EUROPEAN AVIATION SAFETY AGENCY EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT ANNUAL SAFETY RECOMMENDATIONS REVIEW 2012 SAFETYANNUAL RECOMMENDATIONS Annual Safety Recommendations Review 2012 European Aviation Safety Agency, Safety Analysis and Research Department Postal address Postfach 10 12 53 50452 Cologne Germany Visiting address Ottoplatz 1 50679 Cologne Germany Tel. +49 221 89990 - 000 Fax +49 221 89990 - 999 Mail [email protected] Web www.easa.europa.eu EUROPEAN AVIATION SAFETY AGENCY AVIATION EUROPEAN 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 2012 Annual Safety Recommendations Review 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 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 2012. 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, 2013. All rights reserved. Proprietary document. Printed copies are not controlled. Confirm revision status through the EASA-Internet site: www.easa.europa.eu. 2012 Annual Safety Recommendations Review Contents Contents 1 Introduction 4 2 Overview of Safety Recommendations in 2012 6 2.1 Safety recommendations received in 2012............................................................................................7 2.2 Origin of the final safety recommendations received in 2012 �������������������������������������������������������������8 2.3 Trends of investigated occurrences giving way to safety recommendations in 2012, by categories ...........................................................................................................................................8 2.4 Thematic distribution of final recommendations received in 2012 ...................................................10 3 Final safety recommendations replied 14 3.1 Final Safety Recommendations replied in 2012 ����������������������������������������������������������������������������������15 3.2 Status of final safety recommendations replied in 2012 ....................................................................16 3.3 Concluding actions �������������������������������������������������������������������������������������������������������������������������������16 3.4 CONCLUSIONS .......................................................................................................................................18 ANNEX A. Replies to Recommendations in 2012 20 ANNEX B. Definitions 168 ANNEX C. Safety Recommendations classification 172 CHAPTER 1 CHAPTER 2 CHAPTER 3 ANNEX A. Introduction ANNEX B. ANNEX C. © Cobham Engineering and Aviation Services 2012 Annual Safety Recommendations Review Introduction PAGE 5 Introduction At European Union level, the principles governing the investigation of accidents and serious incidents are defined in the European Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 Octo- ber 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC of 21 November 1994. This Regulation is compliant with international standards and recommended practices as described in Annex 13 to the Chicago Convention on International Civil Aviation. It sets an obligation for each European Member State to establish an independent permanent national civil aviation safety authority which shall investigate accidents and serious incidents in order to improve aviation safety and prevent future occurrences without apportioning blame or liability. Investigation reports and the related safety recommendations shall be communicated to the concerned aviation authorities for consideration and appropriate action, as needed. Basic Regulation EC No 216/2008, last amended by Regulation (EC) No 1108/2009 of the European Parliament and of the Council of 21 October 2009, defines the objectives of EASA. It states that “Results of air accident inves- tigations 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”. Currently EASA’s remit involves type-certification, (aircraft, engines, etc.), flight operations and flight crew licens- ing, approval and oversight of aircraft design organisations as well as production and maintenance organisations outside the EU. EASA is also directly involved in the European aviation safety rulemaking process. EASA’s remit has been expanded in 2009 to Air Traffic Management and Airport. As a consequence, EASA has adopted an -or ganisational structure commensurate with its activities. The European Regulation (EU) No 996/2010 establishes, in article 18, the follow-up process to give to safety rec- ommendations. Consequently, the Agency procedures have been aligned with this European legal requirement. Thus, the handling of the safety recommendations in both an expeditious and responsible manner constitutes one of the pivotal responsibilities of EASA. Consequently, EASA provides responses to Safety Recommendations addressed to it and publishes an annual review of the safety recommendations handled in 2012 with a statisti- cal 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 2012. 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 2012 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 2012 ANNEX C. © Schroeder Fire Balloons 2012 Annual Safety Recommendations Review Overview of Safety Recommendations in 2012 PAGE 7 Overview of Safety Recommendations in 2012 2.1 Safety recommendations received in 2012 During the year 2012, 94 final safety recommendations were received by EASA. These safety recommendations were related to 54 different occurrences distributed as follows: 30 accidents, 16 serious incidents and 8 incidents. The total annual number of the final safety recommendations that the Agency has received until 2012 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 maintained 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 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. 2012 Annual Safety Recommendations Review Overview of Safety Recommendations in 2012 PAGE 8 2.2 Origin of the final safety recommendations received in 2012 In 2012, Safety Investigation Authorities of 18 different States addressed 94 final safety recommendations to EASA. With the exemption of 3 countries, which addressed to EASA 9 final safety recommendations accounting for 10% of the total amount, the remaining part was issued by EASA Member States. 2.3 Trends of investigated occurrences giving way to safety recommendations in 2012, by categories ´ Chart2: Final Safety Recommendations received by EASA Member and Non Member States. % EASA Members Non EASA Members % Drawing up a categorisation from a number of relatively limited events has to be carried out with caution. How- ever, a distribution of the 54 occurrences addressed in 2012 to the Agency, for which safety recommendations were issued, has been done. It has to be mentioned that these statistics come from the ICAO ADREP database. In chart 3, it is observed the percentage of aircrafts involved in the referred occurrences by mass group. It shows the same pattern as in 2011. Aircrafts below 2 250 kg (34%) and the mass group from 27 001kg to 272000kg (32%) are the main participants. 2012 Annual Safety Recommendations Review Overview of Safety Recommendations in 2012 PAGE 9 ´ Chart 3: Aircraft mass group involved in the occurrences in 2012 % % 0-2 250 Kg 2 251 to 5