CIAIACCIAIAC 2015-2016 Positive Taxonomy Report GOBIERNO MINISTERIO DE ESPAÑA DE FOMENTO CIAIAC POSITIVE TAXONOMY REPORT 2015 - 2016 © Ministerio de Fomento Secretaría General Técnica Centro de Publicaciones NIPO Línea: 161-18-125-6 NIPO Papel: 161-18-124-0 Depósito legal: M-16717-2018 Maquetación: David García Arcos Impresión: Centro de Publicaciones COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 63 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.ciaiac.es 28011 Madrid (España) CONTENTS 1. INTRODUCTION ................................................................................................................ 1 2. EXECUTIVE SUMMARY .................................................................................................... 1 3. POSITIVE TAXONOMY .................................................................................................... 4 3.1 Introduction.............................................................................................................. 4 3.2. ICAO positive taxonomy ..................................................................................... 5 3.3. Positive taxonomy expanded by the CIAIAC ............................................. 8 3.4. Methodology used in this document ........................................................... 9 4. RELEVANT INVESTIGATIONS WITH POSITIVE FACTORS ............................. 9 5. EVALUATION AND ANALYSIS OF THE POSITIVE FACTORS ........................ 22 5.1. Frequency of occurrence of positive factors ............................................ 22 5.2. Positive lessons and effect on outcome of events ................................ 23 5.2.1. Avoidance Maneuver .......................................................................... 23 5.2.2. Decision to go around ....................................................................... 24 5.2.3. Decision to land as a precaution .................................................. 24 5.2.4. Decision to land on an unexpected runway ............................ 25 5.2.5. Decision to reject takeoff ................................................................ 25 5.2.6. Decision to return to airport of departure or divert to another ..................................................................................................... 26 5.2.7. Aerodrome intervention/assistance ........................................... 27 5.2.8. ATC intervention/assistanc ............................................................. 27 5.2.9. Passenger intervention/assistance ............................................. 28 5.2.10. Third-party intervention/assistance .......................................... 28 5.2.11. Hardware safety net .......................................................................... 28 5.2.12. Communications .................................................................................. 29 5.2.13. Design requirements .......................................................................... 30 5.2.14. Engine failure anticipation .............................................................. 30 5.2.15. Logical problem solving. ................................................................... 31 5.2.16. Use of training instructions/Standard operating procedures .............................................................................................. 32 5.2.17. Visual detection/anticipation ......................................................... 33 5.2.18. Pre-flight preparations and precautions .................................. 33 5.2.19. Threat identification .......................................................................... 34 5.2.20. Good cockpit practices ...................................................................... 35 5.2.21. Airmanship and Flight Skills ........................................................... 36 5.2.22. Third-party intervention .................................................................. 36 5.3. Lessons learned by party involved ................................................................ 36 5.4. Positive factors based on the type of operation .................................... 40 6. CONCLUSIONS ................................................................................................................ 46 Annex A. User Manual ...................................................................................... A.1 Annex B. Safety events with positive factors....................................... B.1 Annex C. List of events .................................................................................... C.1 Annex D. Listing of Positive Factors by Type of Operation from 2013 to 2016 ....................................................................... D.1 Annex E. Definitions and Abbreviations .................................................. E.1 Annex F. List of Figures .................................................................................. F.1 Annex G. List of Tables .................................................................................... G.1 CIAIAC – 2015-2016 Positive Taxonomy Report 1. INTRODUCTION Spain’s Civil Aviation Accident and Incident Investigation Commission (CIAIAC) is pleased to present its second Positive Taxonomy report. The CIAIAC is a specialized collegial body within the Ministry of Development that is fully independent from aeronautic, airport, air traffic and other authorities whose interests could conflict with its own mission. As we noted in the first edition, the severity of accidents and incidents can be minimized through the proper practices of the agents involved in civil aviation operations, as evidenced by the reports published by the CIAIAC. As a result, the CIAIAC has analyzed the reports published in 2015 and 2016 in order to identify those positive factors that reduced the severity of the events in each case, with the conviction that this approach will yield improved operational safety and enhance the safety culture. 2. EXecUTIVE SUMMARY This study was created in an effort to contribute to improving the operational safety of civil aviation and is grounded in the belief that identifying the positive factors identified in the investigation of accidents and incidents can be useful for this purpose. Historically, published safety studies have focused on the element that failed (badly designed or improperly executed procedures, systems that malfunction), the goal being to provide the aviation community and the public in general with examples of what things to avoid. This report, however, aims to disseminate the idea that through their actions (during or prior to the event), professionals, organizations and systems can avoid events of greater severity, even on those flights that involve an accident or incident. The information contained in this report was taken from an analysis of 99 technical reports published by the Commission in 2015 and 2016. In 2015, a total of 53 final reports were published (44 involving events from previous years), while the year 2016 saw the publication of 46 final reports (36 involving events from previous years). Most of these reports, 78 to be exact, identified actions that helped to minimize the severity of the events. Only 21 reports failed to yield a specific action that helped to reduce the negative consequences of the events. Of these, 16 involved accidents and 5 serious incidents. Figure 1 shows that more than half of the accident reports, and practically all 1 CIAIAC – 2015-2016 Positive Taxonomy Report of the serious incident reports, identified positive actions, a trend that mirrors that observed in 2013-2014. Figure 1. Listing of reports published in 2015-2016 with positive factors These factors were initially classified using the taxonomy defined by the Common Taxonomy Team , created by the International Civil Aviation Organization (ICAO) and the Commercial Aviation Safety Team (CAST), which includes government officials and leaders from the international aviation industry. This taxonomy contains 20 positive factors. However, after writing the first edition of this report, positive factors were identified that did not fit into any of these definitions. As a result, five additional positive factors were included for a total of 25 different factors, 22 of which were identified at least once in the reports contained in this study. The 99 reports published by the CIAIAC in 2015 and 2016 were analyzed one by one, with each positive action described in the reports being related to a positive factor in the expanded taxonomy. The positive factors that stand out above the rest by the number of times they helped to reduce the consequences of an event are “Use of training instructions/SOPs” (37 times) and “Threat identification” (31 times). Also appearing a significant number of times were the positive factors “ATC intervention/assistance” (25 times), “Aerodrome intervention/assistance” (21 times), “Design requirements” (21 times) and “Hardware safety net” (20 times). Also analyzed due to its interest is the distribution of positive factors by the 2 CIAIAC – 2015-2016 Positive Taxonomy Report type of operation. Specifically, of the 78 reports in which positive factors were found, if we analyze the operations being conducted by the aircraft involved, 37 correspond to commercial air transport events, 36 involve general aviation, 7 concern events in which the aircraft in question was doing aerial work and 3 involve state flights. Figure 2 shows