft stopped and was subsequently towed to remote stand 17 for engineering inspection. The passengers remained on board while the aircraft was checked by Engineers.
The aircraft was then inspected and declared airworthy by the Engineers (Storm Aviation) and allowed to depart following the completion and signing of the aircraft technical log by the Captain.
SAFETY RECOMMENDATIONS
a) During the pushback procedure the dispatcher should always have eye contact with Captain or Copilot.
b) Tow bar vehicle should move immediately after removing pin at a position clearly visible by the cockpit crew.
c) The last thing to be removed is the headset from the aircraft during the process of removing pin and the jack from the aircraft at a good timing.
d) To continue the existing practice of the A.T.C. intervening and stopping aircraft if Hermes who monitors the aircraft movements on the CCTV Camera observes a situation necessitating intervention from ATC utilizing the direct line between Hermes Operation and the ATC.
e) To discuss also with A.T.C. possible escape routes when large aircraft i.e. B747, IL96 are pushed back and the ground personnel carry out the after push back procedure 8
ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
CYPRUS AIRWAYS (CYP343) A320-232 5B-DCH (A320-232)
MAIN LANDING GEAR TIRE BURST
LARNACA AIRPORT – 5 MAY 2013
SERIOUS INCIDENT
FILE NO.: 16.15.01.2/13
The Final Report prepared by the Operator (Cyprus Airways) and the AAIIB after examining of this, decided to adopt it totally with a few recommendations. (see next paragraph)
SYNOPSIS
On 5th May 2013 at 08:00 LT the HSQ was notified by the Operations Control Center Officer on duty that on landing at LCLK flight CYP 343 OLBA to LCLK, had burst a main landing gear tire. During the incident, the ATC controller at LCLK control tower upon seeing smoke coming from the damaged tire, alerted the fire services who in turn rushed to the aircraft and started spraying water on the damaged wheel. Following this, the Cyprus Airway engineers assessed the damage and concluded that it was limited to the outer port main landing gear tire (MLWA #1), which was destroyed. Both port main landing gear tires were replaced on situ. The aircraft was then towed to the Cyprus Airways hangar for further maintenance actions.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
SAFETY RECOMMENDATIONS (issued by CYPRUS AIRWAYS & adopted by AAIIB)
Corrective:
1. The introduction of a communication frequency for the fire services to talk to cockpit crews as per international airport procedures (121.600 MHz) must be established for both Cyprus International airports, LCLK and LCPH. Communication procedures between emergency services and aircraft concerned to be established, for coordination of any action to be taken by the emergency teams with the aircraft commander. Appropriate training can be undertaken with the cooperation of Cyprus Airways and Emergency services personnel.
2. The conclusion of this investigation with relative technical documentation will be circulated to Cyprus Airways crews with comments from the Technical Pilot and training Department.
3. Recommendation to the engineering and maintenance department to enhance awareness of the procedure required to remove and re-install the type of electrical plugs mentioned in this report, with emphasis on the fitment and locking of the plug. (This type of plugs is self- locking and should be ensured that they are taken right up to the end of the self-lock).
Preventive:
4. The operator will recommend to the manufacturer to enhance the associated information relating to this failure, in the form of FCOM documentation relative to the system and possible ECAM information upgrade.
5. The evaluation of this report will be included in the agenda for the next Flight Operations and Engineering Maintenance meeting as per the Airline’s local procedures for analysis.
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
SAFETY RECOMMENDATIONS (issued by AAIIB)
a) The introduction of communication frequency in order that Fire Services are directly connected with aircraft in emergency cases as is the International Practice will enhance safety and contribute towards a better cooperation
b) Also the addition of a third recommendation concerning the Engineering Work completion
c) Paphos Airport should be included also in the first recommendation
d) The inclusion of a picture indicating the State of the tire following the incident
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ΚΤΠΡΙΑΚΗ ΓΗΜΟΚΡΑΣΙΑ
ΔΠΙΣΡΟΠΗ ΓΙΔΡΔΤΝΗΗ ΑΔΡΟΠΟΡΙΚΩΝ AIRCRAFT ACCIDENT & INCIDENT ΑΣΤΥΗΜΑΣΩΝ & ΤΜΒΑΝΣΩΝ ΚΤΠΡΟΤ INVESTIGATION BOARD CYPRUS
AVIATOR FHBYO AT01 AQUILA TYPE AIRCRAFT DUE TO FUEL EXHAUSTION ON LANDING
LARNACA AIRPORT ON 30 MARCH 2013
SERIOUS INCIDENT FILE NO.: 16.15.01.5/13
SYNOPSIS
The AAIIB was notified by the Department of Civil Aviation (DCA) Cyprus that an incident occurred at Larnaca Airport belonging to the Aviator Flight Center. Registration of this Aquila AT/01 type of aircraft is FHBYO. This aircraft managed to land on runway 04 at Larnaca Airport and on touch down the aircraft engine stopped due to fuel exhaustion.
Aircraft was pushed by the pilot and with the assistance of a Hermes employee who attended the scene, the aircraft was pushed to the holding point of taxiway E clearing runway 04.
SAFETY RECOMMENDATIONS
Training organizations must during initial and recurrent training of pilots pay particular attention on the subject of fuel policy and explain very carefully the fuel management procedures of their individual aircraft to their students.
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