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.