Rule of Confidentiality applies to all content

EXECUTIVE SUMMARY - 420TH UKFSC SIE MEETING – 10 SEPTEMBER 2014

1. Discussion of MH17 security implications. (4.1)

2. Laser attacks in UK have reduced, but significant increase overseas. (5.2)

3. Electronic ops manuals need configuration management and a controlled update cycle. (5.3)

4. The six items at the head of the CAA SAG list were: fatigue assessment; accuracy of aeronautical data; laser attacks; cabin baggage issues; and smoke/fumes events. UAS proliferation now has CAA Board visibility. (5.4)

5. Airprox numbers are up by 1/3 on 2013. There were 30 CAT Airprox in 2013, of which 2/3 occur in Class G. (5.6)

6. Further ATR flame-out incident. (5.8)

7. Notional weights found to be in error, potential industry-wide problem. (5.9)

8. Operator finding ULDs improperly loaded or secured. Training. (5.11)

9. B-747-400 fuel system blockage after incomplete A2 that left residual water in fuel tanks, subsequent refuel with mil-spec JP-8 which included Fuel System Icing Inhibitor (FSII) led to formation of ‘apple jelly’ contaminant. (5.13)

10. Food poisoning on the flight deck, including one incident of pilot incapacitation from UK-sourced but incorrectly packed food. (5.14)

11. There was an in-flight engine shutdown on a B787 trans-Atlantic flight on 5 August. Damage to accessory gearbox housing and 2 hoses led to low oil pressure. ETOPS. (5.16)

Dai Whittingham Chief Executive Sept 2014

1 Rule of Confidentiality applies to all content

MINUTES OF THE 420TH MEETING OF THE UK FLIGHT SAFETY COMMITTEE HELD ON 10 SEPTEMBER AT CITY UNIVERSITY LONDON

Present:

Simon Searle Vice-Chairman Flight Data Services Dai Whittingham Chief Executive UKFSC Dimuthu Adikari Thomson Airways Patrick Arpino Jet2.com Craig Baker Gael Ltd Christopher Barclay Jet2.com Rob Bishton CAA Kerr Brown Cobham Aviation Services Michael Brennan Mark Brosnan CHC Scotia Capt. Marco Castro TAM Executiva / TAM Brazilian Paul Clark McLarens Aviation Will Curtis Monarch Airlines Kevin Daws AirTanker Services Ian Dugmore CHIRP Terry Eglinton Bond Offshore Helicopters Joe Elliott Aer Lingus Capt. Alex Fisher Honourable Company of Air Pilots Cdr Ian Fitter Royal Navy Air Cdre Steve Forward UK Airprox Board John Hamshare Heathrow Airport Steve Hull RTI / VLM Gp Capt Brian James Maurice Knowles RAeS Graham Lee Robert Lunnon Royal Met Society Mohammed Malatani GFSC Charlotte Marfleet Holman Fenwick Willan LLP Felipe Nascimento CAA Capt. John O’Connell Pen Avia Mike O’Donoghue GASCo Diane Parry Jet2.com Simon Place Cranfield Safety & Accident Investigation Zoe Reeves BALPA Lee Smith Thomson Airways David Taylor NPAS Brian Tennant Cobham Aviation Services Mark Trotter GFSL Cengiz Turkoglu City University London Piers Tye BA Cityflyer Bas van Itallie VLM Airlines Grant Walker AirTanker Services Kris Ward Jet2.com Giles Wilson DHL Air Phil Woodley CTC Aviation Jonathan Woodrow AIG Europe Ltd

2 Rule of Confidentiality applies to all content

Opening Remarks

The meeting was opened at 1035.

Introductions

The Vice-Chairman welcomed the following:

Capt. Mohammed Malatani - Chairman, Gulf Flight Safety Council Capt. Mark Trotter - Gulf Flight Safety Council Patrick Arpino - Jet2.com Lee Smith - Thomson Airways Grant Walker - AirTanker Services Felipe Nascimento - CAA

Those present were reminded of the following Confidential Warning which applies to these minutes and to the contents discussed therein:

These Minutes record the proceedings of matters discussed under the Rule of Confidentiality. Circulation to non-UKFSC members, either in whole or part, is to respect the Rule of Confidentiality which states:

“Details of accidents, serious incidents and incidents which may be discussed at this meeting are to be regarded as confidential. You are entitled to make use of the information within your own organisation but please use it with discretion and do not quote anyone by name or organisation without their prior authority.”

ITEM 1 Apologies for Absence

Derek Murphy, Alan Taylor, Anthony O’Keefe, Peter Richards, Karen Bolton, Suzy Scasz, Alan Whiteside, David Elliott, David Copse, Keith Curtis, Stuart Mckie-Smith, Phil Stuckle, Dermot McCarthy, Margaret Dean, Rory McLoughlin, Nick Leach, John Kirke, Shaneen Benson, John Turner, Gary Clinton, Harriet Quenet, Alex Wood, Chris Brady, Edward Spencer, John Eagles, Harry Nelson, David Harvey

ITEM 2 Approval of Minutes of 419th Meeting

A request had been received to amend para 5.5 bullet 4 to read “Runway markings such as TDZ markings may be changed to ICAO-compliant markings as part of the EASA transition work.” This change was approved and with no further requests forthcoming from the floor, the Vice-Chairman signed the Minutes of the 419th Meeting.

ITEM 3 Matters Arising from 419th Meeting

3.1 The CE had been asked to register an interest with the Scottish Court of Session with regard to the Lord Advocate’s request for possession of the CVR and FDR from the 2013 Sumburgh AS332 helicopter accident; the AAIB was opposing the request and BALPA had already registered an interest. On investigation it became apparent that a UKFSC interest could only be registered by a Scottish solicitor and that there would be significant un-budgeted cost

3 Rule of Confidentiality applies to all content involved. The matter was referred to the Chairman who agreed that, given the existing engagement by AAIB and BALPA, no further action should be taken.

3.2 In discussion, it was noted that there was inevitable tension between the need to ensure FDR/CVR access was reserved for safety investigations, the public interest regarding access to data where criminal prosecutions were being considered, and the AAIB desire to ensure the activities of its Inspectors were treated as legally privileged and investigations seen as being conducted purely for safety purposes. A legal device had been successfully employed in other cases whereby experts were invited to comment on the official investigation report.

ITEM 4 Chief Executive’s Report

4.1 The CE reported that there had been significant activity regarding safety of some overseas destinations and overflight of conflict areas in the wake of the MH17 accident in Ukraine. There had been requests for advice from individual flight and cabin crew (non- UKFSC operators) about the risk assessment processes being used. Discussion. The meeting noted that there needed to be a common approach to assessments. The CAA rep reported that a Board-level paper was being prepared but observed that different operators can come to different conclusions based on the same evidence. Work was in hand to identify State-level responsibilities for safety, security and access to sensitive information, and define where CAA oversight of company SMS should be sufficient. Any operating restrictions imposed by EASA or the CAA would have to be evidence-based and applicable to all operators. Capt Malatani offered a broad Gulf-region view, pointing out that the situation in Iraq and Syria was very fluid and dynamic, which had led his own operator to avoid overflight.

4.2 Next Autumn would see the publication of the 100th edition of FOCUS. Members were asked to consider writing suitable articles for inclusion in a special edition.

ITEM 5 Information Exchange and Extracts from MORs

5.1 Royal Navy – Cdr Ian Fitter

 The incidence of loose articles and incorrectly fastened panels had reduced after an education campaign.  Infringements of danger areas had also reduced and there had only been 15 resulting from civil traffic in the year to date. The risks arising from infringement were genuine, one infraction requiring immediate action to halt a live-firing exercise; delays to ships training resulting from these infringements could also have an impact on operational capability and readiness.  MAC was still a major concern (and is Defence-wide). There had been a spike in the numbers of Airprox incidents in the visual circuit area, assessed as being due to complacency and poor planning and communications. Small UAS were a concern and there had already been one Airprox incident with a helicopter.  Aircraft manoeuvring area incursions had increased significantly; the problem was being tackled via another education campaign.

5.2 RAF – Gp Capt Brian James

 MAC covered a range of issues, most of which were being addressed through education programmes. The report on the Tornado GR4 collision in the Moray Firth was available on the MAA website; following this accident, Tornado was being fitted with a collision 4 Rule of Confidentiality applies to all content

warning system and studies were ongoing for the Typhoon fleet. CWS for fast-jets are more complex because of the higher dynamics involved.  As a subset of MAC, the Regional Airspace User Groups had proved particularly effective in proactively addressing areas of potential airborne conflict; membership was open to all and details could be found on the Air Clues website.  The drawdown of ops in Afghanistan presented several risks, including MAC resulting from increased flying activity in the UK. The activity surge required to complete the repatriation of personnel and equipment had generated concerns over fatigue management for the AT fleet; an FRMS was being used along with an innovative approach to rostering, slip patterns etc but any advice from commercial operators would be welcome. Behavioural modification would also be required to ensure that understanding and acceptance of risk reverted to peacetime norms; there had already been an incident where a rotary crew accepted damage resulting from a heavy landing and flew back to base, where the damage was assessed as significant and involving the flight control system.  There had been an increasing incidence of in-cockpit ‘selfies’ appearing on social media, showing that crews were apparently unaware of the dangers of distraction and loose items. Regulations had been amended and an education programme was under way.  SES and SERA would have a profound effect on military aviation and developments were being closely watched.  The Flexible Use of Airspace concept was being further refined with the CAA with the aim of improving civil access to military reserved airspace. Discussion. Mention of laser attacks prompted a lengthy discussion. It was felt that attacks in the UK might have abated slightly at some locations but there was a definite increase in overseas incidents (especially at SSH). Overall, the view was of a general increase. However, this was not reflected in the stats reaching the CAA and, while the matter was on the SAG hotlist, the risk assessment did not point to urgent action being required. Members were encouraged to submit MORs for all laser attacks regardless of location. It was also noted that white light attacks could be as disruptive as lasers. The matter would be revisited at the next meeting.

5.3 CHIRP – Ian Dugmore

 Themes from recently submitted CHIRP reports included complaints about EFBs being introduced before programme maturity and completion of training. The rush to embrace electronic documentation had also produced a new problem with Ops Manuals, as the electronic format had provided change access to multiple stake-holders with the result that changes were being made on an almost daily basis. This made it difficult for crews to ensure that they were aware of changes when they were implemented. A structured programme for changes was required and it needed to be subject to proper configuration management processes.  Rostering and rest periods continued to attract comment. FRMS were not necessarily being fed the right data and there were some unrealistic assumptions being made on reporting times when set against known transit times for commonly used gates. Fatigue was a classic case where evidence also needed to be gathered outside the MOR/ASR system, perhaps by independent observation.  ATCO training at some regional airports was being impacted by manpower shortages, where the loss of trained ATCOs was having a disproportionate effect on the ability to train replacements.

5 Rule of Confidentiality applies to all content

 Cabin crew continue to report rostering and rest issues, but there had been a marked increase in the number of reports questioning cabin air quality. Carry-on baggage was also generating problems and bags were being found stowed inappropriately.  Notwithstanding earlier comments about the rush towards all things electronic, a CHIRP smartphone app was now available!

5.4 CAA – Rob Bishton

 The six items at the head of the SAG list were: fatigue assessment; accuracy of aeronautical data; laser attacks; cabin baggage issues; and smoke/fumes events.  As discussed at Item 4, security had been a major element of work over the summer but it had proved difficult to get the right stakeholders together during the holiday period; the issue was now at Board level but there was still work to do on mechanisms with EASA.  The proliferation of UAS also had Board visibility as being a key risk. There were multiple stakeholders involved including non-aviation interests. Responsible operators engaged appropriately with the CAA but the problem area was with those who did not.  CAS infringements by GA was a seasonal issue, but the CAA also had to consider the EASA desire to improve ease of GA access to airspace.  Standardisation was a significant workstrand, and the CAA was under pressure to embrace all EASA permissions (eg for IREs), which was at odds with the national position on designated examiners. The problem faced by EASA across all the Member States was large; there may be resource implications for the CAA.  Pilot performance issues included concerns over the crew supply chain and the need to align approximately 400 RTF and 100 ATOs.  The main risks being reported by operators were ATM incidents, the ramp; and component failures (non-power plant).

5.5 HAL –John Hamshare

 The second runway resurfacing work was completed on time.  The winter resilience working group was meeting in Edinburgh on 17 Oct. Winter drills were already being practiced at LHR and included full integration of de-icing operations.  There had been no runway incursions for the months of Jul and Aug, the first two consecutive RI-free months since 2006.  LHR was running a 2 week course on advance airside operations starting 10 Nov. Anyone interested in attending should contact John Hamshare.

5.6 UKAB – Steve Forward

 There have been 163 Airprox reports filed in the year to date, an increase of about 1/3 on last year.  10 CAT reports have been assessed (to end May), no significant trend.  A Cat B incident between 2 B737 occurred at a regional airport that was using new ‘optimised’ departure procedures; both aircraft were cleared into the hold at the same altitude.  1 x Cat C (mil v Fokker 70) occurred when the VFR mil aircraft penetrated the IFR CAT flight’s TCAS bubble. Some work required on mil (fast jet) awareness of TCAS operations.

6 Rule of Confidentiality applies to all content

 1 x Cat C at a regional airport with a CAT flight inbound on a procedural ILS. PIC assumed ATC was providing separation but the incident occurred in Class G when GA traffic flew through the ILS feather. Airmanship on both sides…  2013 Review is in draft. Of 172 incidents, 38% were risk-bearing (Cat A/B). There were 30 CAT incidents, 13% risk-bearing (an increasing trend); 20 of these occurred in Class G airspace [ie 2/3 of all CAT Airprox happen in Class G].  50% of all Airprox occur in Class G below3000ft; 15% in an ATZ or MATZ.  A UAS Airprox at Southend would be assessed next month.

5.7 GASCo – Mike O’Donoghue

 MAC was the main concern for GA, though LOC-I was the primary cause of fatal accidents.  Infringements were trending down for 2014 but more work was required. NATS had developed a lightweight airspace alerting device which would be available as a carry- on item (no mod required); this would help with the MAC risk but would not replace the need to look out.  Ideas for inclusion in the safety evening programme would be welcome.

5.8 Atlantic Airlines– Alex Wood (by email)

 There had been a further incident of ‘Transient Torque Reduction’. The crew were trying to avoid rapidly developing CB south of Dover (en route Guernsey-Brussels) and started to pick up ice; the de-icing system then indicated a failure of the tail portion and the aircraft was descended to FL 150 to find positive air temperatures. After about 5 mins and with observed lightning around the aircraft the No 2 engine flamed out but auto-relit after 5 secs. When clear of the weather the crew conducted a handling check with landing flap per QRH but were unable to retract the flaps afterwards and elected to divert to EMA.

5.9 Monarch – Will Curtis

 There had been some instances of deep landings following stable approaches and crews were typically offering good weather and long runways as the reason for not going around. Advice on a suitable policy was sought. Discussion. Jet2 had tackled a similar problem with an education programme. Current advice was that crews should not land beyond the marked touchdown zone.  A crew on pre-flight found MLG oleo fully compressed; investigation showed the hold contained a number of golf bags for which a notional weight of 13kg had been used whereas the actual weight of most of them was 18kg. Discussion. Actual weight surveys and the risk of being over-loaded should be included within company SMS. Jet-2 was using actual weights for its baggage anyway. The question of notional weight validity was raised. Was this an industry-wide problem? There were implications for loading, and performance planning v performance achieved, which could be eroding safety margins.  Action: All operators were invited to check that notional weight inaccuracy was included as a risk within their company SMS. Jet-2 offered to run a comparison between the actual weights being used for planning and the assumed weights for the same load.

7 Rule of Confidentiality applies to all content

5.10 Aer Lingus – Joe Elliott

 An A330 had turned back to Dublin (in June) after 7 of the 8 cabin crew became ill; 3 were yet to return to work. All checks have been ‘clean’ so far and the cause was still a mystery; no passengers were affected. For incident handling, the aircraft was met by paramedics, who wanted to take the sick cabin crew off the aircraft as their first priority. However, the regulations required the cabin crew to be present to supervise the passengers… Operators might therefore want to think about having other personnel available for pax supervision in the event of a similar occurrence.

5.11 AirTanker Services – Kevin Daws

 There had been a number of ULD-related incidents, with ULDs improperly secured, load-shifts, and wrong weights being recorded.  Skill-fade for personnel detached to the Falklands had manifested in competence and hence problems with A330 de-icing. Training was being adjusted.

5.12 BALPA – Zoe Reeves

 BALPA’s work had been concentrated on security issues arising from the MH17 accident.  An RPAS/UAS working group had been established.

5.13 AIG – Jonathan Woodrow

 B-747-400 had undergone an A2 check that should have included fuel sumping (complete drainage) as well as biocide treatment. As a result, some water remained in the tanks. The aircraft then had a short ferry flight and was refuelled with mil-spec JP-8 which included Fuel System Icing Inhibitor (FSII). On a subsequent start one engine had a hot-start, 2 failed to auto-start and one engine flamed out. The investigation showed blockages in the fuel system which required two full fuel loads to flush, 8 filter replacements, a second tank cleaning and 6 days hangarage, total cost around $2m. The source of the blockages was the action of FSII on pooled water, which produced a substance known as ‘apple jelly’ because of its appearance – this is a known issue. The costs would have been avoided if the A2 check had been properly carried out.

5.14 Thomas Cook – Michael Brennan

 TC had experienced problems with load sheets. Training for dispatchers had been reduced by the contractor and some were now unable to carry out gross error checks or action an LMC, load sheet figures were being transposed and there were clear misunderstandings of charter v scheduled aircraft weights. Management action was in hand.  There had been 4 cases of food poisoning on the flight deck, including one incident of pilot incapacitation. All food had been sourced in UK but had been incorrectly packed and was therefore unfit when served to the crew on return legs.

8 Rule of Confidentiality applies to all content

5.15 Bond – Terry Eglinton

 CAP 1145 was raised. There was a question whether the approach taken had concentrated too heavily on post-crash survival at the expense of preventing the accident in the first place.

5.16 Thomson – Dimuthu Adikari

 The previously reported incident of a dropped EFB knocking the fuel cut-off switch on a B787 flight deck had been subject to further investigation. The probability of a recurrence was assessed as low as the laptops were being replaced. The same fuel switch is present on the B767 flight deck. Suitable information had been given to all B787 and B767 crews.  There had been a 3-fold increase in the incidence of baggage being loaded onto the wrong aircraft at Manchester and Gatwick, which had clear safety and security implications.  There was an in-flight engine shutdown on a B787 trans-Atlantic flight on 5 August. The incident was under investigation but there was evidence of damage to the accessory gearbox housing and 2 hoses which led to low oil pressure on the affected engine. There were no concerns with crew actions and decision making in the ETOPS environment.

5.17 DHL – Giles Wilson

 An injury and consequent 6 weeks off flying had caused the reporter to realise he had previously been fatigued and he also noticed symptoms of deep fatigue in others. This raised questions about the utility of the FRMS being used, which relied on Karolinska Sleepiness Scale observations at TOD. This had led one route to be extended by a further sector, which placed the crew at a better point in their Circadian cycle but with a much longer day, which seemed counter-intuitive.

ITEM 6 Presentations

6.1 Captain Mohammed Malatani, Chairman of the Gulf Flight Safety Council gave a short presentation on the work of the GFSC. He extended an invitation for UKFSC members to attend GFSC meetings.

ITEM 7 Membership Applications

7.1 A membership application had been received from the London Air Ambulance and was approved unanimously.

ITEM 8 Any Other Business

8.1 There was no other business pre-notified or raised at the meeting.

Next Meeting

8. The 421st SIE Meeting would commence at 1030 on Tuesday 11 November 2014 at BAES Farnborough. Detailed instructions and a map are available on the UKFSC website. 9 Rule of Confidentiality applies to all content

Closing Remarks

The Vice-Chairman thanked City University for the use of its facilities and for the catering. He also thanked the Members for their attendance and contributions to the Safety Information Exchange. The Meeting was closed at 1510.

Signed…………………………. Signed………………………………… Chief Executive Chairman UKFSC September 2014

10