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Annual Safety Recommendations Review ANNUAL SAFETY RECOMMENDATIONS REVIEW 2015 SAFETYANNUAL RECOMMENDATIONS Annual Safety Recommendations Review 2015 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 2015 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 2015. 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, 2016. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 2015 Annual Safety Recommendations Review Contents Abbreviation list 4 1. Introduction 6 2. Safety Recommendations received in 2015 9 Overview of Safety Recommendations received in 2015 ��������������������������������������������������������������������������10 Origin of the Safety Recommendations received in 2015 �������������������������������������������������������������������������12 3. Safety Recommendations replied in 2015 14 Overview of Safety Recommendations replies in 2015 �����������������������������������������������������������������������������15 Status of the Safety Recommendations replies in 2015 �����������������������������������������������������������������������������16 4. Overview of key safety issues processed and actions carried out in 2015 18 Aircraft tracking, rescue operation and safety investigations ������������������������������������������������������������������19 Cabin Air Quality ������������������������������������������������������������������������������������������������������������������������������������������20 Risks posed by Lithium Batteries on Board / Transportation of Lithium Batteries ����������������������������������21 Unexpected Autopilot Behaviour on Instrument Landing System (ILS) Approach �����������������������������������22 Unreliable Airspeed Indication at High Altitude/ Manual Handling at High Altitude �����������������������������23 Loss of Control Prevention and Recovery Training �������������������������������������������������������������������������������������23 Runway Safety/ Mitigating the risk of Runway Excursion (RE)������������������������������������������������������������������24 Inadequate Go Around ��������������������������������������������������������������������������������������������������������������������������������25 Helicopter Offshore Operations ������������������������������������������������������������������������������������������������������������������25 Rotorcraft fuel tank crashworthiness ����������������������������������������������������������������������������������������������������������26 Parachuting operations �������������������������������������������������������������������������������������������������������������������������������26 Ballistic Parachute Recovery Systems (BPRS) ����������������������������������������������������������������������������������������������27 Medical and psychological conditions of flight crew ���������������������������������������������������������������������������������28 5. Conclusions 29 ANNEX A: List of 2015 Safety Recommendations Replies 31 ANNEX B: Definitions 154 ANNEX C: Safety Recommendations classification 157 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 Abbreviation list ANNEX A. ANNEX B. ANNEX C. 2015 Annual Safety Recommendations Review Abbreviation list PAGE 5 Abbreviation list AD Airworthiness Directive AFM Aircraft Flight Manual 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 BPRS Ballistic Parachute Recovery Systems CAT Commercial Air Transport 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 GM Guidance Material GP Glide Path HOFO Helicopter Offshore Operations ICAO International Civil Aviation Organization 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 RE Runway Excursion CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 Introduction ANNEX A. ANNEX B. ANNEX C. 2015 Annual Safety Recommendations Review Introduction PAGE 7 Introduction At the European Union level, the principles governing the investigation of accidents and serious incidents are de- fined 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 down an obligation for each Member State of the European Union (EU) to establish an independent permanent national civil aviation safety investi- gation 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 recommendations shall be communicated to the concerned aviation authorities for consideration and appropri- ate action, as needed. Regulation (EC) No 216/2008, which established EASA, states 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 opera- tional 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 effective proce- dures to that effect: EASA delivers the first response to incoming recommendations within 90 days; The safety recommendations process is subject to continuous internal monitoring until all corrective actions are closed; The Agency receives assessments of its responses from Safety Investigation Authorities and can identify when opinions diverge. In this context, EASA considers the assessment given by the safe- ty investigation authority on the appropriateness of the mitigation measures when closing the recommendation. All safety recommendations must be taken into full consideration by all stakeholders to whom they are ad- dressed. In this context, the Agency maintains transparency with respects to its decisions and actions, in line with its safety mission. The Annual Safety Recommendations Review provides an overview on the follow-up performed by EASA in response to recommendations addressed to the Agency by Safety Investigation Authorities in relation to the in- vestigation of Accidents and Serious Incidents or with respect to safety studies. The first edition of this review was issued in 2007. This 9th edition shows the 2015 activity and presents: general statistical data of the safety recommendations addressed by safety investigation authorities to EASA in 2015. replies that EASA has given in 2015 to safety recommendations and safety issues that have been pro- cessed with actions taken. 2015 Annual Safety Recommendations Review Introduction PAGE 8 Since 2011 a process to assess and mitigate safety risks at European level has been established. At the heart of this system is the concept of safety risks management, namely hazards identification, risks assessment and deci- sion-making on the best course of action to mitigate those risks. EASA, Member States (MS) and industry work closely together in this process. At European level, this process is coordinated by the Agency and documented in the European Plan for Aviation Safety (EPAS). The EPAS identifies the key safety issues as well as the safety actions to resolve or mitigate the hazards. Safety recommendations are one of the key inputs to the safety risk management process. They provide informa- tion on the hazards as well as proposed solutions to mitigate the associated safety risks to the aviation system. CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 Safety CHAPTER 5 Recommendations ANNEX A. received in 2015 ANNEX B. ANNEX C. 2015 Annual Safety Recommendations Review Safety Recommendations
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