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 Thomas Cook Airlines 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 Royal Air Force Maurice Knowles RAeS Graham Lee Bristow Helicopters 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.