ANNUAL SAFETY RECOMMENDATIONS REVIEW 2016 SAFETYANNUAL RECOMMENDATIONS EUROPEAN AVIATION SAFETY AVIATION EUROPEAN AGENCY EUROPEAN AVIATION SAFETY AGENCY SAFETY ANALYSIS AND RESEARCH DEPARTMENT Designed in Luxembourg Strategy & Safety Management Directorate Safety Intelligence & Performance Department Annual Safety Recommendations Review 2016 Disclaimer: Neither the European Aviation Safety Agency, nor any person acting on behalf of the European Aviation Safety Agency is responsible for the use which might be made of the following information. The Annual Safety Recommendations 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 2016. 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 con- text 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, 2016. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 2016 Annual Safety Recommendations Review PAGE 3 Foreword by the Executive Director I am pleased to introduce the 10th edition of the Annual Safety Recommendations Review, which provides infor- mation on the activity of the Agency in 2016 in the field of safety investigation and follow-up. In addition, the review highlights a range of safety issues and the Agency’s safety improvement efforts that are of interest to the European Aviation Community and the public. During the last 10 years the Agency has become the main actor in safety investigation follow-up within Europe through rigorously processing safety recommendations that have been addressed to it. Owing to EASA’s posi- tioning in the system, the Agency is able to take action with respect to systemic problems and other issues in the management of risk. The implementation of safety recommendations provides tangible improvements in safety as a result of infor- mation that has been learned during safety investigations. In Europe, the methodical approach to investigatory work and the implementation of recommendations brings some meaning to the loss experienced as a result of accidents. During 2016, Safety Investigation Authorities from 18 different States addressed 88 safety recommendations to EASA in the context of the Agency’s remit. Therefore, the handling of the safety recommendations in both an ex- peditious and responsible manner constitutes one of the pivotal responsibilities for EASA. EASA also monitors safety recommendations issued to other aviation and non-aviation addressees. As during 2015, the number of recommendations that were issued to non-aviation addressees has continued to increase in 2016. Such recommendations include those related to drones, research, crew employment, passenger health and criminal acts. Updating the EASA Basic Regulation will aid the Agency to better regulate, thereby giving ef- fect to safety recommendations. This further illustrates the dynamic nature of the aviation environment and it also means that the framework in which the Agency operates must be continuously reviewed. In preparing for the challenges ahead, areas for consideration include the safety of ground handling services and security aspects of aircraft and aviation system design, including cybersecurity. Despite the fluidity of the avia- tion environment created by external factors and technological changes, the system will continue to ensure safe and secure air transport for passengers and the general public. Patrick Ky Executive Director 2016 Annual Safety Recommendations Review PAGE 4 Contents Foreword by the Executive Director 3 0 Abbreviation list 7 1 Introduction 9 2 Safety Recommendations received in 2016 12 2.1 Overview of Safety Recommendations received in 2016..................................................................12 2.2 Origin of the Safety Recommendations received in 2016 ................................................................14 2.3 Involvement in the safety investigations ...........................................................................................16 3 Safety Recommendations replies in 2016 19 3.1 Overview of Safety Recommendations replies in 2016.....................................................................19 3.2 Status of the Safety Recommendations replies in 2016 ....................................................................20 4 Overview of key safety topics processed and actions carried out in 2016 24 4.1 Medical and psychological conditions of flight crew ������������������������������������������������������������������������25 4.2 Helicopter Offshore Operations .........................................................................................................26 4.3 Collisions warning systems for general aviation to mitigate the risk of Mid-air collision/ Near mid-air collision (MAC/NMAC) ..................................................................................................28 4.4 Erroneous Parameters at Take-off ......................................................................................................29 4.5 Cabin Air Quality ���������������������������������������������������������������������������������������������������������������������������������29 4.6 Aircraft localisation and flight recorders ...........................................................................................31 4.7 Risks posed by Lithium Batteries on Board........................................................................................33 4.8 Loss of Control Prevention and Recovery Training ............................................................................34 4.9 Security Related (SEC) events .............................................................................................................36 4.10 Unmanned Aircraft (Systems) .............................................................................................................37 5 Conclusions 40 ANNEX A: List of 2016 Safety Recommendations Replies 42 ANNEX B: Definitions 213 ANNEX C: Safety Recommendations classification 217 2016 Annual Safety Recommendations Review PAGE 5 List of Figures Figure 1: Safety Recommendations addressed to EASA per year .......................................................... 12 Figure 2: Safety Recommendations by occurrence class per year ......................................................... 13 Figure 3: Safety Recommendations received in 2016 by aircraft category ........................................... 13 Figure 4: Origin of Safety Recommendations received by EASA ........................................................... 14 Figure 5: States contribution to Safety Recommendations received in 2016 ....................................... 16 Figure 6: EASA responses to safety recommendations in 2016 by year received ................................. 19 Figure 7: Safety Recommendation Responses sent in 2016 ................................................................... 20 Figure 8: Received response assessments of EASA Final Replies sent in 2016 (Status: 14.03.2017) .................................................................................................................................. 21 Figure 9: Assessment EASA received on the Final Responses sent in 2016 [total] (Status: 14.03.2017) .................................................................................................................................. 22 Figure 10: Safety Recommendations addressed to EASA per topic....................................................... 24 CHAPTER 0 CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 Abbreviation list ANNEX A. ANNEX B. ANNEX C. 2016 Annual Safety Recommendations Review Abbreviation list PAGE 7 Abbreviation list AD Airworthiness Directive AFM Aircraft Flight Manual AAIB UK Air Accidents Investigation Branch United Kingdom AMC Acceptable Means of Compliance ANSV Italian National Agency for the Safety of Flight BEA Bureau d’Enquête et d’Analyse pour l’Aviation Civile CAT Commercial Air Transport CM Certification Memo CRI Certification Review Item CRM Crew Resource Management CS Certification Specifications CS-LSA Certification Specifications for Light Sport Aeroplanes CVR Cockpit voice recorder DSB Dutch Safety Board ELT Emergency Locator Transmitter ENCASIA European Network of Civil Aviation Safety Investigation Authorities EPAS European Plan for Aviation Safety ETOPS Extended Operation ETSO European Technical Standard Order EU European Union FAA Federal Aviation Administration FCOM Flight Crew Operating Manual FDM Flight Data Monitoring GA General Aviation GM Guidance Material HOFO Helicopter Offshore Operations ICAO International Civil Aviation Organization ICCAIA International Coordination Council for Aerospace Industry Associations ILS Instrument Landing System LOC-I Loss of control-inflight MOPSC Maximum Operational Passenger Seating Configuration MS Member States NCO Non-Commercial operations with Other than complex motor-powered aircraft PED Portable Electronic Devices RE Runway Excursion RMT Rulemaking task SIA Safety