Subject Page Number

Forward 8

AIB Vision 9

AIB Mission 10

AIB Values 11

Introduction 12

Notifications 14

Introduction 15

Reporting Culture Rates 15

Notification Classes for 2016 17

1) Accident 17

2) Serious incident 17

3) Incident 18

4) Others 18

Reported Occurrences Categories 18

Investigations 20

Introduction 21

Full investigation annex 13 format report 21

Limited scope investigation report 21

Safety concern report 21

Investigation Status 21

Some selected cases of occurrences investigated in 2016 22

1) Case number AIB-2016-0272 (24/06/2016) 22

2) Case Number AIB-2015-0156 (31/07/2015) 22

2.1) Description 22

2.2) Conclusion 23

2

Subject Page Number

3) Case number AIB-2014-0293 (02/12/2014) 23

3.1) Description 23

2.2) Conclusion 24

4) Case number AIB-2016-0067 (23/02/2016) 25

4.1) Description 25

4.2) Conclusion 25

5) Case number AIB-2014-0173 (06/07/2014) 25

5.1) Description 25

5.2) Conclusion 26

Recommendations 28

Introduction 29

Responding to Safety Recommendations 29

Issued Safety Recommendations 29

Engineering Lab. 40

Activities 41

Flight Recorder Laboratory (FRL) facilities’ work flow arrangements 42

Stage One: Receiving 42

Stage Two: Level two and three data recovery 43

Stage Three: Data Download 44

Stage Four: Cockpit Voice Recorder (CVR) Listening and transcribing 44

Equipment Maintenance 45

Equipment Inventory 45

Measuring Equipment Calibration Requirement 46

Capability Development 46

Frame Format Description Files (FFD) 46

3

Subject Page Number

Layout File (LF) 47

Flight Analysis System (FAS) 47

Memory Access Retrieval system (M.A.R.S) 48

Characteristics of MARS 49

Safety Analysis 52

Safety Study 53

Scope of Work 53

1) Data Collection 53

2) Data Analysis 53

3) Team Formation 54

4) Result of Working Group 54

5) Standards' Assessment 54

6) Recommendations 54

6.1) Security and Air Transport (SSAT-GACA) 54

6.2) Saudia Ground Services (SGS) 55

6.3) Aviation Investigation Bureau (AIB) 55

6.4) GACA Airports 55

6.5) Operators (Saudia and Flynas) 55

Safety Concern and Issues 56

Bird Strike 57

Air Proximity 59

Financial & Admin Affairs 60

Introduction 61

1) Human Resources 61

1.1) Recruitment 61

4

Subject Page Number

1.2) Employee Retention 61

1.3) Saudization 61

1.4) Policies and Procedures 61

1.5) Training and Development 61

1.6) Employee-Engagement Program 61

1.7) Leave Planning 61

1.8) Employee Database 61

1.9) Job Descriptions 61

1.10) Attendance 61

1.11) Forms 61

2) AIB’s Organizational Chart 62

3) Information Technology 63

3.1) AIB Website 63

3.2 FTP (File Transference Protocol) 63

3.3) Twitter 63

3.4) SharePoint System 63

3.5) AOMS (Aviation Occurrences Management System) 63

3.6) Network Wireless Access Point 63

3.7) Data Tracking System (DTS) 63

4.0) Public and Government Relations 63

4.1) Workshops, Conferences and Events 63

4.2) International Collaboration 64

4.3) Global Ministerial Aviation Summit 64

4.4) Employee Discount Program 64

Development 66

Introduction 67

5

Subject Page Number

Cooperation and Collaboration Enhancement in Accident Investigations 67

MOU with the Interstate Aviation Committee of the Russian Federation 67

MOU with the Air Accident Investigation Bureau (AAIB) of Singapore 68

MOU with the Investigation Bureau of the Moroccan General Directorate of Civil Aviation 69

MOU with the Office of Aviation Safety of the Civil Aviation Administration of the Republic of China 69

Flight Data Analysis Workshop 69

Ministry of Interior communication program 70

Ministry of Defence communication program 71

Aviation Security communication program 71

Airports coordinators workshop 72

Workshop Objectives 72

Crash Landing Drill 73

Activities performed during the drill 73

National Disaster Plan Drill 75

Aviation Occurrence Management System (AOMS) Project 77

Project Vision 77

Process Scope 77

ECCAIRS (European Coordination Centre for Accidents and Incident Reporting Systems) 79

Post-Accident Communication Strategy 79

Introduction 79

Objectives 81

Main Successes and achievements of the communication Strategy 82

6

7

The AIB team is committed to aviation safety and will continue its mission in conducting its function to the highest standards to promote aviation safety.

I am honored to present to His Excellency the Minister of Transport Chairman of the Board of Directors of the General Authority of Civil Aviation the 2016 Annual report of the Aviation Investigation Bureau. This is the third annual report since the establishment of the AIB in November 2013.

It is without a doubt, that the continuous support of His Excellency has enabled the AIB to pursue ambitious initiatives and to achieve major accomplishments during 2016, in various areas of AIB functions.

There was a 70% increase in the number of received notifications of occurrences compared to 2015. This is perceived as a significant enhancement in the reporting culture, and as a result of an extensive outreach program in 2015, which included KSA service providers and operators.

The AIB has successfully engaged the aviation industry and stakeholders in the development of a National Post Accident Communication Strategy. This effort has also triggered among other initiatives, the development and enhancement of Family Assistance plans within the aviation sector of KSA.

Director General

Abdulelah Othman Felemban

8

AIB

Vision

To be recognized as an international leader in

advancing global

aviation safety.

9

AIB

Mission

To advance aviation

safety through independent occurrence

investigations and safety

studies, promote an

effective and

comprehensive safety

reporting system and communicate risks and

safety recommendations.

10

AIB

Values

Respect:

Fostering an environment that allows staff to contribute, innovate and excel.

Integrity and impartiality:

In all activities.

Competence: Continual professional and technical development.

Transparency: Exchange information to enhance aviation safety.

11

The Aviation Investigation Bureau “AIB” of the Kingdom of Saudi Arabia investigates accidents and other occurrences involving civil aircraft. It analyses data on all notified accidents and incidents. It conducts research into specific matters of concern that emerge from data analysis and specific incidents, or matters that may be referred to by other organizations.

It does so in a manner consistent with the Aircraft Accident and Incident Investigation Convention on International Civil Aviation that was signed in Chicago in the year of 1944 (Annex 13).

The AIB may also investigate serious accidents or incidents involving Saudi registered aircraft overseas, or assist with overseas investigations involving Saudi registered or foreign aircraft if an overseas investigative authority seeks assistance and the AIB has the suitable resources available.

The AIB may also have observer status in important overseas investigations, which provides valuable opportunities to learn from overseas organizations and to benchmark its knowledge and procedures against other organizations. The AIB cooperates with the following organizations:  The General Authority of Civil Aviation (GACA) of the Kingdom of Saudi Arabia.  Operators in Saudi Arabia.  Aircraft manufacturers.  Other safety agencies to assist the government in implementing aviation safety initiatives.

12

13

14

Introduction: The AIB has an Operation Control Center “OCC” that maintains a 24/7 notification service. It receives all notifications such as; telephone calls, emails, facsimiles and web forms that are utilized to notify the AIB of the aviation occurrences. A single occurrence can generate multiple notifications from different sources, it is common that duplicate notifications occur.

The number of occurrences has increased up to 606 occurrences in 2016, where it was 338 in 2015, with an increase rate of 79%. Once a notification is received by an OCC duty officer, it’s logged into a database called the Aviation Occurrence Tracking System “AOTS”. AOTS helps track occurrences from initiation, to investigation, to closure. This process is consistent with the AIB Regulation and Annex 13 of the International Civil Aviation Organization “ICAO”. The graph below shows the comparison between 2015 and 2016 on a monthly basis.

70 67 66 60 59 54 57 54 50 47 55 42 36 45 40 37 40 41 30 26 36 20 27 19 21 23 27 20 29 16 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015 20 26 19 21 27 23 16 27 54 40 36 29 2016 36 42 47 67 37 54 59 57 45 66 41 55

Notifications on a monthly basis

Reporting Culture Rates: 2016 shows a significant improvement in the occurrence reporting culture in airports. The outreach program that AIB conducted with airports has played a major role in emphasizing the importance of occurrence reporting. Yet, one of the biggest challenges identified by the AIB is addressing the un-reported occurrences. The graph below shows a comparison of occurrence notifications in the four major airports in KSA.

15

157 160

140 114 120

100 89 2015 80 66 61 2016 60

40 26 19 20 11

0 KAIA KKIA KFIA PMIA

Reporting Rate Chart

The graph below shows notifications by airports in KSA.

180 157 2015 2016 160 140 114 120 100 89 80 61 66 60 40 22 26 19 9 88 11 20 11 31 33 36 35 12 27 10 01 01 41 76 54 25 20 10 21 24 0

Notifications by airport in KSA

16

432 450

400

350

300

250 In-Kingdom Out-Of_Kingdom 200

150 102 56 100 16 50

0 Airports Aerospace

Number of occurrences for the year 2016 (Airports Vs Aerospace comparison)

Notification Classes for 2016: The four basic occurrence classes are as follows:

0.16% 1 32.45% 5.76% 197 35

Accidents Serious Incidents Incidents Others 374

61.61%

Occurrence Classes for 2016

1) Accident: An occurrence associated with the operation of an aircraft which a person is fatally or seriously injured, or the aircraft sustains substantial damage.

2) Serious incident: An incident involving circumstances indicating that an accident nearly occurred.

17

3) Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.

4) Others: A reported event that does not classify as an accident or incident.

The reported occurrences are identified based on severity and impact for both, passengers and flight operations as noted in the graph below. Some minor events could be non- significant in nature, but still recorded for data collection purposes and safety analysis.

Reported Occurrences Categories: All of the occurrences reported to AIB are categorized in accordance with the ICAO categorization taxonomy. The ICAO Accident/Incident Data Reporting (ADREP) system is based on the ADREP taxonomy to allow for international data sharing. The ADREP taxonomy is a set of definitions and descriptions used during the gathering and reporting of accident and incident data that is forwarded to ICAO. This taxonomy is maintained by the ICAO Accident Investigation Group. Some occurrences are categorized in more than one category.

OTHR: Other 43 48 UNK: Unknown 1 4 WSTRW: Windshear or thunderstorm 8 57 TURB: Turbulence encounter 34 SEC: Seurity related 3 19 SCF-PP: Powerplant failure or malfunction 17 40 SCF-NP: System/component failure 48 110 RI-VAP: Runway incursion vehicle 56 RI-VA: Runway incursion vehicle 01 RI-A: Runway incursion animal 01 RAMP: Ground handling 48 70 MAC: AIRPROX/near miss/midair collsion 34 48 LOC-I: Loss of control inflight 1 5 LOC-G: Loss of control ground 01 GCOL: Ground collision 2 6 FUEL: Fuel related 5 14 F-NI: Fire/Smoke (non-impact) 14 22 CTOL: Collisions with obstacle 0 3 CABIN: Cabin safety events 5 39 BIRD: Birdstrike 60 74 ATM: ATM/CNS 11 38 ARC: Abnormal runway contact 2 5 AMAN: Abrupt maneuvre 1 ADRM: Aerodrome 3 14 0 20 40 60 80 100 120

2016 2015

Occurrence Categories Comparison

18

19

20

Introduction: The purpose of an investigation is to determine the facts, conditions, and circumstances in order to arrive at findings that will identify causal factors. The sole objective of the investigation of an aviation occurrence shall be the prevention of aviation occurrences. It is not the purpose of this activity to apportion blame or liability.

The AIB, in carrying out investigations, usually publishes three kinds of reports for aviation occurrences depending on its safety significance. The reports differ in size and scope, but they all follow the basic ICAO annex 13 concept in its structure. All reports present facts, analysis, findings and when necessary safety recommendations. It’s important to state that this is only for the sake of practicality. Certain circumstances may require AIB to deviate from this practice. The three kinds of reports are as follows:

Full investigation annex 13 format report: This is for investigated Accidents and serious incidents that involve international interested parties.

Limited scope investigation report: for incidents that involve domestic interested parties only, such as ground incidents or ATC incidents.

Safety concern report: for safety critical observations and standalone recommendations addressing specific safety matters.

Investigation Status: In 2016, 65 occurrences were investigated, 14 cases were completed, and 51 are On-Going investigations. The graph below shows the number of investigated occurrences and the status of the investigation.

65 70 51 60

50 On-Going 40 Completed 30 Total 14 20

10

0 On-Going Completed Total

2016 Investigations Status

21

Some selected cases of occurrences investigated in 2016: 1) Case number AIB-2016-0272 (24/06/2016): This aviation occurrence is categorized as “Accident”. It occurred to a private powered parachute aircraft with Rotax 912 engine that crashed into a swamp at As Suwadirah, 70 km east of Medina. A pilot and one passenger were on board and the passenger died in this accident.

Powered Parachute

2) Case Number AIB-2015-0156 (31/07/2015): 2.1) Description: At the end of a routine flight, aircraft HZ-IBN entered the visual circuit to land on Runway 25 at Blackbushe airport in UK. A number of TCAS alerts occurred while flying in the circuit, and the pilot maneuvered the aircraft until it was significantly higher and faster than normal for a visual approach. Following several TAWS alerts, the aircraft crossed the runway threshold 43 kt above the target threshold speed1.

Aircraft HZ-IBN

The aircraft floated before touching down and overran the runway end. It collided with an earth bank, and then cars in a car park, causing the wing to separate and a fire to start. The four occupants were fatally injured. Several factors combined to create a very high workload

22

for the pilot. This may have saturated his mental capacity, impeding his ability to handle new information and adapt his mental model, leading him to become fixated on continuing the approach.

2.2) Conclusion: Aircraft HZ-IBN joined the circuit at a speed and height which would have been consistent with the pilot’s stated plan to extend downwind in order that the microlight could land first. The subsequent positioning of HZ-IBN and the microlight involved HZ-IBN maneuvering across the microlight’s path, in the course of which the first of several TCAS warnings was generated.

After maneuvering to cross the microlight’s path, HZ-IBN arrived on the final approach significantly above the normal profile but appropriately configured for landing. In the ensuing steep descent, the pilot selected the speed brakes out but they remained stowed because they are inhibited when the flaps are deployed. The aircraft’s speed increased and it crossed the threshold at the appropriate height, but 43 KIAS above the applicable target threshold speed. The excessive speed contributed to a touchdown 710 m beyond the threshold, with only 438 m of paved surface remaining.

From touchdown, at 134 KIAS, it was no longer possible for the aircraft to stop within the remaining runway length. The brakes were applied almost immediately after touchdown and the aircraft’s subsequent deceleration slightly exceeded the value used in the aircraft manufacturer’s landing performance model. The aircraft departed the paved surface at the end of Runway 25 at a groundspeed of 83 kt. The aircraft collided with an earth bank and cars in a car park beyond it, causing the wing to separate and a fire to start. Although the aircraft occupants survived these impacts, they died from the effects of fire.

Towards the end of the flight, a number of factors came together to create a very high workload situation for the pilot, to the extent that his mental capacity could have become saturated;  His ability to take on new and critical information, and adapt his situational awareness, would have been impeded.  In conjunction with audio overload and the mental stressors this can invoke, this may have lead him to become fixated on continuing the approach towards a short runway.

3) Case number AIB-2014-0293 (02/12/2014): 3.1) Description: A Cessna 340 twin-engine airplane was on final approach to land at King Khalid International Airport (OERK) – Riyadh, Kingdom of Saudi Arabia (KSA). At approximately 600 feet altitude, the left engine sputtered and quit and ten (10) seconds later the right engine quit. The pilot quickly notified the Air Traffic Control Tower of the emergency due to the loss of power in both engines. The airplane touched down on the desert like terrain outside the perimeter fence of the airport, skidding and then hit a pile of rocky earthen rubble. A Cessna 340, Registration N340JC, was in the process of being sold to a buyer in Malaysia. For this purpose, N340JC was being ferried / operated by a professional aviation ferrying company. The ferry trip was from the Yoakum County Airport, Plains, Texas, and United States to the Sultan Abdul Aziz Shah Airport, Subang International Airport, Kuala Lumpur, Malaysia (see

23

image on figure 10). The entire ferry trip was divided into many segments which were mainly limited by the availability of fuel for each segment. It should be noted the aircraft’s flight plan routing deviated from its flight plan noted in the aircraft’s ferry insurance policy.

Route of Aircraft N340JC

This accident occurred at 1457 UTC (1757 local time), in the hours of darkness, 1.25 nm from the threshold of runway 33R at the King Khalid International Airport-Riyadh, KSA. The aircraft landed on desert like terrain, skidding into a pile of earthen rubble and sustained serious damages.

Extent of serious damages on aircraft N340JC

3.2) Conclusion: The Pilot-In-Command (PIC) did not adequately prepare the aircraft for this international ferry flight. The PIC did not accurately calculate the required fuel necessary to complete the flight from Hurghada to Riyadh.

24

It is likely the Flight Crew’s flight plan estimate included the flight time en-route from Hurghada International Airport to King Khalid International Airport in Riyadh without any consideration for additional fuel consumption for starting, taxi, takeoff, climb and vectoring or maneuvering for a landing approach when arriving into Riyadh. The aircraft was carrying an additional non-essential cargo that likely derogated the aircraft’s performance.

Neither Flight Crew member notified ATC of the fuel shortage. The loss of both engines was due to fuel exhaustion. The aircraft’s fuel exhaustion resulted in the subsequent off airport landing.

4) Case number AIB-2016-0067 (23/02/2016): 4.1) Description: SriLankan Airlines 282 (ALK282) was an Airbus 330-200 (A332) that was departing King Abdul-Aziz International Airport (OEJN), Jeddah Kingdom of Saudi Arabia (KSA) on a regular scheduled passenger flight to Bandaranaike International Airport (VCBI), Colombo, Sri Lanka. N851AB was an Embraer 300 (E55P) Phenom 300 business jet that was departing OEJN on a repositioning flight to King Khalid International Airport (OERK), Riyadh KSA.

4.2) Conclusion: A Runway Incursion occurred when N851AB entered RWY 34L at a location not planned by the controller.  A Loss of Separation existed when N851AB was issued a taxi clearance onto RWY 34L prior to the departure of ALK282 and without determining the location of the aircraft.  A loss of Separation existed when N851AB was issued a take-off clearance without the requisite turbulence separation minima.  A Hazardous Situation (Risk of Collision) existed when ALK282 commenced a take-off roll behind N851AB occupying the same runway.  A Hazardous Situation existed when the controller was unsure of the location of N851AB (having already departed).

5) Case number AIB-2014-0173 (06/07/2014): 5.1) Description: On 06 July 2014, an Airbus A320-214, Registration HZ-AS41, operated by Saudi Arabian Airlines as Flight SVA 1655, was performing a scheduled domestic flight from King Khalid International Airport (OERK), Riyadh to Abha Regional Airport (OEAB). When landing in

25

Abha, the aircraft experienced a severe hard landing resulting in a computed vertical acceleration of 4.09 gravitation force (g). The Pilot-in-Command requested the Air Traffic Control Tower controller to arrange for an ambulance to meet the aircraft upon parking. One cabin crew member was seriously injured with two passengers receiving minor injuries during the severe hard landing.

Hard Landing

5.2) Conclusion: On the final approach into OEAB, at 240 ft., HZ-AS41 encountered vertical wind gusts resulting in the Pilot Flying manipulating the sidestick control. The approach for landing in OEAB became unstable below 240 feet. The Pilot Flying did not initiate a “Go-Around” procedure when the approach was destabilized. The simultaneous variant sidestick inputs from the Captain and First Officer for 14 seconds during the flare phase of the flight were not adequate to reduce the aircraft’s vertical speed before landing. The aircraft initially touched down at 4.09g as noted as a severe hard landing. The thrust levers were not retarded during the initial touchdown.

The energy of the initial severe hard landing associated with the full back sidestick input applied at touchdown and the inhibition of the ground spoilers’ extension led to a gain of lift resulting in a light bounce. A strong nose down input applied during the bounce, associated with ground spoilers extension resulted in a sharp drop of lift creating a hard landing of 2.56g.

The flight crew recognized the unstable approach between 100 and 50 feet but continued with the landing as they believed it was too late for an alternate flight action.

26

27

28

Introduction: In accordance with the AIB Regulations Chapter 8, paragraph 8.2, the AIB recommend corrective or remedial actions as a result of investigations or safety studies for the purpose of preventing further aviation occurrences. If during the course of an investigation any safety deficiency becomes known for which prompt preventative action is required, then it will be addressed through a Stand-Alone Recommendation (SAR) in accordance to AIB Regulation Chapter 6, paragraph 6.3. The recommendations are usually broad in application to allow the addressees of the recommendations to have some discretion in implementing specific remedial actions.

Responding to Safety Recommendations: This annual report contains the safety recommendations issued in 2016 for the completed investigation during 2016, including recommendations status. The status of the Safety recommendations are categorized in to the following categories:

1) Issued: The recommendation has been issued and sent. 2) Implemented: The recommendation has been accepted and implemented. 3) Open: The recommendation still open and waiting for replay. 4) Over Due: The recommendation. 5) Rejected: The implementation proposal is not accepted.

Issued Safety Recommendations: In 2016, 88 safety recommendations were issued. These recommendations are listed in the following table: Issued Safety Recommendations Rec. No. Recommendation Assigned to Status The operator, Saudi Arabian Airlines, should coordinates with the manufacturer of the type of aircraft to replace the existing pitot probe Saudi Arabian AIB-2013-0003-SR-01 protection device with a protection device that Over Due Airlines is heat resistive and made of inflammable material to avoid burning the device whenever the pitot probe is inadvertently activated. The operator, Saudi Arabian Airlines, should revise maintenance work order to include a log Saudi Arabian AIB-2013-0003-SR-02 book entry for covering the pitot probes Over Due Airlines whenever an aircraft is intended to be parked for more than 24 hours. The operator, Saudi Arabian Airlines, should revise maintenance work order to include Saudi Arabian AIB-2013-0003-SR-03 placing a decal on the Pitot Probe switch in the Over Due Airlines cockpit whenever a protective cover is placed on the probes. GACA should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing and other AIB-2013-0013-SR-01 factors. Details of actions to include GACA Open Completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided. AIB-2014-0043-SR-01 GACA-Air Navigation Service (ANS) should GACA- ANS Over Due 14-

29

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status establish and confirm the effectiveness of a Jun-2016 system to monitor and alert controllers of validity dates of license validation certifications (Medical and English Language Proficiency). This alerting would include notification to Supervisors and Managers to ensure that no controller is assigned an operational position without possessing the required validations. GACA-ANS should confirm that a process is in place to ensure required documentation is Over Due 14- AIB- 2014-0043-SR-02 complete. This includes confirming the required GACA- ANS Jun-2016 certificates and that these are all accurate and signed. GACA- ANS and the Regulatory Branch must ensure that controllers are fully aware of their individual responsibilities as per ATSP-1, 203.3 203.3 A person shall not provide an air traffic control service unless he holds an ATC license Over Due 14- AIB-2014-0043-SR-03 issued or approved by GACA, with a valid GACA- ANS Jun-2016 rating, including any associated rating and/or unit license endorsement relating to the air traffic control service to be provided, a current Class 3 Medical assessment certificate and a valid English proficiency certificate. The General Authority of Civil Aviation, Safety, Security and Air Transport must provide the Over Due 14- AIB- 2014-0043-SR-04 necessary regulatory oversight to ensure full GACA- ANS Jun-2016 compliance with licensing and certification requirements. Saudi Arabian Airlines should evaluate its pilot flight training program to mitigate any Saudi Arabian Over Due 01- AIB-2014-0173-SR-01 associated risks encountered during operations Airlines Jan-2017 at special airports (high elevation /mountainous area). Saudi Arabian Airlines should evaluate its Cabin Crew member Training syllabus for dealing with Saudi Arabian Over Due 01- AIB-2014-0173-SR-02 passengers not seated while maintaining Airlines Jan-2017 principal safety position during critical phases of flight. Saudi Arabian Airlines should communicate with the manufacturer to incorporate the Saudi Arabian Over Due 01- AIB-2014-0173-SR-03 activation of FDC alert for hard landing reports Airlines Jan-2017 (LOAD <15>). Saudi Arabian Airlines should highlight in its simulator training curriculum the adverse Saudi Arabian Over Due 01- AIB-2014-0173-SR-04 impact of dual side stick inputs scenario during Airlines Jan-2017 critical phases of flight. The General Authority of Civil Aviation (GACA), Air Navigation Services should provide the AIB with corrective actions (planned, initiated or Over Due 14- AIB-2014-0178-SR-01 GACA completed) to address identified contributing Jun-2016 and other factors (CF1- CF 6 and OF1). Details of actions to include Completion dates or

30

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status planned and estimated completion dates. Saudi Arabian Airlines should review the air carrier’s current A-320 oven maintenance Saudi Arabian AIB-2014-0181-SR-01 program and make adjustments to this Implemented Airlines program to preclude equipment failures related to corroded water fittings. Saudi Arabian Airlines should issue an alert to its cabin crewmembers noting: A) Pre-departure checks include an inspection of all ovens to ensure that no foreign Saudi Arabian AIB-2014-0181-SR-02 objects or other flammable residues are in Implemented Airlines the ovens. B) A special emphasis should be placed on SVA firefighting practices used for combating on board fires. The General Authority of Civil Aviation should create an advisory committee to assist the Over Due 11- AIB-2014-0182-SR-01 Saudi Aviation Club to develop the GACA Aug-2016 infrastructure that would allow it to exercise adequate oversight of sports aviation activities. The Saudi Aviation Club should establish a “policy and procedures” manual that includes: a) Minimum qualifications, experience and training requirements for Saudi Aviation Club member pilots; b) Minimum qualifications and standards for Saudi Aviation Club flight instructors. c) Standardized Saudi Aviation Club pilot training program curriculum for entry level pilots; Saudi Aviation Over Due 11- AIB-2014-0182-SR-02 d) Procedures for a Saudi Aviation Club pilot Club Aug-2016 record keeping system; e) Qualifications for maintenance personnel maintaining Saudi Aviation Club aircraft; f) Procedures to follow the manufacturer recommended maintenance program to ensure Saudi Aviation Club aircraft are airworthy and provide historical maintenance documentation to support the aircraft airworthiness status; and, g) Safety reporting system. All aviation schools certified by the Saudi Aviation Club shall monitor all sport aviation activities under their jurisdiction to ensure All aviation Over Due 11- AIB-2014-0182-SR-03 compliance with applicable pilot operating schools Aug-2016 handbook, maintenance requirements and report non-compliance to the Saudi Aviation Club. The Saudi Aviation Club should establish procedures to effectively administer violations and issue penalties to Saudi Aviation Club Saudi Aviation Over Due 11- AIB-2014-0182-SR-04 schools and members who do not comply with Club Aug-2016 Saudi Aviation Club policies, procedures and applicable General Authority of Civil Aviation

31

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status regulations. The Saudi Aviation Club should ensure SAC certified pilots understand the contents of the Saudi Aviation Over Due 11- AIB-2014-0182-SR-05 Auto-Gyro MTO-sport Pilot Operating Club Aug-2016 Handbook. GACA-ANS shall re-evaluate the procedures to ensure the transmission of flights on the radar Over Due 05- AIB-2014-0221-SR-01 GACA-ANS screens of ATC sectors of the regional areas, Oct-2016 including the proper definition of the sectors GACA-ANS shall re-examine the ACNE, both top and the lowest level commensurate with the Over Due 05- AIB-2014-0221-SR-02 nature and the air traffic flying sector, taking GACA-ANS Oct-2016 into account the active maneuver operations requirements GACA-ANS shall rationing comfort effective mechanism commensurate with the nature of the work and take into account the natural Over Due 05- AIB-2014-0221-SR-03 needs of the observers, while ensuring the GACA-ANS Oct-2016 effectiveness of the delivery and receipt and oversee the dissemination and application times. GACA-ANS shall disclose and manage risks in Over Due 05- AIB-2014-0221-SR-04 the sectors centers and air traffic management GACA-ANS Oct-2016 and to take appropriate corrective action. GACA-ANS shall not to allow observers who do not have licenses and certificates of medical Over Due 05- AIB-2014-0221-SR-05 GACA-ANS and linguistic valid work in air traffic Oct-2016 management sites. Saudi Arabian Airlines, Flight Operation Department should consider introducing an additional item in the "Engine Start Saudi Arabian Over Due 10- AIB-2014-0304-SR-01 Procedures" checklist in the FCOM to ensure Airlines-FO Aug-2016 that "Thrust Levers … Check at CLOSED position". Saudi Aerospace Engineering Industries (SAEI) should introduce additional item in the Over Due 04- AIB-2014-0304-SR-02 Technical Preflight Checklist to address the SAEI Aug-2016 tidiness and cleanliness of aircraft cockpit and its instrument/control panels. The General Authority of Civil Aviation should review the phraseology for imperative AIB-2015-0026-SR-01 instructions to ensure that the desired actions GACA Open are immediately understood by the flight crew for expeditious compliance The General Authority of Civil Aviation should incorporate this part of Human Factors in AIB-2015-0026-SR-02 GACA Open Refresher Training so that controllers may be better prepared for these reactions. As a component of the Unit Preliminary Investigation, occurrences involving Loss of AIB-2015-0026-SR-03 Separation or other significant event should be GACA-ANS Open reviewed by a Training Manager and/or Supervisor to ensure that there are no

32

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status knowledge or skills gaps. Should any be noted during this review then appropriate, non- punitive corrective action can be taken coincident with the ATCO’s return to duty. The General Authority of Civil Aviation should review the practice of “penalizing” ATCOs who have experienced an Operating Irregularity, AIB-2015-0026-SR-04 GACA Open such as the “Black Mark” on personal record with the aim to ensure and maintain a climate of open reporting. The General Authority of Civil Aviation, ANS, should develop and deliver an educational training module on “Human Factors in Over Due 13- AIB-2015-0072-SR-01 Emergencies” to the air traffic control staff. GACA Apr-2016 This training would better prepare the control staff on dealing with emergency or other stressful situations that they may encounter. The General Authority of Civil Aviation, ANS, should ensure the process of monitoring and alerting controllers, supervisors and Unit Management of validity dates of license validation certifications (License, Medical and Over Due 13- AIB-2015-0072-SR-02 GACA English Language Proficiency). This alerting Apr-2016 would include notification to ensure that no controller is permitted to assume an operational position without the required validations. The General Authority of Civil Aviation, ANS, should confirm that a process is in place to ensure and confirm that required Over Due 13- AIB-2015-0072-SR-03 GACA documentation is complete, this would include Apr-2016 all certificates and forms have required signatures. The General Authority of Civil Aviation, ANS, should develop and deliver an educational training module on “Aircraft Flight AIB-2015-0100-SR-01 GACA-ANS Open Performance” and Flight Deck Operation to understand how react to normal and abnormal flight situations flight crew. The General Authority of Civil Aviation, ANS, should ensure the process of monitoring and alerting controllers, supervisors and Unit management of validity dates of license validation certifications (License, Medical and AIB-2015-0100-SR-02 GACA-ANS Open English Language Proficiency). This alerting would include notification to ensure that no controller is permitted to assume an operational position without the required validations. The General Authority of Civil Aviation, ANS, should undertake a Hazard Identification and AIB-2015-0100-SR-03 GACA-ANS Open Risk Assessment of the use of Bi-Directional Airways.

33

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status The General Authority of Civil Aviation, ANS, should undertake a program of Random Audio/Radar Playback Review no less than yearly to assess controller Skill, Adherence to Approved Phraseology, Use of Approved AIB-2015-0100-SR-04 GACA-ANS Open Procedures, and Operational Proficiency. This review would include (at minimum) a controller/assessor debrief as well as a corrective action plan for any noted deficiencies. GACA ANS to provide the AIB with corrective actions (Planned, Initiated or Completed) to address Other Factor (OF1: The Jeddah East Controller was occupying an operational Over Due 14- AIB-2015-0152-SR-01 GACA-ANS position and providing Air Traffic Control Jun-2016 Services with an expired License). Details of actions to include Completion dates or Planned/Estimated Completion dates. Ethiopian Airlines to provide AIB with corrective actions (Planned, Initiated or Completed) to address Contributing Factor Ethiopian Over Due 13- AIB-2015-0152-SR-02 (CF1: The Flight Crew of ETH3403 “forgot” to Airlines Jun-2016 adjust the altimeter to Standard Pressure). Details of actions to include Completion dates or Planned/Estimated Completion dates GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing factors (CF1 to CF6) and other factors (OF1). Over Due 14- AIB-2015-0171-SR-01 GACA ANS Details of actions to include Completion dates Jun-2016 or planned and estimated completion dates. Should no action be planned, rationale to be provided. GACA ANS should provide the AIB with corrective actions (planned, initiated or Over Due 14- AIB-2015-0202-SR-01 completed) to address identified Contributing GACA ANS Jun-2016 Factors (CF1, CF2, CF3) and Other Factors (OF1, OF2, OF3). GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing factors (CF1-CF6) and other factors (OF1-OF4). Over Due 22- AIB-2015-0258-SR-01 GACA ANS Details of actions to include Completion dates Jun-2016 or planned and estimated completion dates. Should no action be planned, rationale to be provided. GACA-ANS should provide the AIB with corrective actions (planned, initiated or completed) to address identified contributing Over Due 22- AIB-2015-0297-SR-01 factors (CF1, CF2 and CF3) and other factors GACA ANS Jun-2016 (OF1, OF2 and OF3). Details of actions to include Completion dates or planned and estimated completion dates.

34

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status Saudi Arabian Airlines must emphasize on the “Stress Management” techniques for Saudi Arabian AIB-2015-0304-SR-01 Open crewmembers trainings, publications and Airlines related events. Saudi Arabian Airlines must ensure proper implementation of “Fatigue Risk Management” Saudi Arabian AIB-2015-0304-SR-02 Open as applies to its mode of operations and the Airlines variations of crew assignments. Saudi Arabian Airlines Crew Management and Corporate Safety need to promote the awareness on the “Change” and “Change Saudi Arabian AIB-2015-0304-SR-03 Open Management” concepts, being an element of Airlines Safety Management System that needs to cascade down to line operations level. GACA ANS should provide the AIB with corrective actions (planned, initiated or AIB-2015-0328-SR-01 completed) to address identified Contributing GACA ANS Open Factors (CF1, CF2, CF3, CF4, CF5) and Other Factors (OF1, OF2). RSAF should provide the AIB with corrective actions (planned, initiated or completed) to address contributing factors (CF 1) and Other Saudi Ground Over Due 01- AIB-2016-0001-SR-01 Factors (OF 1). Details of actions to include Services Oct-2016 completion dates or planned and estimated completion dates. Should no action be planned, rationale to be provided. Saudi Ground Services Company (SGS) shall ensure operational staff situational awareness Over Due 06- AIB-2016-0023-SR-01 and compliance with established equipment RSAF Jun-2016 handling procedures in order to reduce the risk of such avoidable occurrence. Military Control Agencies should establish Military AIB-2016-0036-SR-01 connectivity ability (hotlines) with civilian ATC Control Implemented at the operational level. Agencies A Military/Civilian workshop should be conducted to formalize shared use airspace procedures including:  Co-ordination. AIB-2016-0036-SR-02  Separation. All Implemented  Terminology.  Reduced Separation Criteria.  Civilian Response to Military activity.  Levels of activity (training, operational). RSAF to ensure understanding and compliance AIB-2016-0036-SR-03 RSAF Implemented with aircrew and control agency personnel. When practicable, Air Traffic Control should provide advisory of observed flight activity Over Due 23- AIB-2016-0057-SR-01 within the OERY control zone for arriving ATC Jul-2016 aircraft that are west of the final approach for runway 33 left/right at OERK. GACA-ANS should provide the AIB with Over Due 15- AIB-2016-0067-SR-01 corrective actions (Planned, initiated or GACA-ANS Jun-2016 completed) to address identified Contributing

35

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status Factors (CF-1 to CF-5) and Other Factors (OF1 to OF4). The Ground Controller should, for aircraft that have been approved for any intersection Ground Over Due 15- AIB-2016-0067-SR-02 departure, instruct the aircraft to contact the Controller Jun-2016 Local Controller and to advise its position when ready to depart.  All controllers should be given formal briefings on the use of the REST checklists.  Checklist should be placed in each operational position. Ground Over Due 15- AIB-2016-0067-SR-03  Compliance with ATSP-2, 1102.3 is to be Controller Jun-2016 ensured by supervisors and random checks to be completed by the ANS manager and GACA-ANS Safety Department. GACA-ANS should ensure that supervisors are aware of their roles and responsibilities as it pertains to compliance with existing rules and Over Due 15- AIB-2016-0067-SR-04 regulations and over-all decorum within the GACA-ANS Jun-2016 workplace. GACA-ANS should adopt a method of randomly assessing supervisory effectiveness and address any found deficiency accordingly. A method of enhancing controller situational awareness should be determined to highlight Over Due 15- AIB-2016-0067-SR-05 GACA-ANS significant areas on the Electronic Flight data Jun-2016 strip (improve visual clues). GACA-ANS should provide training to all tower controllers to confirm their understanding of Over Due 15- AIB-2016-0067-SR-06 the application of turbulence separation and a GACA-ANS Jun-2016 countdown timer installed in the Local Position to ensure timing compliance. GACA-ANS should immediately take action to address the external distractors. This includes (not limited to):  Dedicated, approved and secure parking for operational tower staff at Gate 10; Over Due 15- AIB-2016-0067-SR-07 GACA-ANS  Improvements into the airside vehicle usage; Jun-2016 and  Shift Scheduling to ensure appropriate resource overlap to address briefing requirements. Saudi Arabian Airlines to review the SOP in General Operations Manual paragraph (8.34.1) Saudi Arabian AIB-2016-0079-SR-01 and consider adjustments to this policy to Implemented Airlines permit the First Officer to taxi the aircraft when a situation necessitates. Saudi Arabian Airlines to review the “Flight Crewmember Incapacitation” procedures in Cabin Crew Operations Manual and establish a Saudi Arabian AIB-2016-0079-SR-02 Implemented clear procedure of evacuating an incapacitated Airlines crewmember from the flight deck on all types of aircraft. AIB-2016-0079-SR-03 Saudi Arabian Airlines to review the “First Aid” Saudi Arabian Implemented

36

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status procedures in Cabin Crew Operations Manual Airlines and include a precaution against metal conductivity when using the automated external defibrillator (AED) in locations of aircraft cabin where metal structures exist on the floor or at the wall dividers or galley. Such a precaution should also include instructions to utilize non-conductive materials to isolate the victim from those metals. Saudi Arabian Airlines to emphasize the importance of “Wide Perspective” concept of Saudi Arabian AIB-2016-0079-SR-04 managing cabin safety when handling one Implemented Airlines emergency situation and being vigilant to other safety hazards. Saudi Arabian Airlines to assess the body of knowledge and competence of its Station Saudi Arabian Over Due 18- AIB-2016-0079-SR-05 Managers and ensure that a development Airlines Dec-2016 program is in place for such competencies. GACA-SSAT to ensure that the material and duration of the ATC ab-initio course fulfill the Over Due 18- AIB-2016-0079-SR-06 requirement as set forth in ICAO Annex 1 — GACA - SSAT Dec-2016 Personnel Licensing and the guidelines of ICAO Doc.9835 and ICAO circular 323. GACA/ANS/S&Q to ensure the efficiency of the GACA Over Due 18- AIB-2016-0079-SR-07 annual competency check program for Air ANS Dec-2016 Traffic Controllers. S&Q Saudi Academy of Civil Aviation (SACA) to fulfill the requirement for the ATC abinitio Course as set forth in ICAO Annex 1 — Personnel Over Due 18- AIB-2016-0079-SR-08 SACA Licensing and the guidelines of ICAO Doc.9835 Dec-2016 and ICAO circular 323 in terms of material and duration. GACA / AIRPORTS to review its Training Policies and Programs for “Airfield Operations Centers” GACA Over Due 18- AIB-2016-0079-SR-09 and establish a systemic training and AIRPORTS Dec-2016 competency levels for AOC officers. GACA/AIRPORTS to review its policy regarding the “Airfield Operations Centers” and its GACA Over Due 18- AIB-2016-0079-SR-10 Officers and emphasize the importance of AIRPORTS Dec-2016 keeping proper and valid logs of the AOC activities. The Saudi Private Aviation (SPA) must emphasize compliance with special ramp Saudi Private AIB-2016-0184-SR-01 handling requirement pertaining to Implemented Aviation apron/stand within its Ground Handling Agreement with contracted operators. The Saudi Private Aviation (SPA) must ensure aircraft operators' compliance to Ramp Saudi Private Over Due 15- AIB-2016-0184-SR-02 Handling requirement and report Aviation Jun-2016 incompliances to the Authority. KAIA to develop and implement a detailed AIB-2016-0563-SR-01 Runway / Taxiway closure procedures and KAIA Open compliance checklist with proper approvals

37

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status that is acceptable to GACA-SSAT. KAIA to review and enhance the current NOTAM request procedures to ensure that AIB-2016-0563-SR-02 KAIA Open NOTAMs are properly reviewed and validated prior to issuance. KAIA to ensure the currency of its NOTAM AIB-2016-0563-SR-03 KAIA Open originators list. KAIA to activate the function of the runway safety committee and utilize that expertise in AIB-2016-0563-SR-04 KAIA Open hazard identification and risk assessment and safety assurance for the runway systems. KAIA to submit its SMS Implementation Plan for Over Due 15- AIB-2016-0563-SR-05 KAIA GACA-SSAT review within 30 days. Jan-2017 KAIA management team to attend Safety AIB-2016-0563-SR-06 Management System training, initial and KAIA Open refresher. KAIA accountable executive to ensure that the designated SMS Manager exercises his role AIB-2016-0563-SR-07 especially in facilitating hazard identification KAIA Open and safety risk analysis while monitoring the effectiveness of safety risk controls. NasJet should provide a set of approved food Response AIB-2016-0058-SAR-01 containers and foil wrap that is suitable for the NasJet awaited type of ovens on-board of aircraft. NasJet should advise Cabin Crew to only use Response AIB-2016-0058-SAR-02 the company's provided food containers and NasJet awaited foil wrap in aircraft’s oven. NasJet should introduce procedures for the use of food containers and foil wrap in the training syllabus for the cabin crew training. The Response AIB-2016-0058-SAR-03 NasJet procedures should be included in both, in-flight awaited service training and flight safety training along with its annual recurrent training. NasJet should include procedures for the use of Response AIB-2016-0058-SAR-04 food containers and foil wrap in its related NasJet awaited operations manuals. General Authority of Civil Aviation (GACA), Kingdom of Saudi Arabia, must immediately undertake action to provide (short term) authorization (documented and traceable) to all operational Air Traffic Controllers to operate Over Due 15- AIB-2016-0067-SAR-01 GACA in contravention to ATSP-1, Section 203.1, And Jun-2016 GACA Regulations, Personnel Licensing, Chapter 2, Sections 2.1.1.1 , 2.1.2.1 , 2.1.3.2 , 2.1.4.1. (a, b, & j ) , 2.1.4.2.1 , and that GACA assumes the responsibility for this action. GACA must immediately undertake a detailed review of all required certificates as held by Air Traffic Controllers. This includes (not limited Over Due 15- AIB-2016-0067-SAR-02 GACA to): Jun-2016  Airman’s Certificate issued for the authority to provide Air Traffic Control Services.

38

Issued Safety Recommendations Rec. No. Recommendation Assigned to Status  Medical Certificate  English Language Proficiency (ELP) This review will identify all deficiencies and provide direction, corrective actions and further actions to address all licensing issues and to ensure compliance with all applicable regulations. GACA/ANS shall immediately take appropriate action to ensure that, when an emergency is declared by an aircraft, the Air Traffic Controller shall ascertain the type of AIB-2016-0079-SAR-01 emergency and the intentions of the flight crew GACA/ANS Implemented by writing/taking notes of the emergency message and crew intentions, confirm it (read back), and then shall relay the message exactly as received. GACA/ANS to include the contents of AlB-2016-0079-SAR-02 recommendation AIB-2016-0079-SAR-01 in its GACA/ANS Implemented operating procedures and training manuals

39

40

Activities: 2016 was the first full year of operation of FRL at AIB facilities, this allowed investment of more time from assigned investigators to brush up skills and explore additional capability features with available hardware and software.

On the investigation side: downloaded and analyzed data for twenty-two (22) recorders. The product of these analyzed factual data are plots, excel sheet text data tables, audible sessions conducted in CVR LAB; all populated in FRL reports and to be used in completing the relevant investigations.

Foreign Recorders KSA Registered Occurrences Occurrences Quarter Registered Downloaded and Aircraft in KSA Abroad Aircraft Analysed 1st 0 2 2 0 4 2nd 3 1 4 0 8 3rd 2 1 1 2 2 4th 2 2 3 1 8

Downloaded Recorder Flight Recorder Date Occurrence Laboratory (FRL) FDR CVR Report Air Atlanta, TF-AMU, and Returned from 24/03/2016 flight to Jeddah due to Engine NO.2 Stall Yes Yes FRL-2016-03-001 during climb mode. Tunis Air TS-IFN, Returned from flight to 29/03/2016 Madinah due to Engine NO.1 Stall during Yes Yes FRL-2016-03-002 climb mode. Air Arabia, A6-AOJ, Flight diverted to 17/04/2016 Riyadh due to smoke detection warnings Yes Yes FRL-2016-04-003 in the aft cargo bay activated. FLYNAS, VP-CXJ, returned from flight to 20/04/2016 Jeddah due to engine cowls were fully Yes Yes FRL-2016-04-004 opened during climb mode. SAUDIA, HZ-ASV, Crew incapacitation, in 29/05/2016 Yes Yes FRL-2016-05-005 Riyadh. SAUDIA, HZ-AS34, Hard Landing in 13/06/2016 Yes Yes FRL-2016-06-01 Jeddah Private, HZ-N777AS, Wing tip touched 19/07/2016 Yes Yes NO Report the ground. In Le Bourget, Paris, France Emirates, EK-521, Crashed while landing, Copy of data 04/09/2016 from UAE NO FRL-2016-09-01 in Dubai authority, GCAA Copy of data 18/09/2016 SAUDIA HZ-AS38, Hard Landing in Taif from Operator NO FRL-2016-09-02 Egypt Air, SU-GBD, flight diverted to 11/10/2016 MED due to Hydraulic system Yes Yes FRL-2016-10-01 overheated. Korean air, HL-8211, Returned flight to 17/10/2016 Riyadh due to engine NO. 1, Stall during Yes Yes FRL-2016-10-02 climb mode.

41

Downloaded Recorder Flight Recorder Date Occurrence Laboratory (FRL) FDR CVR Report SAUDIA HZ-ASJ, Takeoff aborted due to engine NO.1 Master warning both visual 03/11/2016 Yes Yes FRL-2016-11-01 and audible activated. In Alexandria, Egypt. 07/11/2016 FLYNAS, VP-CXO, TCAS RA, in Jeddah Yes Yes NO Report

10 10 8 8 8 6 6 4 4

2 2 0 0 0

2015 2016

Flight Recorders Activities (2015 vs 2016)

Flight Recorder Laboratory (FRL) facilities’ work flow arrangements: The Flight Recorder Laboratory (FRL) facility arranged for the following stages: Stage One: Receiving. Stage Two: Level two and three data recovery. Stage Three: Data download. Stage Four: CVR listing and transcribing.

Stage One: Receiving: The receiving stage is the introductory phase of the flight recorders in AIB premises. Flight Recorders will be inducted at this stage in the same status as received from the operator/site, i.e. damaged or undamaged, and comply with the following receiving inspection check list: A) Photographing the Flight Recorders as received status. B) Cleaning Flight Recorders as needed, if the Flight Recorders are damaged all necessary tasks will be accomplished in this room i.e. crashed, or underwater recovery procedures. C) Repairing the Flight Recorders as required. D) Once the recorders handling cycle in all stages is completed, the recorders will be returned back to receiving stage to preserve and prepare for shipping back to operator.

42

The four stages of receiving inspection

Stage Two: Level two and three data recovery: The main function at this stage is to obtain data from damaged Flight Recorders by applying Memory Retrieval Processes; A) Level Two recoveries are equipped to serve Flight Recorders with minor damaged Crash Survivable Memory unit outer case that cannot be used, therefore the capability is to remove the damaged memory module and fit it on a dummy Flight Recorder/Bench Unit, and then proceed with regular downloading process.

Level two recovery

B) Level three recoveries are equipped to serve Flight Recorders with major damage and requires repairing to the Chassis of the recorder and/or downloading data directly from Printed Circuit Board.

43

Level three recovery

Stage Three: Data Download: The main function of the FRL is performed at this stage i.e. download of flight recorders via downloaders, and configure the retrieved data into readable files for INSIGHT / FAS system.

Data download

Stage Four: Cockpit Voice Recorder (CVR) Listening and transcribing: The analog mixer with digital control console provides clear CVR replay with filtration and channeling functions and visual plotting for traceability of channels; the listening can be done through headsets, or wall-mounted speakers.

44

CVR Listening and transcribing

Equipment Maintenance: Equipment Inventory: In 2016, completed a review for all preventive maintenance (PM) requirement for available equipment, and software update. Developed a database to alert for due PM / software update, and a log for PM performed and/or software update completion.

Part No Name of Equipment Manufacturer Serial Number Location Number 1 AC Power Supply MAGNUS LF1-400 2212 Download room 2 DC Power Supply MAGNUS LDC-28 2118 Download room Computer Workstation 3 DELL XPS 730 2HC7LH1 Download room (WS1) Computer Workstation 4 DELL XPS 730 5HC7LH1 Audio room (WS2) Computer Workstation 5 DELL XPS 730 4HC7LH1 Download room (WS3) 6 LAPTOP (L1) DELL M1730 A042-74F8 Download room 7 LAPTOP (L2) DELL M1730 9202-AC70 Audio room 8 Ture RMS DMM GREENLEE DM-820 083270436 Receiving room 9 Oscilloscope AGILENT DS05014A MY48260312 Equipment rack 10 Function Generator AGILENT 33220A MY44039201 Equipment rack 799A- 11 Electronic Caliper STARRETT 08/300121-1 Receiving room 06/150 12 Data Retrieval Unit UNIVERSAL CORP 1601-75 101 Download room 13 CVR/FDR Test Set UNIVERSAL AVIONICS 1623-01 228 Download room Ruggedized Service Download room 14 AVIONICA INC 650-0300 15481 Unit (Rsuii) (Photo) Recorders Portable 952-0035- RPGSE 1- Download room 15 Ground Support HONEYWELL 002 00399 (Photo) Equipment (RPGSE)

45

Downloaders

Measuring Equipment Calibration Requirement: Defined calibration requirement and interval for available measuring testing equipment and precision measuring tools.

Equipment No Part No Serial No Manufacturer (OEM) Location at FRL Lab Nomenclature 1 True RMS DMM DM-820 083270436 GREENLEE Receiving room 2 Oscilloscope DS05014A MY48260312 Agilent Technologies Tape rack- mount 3 Function Generator 33220A MY44039201 Agilent Technologies Tape rack- mount 4 Electronic Caliper 799A-6/150 08/300121-1 STARRETT Receiving room

Measuring equipment

Capability Development: Frame Format Description Files (FFD): FFD is the data format used by INSIGHT application. Aircraft Parameter Database files; describes how to “Demultiplex” flight parameters from ARINC Frame Data and convert them into engineering units. The Capability since initial start in 2010 until 2015 was limited to 18 files in FFD file library, in 2016 the capability has expanded by 100% and increased the number in FFD file library to 36 files.

46

36 40

35

30

25 18 2010 - 2015

20 2016

15

10

5

0 2010 - 2015 2016

Frame Format Description Files

Layout File (LF): AIB acquired a new system (FAS) Flight Analysis System to analyze, plot, and animate Flight Recorders data. The new system requires files conversion from original format to Layout File (LF). The LF is a file format that integrates the downloaded data into the new sophisticated real time data which is used with FAS. AIB started configuring these data files for the new system in the last quarter of 2016, and successfully completed 3 files. In 2017, our target is to convert 12 FFD files to LF configuration.

Layout Files configured in 2016 for some aircraft

Aircraft Type Bits

A320 256

A320 1024

A330 256

Flight Analysis System (FAS): FAS is a new system acquired in 2016, developed by Canadian Plane Sciences Inc., and fitted in Data Download room, it is a new integrated technology for accidents / incidents analysis and simulation. FAS is the next generation accident investigation system, it is a new aircraft generic display optimized for analysis plus traditional cockpit replica displays.

47

Flight Analysis System (FAS)

FAS software has many features built in to allow investigators to interactively work with the source data downloaded. A special ‘investigation’ display has been developed to enable investigators to quickly look at flight data in a common way across many aircraft types. The software can also model replicas of the cockpit instrumentation when needed but the generic investigative display is rapidly gaining acceptance as a ‘first look’ to undertand what is happening and next steps.

FAS Software

Memory Access Retrieval system (M.A.R.S): Under contract from the AIB, Plane Sciences has completed the first prototype of MARS (Memory Access Retrieval System) which enables the AIB to connect the memory board from the accident recorder directly and read the memory chips one by one. MARS was designed with an extendable methodology to allow additional recorder types to be added with an appropriate adapter cable to connect to the one standard MARS connection point. Since data is critical to accident investigators every precaution must be taken to ensure he memory cannot be damaged. To that end, AIB first uses a specially built tester to test the MARS reader as well as use special procedures to test that there are no shorts in the connector cable.

48

Solid State Memory Board from a past AIB accident connected directly to MARS

MARS reader connected to MARS Tester which has built in precautions to minimize any risk to the readout process.

Characteristics of MARS:  Eliminates need for inventory of “Golden Chassis” Bench Units.  One integrated system handles ALL ARINC recorders types.  Memory structure / format source documentation provided (for potential chip level retrieval).  Bit editing for recovering sync losses/missing data.  Circumvents CVR erase logic.  Improves playback probability without reliance on recorder OEM.

49

Current industry practice to handle crash-damaged recorders.

MARS is now ready as a product handling (2) out of (7) Honeywell solid state recorder types with plans to complete testing of all seven in the first half of 2017. Product development plans include all other types of recorders within the next 24 months. The product will read the memory board directly without the recorder OEM Bench Unit.

50

51

52

Safety Study: Ground Accidents or Incidents represent a significant concern for the Aviation industry. Statistics indicate that various countries of the world suffer exhaustion of their resources in Ground Accidents or Incidents. Data developed by the International Air Transport Association (IATA) and the Flight Safety Foundation (FSF) estimates that 27,000 ramp Accidents and Incidents occur worldwide every year (one per 1,000 departures), resulting in about 243,000 injuries (9 injuries per 1,000 departures). The annual cost to major airlines worldwide is estimated at least US$10 billion. Aviation Investigation Bureau (AIB) receives all notifications related to Aviation Occurrences (as defined in the ICAO Annex 13) in which Ground Accidents or Incidents is one of them.

Safety Study Description Status

RAMP Ground Incidents Reporting On-Going

Scope of Work: Aviation Investigation Bureau (AIB) receives notifications of Aviation Occurrences (as defined in the ICAO Annex 13) in the Kingdom of Saudi Arabia or whenever a Saudi registered or operated aircraft is involved. Amongst these occurrences there are incidents that occur during ground handling of aircraft at KSA airports which will be referred to as RAMP incidents. Comparison between 2014 and 2015 showed a noticeable increase in the number of RAMP Incidents at KSA Airports. The increase in number is partly attributed to enhancement of reporting. The increasing rate of RAMP incidents required a special focus on the circumstances and factors that contributed to RAMP incidents and to take the necessary action towards prevention. This initiative endeavored to shed light on the impact of RAMP incidents to get the required attention from the involved parties so that proper mitigation and prevention measures are sought and pursued. The initiative involved and engaged all of the relevant parties in a working group.

1) Data Collection: The AIB in coordination with Air Operators, Saudia Ground Services (SGS) and GACA –SSAT collected RAMP incidents data for 2014 and 2015. The data was then crossed referenced with the available data in AIB and following is the result:

Year: 2014 2015

Number of Ground incidents: 24 56

2) Data Analysis: The AIB analyzed the RAMP incident data and identified the following contributing factors: a. Lack of supervision by the Ground Services provider during ground operations; b. Poor serviceability condition of Ground Support Equipment. c. Not adhering to Standard Operating Procedures (SOP). d. Labors Fatigue due to lengthy working hours, Unavailability of proper rest areas, multi task assignments… etc.).

53

3) Team Formation: The AIB established the Terms of Reference (ToR) for the working group for this initiative (appendix 1) addressing the project objectives, scope of work, time line and deliverables. The working group consisted of members representing the following organizations: a. Safety Security and Air Transport (SSAT- GACA); b. Safety and Quality Division (Saudi Arabian Airlines); c. Safety Department (Flynas); d. Safety, Security and Quality (SGS ); and e. Aviation Investigation Bureau (AIB).

4) Result of Working Group: The working group held four meetings to discuss RAMP incidents and prevention measures (minutes of meetings are in appendix 2). As a result the working group agreed on the following: a. Saudia and Flynas to adopt Flight Safety Foundation (FSF) method for calculating direct cost of Ground Handling (RAMP) incidents. The calculation method depends on obtaining the rate of Incidents and / or Personal injuries per 1000 flight departures; it also considers the total number of flights, number of RAMP incidents and types of Airplanes during a specific period. b. Standardizing and improving RAMP incidents reporting and collection of detailed data. AIB developed a standardized reporting form. c. Continue coordination, review reports and effectiveness of safety recommendations related to RAMP incidents amongst the stakeholders of the working group periodically. d. Operators (Saudia and Flynas) to evaluate/monitor the ground handling activities around their Airplanes through assigned safety officer and immediately report any discrepancies or violations to SGS duty manager for necessary action. e. SGS removed 200 defective baggage trolleys outside KAIA Airport that contributed to RAMP incidents.

5) Standards' Assessment: Stakeholders were requested to assess current standards and regulations and following is the result: a. No comments were received from Stakeholders with an exception of Saudia Ground Services. b. SGS Ground Operation Manual (GOM) chapter 6.2 stipulates the c. Responsibility of the Ramp Supervisor to ensure safe, secure and on. d. Time flight turn around. This responsibility is not applied due to lack of qualified staff.

6) Recommendations: 6.1) Security and Air Transport (SSAT-GACA): a. SSAT to promote awareness of GACA Regulations 151 and 68 amongst KSA airport operators and ground handling service providers. b. Boost the audit program on ground handling service providers to ensure implementation of applicable regulations. c. SSAT to lead a quarterly meeting involving stakeholders of the working group and including representation of Airport operators to discuss AIB RAMP incidents report and required prevention measures.

54

6.2) Saudia Ground Services (SGS): a. SGS to effectively carry out daily inspection for motorized and non- motorized Ground Support Equipment (GSE). b. SGS to assure that GSE operators are properly trained and certified in accordance with GOM. c. SGS to assure that GSE are safe, serviceable and properly utilized. d. SGS to establish a mechanism - acceptable to SSAT - to prevent GSE operators from operating unserviceable and unsafe equipment. e. SGS to effectively implement the Ramp Supervisor (Turnaround Coordinator) function as required by SGS GOM chapter 6. f. SGS to submit a phase out plan to SSAT for GSE that are not in compliance with GACA Regulation 151.83 paragraph (e): “Unless authorized by the President in the certificate holder's operations specifications, ground support equipment must not be more than fifteen years old” g. SGS to ensure GSE maintenance service provider comply with Service Level Agreement (SLA).

6.3) Aviation Investigation Bureau (AIB): a. AIB to create data platform for collecting and capturing related RAMP incidents. b. AIB to provide Stakeholders with RAMP Incidents analysis reports for discussions in the quarterly working group meeting. The reports shall contain incidents categorized by Airports, contributing factors and assessment of safety recommendation effectiveness. c. AIB to establish standard notification mechanism for the stakeholders to report RAMP incidents. d. AIB to establish standard data collection mechanism for stakeholders to report RAMP incidents findings, contributing factors and preventive measures.

6.4) GACA Airports: a. To establish Standard Operating Procedures (SOP) for handling the certification of Ground Support Equipment in accordance with GACA regulations. b. Introduce the concept of third party inspections at KSA airports to ensure continuous operational safety of ground service equipment.

6.5) Operators (Saudia and Flynas): Operators to utilize the Flight Safety Foundation cost calculation method to produce quarterly RAMP incidents financial impact report to stakeholders.

55

Safety Concern and Issues: The AIB will be monitoring certain occurrences categories which are mostly quantitative but more initiatives are planned to mitigate the current escalating trends. The three most notable areas of concern are shown below.

70 62 60 61

50 42 46 40

30 27 20

10 4 0

BIRD CABIN RAMP

BIRD CABIN RAMP 2015 42 4 46 2016 62 27 61

Top three categories of safety concern

During 2016, there was a noticeable increase in incidents involving ground handling services. This includes catering trucks, airplane tugs and baggage vehicles colliding with serviced aircraft. In some cases, it resulted in serious injuries and/or significant damage to aircraft.

25 25 21 20 20 16 15 10 10 5 6 0 0 1 KAIA KKIA KFIA PMIA

KAIA KKIA KFIA PMIA 2015 21 16 6 0 2016 25 20 10 1

Ramp occurrences in the four major airports in the Kingdom

56

The main causes were: 1. Equipment operators were not following proper operating procedures due to lack of knowledge or cutting corners. 2. Equipment failure due to poor maintenance. 3. Lack of supervision

Bird Strike:

During the year 2015 forty-two (42), and sixty-two (62) in 2016 occurrences in kingdom of bird strike to the aircrafts has been reported. The damage to the aircraft was reportedly minor and all the occurrences were consequently not serious in nature. Most bird strikes occurred during the months of September, October and November which coincides with the seasonal bird’s migration period.

57

16 16 14 12 10 10 9 10 8 7 6 7 4 4 2 3 3 4 5 6 5 2 1 0 1 2 2 4 0 0 1 Jan Feb 1 1 Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015 2 0 3 4 1 2 0 1 16 7 5 1 2016 1 3 9 10 7 4 2 5 10 6 4 1

Bird strike comparison (all)

30 17 26 20 11 21 10 7 7 10 4 0 3 2 KAIA KKIA KFIA PMIA Other Airports

KAIA KKIA KFIA PMIA Other Airports 2015 11 7 4 3 21 2016 17 7 10 2 26

2015 2016

Bird strike comparison (between major and other airports in the Kingdom)

The Bird Strike Safety Study will be ongoing utilizing research and outreach programs with airports having the greatest number of bird strikes as the AIB wishes to stay ahead of the issue.

58

Air Proximity:

The AIB had issued numerous safety recommendations on this subject matter. In addition, two days’ workshop was organized on 11th and 12th May 2015 involving all the relevant stakeholders, Air Traffic Control Units, aircraft operators, GACA-ANS and GACA-SSAT. The purpose of the workshop was to address and highlight the noticeable rise in the number of TCAS RA incidents in KSA airspace and to discuss and promote safety and efficiency enhancement to the current KSA airspace structure, participants were given opportunity to share and present their experiences, challenges or issues related to Saudi Airspace. The outcome of the workshop was a list of recommendations addressing organizational, procedural, technical and work environment issues, aiming to achieve the safety and efficiency enhancement in the KSA airspace.

16 15

14 12 12 12

10

8 2015 6 6 2016 6 5

4 3 2 2 2 2 1 1 1 1 1 1 0 0 0 North East North West Central RUH JED CTA South South East CTA East

TCAS RAs occurrences based on aviation sectors

59

60

Introduction: Need some text here

1) Human Resources: 1.1) Recruitment: 6 candidates were hired 4 of which are of technical expertise, 1 in Administration, and 1 in operations.

1.2) Employee Retention: Employee retention is at 97%.

1.3) Saudization: Saudization is at 95% in the whole organization and 100% at all positions in the Organization Structure.

1.4) Policies and Procedures: Overall 75% of AIB Financial and Admin. Affairs policies and procedures has been completed as follows:  HR and Administration Policies and Procedures has been completed.  IT Policies and procedures has been completed.  Remaining policies and procedures are under process.

1.5) Training and Development: 2 year plan has been established to train Admin staff to be able to support the technical teams.

1.6) Employee-Engagement Program: To encourage job rotations and diversity, most employee are carrying out multiple functions in Administration and operations that are related to incident/accident sites.

1.7) Leave Planning: A built structured plan for the whole year regarding all types of leave, in order to know the whereabouts and availability of staff in case of an incident or accident.

1.8) Employee Database: All relevant information regarding training, employee information, overtime balance are registered and saved in the AIB SharePoint.

1.9) Job Descriptions: 100% of all positions’ Job Descriptions has been completed.

1.10) Attendance: Daily attendance reports and quarterly statistical analysis for each employee has been established to measure availability.

1.11) Forms: Forms that accommodate AIB functions and needs has been completely established.

61

62

3) Information Technology: 3.1) AIB Website: An agreement has been established with GACA IT to create and interactive modern website that suites the AIB’s functions and role in Aviation Investigation. it will allow occurrences reporting from anonymous individuals and known organization which will be via the website to the designated AIB officials. The launch will be 2nd quarter of 2017.

3.2 FTP (File Transference Protocol): An agreement has been established with GACA IT to create it in order to exchange large files such as videos, high resolution 3D photographs, and files. The launch will be 2nd quarter of 2017.

3.3) Twitter: AIB Twitter official account has been established to update current events and aviation related safety and investigation occurrences. 2000+ followers so far in less than a year. People in safety and investigation background are interacting with the account asking questions in the field.

3.4) SharePoint System: It was created for the following reasons:  To have a Powerful, reliable server platform designed to perform a great of applications and services while suffering minimal downtime.  To have Powerful, fast search engine – search for docs and via metadata.  To Facilitate Collaboration.  Flexible web server – serves up documents for different types of end user devices  Scalable infrastructure – build and add apps and services  Improve Workflows.

3.5) AOMS (Aviation Occurrences Management System): Exclusive in-house system is being created with the assistance of GACA IT in order to document occurrences and be able to extract information based on specific criteria. All departments can use the system to get the required information such as dates, airline, people etc.

3.6) Network Wireless Access Point: An access point was created in all AIB facilitates in order for employees and visitors to utilize the web using laptops and mobile phones to efficiently finalize tasks and facilitate communications.

3.7) Data Tracking System (DTS): The system was created to document internal memos and all documents to create a referencing mechanism for all AIB Ducments.

4.0) Public and Government Relations: 4.1) Workshops, Conferences and Events: The AIB is extremely vigilant in regard to media and social events to spread awareness and increase the safety standards of aviation. Henceforth, workshops and conferences are routinely conducted by the AIB inviting various key individuals and instructors to spread

63

awareness and to educate key figures in the aviation field. Key figures from all over the world from airlines, airport, and organizations are participating. The AIB vision has been successfully shared across the world. Some of the key workshops are as follows:  National Aviation Accident Communication Strategy.  Quality Integrated Management System Training.  Family Assistant Plan.  Investigation Management Course.  Aviation Accident Report Writing.

4.2) International Collaboration: Collaborating with government officials in the aviation fields and assisting when required in regard to blackbox data, analysis, etc.

4.3) Global Ministerial Aviation Summit: AIB was one of the partners and participated in spreading awareness by having booth.

4.4) Employee Discount Program: A program has been created to ensure the well-being of employees; discounts are available in regard to car accessories, gym memberships, hotel reservations, restaurant, etc.

64

65

66

Introduction: One of the AIBs objectives is to raise the productivity of its employees to the highest levels possible, by implementing proper performance management standards, providing continuous training for professional development, and sharing knowledge, therefore, the AIB developed a targeted policies to identify and empower its employee, and furnished a stimulating environment that provides equal opportunities and rewards for excellence.

In 2016 AIB has sent investigation specialists out of kingdom and in kingdom to receive a training at best training institutes in aviation investigation like Cranfield University, and the southern California safety institute (SCSI), furthermore, in Sep 2016 the AIB has conducted the Aviation Accident Report Writing course in coordination with International Society of Air Safety Investigations in Jeddah.

Drill is an exercise performed to rehearse functions and practices used in investigations, and made to provide training, test readiness and response, reduce cofnusion and conflects between particepants roles, and test the adequacy and functionality of equipment used, staff skills, and knowledge.

Cooperation and Collaboration Enhancement in Accident Investigations: Although, ICAO annex 13 of the Chicago Convention sets the standards and recommended practices for the conduct of Aviation Accident/Incident Investigations which also covers the relationships and interfaces between the involved states, mutual agreements and understandings between the concerned, facilitates the highest level of cooperation and collaboration. The AIB identified the following investigation authorities to sign a Memorandum of understanding with in 2016:

MOU with the Interstate Aviation Committee of the Russian Federation: On 17 March 2016, the AIB signed an MOU with the Interstate Aviation Committee of the Russian Federation. The significance of the MOU for AIB is to ensure the support when investigation Russian manufactured aircraft.

67

The MoU focus was on flight recorders capability in general and the Russian made recorders handling in particular, MoU included future plans for training for AIB specialists to recover memory module from recorders to transfer to Moscow according to the agreed protocol.

AIB Delegation visit to HE Abdulrahman Ibrahim Al Rassi, Ambassador Extraordinary and Plenipotentiary of the Kingdom of Saudi Arabia to the Russian Federation

MOU with the Air Accident Investigation Bureau (AAIB) of Singapore: On 19 April 2016, the AIB signed an MOU with the Air Accident Investigation Bureau (AAIB) of Singapore. The significance of the MOU for AIB is to gain the experience of AAIB in underwater recovery of flight recorders.

68

MOU with the Investigation Bureau of the Moroccan General Directorate of Civil Aviation: On 21 September 2016, the AIB signed an MOU with the Investigation Bureau of the Moroccan General Directorate of Civil Aviation. The significance of the MOU is to enhance the regional cooperation in accident investigation.

MOU with the Office of Aviation Safety of the Civil Aviation Administration of the Republic of China: On 26 October 2016, the AIB signed an MOU with the Office of Aviation Safety of the Civil Aviation Administration of the Republic of China. The significance of the MOU is mainly to ensure optimum representation in accident/incident investigations relevant to KSA aircraft flying to China.

Flight Data Analysis Workshop: The AIB of Saudi Arabia sponsored a flight recorder workshop delivered by Canadian based Plane Sciences Inc., the workshop was held in Ottawa, Canada. Fifteen attendees from several investigation authorities attended the four-day session at the invitation of the AIB Director General. The AIB invitation is part of outreach strategy that AIB have adopted to harness cooperation with all investigation authorities around the world, a number of investigation authorities were invited to participate in this workshop, attended by: UAE GCAA, Russia MAK (IAC), French BEA, Swiss STSB, German BFU, and Malaysian AAIB. The four-day session included a detailed training course on all aspects of flight data analysis from the early days through to the latest technologies used today as well as a glimpse into

69

the future. The training was followed by a review of the latest flight data analysis software FAS under development by Applied Informatics & Research (AIRINC) and Plane Sciences Inc., A significant component of the workshop was a detailed review of the progress of the (MARS) MEMORY ACCESS RETREIVAL SYSTEM under development by Plane Sciences for the AIB’s flight recorder laboratory.

Ministry of Interior communication program: Based on the approval of His Royal Highness the Crown Prince, Minister of Interior in his message addressed to the Minister of Transport and Chairman of the GACA in charge, regarding the order from HE, on facilitation procedures for the AIB team, and provide logistical support, including contributing to the access to the site of the accident and to facilitate the duties speed through security channels. HRH message included the approval and support for the recommendations of the Meeting Minutes. The committee studying the role played by the Ministry of Interior sectors to facilitate the procedures for AIB, which supports the work of AIB to enable it to reach the desired goal of its establishment. HRH directed to work on the preparation of (Reference Guidance Manual) containing the tasks and work of the AIB as well as the role of the security and governmental sectors in detail based on the rules and regulations and plans that have already been approved.

Ministry of Defense communication program :

70

Based on the approval of HRH Minister of Defense Minister, in his message addressed to HE the Chairman of the GACA 1/1/11846 on date of 08/05/1437 AH included to provide support and facilitate the tasks of the investigation team aviation investigations office on the Kingdom as well as the international and domestic airports. The AIB visited the Commander of the Royal Saudi Air Force, who explained that in the event of an aviation accident in any location on Saudi territory serve as a state and national response at all levels where efforts of all government and security agencies to contribute in dealing with professionally event reflects honorable in treated everyone in such emergencies.

Aviation Security communication program: Within the communication program with the Ministry of Interior sectors of the, the AIB team visited the aviation security commander, the visit included a visual presentation about AIB including the role and functions and responsibilities of the AIB, also included the meeting to discuss cooperation frameworks and logistical support to be provided to the AIB investigation team, through the transfer of the investigation team to the crash site in the desert and rugged areas in all parts of the Kingdom. The aviation security commander directed to provide all the facilities required for the AIB, and the implementation of some functional testing within the framework of a training flight between the probes and the Office of Aviation Security.

Airports coordinators workshop:

71

In order to continu the coordination with airports in kingdom, the AIB conducted a workshops for the new coordinators, and prepared a program including lectures, presentations regarding AIB and its achievements, moreover, the workshop includes an analytical results review of the occurrences during the years 2013, 2014, 2015, 2016 for all accidents and incidents, including the results and recommendations. The program provids a familiarization of the role of the airport coordinators in the event of an accident or incident.

Workshop Objectives:  Enhance the safety of civil aviation in Saudi Arabia.  AIB communication with KSA airports.  Identify the competent authority at the airport to communicate directly with AIB in cases of occurrences.  Prepare airports coordinators to connect with AIB.  Train airports coordinators about the role and tasks required in the event of aviation accidents and incidents.  Train airports coordinators regarding the notfication forms, initial reports, and the investigation delegation.  Train airports coordinators how to capture photographs of the accident.  Basic investiagtion concept, and investiagtion initail report.

Airports coordinators workshops Date Location Attendees Nov 23, 2016 King Abdulaziz Intl Airport 17 Dec 1, 2016 King Khalid Intl Airport 10 Dec 6, 2016 King Fahad Intl Airport 7 Dec 11, 2016 Prince Muhammed Intl Airport 9 Dec 21, 2016 Yanbu Airport, and Westren Aiports 26 Dec 28, 2016 Qasim PNA, and Central Airports 22 Jan 4, 2017 Hail Airport, and North Aiports 20 Jan 8, 2017 Abha Airport, and South Airports 17 Total number of Attenddees: 128

72

Crash Landing Drill:

On August 2016, AIB performed drill 3 , drill location was Rabigh airport (OERB). A private aircraft, Seneca-Piper. Regestration – N342HP.performing a flight (XY123 )from Jeddah(OEJN) to Madinah (OEMA). PIC during flight reported having a technical problem. PIC had to divert to Rabigh airport(OERB). During landing the aircraft veered off the runway. Upoon recieving the notification, director of Investigation called for a staff meeting . Meeting took place at the AIB office at 06:30 am. Decision was made to investigate the occurence and an Investigator in Charge (IIC) was assigned, team of approximately 25 employee were ready to travel to Rabigh airport to start the investigatin.

Activities performed during the drill:

Staff Meeting

Mobilization of equipment and supplies

Site Inspection

73

Tints Installation

Aerial Photography

Evidence documenting

3D scanning (FARO) Bloodborne pathogen kit is used in a polluted spot

Post Incident Press Conference

74

National Disaster Plan Drill:

On 15 December 2016, AIB participated in a drill that took place in the eastern province (Alkhafji City) in conjunction with various entities and authorities in the kingdom. Drill scenario was about an aircraft that crashed into the sea, AIB function was to locate the Flight Data Recorder (FDR) position using Hydro-Phones. In addition to supervising the process of (FDR) salvage. And preserve the (FDR) in an appropriate media (Water Container) as a preparation for the (FDR) to be shipped to Flight Data Recorders Lab in Jeddah. AIB role was not limited to that function only. The AIB had prepared the Wreckage parts needed for the drill, also supervised and commanded the deployment of wreckage into the sea.

Preparation for wreckage deployment using a boat

75

Wreckage parts

Wreckage parts after deployment into the sea

Locating (FDR) using (Hydrophones)

76

Flight Data Recorder retrieval

Flight Data Recorder preserved in a container filled with water

Aviation Occurrence Management System (AOMS) Project: Project Vision: Develop a system using advanced technologies to support AIB to be ready for national transformation, and to be aligned with KSA’s 2030 vision, manage investigation processes, accomplish safety studies in a timely manner and generates reports to communicate risks and safety recommendations.

Process Scope: The focus of this project is to develop a system that provides the facilities for AIB investigators and specialist to perform their duties online. The first phase of the process is registering the occurrence in the system, while the second phase is the investigation, then

77

producing the reports and recommendation. The system will be developed using the latest advanced technologies from Oracle Company.

Aviation Occurrence Management System

Employee Occurrence Investigation Reports Inventory Module Reporting Module Module Module Module

Security Message Audit Assignment Control Manager Module Module Module Panel Module

Oracle Weblogic Server 12c R2

78

ECCAIRS (European Coordination Centre for Accidents and Incident Reporting Systems):

One of ICAO requirements is to share occurrences taxonomy by sending a selected taxonomy to the ECCAIRS database, therefore, in 2016 the AIB has adapted the ECCAIRS, and hence, the AIB has sent some of its specialist to be trained to use the system. The mission of ECCAIRS is to “assist transport authorities and accident investigation bodies in collecting, sharing and analyzing their safety information in order to improve public transport safety”. ECCAIRS helps to cope with the implementation of the legislation. It offers standard and flexible accident and incident data collection, representation, exchange and analysis tools. However, the AIB has received an organization code, and sent the first report on the first week of January 2017.

Post-Accident Communication Strategy: Introduction: The AIB recognized that an aviation accident is an event of international focus. If handled incorrectly and communicated improperly it could bring negative exposure to the entire aviation industry in KSA. Since the communication response to an aviation accident involves various stakeholders, it was paramount to develop a post-accident communication strategy at a national level. The AIB organized and conducted two industry workshops that involved high-level representation from all stakeholders including:  Ministry of Interior, Ministry of Defense, Ministry of Foreign Affairs, Saudi Red Crescent Agency.  GACA Sectors: SSAT, AIRPORTS, COMMUNICATION & MARKETING, STRATEGY, Training ACADEMY.  SAUDI AIRLINES, FLYNAS, SAUDI GULF, NESMA.

79

Both workshops were presented by Ms. Linda Tavlin, who has been an aviation communication consultant since April 1989 as the sole proprietor of her corporation. She graduated from the University of California at Irvine with a bachelor’s degree in social science.

The workshop presenter Ms. Linda Tavlin & AIB DG in the first workshop

Group photo in the first workshop

80

The second workshop

Objectives:  Protect the national product in the international arena while safeguarding the investigation information according to ICAO standards.  Provide the industry of Saudi Arabia a foundation for a team approach and coordinated effort to protect the national product.  Set national standards for the use of all media to execute the national strategy.  Work in coordination with GACA, other Ministries, and stakeholders as a team approach on behalf of the national product in accordance with international standards for accident investigation.

First edition of the Post Accidents Communication Manual

81

Main Successes and achievements of the communication Strategy:  The AIB produced its Communication Manual.  Communication interfaces were coordinated with GACA communication plan.  Communication interfaces were coordinated with operators and airports.  The Family Assistance Regulation was triggered and accomplished end of 2016.  The process to integrate FAP into operators and service providers emergency planning started.

82

83