CAP 776 Global Fatal Accident Review 1997–2006
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Safety Regulation Group CAP 776 Global Fatal Accident Review 1997–2006 21 July 2008 CAP 776 Global Fatal Accident Review 1997–2006 © Civil Aviation Authority 2008 All rights reserved. Copies of this publication may be reproduced for personal use, or for use within a company or organisation, but may not otherwise be reproduced for publication. To use or reference CAA publications for any other purpose, for example within training material for students, please contact the CAA at the address below for formal agreement. ISBN 978 0 11792 057 6 Published 21 July 2008 Enquiries regarding the content of this publication should be addressed to: Safety Investigation and Data Department, Safety Regulation Group, Civil Aviation Authority, Aviation House, Gatwick Airport South, West Sussex, RH6 0YR. The latest version of this document is available in electronic format at www.caa.co.uk/publications, where you may also register for e-mail notification of amendments. Published by TSO (The Stationery Office) on behalf of the UK Civil Aviation Authority. Printed copy available from: TSO, PO Box 29, Norwich NR3 1GN www.tso.co.uk/bookshop Telephone orders/General enquiries: 0870 600 5522 E-mail: [email protected] Fax orders: 0870 600 5533 Textphone: 0870 240 3701 CAP 776 Global Fatal Accident Review 1997–2006 List of Effective Pages Chapter Page Date Chapter Page Date iii 21 July 2008 Chapter 6 2 21 July 2008 Contents 1 21 July 2008 Chapter 6 3 21 July 2008 Contents 2 21 July 2008 Chapter 6 4 21 July 2008 Contents 3 21 July 2008 Chapter 6 5 21 July 2008 Executive Summary 1 21 July 2008 Chapter 6 6 21 July 2008 Executive Summary 2 21 July 2008 Chapter 6 7 21 July 2008 Chapter 1 1 21 July 2008 Chapter 6 8 21 July 2008 Chapter 2 1 21 July 2008 Chapter 6 9 21 July 2008 Chapter 2 2 21 July 2008 Chapter 6 10 21 July 2008 Chapter 2 3 21 July 2008 Chapter 6 11 21 July 2008 Chapter 2 4 21 July 2008 Chapter 7 1 21 July 2008 Chapter 2 5 21 July 2008 Chapter 7 2 21 July 2008 Chapter 2 6 21 July 2008 Chapter 7 3 21 July 2008 Chapter 2 7 21 July 2008 Appendix 1 1 21 July 2008 Chapter 2 8 21 July 2008 Appendix 1 2 21 July 2008 Chapter 2 9 21 July 2008 Appendix 1 3 21 July 2008 Chapter 2 10 21 July 2008 Appendix 2 1 21 July 2008 Chapter 2 11 21 July 2008 Appendix 2 2 21 July 2008 Chapter 2 12 21 July 2008 Appendix 2 3 21 July 2008 Chapter 2 13 21 July 2008 Appendix 2 4 21 July 2008 Chapter 2 14 21 July 2008 Appendix 3 1 21 July 2008 Chapter 2 15 21 July 2008 Appendix 4 1 21 July 2008 Chapter 2 16 21 July 2008 Appendix 4 2 21 July 2008 Chapter 2 17 21 July 2008 Appendix 4 3 21 July 2008 Chapter 2 18 21 July 2008 Appendix 5 1 21 July 2008 Chapter 2 19 21 July 2008 Appendix 5 2 21 July 2008 Chapter 2 20 21 July 2008 Chapter 3 1 21 July 2008 Chapter 3 2 21 July 2008 Chapter 3 3 21 July 2008 Chapter 3 4 21 July 2008 Chapter 3 5 21 July 2008 Chapter 3 6 21 July 2008 Chapter 4 1 21 July 2008 Chapter 4 2 21 July 2008 Chapter 4 3 21 July 2008 Chapter 4 4 21 July 2008 Chapter 4 5 21 July 2008 Chapter 4 6 21 July 2008 Chapter 4 7 21 July 2008 Chapter 5 1 21 July 2008 Chapter 5 2 21 July 2008 Chapter 5 3 21 July 2008 Chapter 5 4 21 July 2008 Chapter 5 5 21 July 2008 Chapter 6 1 21 July 2008 21 July 2008 Page iii INTENTIONALLY LEFT BLANK CAP 776 Global Fatal Accident Review 1997–2006 Contents Executive Summary Worldwide Fatal Accident Numbers 1 Worldwide Aircraft Utilisation 1 Worldwide Fatal Accident Rates 1 Factors and Consequences 2 Chapter 1 Introduction Chapter 2 Fatal Accident Statistics Introduction 1 Worldwide Fatal Accident Numbers 1 Number of Worldwide Fatal Accidents and Fatalities by Year 1 Number of Worldwide Fatal Accidents and Fatalities by Aircraft Class, Age and Weight Group 2 Number of Worldwide Fatal Accidents and Fatalities by Nature of Flight 5 Number of Worldwide Fatal Accidents and Fatalities by Phase of Flight 6 Number of Worldwide Fatal Accidents and Fatalities by Accident Location 7 Number of Worldwide Fatal Accidents and Fatalities by Operator Region 8 Worldwide Aircraft Utilisation 9 Introduction 9 Overall Flights and Hours Flown 9 Worldwide Flights and Hours Flown by Aircraft Class 9 Worldwide Flights and Hours Flown by Nature of Flight 10 Worldwide Fatal Accident Rates 11 Introduction 11 Worldwide Fatal Accident and Fatality Rates by Year 11 Worldwide Fatal Accident and Fatality Rates by Aircraft Class and Weight Group 12 Worldwide Fatal Accident and Fatality Rates by Nature of Flight 15 Worldwide Fatal Accident and Fatality Rates by Operator Region 17 Worldwide Mortality Risk for Passenger Flights 20 Chapter 3 Analysis of Primary Causal Factors Primary Causal Groups 1 Primary Causal Factors 2 Primary Causal Factors for All Fatal Accidents 2 Primary Causal Factors by Aircraft Class 3 Primary Causal Factors by Nature of Flight 4 Primary Causal Factors by Operator Region 4 21 July 2008 Contents Page 1 CAP 776 Global Fatal Accident Review 1997–2006 Chapter 4 Analysis of All Causal Factors Causal Groups 1 Causal Factors 3 Causal Factors for All Fatal Accidents 3 Causal Factors by Aircraft Class 5 Causal Factors by Nature of Flight 5 Causal Factors by Operator Region 6 Chapter 5 Analysis of Circumstantial Factors Circumstantial Factors for All Fatal Accidents 1 Circumstantial Factors by Aircraft Class 2 Circumstantial Factors by Nature of Flight 3 Circumstantial Factors by Operator Region 4 Chapter 6 Analysis of Consequences Consequences for All Fatal Accidents 1 Consequences by Aircraft Class 3 Consequences by Nature of Flight 4 Consequences by Operator Region 5 Consequential Analysis 7 Introduction 7 Loss of Control In Flight 8 Controlled Flight Into Terrain (CFIT) 9 Runway Excursion 10 Chapter 7 Summary Worldwide Fatal Accident Numbers 1 Worldwide Aircraft Utilisation 1 Worldwide Fatal Accident Rates 2 Primary Causal Factors 2 All Causal Factors 2 Circumstantial Factors 3 Consequences 3 Appendix 1 The CAA Accident Analysis Group (AAG) Introduction 1 AAG Working Methodology 1 Limitations of AAG Data 3 Differences to CAP 681 Global Fatal Accident Review 1980-96 3 21 July 2008 Contents Page 2 CAP 776 Global Fatal Accident Review 1997–2006 Appendix 2 Definitions Appendix 3 Glossary Appendix 4 Aircraft Types Included in Study Jets 1 Turboprops 2 Business Jets 3 Appendix 5 List of Factors and Consequences Attributed to Worldwide Fatal Accidents 1997 to 2006 21 July 2008 Contents Page 3 INTENTIONALLY LEFT BLANK CAP 776 Global Fatal Accident Review 1997–2006 Executive Summary The main risks to large public transport aeroplanes are identified through analysis of worldwide fatal accidents, which is a task carried out annually by the CAA Accident Analysis Group (AAG). The output of the AAG forms a key part of the CAA Safety Planning process in that these main risks are assessed for their relevance to the UK aviation system and, where appropriate, safety interventions are identified to mitigate them. These safety interventions can be found in the CAA Safety Plan. This document summarises a study of AAG analysed worldwide fatal accidents to jet and turboprop aeroplanes above 5,700 kg engaged in passenger, cargo and ferry/positioning flights for the ten-year period 1997 to 2006. The style and content of the document are similar to the previous Global Fatal Accident Review (CAP 681). The main findings of the study are listed below. 1 Worldwide Fatal Accident Numbers 1.1 There was a total of 283 worldwide fatal accidents, which resulted in 8,599 fatalities to passengers and crewmembers onboard the aircraft. The proportion of aircraft occupants killed in these fatal accidents was 69%. 1.2 There was an overall decreasing trend in both the number of fatal accidents and fatalities, although there was more fluctuation in the number of fatalities. 1.3 The approach, landing and go-around phases accounted for 47% of all fatal accidents and 42% of all onboard fatalities. Take-off and climb accounted for a further 30% of the fatal accidents and 29% of the onboard fatalities. 2 Worldwide Aircraft Utilisation 2.1 In the ten-year period from 1997 to 2006, the number of flights flown increased by 17%, which equated to an average annual growth of 1.5%. The equivalent values for hours flown were 31% for overall growth and 2.8% for average annual growth. 3 Worldwide Fatal Accident Rates 3.1 The overall fatal accident rate for the ten-year period 1997 to 2006 was 0.79 fatal accidents per million flights flown or 0.49 when expressed as per million hours flown. 3.2 There was a decreasing trend in both the overall rate of fatal accidents and onboard fatalities. 3.3 On average, the fatal accident rate for turboprops was three times that for jets, based on flights flown, and nearly seven times greater when using hours flown as the rate measure. 3.4 On average, the fatal accident rate for aircraft with maximum take-off weight below 15 tonnes was twice that for aircraft with maximum take-off weight above 27 tonnes, based on flights flown, and over four times greater when using hours flown as the rate measure.