Annual Safety Recommendations Review 2013 EUROPEAN AVIATION SAFETY AGENCY SAFETY ANALYSIS and RESEARCH DEPARTMENT
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EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT Annual Safety Recommendations Review 2013 EUROPEAN AVIATION SAFETY AGENCY SAFETY ANALYSIS AND RESEARCH DEPARTMENT Designed in Luxembourg EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT European Aviation Safety Agency Safety Analysis and Research Department Executive Directorate 2013 Annual Safety Recommendations Review Executive summary: The Annual Safety Recommendation Review is produced by the European Aviation Safety Agency (EASA). This edition provides an overview of the safety recommendations that have been addressed to EASA in 2013. It also presents the replies produced during the year. This annual review aims at providing a feedback on the follow-up given to Safety Recommendations in the context of openness, transparency and accountability that characterises the European Public Administration. Apart from its safety related information character, this review is also expected to provide relevant information related to raised safety concerns, both for EASA itself, as well as its stakeholders, including the European public. © European Aviation Safety Agency, 2014. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet/Intranet. 2013 Annual Safety Recommendations Review Contents PAGE 5 Contents 1 Introduction 4 2 Overview of Safety Recommendations in 2013 6 2.1 Safety recommendations received in 2013............................................................................................7 2.2 Origin of the final safety recommendations received in 2013 .............................................................8 2.3 Trends of investigated occurrences giving way to safety recommendations in 2013, by categories ...........................................................................................................................................9 2.4 Thematic distribution of final recommendations received in 2013 ...................................................12 3 Final safety recommendations replied 15 3.1 Final Safety Recommendations replied in 2013 ..................................................................................16 3.2 Status of final safety recommendations replied in 2013 ....................................................................17 3.3 Concluding actions �������������������������������������������������������������������������������������������������������������������������������18 3.4 CONCLUSIONS .......................................................................................................................................20 ANNEX A. Replies to Recommendations in 2013 21 ANNEX B. Definitions 184 ANNEX C. Safety Recommendations classification 187 CHAPTER 1 CHAPTER 2 CHAPTER 3 ANNEX A. Introduction ANNEX B. ANNEX C. © Hawker Beechcraft Corporation 2013 Annual Safety Recommendations Review Introduction PAGE 7 Introduction At European Union level, the principles governing the investigation of accidents and serious incidents are defined in Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investi- gation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC. Regulation (EU) No 996/2010 implements international standards and recommended practices as described in Annex 13 to the Chicago Convention on International Civil Aviation. It sets an obligation for each Member State of the European Union (EU) to establish an independent permanent national civil aviation safety investigation authority which shall investigate accidents and serious incidents in order to improve aviation safety and pre- vent future occurrences without apportioning blame or liability. Investigation reports and the related safety rec- ommendations shall be communicated to the concerned aviation authorities for consideration and appropriate action, as needed. The Regulation (EC) No 216/2008 as amended (“the Basic Regulation”) has transferred to the EU the competence for regulating civil aviation safety in the areas of initial and continuing airworthiness, environmental certification, aircrew licensing, air operations, ATM/ANS and aerodromes. The principal objective of the Regulation is to establish and maintain a high uniform level of civil aviation safety in Europe. Results of accident investigations play an impor- tant role in achieving this objective. This is fully recognised in the preamble to the Basic Regulation stating that “Results of air accident investigations should be acted upon as a matter of urgency, in particular when they relate to defective aircraft design and/or operational matters, in order to ensure consumer confidence in air transport”. EASA assigns high priority to the follow-up of safety recommendations. and has established effective procedures to that effect. In addition, EASA publishes this annual review of the safety recommendations handled during the year, including a statistical overview of the situation. The aim of this annual safety recommendations review is twofold: • first, the review presents general statistical data of the final safety recommendations that the safety investigation authorities have addressed to EASA in 2013. It gives an overview of the work performed by EASA in the area of safety recommendations. • second, it presents the replies that EASA has given in 2013 to safety recommendations and shows the safety issues that have been managed and their follow-up. CHAPTER 1 CHAPTER 2 CHAPTER 3 Overview of Safety ANNEX A. Recommendations ANNEX B. in 2013 ANNEX C. © iStock 2013 Annual Safety Recommendations Review Overview of Safety Recommendations in 2013 PAGE 9 Overview of Safety Recommendations in 2013 2.1 Safety recommendations received in 2013 During the year 2013, 98 final Safety Recommendations (SRs) were received by EASA. These safety recommenda- tions were related to 3 studies and 43 different occurrences distributed as follows: 27 accidents, 11 serious inci- dents and 5 incidents. The total annual number of the final safety recommendations that the Agency has received until 2013 is shown in Chart 1. The number of safety recommendations varies according to aircraft operations and number of safety events. In 2009 it is observed a significant increase of incoming final safety recommendations that is kept since then. ´ Chart 1: Final Safety Recommendations per year 140 120 100 80 60 40 20 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 It is worth mentioning that with similar amount of safety recommendations, there have been 22% less occur- rences in 2013 but 3 more studies with respect to 2012. In Chart 2 it is depicted the amount of safety recommendations coming from different occurrence classes since 2009. 2013 Annual Safety Recommendations Review Overview of Safety Recommendations in 2013 PAGE 10 ´ Chart 2: Final Safety Recommendations (SR) by occurrence class per year 90 80 70 60 50 40 30 20 10 0 2009 2010 2011 2012 2013 SR from Accidents SR from Serious Incidents SR from Incidents SR from Studies As the remit of EASA expanded, final safety recommendations related to this new remit and initially addressed to the Member States have now been transferred to EASA. Also in some exceptional cases, EASA, acting on its own initiative, has taken on board final safety recommenda- tions which, although they were not addressed to it, were found to fall within its area of activities. 2.2 Origin of the final safety recommendations received in 2013 In 2013, Safety Investigation Authorities of 17 different States addressed 98 final safety recommendations to EASA. With the exemption of 6 countries, which addressed to EASA 15 final safety recommendations accounting for 15% of the total amount (5% more than in 2012), the remaining part was issued by EASA Member States. 2013 Annual Safety Recommendations Review Overview of Safety Recommendations in 2013 PAGE 11 ´ Chart 3: Final Safety Recommendations received by EASA Member and Non Member States % EASA Members Non EASA Members % 2.3 Trends of investigated occurrences giving way to safety recommendations in 2013, by categories Drawing up a categorisation from a number of relatively limited events has to be carried out with caution. However, a distribution of the 43 occurrences addressed in 2013 to the Agency, for which safety recommenda- tions were issued, has been done. It is noted that these statistics come from the ICAO ADREP database. In chart 4, it is observed the percentage of aircraft involved in the referred occurrences by mass group. It shows similar pattern as in 2012, the mass group from 27 001kg to 272000kg (36%) and aircraft below 2 250 kg (36%) are the main participants. 2013 Annual Safety Recommendations Review Overview of Safety Recommendations in 2013 PAGE 12 ´ Chart 4: Aircraft mass group involved in the occurrences in 2013 % % 0-2 250 kg 2 251 to 5 700 kg 5 701 to 27 000 kg % 27 001 to 272 000 kg > 272 000 kg % % As shown in Chart 5, for 2013, the pattern of the distribution by type of operations changes with respect to 2012. “General Aviation” has decreased significantly from 32% to 16%, “Commercial Air Transport” has maintained the percentage and “Aerial Work” has increased from 7% to 23%. Again, there were not occurrences involving aircraft that conducted “State Flights” in 2013. ´ Chart 5: Type of operation in the occurrences in