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ANNUAL SAFETY RECOMMENDATIONS REVIEW 2017 SAFETYANNUAL RECOMMENDATIONS 2017 EUROPEAN AVIATION SAFETY AVIATION EUROPEAN AGENCY Catalogue number ISBN ISSN DOI PDF TO-AE-18-001-EN-N 978-92-9210-212-8 2599-7793 10.2822/177336 EUROPEAN AVIATION SAFETY AGENCY SAFETY ANALYSIS AND RESEARCH DEPARTMENT Designed in Luxembourg Strategy & Safety Management Directorate Safety Intelligence & Performance Department Annual Safety Recommendations Review 2017 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 Recommendations 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 2017. 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 context 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. Image credits Chapter 0- Vasco Morao Chapter 1- iStock Chapter 2- Samuel Pernet Chapter 3-Alina Daliani Chapter 4- iStock Chapter 5- iStock Chapter 6- Arjan Van Dijk Annex A- iStock Annex B- Gilles Gardiol Annex C- iStock © European Aviation Safety Agency, 2018. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 2017 Annual Safety Recommendations Review Contents 0 Abbreviation list 5 1 Executive summary 7 2 Introduction 10 3 Safety Recommendations received in 2017 13 3.1 Overview of Safety Recommendations received in 2017 .....................................................................14 3.2 Origin of the Safety Recommendations received in 2017 ....................................................................16 3.3 Involvement in accident and serious incident investigations .............................................................20 4 Safety Recommendations replies in 2017 23 4.1 Overview of Safety Recommendations replies in 2017 ........................................................................24 4.2 Status of the Safety Recommendations replies in 2017 .......................................................................25 5 Overview of key safety topics processed and actions carried out in 2017 28 5.1 Large aeroplane cabin and passenger safety - emergency evacuation ..............................................30 5.2 Encountering severe turbulence at high altitude.................................................................................32 5.3 Runway surface conditions and aircraft ground anti/de-icing ............................................................33 5.4 Helicopters performing CAT operations ...............................................................................................35 5.5 Flight simulation training and other flight training exercises .............................................................37 5.6 General Aviation (GA) – various aspects in the frame of airworthiness .............................................39 5.7 Unmanned Aircraft (UA) ��40 5.8 Ballistic Parachute Recovery Systems (BPRS) ........................................................................................41 6 Conclusions 43 ANNEX A: List of 2017 Safety Recommendations Replies 45 ANNEX B: Definitions 226 ANNEX C : Safety Recommendations classification 230 2017 Annual Safety Recommendations Review PAGE 4 List of Figures Figure 1: Safety Recommendations addressed to EASA per year .......................................................... 14 Figure 2: Annual Safety Recommendations by occurrence class 2012-2017 ......................................... 15 Figure 3: Safety Recommendations received in 2017 by Type of Operation and Aircraft Category .........16 Figure 4: Origin of Safety Recommendations received by EASA ........................................................... 17 Figure 5: States contribution to Safety Recommendations received in 2017 ....................................... 18 Figure 6: EASA responses to safety recommendations in 2017 by year received ................................. 24 Figure 7: Safety Recommendation Responses sent in 2017 [status, total number] .............................. 25 Figure 8: Response assessment received by originator on EASA Final Replies sent in 2017 [percentage, reference date: 26.03.2018] .................................................................................. 26 Figure 9: Assessment EASA received on the Final Responses sent in 2017 [total, reference date: 26.03.2018] .......................................................................................................... 27 Figure 10: Safety Recommendations addressed to EASA per topic by EU SIAs .................................... 29 CHAPTER 0 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 Abbreviation list ANNEX A. ANNEX B. ANNEX C. 2017 Annual Safety Recommendations Review Abbreviation list PAGE 6 AD Airworthiness Directive AFM Aircraft Flight Manual AAIB UK Air Accidents Investigation Branch United Kingdom AMC Acceptable Means of Compliance ANSV Italian National Agency for the Safety of Flight BEA Bureau d’Enquête et d’Analyse pour l’Aviation Civile CAT Commercial Air Transport CIAIAC Civil Aviation Accidents and Incidents Investigation Commission CM Certification Memo CRI Certification Review Item CRM Crew Resource Management CS Certification Specifications CS-LSA Certification Specifications for Light Sport Aeroplanes CVR Cockpit Voice Recorder DSB Dutch Safety Board ELT Emergency Locator Transmitter ENCASIA European Network of Civil Aviation Safety Investigation Authorities EPAS European Plan for Aviation Safety ETOPS Extended Operation ETSO European Technical Standard Order EU European Union FAA Federal Aviation Administration FCOM Flight Crew Operating Manual FDM Flight Data Monitoring GA General Aviation GM Guidance Material HEMS Helicopter Emergency Medical Service HOFO Helicopter Offshore Operations ICAO International Civil Aviation Organisation ICCAIA International Coordination Council for Aerospace Industry Associations ILS Instrument Landing System LOC-I Loss of control-inflight MOPSC Maximum Operational Passenger Seating Configuration MS Member States NCO Non-Commercial operations with Other than complex motor-powered aircraft NTSB National Transportation Safety Board PED Portable Electronic Devices RE Runway Excursion RMT Rulemaking Task SIA Safety Investigation Authority SIB Safety Information Bulletin SRGC Safety Recommendation of Global Concern SRUR Safety Recommendations of Union-wide Relevance STC Supplemental Type Certificates STSB Swiss Transportation Safety Investigation Board VFR Visual Flight Rules CHAPTER 0 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 Executive summary ANNEX A. ANNEX B. ANNEX C. 2017 Annual Safety Recommendations Review Executive summary PAGE 8 Executive summary The Annual Safety Recommendations Review provides infor mation on the activity carried out by the Agency in the field of safety investigation and follow-up. In addition, the review highlights a range of safety issues and Agency safety improvement efforts that are of interest to the European Aviation Community and the public. This 11th edition reviews the 2017 activity and presents: General statistical data on the safety recommendations addressed by safety investigation authorities to EASA in 2017; Replies that EASA has given to safety recommendations in 2017; Main safety topics related to the above mentioned recommendations and/or replies that have been addressed through actions taken. At the European Union level, the principles governing 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 imple- ments international standards and recommended practices as described in Annex 13 to the Chicago Convention on International Civil Aviation. During the last 10 years the Agency has become the main actor in safety investigation follow-up within Europe and this has also been reflected in the establishment of a robust and rigorous processing of the safety recommendations received. Owing to EASA central posi tioning in the system, the Agency is able to take actions with respect to systemic problems and other issues in the management of risk. The implementation of safety recommendations provides tangible improvements in safety as a result of information that has been learned during safety investigations. In Europe, the methodical approach to investigatory work and the implementation of recommendations brings some meaning to the loss experienced as a result of accidents. During 2017, Safety Investigation Authorities from 15 different States addressed 42 safety recommendations to EASA in the context of the Agency’s remit. This number is about the half of the safety recommendations received

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